Benign Breast disorders 4

3.5 FIBROADENOMA

Firm well defined painless lesion.

this is a benign tumour and is usually present in young females.

The lump is :

   *  Freely mobile

   *  Non Tender

and there is:

   *  No nipple distortion

   *  No discharge

   *  No lymph gland enlargement

Treatment is the removal of the lump

 

3.6 Phylloides Tumour also named cystosarcoma phylloides is  most

often a benign unilateral enlargement of the breast normally seen

in women over 40 years.  It can also occur in young females.  Can

ulcerate but remains mobile on chest wall (no adherance). 

 

It is a variant of fibroadenoma showing rapid growth and assuming

giant size.

 

and  gives  rise  to  local recurrence  if  there  is  incomplete

removal.

 

About 10% of these lesions produce metastasis.

 

TREATMENT

By surgical excession.

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Benign Breast disease 3

OTHER BENIGN LESIONS

3.4  Mammary dysplasia : (Fibrocystic  disease,Chronic  mastitis,

Fibroadenosis)

Patients usually present with complaints of  pain,

tenderness  and small lump in any part of the breast usually  the upper  and  outer quadrant there may be more than one  lump 

The lesion may be bilateral, the disorder is suspected to be due to hormonal imbalance probably excess estrogen and low  progestogens (anovular cycle).

 

Clinical features include :

   *  Middle aged females

   *  Pain and lump in both breasts

   *  Pain worst in premenstrual period

   *  15% have nipple discharge

   *  On Examination:

      a)  Tenderness is present

      b)  More than one ill-defined lump

      c)  Felt best with tip of fingers rather than flat of the

          hand

      d)  Cysts may feel firm and palpable with flat of the hand

      e)  There are no lymph glands in the axilla

A mammogram is required.

A fine needle aspiration cytology, or a biopsy may be required to

eliminate the possibility of carcinoma.

 

TREATMENT

Is  for symptom of pain.

 Hormone progesterone or danazol  may  be

prescribed.

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Breast Disorders Benign 2

 

3.2 Nipple Discharge

 

This  occurance  in  a  non-lactating  female  is  a   disturbing

complaint  for the patient.  
If it is a blood colored  discharge,

it  needs  follow up.  
If there is no palpable lump  and  nothing

detected  on a mammogram.  
There may be a small pappiloma in  one

of the ducts.  If the discharge is from both nipples it should be

investigated for hormone levels especially prolactin.

 

3.3 GYNECOMASTIA

This term refers to the development of female type breast  tissue

in pubertal boys it is seen frequently between the ages of  13-17

years.   This  disappears and is treated by  reassurance.   Where

this  occurs on both sides a cause must be looked for. Among  the

areas to be investigated are:

   1.  Liver for function(estrogen levels can be high in cirrhosis

   2.  Exogenous estrogen intake

   3.  External genitalia(for any signs of ambiguity of

       genitalia or testicular tumours)

 

If no cause is found and there is pain or  
the size is large surgical excision is required

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Breast disorders benign

2. CONGENITAL AND DEVELOPMENTAL DISORDER

Extra  Breast  tissue may be found anywhere along the  milk  line

(mid-clavicular to midinguinal point) 

These supernumerary breasts may or may not have a nipple. 

Absence  of  breast development (amastia) is  a  rare  occurance. 

Unilateral underdevelopment of breast is more commonly observed.

3. BENIGN BREAST DISEASE

3.1 BREAST ABSCESS

Acute  mastitis occurs most often in the first fourteen  days  of

lactation,the   infecting   organisms   are   Staphylococcus   or

Streptococci  and they enter through an injury to the  nipple  or

through the opening of the lactiferous ducts.

The patient presents with a :

   *  Firm tender mass in the breast

   *  Fever and toxaemia

   *  Local redness and cellulitis

Treatment includes

   -  Stoppage of breast feeding

   -  Use of breast pump to relieve engorgement with milk.

   -  Antibiotics

   -  Drainage of abscess (with a radial incision is required

      

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BREAST LYMPHATIC DRAIAGE

1.2 LYMPHATICS

There are a large number of lymphatic vessels which drain the skin

and the glandular tissue of the breast.

