Twisting or rotational injuries to the knee in sports, followed by delayed onset of knee swelling and locking are strongly suggestive of a meniscal tear. Arthroscopic meniscectomy is the usual treatment.

Meniscal tear is one of the most common knee injuries, characterized by:
1. A popping sensation
2. Delayed swelling or stiffness of the affected knee
3. Pain, especially when twisting or rotating the knee
4. Difficulty straightening the knee fully
5. Locking of knee in place (patient may be able to unlock the knee)

In older adults, degenerative changes of the knee can also contribute to a torn meniscus with little or no trauma.

A torn meniscus may lead to knee instability, inability to move the knee normally, or persistent/recurrent knee pain. There is a strong likelihood of developing osteoarthritis in the injured knee.

The hoarseness of voice implies vocal cord paralysis denoting the spread of malignancy which is a contraindication to surgery.

Summary of Guidelines on the selection of patients with lung cancer for surgery (Related to this case)

PART I: FITNESS FOR SURGERY
Age:
1. Perioperative morbidity increases with advancing age. Elderly patients undergoing lung resection are more likely to require intensive perioperative support. Preoperatively, a careful assessment of co-morbidity needs to be made.
2. Surgery for clinically stage I and II disease can be as effective in patients over 70 years as in younger patients. Such patients should be considered for surgical treatment regardless of age.
3. Age over 80 alone is not a contraindication to lobectomy or wedge resection for clinical stage I disease.
4. Pneumonectomy is associated with higher mortality risk in the elderly. Age should be a factor in deciding suitability for pneumonectomy.

Pulmonary function:
There should be a formal liaison in borderline cases between the referring chest physician and the thoracic surgical team.
2.No further respiratory function tests are required for a lobectomy if the post-bronchodilator FEV1 is >1.5 litres and for a pneumonectomy, if the post-bronchodilator FEV1 is >2.0 litres, provided that there is no evidence of interstitial lung disease or unexpected disability due to shortness of breath.
STEP 1
3.All patients not clearly operable on the basis of spirometry should have: (a) full pulmonary function tests including estimation of transfer factor (TLCO); (b) measurement of oxygen saturation on air at rest; and (c) a quantitative isotope perfusion scan if a pneumonectomy is being considered.
4.These data should be used to calculate estimated postoperative FEV1 expressed as % predicted and the estimated postoperative TLCO expressed as % predicted, using either the lung scan for pneumonectomy or an anatomical equation for lobectomy, taking account of whether the segments to be removed are ventilated or obstructed.
STEP 2
5.(a) Estimated postoperative FEV1 >40% predicted and estimated postoperative TLCO >40% predicted and oxygen saturation (SaO 2) >90% on air: average risk.
(b)Estimated postoperative FEV1 <40% predicted and estimated postoperative TLCO <40% predicted: high risk.
(c)All other combinations: consider exercise testing.
6.Patients for whom the risk of resection is still unclear after step 2 tests should be referred for exercise testing.
STEP 3
7.(a) The best distance on two shuttle walk tests of <25 shuttles (250 m) or desaturation during the test of more than 4% SaO 2 indicates a patient is a high risk for surgery.
(b)Other patients should be referred for a formal cardiopulmonary exercise test. For cardiopulmonary exercise testing peak oxygen consumption (V˙O 2peak) of more than 15 ml/kg/min indicates that a patient is an average risk for surgery.
(c)A V˙O 2peak of <15 ml/kg/min indicates that a patient is a high risk for surgery. PART II: OPERABILITY
Diagnosis and staging
1.All patients being considered for surgery should have a plain chest radiograph and a computed tomographic (CT) scan of the thorax including the liver and adrenal glands.
2.Confirmatory diagnostic percutaneous needle biopsy in patients presenting with peripheral lesions is not mandatory in patients who are otherwise fit, particularly if there are previous chest radiographs showing no evidence of a lesion.
3.Patients with mediastinal nodes greater than 1 cm in short-axis diameter on the CT scan should undergo biopsy by staging mediastinoscopy, anterior mediastinotomy, or needle biopsy as appropriate.
Operability and adjuvant therapy
1.The proportion of patients found to be inoperable at operation should be 5–10%.
2.Patients with stage I (cT1N0 and cT2N0) and stage II (cT1N1, cT2N1 and cT3N0) tumours should be considered operable.
3.Patients with stage I tumours have a high chance and those with stage II tumours a reasonable chance of being cured by surgery alone.
4.Patients who are known preoperatively to have stage IIIA (cT3N1 and cT1–3N2) tumours have a low chance of being cured by surgery alone but might be considered operable in the context of a trial of surgery and adjuvant chemotherapy.
5.Participation in prospective trials of multimodality treatment for locally advanced disease is strongly recommended.
6.Some small individual studies indicate a place for surgery in T4N0 and T4N1 tumours within stage IIIB, few long term data are available. Generally, stage IIIB tumours with node involvement and stage IV tumours should be considered inoperable.
7.There is no place for postoperative radiotherapy following complete primary tumour resection.

