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Gold standard case presentation:
Metastatic pleural effusion
This lady has an interesting clinical story, which is entirely determinable from the clinical examination. This case demonstrates the value in exposing (while maintaining dignity) and ensuring you look at the patient properly. You would miss the key feature if you do not.
She has a left prosthetic breast insert in her bra – this is used to maintain the shape of the breasts, that many women post mastectomy use either while waiting for breast implantation, or if they cannot/do not want a breast implant. On examination she has a clear left sided pleural effusion, which in this case indicates that the breast cancer has returned and spread to the chest.
The total number of patients with breast cancer in the West that will suffer some recurrence is around 40%, but this is dependent upon a number of factors and has a number of layers. The 5-year overall survival with isolated recurrence of the chest wall is 68% and 81% after intra-breast recurrence. Recurrence is highest in the initial 2-3 years after diagnosis and treatment. Lung and pleural recurrence can affect up to three-quarters of those that have recurrence.
The management in this lady will include the following:
- breast examination (with chaperone)
- baseline bloods
- looking for anaemia, infection, hypercalcaemia with bone metastases and liver dysfunction from the same
- clotting screen and platelet count prior to chest aspiration
- plain chest radiograph
- confirm clinical findings
- diagnostic aspiration under ultrasound guidance
- laboratory analysis for protein, blood, infection and cytology
- confirm whether the effusion is an exudate or not – if not, then further investigations for other causes required (Light’s criteria)
- therapeutic aspiration if symptomatic (breathless on exertion and/or oxygen de-saturation)
- urgent breast mammogram and biopsy as required
- staging CT of the chest, abdomen and pelvis to confirm if other metastases are present
- referral to the Breast Multi-Disciplinary Meeting for discussion about treatment options
For more information about breast cancer recurrence, here is a thorough review.
- Review / Skip
Question 1 of 5
1. Question1 point(s)
Where you paying attention? This lady has a prosthesis. What is it?CorrectIncorrect
Question 2 of 5
2. Question1 point(s)
What findings were present on auscultation?CorrectIncorrect
Question 3 of 5
3. Question1 point(s)
The examiners invite you to speculate about what might have caused this lady’s pleural effusion. What would you suggest as a possible aetiology based on your clinical findings?CorrectIncorrect
Question 4 of 5
4. Question1 point(s)
The examiners ask you which of the following can be used to differentiate an exudate from a transudate. Select all that apply:CorrectIncorrect
Question 5 of 5
5. Question1 point(s)
Aside from discriminating exudate from transudate, what other test would be useful to determine whether this is indeed a malignant pleural effusion?CorrectIncorrect