The  large majority of these vessels drain into three  groups  of

lymph nodes (fig above):

    * The  axillary  route  provides lymphatic  drainage  to  the

      central  and  posterior  part  of  the  breast  and   these

      Lympatics  end  in  PECTORAL and THORACIC  group  of  lymph

      nodes.

      This drainage finally ends in the highest group of axillary

      lymph nodes.

    * Lymphatics  from the medial part of the breast end  in  the

      INTERNAL MAMMARY group of lymph nodes.

    * A  similar and less frequent pathway of lymphatic  drainage

      is via the lymphatic vessels in the RECTUS SHEATH, this  is

      from the lowest and most medial portion of the breast.

      Information  regarding the lymphatics is of  importance  in

      the  treatment  of breast carcinoma since it  dictates  the

      direction  of  flow  of  metastasis and  this  in  turn  is

      dependent on location of the tumour in the breast.

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BREAST ANATOMY BLOOD SUPPLY

ANATOMY

The  functional portion of the breast is a modified  SWEAT  GLAND

gland and is thus an modified appendage of the skin.

It  is  suspended on the anterior chest wall and extends  in  the

female from the SECOND to the SIXTH ribs Fig. 13.1. 

Medially  it  extends to the lateral border of  the  STERNUM  and

laterally upto and ANTERIOR AXILLARY LINE.

1.1 BLOOD SUPPLY

Breast  as an organ is vascular and supplied by  the  perforating

brances  of  the INTERNAL MAMMARY ARTERY from the  first  to  4th

intercostal space.

LATERAL THORACIC ARTERY which is a branch of the axillary artery

The pectoral branch of the ACHROMIO-THORACIC ARTERY also provides

blood supply.

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SKIN DECUBITUS ULCER

DECUBITUS ULCER (Pressure sores)

Met within the surgical and medical patients confined to bed  for

long periods (weeks or months).

 - Common sites are where skin is pressed between bed surface and

   superficial bone of patients as:

   Sacrum                      

   heels

   occiput

The skin in these area becomes red and later ulcerates.

Prophlaxis  is  achieved  by  turning  the  patient  to   prevent

continous  pressure at one point,  and skin care (Keep skin dry,  massage  with

cream).

Have cushions for avoiding injury to the skin.

Surgical treatment with rotation flap may be required

 

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.

Malignant 4 Melanoma treatment

Treatment in most cases is wide surgical excision,prognosis depends on depth of extension
A biopsy gives information on depth of extension .
Clark's classification is shown above Grade 1 spread confined within basal layer gives best results
!00% 5 year survival
Grade 11 Extend to pappilary dermis
Grade 111Extend upto reticular dermis
Grade 1V extend into reticular dermis
Grade V extend into the dermis
All these grades show diminishing survival rates

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MALGNANT SKIN 3 melanomma

MELANOMA

Nearly 50% of melanomas arise in a mole. 

The development of malignancy should be suspected if there is any

one of the following changes observed in a coloured lesion:

   *  Increase in size

   *  A change in the outline of the mole

   *  A change in the colour of the mole

   *  Itching in the mole

   *  Bleeding from the mole

       -  It is believed that exposure to sunlight is responsible

          for these changes to occur

       -  Increased RISK is associated with those of fair skin. 

       -  The other RISK factors are socio-economic status and

          life style.

       -  Lesions in the upper extremity have a better PROGNOSIS

          than the lower extremity. 

       -  The worst PROGNOSIS are those of the

          head and

          neck or

          on the trunk

       -  Ulceration in the lesion is a bad sign. 

       -  Palpable lymph node are also a poor sign.

On  pathological  examination a more accurate  prognosis  can  be

given  on  histological examination since now the  depth  of  the

involvement of the skin can be identified according to the method

of Clark's .

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MALIGNANT SKIN 2

SQUAMOUS CELL CARCINOMA (EPITHELIOMA)

These tumours can occur anywhere but usually occur on the exposed

parts  of the body (hand face).

 It also occurs in old burn scars, and sites of chronic irritation or irradiation.

 

CLINICAL FEATURES

The site of tumours formation starts as a hard nodule and develop

into an ulcer or cauliflower like growth.

Metastasis  occurs to the regional lymph nodes. These  are  hard

and soon get fixed to surrounding structure.

