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Case History

Image not available. A 70-year-old woman presented to her general physician (GP) with increasing shortness of breath on exertion over a two-month period. The patient's symptoms had deteriorated significantly within the last week and she was admitted as an emergency to her local emergency department. On admission, her performance status was 2 on the Eastern Cooperative Oncology Group (ECOG) score. The patient had a past medical history of a mastectomy and axillary node clearance for a T3 N0, ER-positive infiltrating ductal carcinoma of the left breast eight years ago, and received adjuvant radiotherapy and tamoxifen but had declined chemotherapy.

What is the differential diagnosis?

What are the appropriate investigations?

How would you manage this patient?


What is the differential diagnosis?

Image not available. There are many causes of shortness of breath in patients with a current or past history of cancer. In this case, the acute presentation against a background of chronic symptoms may have been triggered by a thromboembolic or cardiac event, or infection. In a patient with a prior history of cancer, malignant disease (including pleural or pericardial effusions), lymphangitis carcinomatosis, and disease progression due to pulmonary metastases should be considered.

What are the appropriate investigations?

An accurate history of the duration and onset of shortness of breath, including whether acute or chronic, together with associated symptoms such as fever, cough, chest pain or haemoptysis is important in determining the likely diagnosis, as is establishing if there is any history of prior lung disease or smoking. In this case, it was very important to elicit the past history of malignancy, since this adds a number of further differentials to the diagnostic list as breast cancer may relapse after a long disease-free interval.

A full history and clinical examination, including vital signs, should be performed. Typically a fluid collection of 500 ml can be detected clinically, with reduced air entry on the affected side and dullness to percussion. Blood tests that include biochemistry, haematology and inflammatory markers may be useful if infection is suspected. Initial radiological investigations should include a chest X-ray. This patient's chest X-ray (Figure 38.1) demonstrates a left pleural effusion together with loss of the left breast shadow. Pleural aspiration under ultrasound guidance confirmed a diagnosis of recurrent metastatic breast cancer on cytology. Samples should also be sent for protein, lactate dehydrogenase (LDH) and Gram stain if a diagnosis has not already been established to allow assessment of whether the effusion is an exudate or transudate.1 Full staging with a computed tomography (CT) scan of chest and abdomen is indicated for patients in whom anticancer therapy is planned (Figure 38.2).

Figure 38.1

Chest X-ray demonstrates moderate-large left pleural effusion together with loss of the left breast shadow.

Figure 38.2

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