Acetaminophen, NSAIDs, and opiates are recommended in the basic approach to cancer pain associated with bone metastases. They should provide patients with adequate analgesia when used appropriately. NSAIDs including COX2 inhibitors are especially useful for patients with bone pain. Acetaminophen is an effective analgesic but is a weak anti-inflammatory agent. Ketorolac tromethamine is a potent NSAID capable of relieving moderate to severe acute bone pain.

Breast cancer frequently metastasizes to the skeleton, interrupting the normal bone remodelling process and causing bone degradation. Breast cancer is the commonest cause of lytic bone metastasis in women of this age, especially from amongst those options given.

Osteolytic lesions are the end result of osteoclast activity; however, osteoclast differentiation and activation are mediated by osteoblast production of RANKL (receptor activator for NFκB ligand) and several osteoclastogenic cytokines. Osteoblasts themselves are negatively affected by cancer cells as evidenced by an increase in apoptosis and a decrease in proteins required for new bone formation. Thus, bone loss is due to both increased activation of osteoclasts and suppression of osteoblasts. The clinical outcomes of bone pain, pathologic fractures, nerve compression syndrome, and metabolic disturbances leading to hypercalcemia and acid/base imbalance severely reduce the quality of life.

Dukes staging and 5 year survival:
Dukes A – Tumour confined to the bowel but not extending beyond it, without nodal metastasis (95%)
Dukes B – Tumour invading bowel wall, but without nodal metastasis (75%)
Dukes C – Lymph node metastases (50%)
Dukes D – Distant metastases (6%)

Extravasation is the process by which any liquid (fluid or drug) accidentally leaks into the surrounding tissue. In terms of cancer therapy, extravasation refers to the inadvertent infiltration of chemotherapy into the subcutaneous or subdermal tissues surrounding the intravenous or intra-arterial administration site.
Extravasated drugs are classified according to their potential for causing damage as ‘vesicant’, ‘irritant’ and ‘non-vesicant’.
Doxorubicin is one of the vesicant drugs.
Regardless of the chemotherapy drug, early initiation of treatment is considered mandatory. In this context, patient education is crucial for prompt identification of the extravasation.
Step 1: Stop the infusion and leave the needle in place
Step 2: Identify the extravasated agent
Step 3: Leave the cannula in place, gently aspirate the agent and avoid manual compression, then remove the cannula
Step 4: Use a pen to outline the extravasated area
Step 5: Start Specific measures
Step 5A: For Anthracyclines (Doxorubicin), Apply cold compressions for 20 minutes, 4 times daily for 1-2 days.
Step 5B: Using Specific Antidotes as Topical Dimethyl sulfoxide (DMSO) or Dexrazoxane

The role of surgery for bone metastasis can be divided into (i) prophylactic fixation to prevent impending pathological fractures, (ii) stabilization of a pathological fractures, (iii) segmental resection of tumours, and (iv) arthroplasty for replacing joints that have been destroyed by a tumour. To this end, orthopaedic surgeons have a vast array of surgical devices and implants in their surgical armamentarium at their disposal. These include plates and screws, intramedullary fixation devices, and tumour endoprostheses.
Even with surgical fixation only 30% of pathological fractures unite.

In females, the breasts and lungs are the most common primary disease sites; approximately 80% of cancers that spread to bone arise in these locations. In males, cancers of the prostate and lungs make up 80% of the carcinomas that metastasize to bone. The remaining 20% of primary disease sites in patients of both sexes are the kidney, gut, and thyroid, as well as sites of unknown origin.

On contrast-enhanced CT scans, RCC is usually solid, and decreased attenuation suggestive of necrosis is often present. Sometimes, RCC is a predominantly cystic mass, with thick septa and wall nodularity.
RCC may also appear as a completely solid and highly enhancing mass

If pain occurs between regular doses of morphine (‘breakthrough pain’), an additional dose (‘rescue dose’) of immediate-release morphine should be given. Breakthrough dose = 1/6th of daily morphine dose

The total daily morphine dose is 30 * 2 = 60 mg, therefore the breakthrough dose should be one-sixth of this, 10 mg.

Epirubicin is an anthracycline; intercalates between DNA base pairs and triggers cleavage by topoisomerase II, which results in cytocidal activity.
Inhibits DNA helicase and generates cytotoxic free radicals.

Contraindications:
– Severe hypersensitivity to drug, other anthracyclines, or anthracenediones
– Baseline ANC<1500/mm³
– Cardiomyopathy and/or heart failure, recent MI, or severe arrhythmias
– Severe myocardial insufficiency
– Cumulative dose achieved in previous anthracycline treatment
– Severe persistent drug-induced myelosuppression
– Severe hepatic impairment (Child-Pugh Class C or serum bilirubin level greater than 5 mg/dL)