Histologic  examination  shows hyperchromatic  atypical  squamous

cells infiltrating the dermis forming "nests" or "pearls".

 

Treatment  is wide-excision with healthy margin or irradiation. 

The  involved lymph nodes need to be removed en block.

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SKIN TUMOURS MALIGNANT 1

6. MALIGNANT TUMOURS

6.1 Basal Cell Carcinoma (Rodent Ulcer  above left)

 

Clinical features:

Presents  as a hard pearly nodule on the face above the level  of

the  lips. It occurs most often in those above 40 years  of  age. 

The  nodule  shows small blood vessels and may  ulcerate  in  the

centre it grows slowly but does not metastasis.

 

On  histology shows a down growth of cells of the basal layer  of

the  epidermis.The nuclei of these cells show deep  staining  and

there may be extension of spread into the dermis.

 

TREATMENT

Can be with either with surgery (wide excision)or radiotherapy.

 

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SKN TUMOURS 2

4.4 BOWEN'S DISEASE

This is a slow enlarging red raised patch with irregular  outline

crusting is present.

   *  Histologic examination shows that the epidermis is

      thickened, cells are atypical and keratinisation is marked.

   *  Squamous cell carcinoma develops after many years.

   *  Treatment is wide excision.

 

5. TUMOURS OF THE DERMIS

5.1  The  tissue  of  the dermis can give  rise  to  LIPOMAS  and

NEUROFIBROMAS   the   latter  present  as  single   or   multiple

neurofibromas and can be inherited (von Recklinghausens Disease),

the epidermis moves free on these nodules and these nodules  move

free of the deep fascia and muscles. These are benign lesions and

rarely  undergo  malignant change.Malignant change  is  diagnosed

clinically on the basis of :

     a)  Rapid increase in size

     b)  Pain in the lesion

     c)  Fixity to skin or deeper structures

     d)  Metastasis

 

Treatment  of  any skin nodule should be  EXCISION  to  establish

histopathologic diagnosis

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SKIN TUMOURS 1

4. TUMOURS OF SKIN

4.1 Papilloma

Simple non-infective papillomas can occur at any site.

They  are usually pedunculated (Fig.) and the small  finger

like  processes on the surface can be seen with magnifying  lens. 

If  small they can be excised with an ellipse of skin to  include

the base.

 

4.2 KERATO-ACANTHOMA (Moluscum Sebaceum)

This  presents  as a rapidly increasing  hemisepherical  swelling

which soon ulcerates with crust formation (keratin),

It can also be cured by curreting Fig. .

 

4.3 CUTANEOUS NEUROFIBROMA

These  take origin from the sheath of nerves a nodule  can  occur

anywhere on the body and can be multiple.  They may be associated

with pigment of patches of skin.  One of these lesions should  be

removed and submitted for histology.

 

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DERMOID CYSTS

DERMOID CYSTS

These  are  cysts  situated  deep to the skin  and  there  is  no

punctum,thus the skin moves over the cysts.

 - They are either along lines of embryonic union (congenital) in

   the mid line and external angular dermoids

 - They can  also  occur on the palms of hands and  back  due  to

   puncture wounds and result  from  deep  implantation  of  skin

   elements (Implantation dermoid). 

Both varieties are filled with Sebum.

 

TREATMENT

Most dermoids cam be excised under local anaesthesia.The external

angular  dermoids  should  be preceded by  X-ray  to  exclude  an

intraceranial extension.

 

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KELOIDS AND SUBACEOU CYSTS

3.4 KELOID
Following an  injury or surgical incisions,sites of repair show enlarging overgrowth of vascular collagen in the healing wound
leading to ugly scars.

There is a constitutional factor responsible in affected individuals  

The hyperplastic scar as opposed to keloid usually stops  growing,and does not itch.

 

TREATMENT

Lesions  may  be  helped  by small dose  of  radiotherapy  or  local cortisone application.
Surgical excision in combination with other methods may
provide comparable results

 

3. CYSTS

3.1 Subaceous Cysts

This is a cyst in the skin usually in a hair bearing area and  is

believed to originate from a subaceous gland in a hair  follicle,

it is in fact a retnetion cyst due to obstruction of the mouth of

subaceous  gland.  The cyst is found on the scalp and  is  filled

with putty like subaceous material

The  punctum is visible on its summit and is the site  of  block. 

The cyst is attached to the skin on clinical examination.

 

TREATMENT

The uninfected cyst can be excised under local anaesthesia.  

If infected they require antibiotics and drainage

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SKIN CONDITIONS

2.1 Callosity

 

This  is  an acquired localised thickening of the  skin.   It  is

usually  seen in the hands of manual workers. 

 

The thickening  is as  a  result  of use of the hands in  response  to  the  persons

occupation  it  is  protective in nature  and  thus  requires  no

treatment.

 

2.2 Corns

 

These  are  also  callosities on the foot and  are  localised  to

points where the skin is over a joint and receives pressure  from

the joint within and the ill fitting footwear from outside.  They

can also be seen on the sole of the foot.  They can sometimes get

painfull .

 

A change to open foot wear can provide relief.  This can also  be

treated  with  painting with 10% Salicylic acid in  collodian  or

acetone.  The corn peels off.

 

2.3 WARTS

These  are  localised  areas of skin hyperplasia  and  look  like

papillomas and are caused by infection by filterable virus.  They

can  be multiple through cross infection and occur often  on  the

hands and face .

 

TREATMENT

Warts  may be removed by curettage, diathermy or  excision  under

local or general anaesthesia if multiple.

They also respond to treatment with 10% formalin, podophyllin  or

salicylic acid plaster (50%)

 

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SKIN & APPENDAGES

SKIN AND APPENDAGES

 

1. ANATOMY

The skin is the outer envelop of the body and has a large surface

area (1-1.8 sq. meters).

   *  The thickness varies, being thin on the the eyelids, glans

      penis and thick on the soles of the feet, palms of the

      hands and back

   *  There are two components of skin the outer (superficial)

      epidermis with the function of producing keratin.

      The cells show characteristics of differentiation

      proceeding on to degeneration with the keratin placed most

      superficially.

   *  The deeper layer,the dermis consists of collagen, elastic

      fibres and fat cells(

   *  This deep layer supports the nerves, blood vessels and the

      skin appendages (hair follicles, sweat glands).

   *  The skin also contains melanocytes that prduce melanin.

   *  This material provides colour to the skin and protects the

      germinal layers and the melanocyte from the effects of

      ultraviolet light.

 

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RESPIRATORY SUPPORT

10. RESPIRATORY SUPPORT

   1.  In cases of loss of consciousness.  This may be because of

       a)  Head injury

       b)  Poisoning

       c)  Diabetic coma

       d)  Fainting because of fright

       e)  Stroke

       f)  Heart-attack

       g)  Drunkeness

 

       In these cases, check the airway is clear, pull the head

       back,jaw and tongue forwards, clear the throat.

 

   2.  If not breathing, give mouth to mouth breathing as shown

       in  or  ventilation of self inflating bag if

       available

   3.  Some may require long term support on a ventilator

 

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ANESTHESIA RECOVERY ROOM

9. RECOVERY ROOM

-  On  the  completion of a surgical  procedure  the  patient  is

   allowed  to recover from the effect of the anaesthetic  agents

   and  the relaxants by giving appropriate medication  till  the

   point   that  the  patient  is  respiring  spontaneously   and

   adequately.

-  He is disconnected from the anaesthetic machine and the  endo-

   trachael  tube  can  now be removed after  ensuring  that  the

   patient has a clear air-way by sucking out all secretions.

-  He  is  then  wheeled in the recovery room  where  he  can  be

   observed   frequently till complete recovery from the  effects

   of the pre-medication and the anaesthetic agents.

The points to be observed are:

   *  Continuous free airway

   *  Adequate perfusion is observed by skin colour, temperature,

      pulse, blood pressure records

   *  Prevention of aspiration

   *  Medication for pain

 

Patients  that are severely ill because of extensive surgery  are

kept  in an intensive care unit. Monitoring to  gain  information

on;

   -  Cardiac function (ECG)

   -  Blood biochemistry, pH, PCO2

   -  Pulse, Blood pressure and central venous pressure records

   -  Adequate ventilation

 

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