Benign breast disorders in nonwestern populations: Part II—Benign breast disorders in India

Experience with benign breast disorders has been analyzed in 3 nonwestern populations: Hong Kong, India, and Northern Nigeria. Similarities to and differences from Western experience are found, but of great interest are notable differences between these populations which, as yet, lack explanation. All show fibroadenosis and fibroadenoma as common conditions, but the frequency with which phyllodes tumor is diagnosed varies between different centers in India as well as between different racial groups. Tuberculosis is another interesting example—wide differences in the frequency of breast infection are found although tuberculosis itself is common in all 3 countries. The value of prospective studies was shown when mastalgia was studied in this way in India. Often considered a Western affliction, these authors have been able to study 112 cases of mastalgia and found it to be twice as common as cancer as a presentation. These differing experiences between populations have been little explored and must hold promise for unravelling some of the enigmas of benign breast disorders in all countries.

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Resumen Se analizó la experiencia con enfermedades mamarias benignas en 3 poblaciones no occidentales: Hong Kong, India, y Nigeria Septentrional. Se hallaron similitudes y también diferencias con relación a la experiencia occidental; pero de mucho interés son algunas notorias diferencias entre estas poblaciones para las cuales no existe explicación. Todas exhibieron adenosis y fibroadenoma como entidades comunes, pero la frecuencia en el diagnóstico de tumores filodes varía en diferentes centros en la India, así como en los diferentes grupos raciales. La tuberculosis constituye otro ejemplo de interés; se encuentran grandes variaciones en la incidencia de infección mamaria, aunque la tuberculosis es común en las 3 naciones. La utilidad de los estudios prospectivos fue demostrada cuando se estudió la mastalgia en esta forma en la India. Frecuentemente considerada como una entidad nosológica occidental, los autores pudieron estudiar 112 casos de mastalgia y encontraron que es 2 veces más común que el cáncer como forma de presentación. Estas diferencias entre poblaciones han sido escasamente investigadas y son promisorias en cuanto a clarificar algunos de los enigmas de las enfermedades mamarias benignas prevalentes en todos los países.

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Résumé L'expérience de 3 équipes de pays non occidentaux (Hong Kong, Inde, et Niger du Nord) avec des maladies bénignes du sein a été analysée. On a trouvé peu de similitudes, mais aussi des différences par rapport aux pays occidentaux. C'est surtout pour ces dernières, qui sont les plus intéressantes, qu'on manque d'explications. Dans les 3 pays, on voit fréquemment des fibroadénomes et des patientes avec une fibroadénose, mais la fréquence des tumeurs phyllodes varie parmi les différents centres de l'Inde, ainsi que parmi les groupes de races différentes dans ce pays. La tuberculose est un autre exemple. De grandes variations de l'incidence des infections du sein sont retrouvées alors que la tuberculose est fréquente dans les 3 pays. La valeur des études prospectives a été démontrée par une étude sur les mastalgies en Inde. Les auteurs ont étudié 112 cas de mastalgie, souvent considérée comme une maladie occidentale. Ils ont trouvé qu'elle était deux fois plus fréquente que le cancer. Ces expériences entre populations différntes n'ont pas été explorées en totalité et pourraient éclaircir un jour quelques unes des énigmes qui entourent les maladies bénignes du sein dans tous les pays du monde.

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This is a continuation of a 3-part series.     

Benign breast papilloma: Is surgical excision necessary?

In many centers internationally, current standard of care is to excise all papillomas of the breast, despite recently reported low rates of upgrade to malignancy on final excision. The objective of this study was to determine the upgrade rate to malignancy in patients with papilloma without atypia. A retrospective review of a prospectively maintained database of all cases of benign intraductal papilloma in a tertiary referral symptomatic breast unit between July 2008 and July 2018 was performed. Patients with evidence of malignancy or atypia on core biopsy and those with a history of breast cancer or genetic mutations predisposing to breast cancer were excluded. One hundred and seventy‐three cases of benign papilloma diagnosed on core biopsy were identified. Following exclusions, the final cohort comprised of 138 patients. Mean age at presentation was 51. Mean follow‐up time was 9.6 months. The most common symptom was a lump (40%). Of the 124 patients who underwent excision, three had ductal carcinoma in situ and there were no cases of invasive disease, giving an upgrade rate to malignancy of 2.4%. Upgrade to other high‐risk lesions (atypical lobular and ductal hyperplasia and lobular carcinoma in situ) was demonstrated in 15 cases (12.1%). Benign papilloma was confirmed in 100 cases (81.5%), and 6 (4.8%) had no residual papilloma found on final excision. Twelve patients (8.7%) were managed conservatively. Of those, one later went on to develop malignancy. Patients with a diagnosis of benign papilloma without atypia on core biopsy have a low risk of upgrade to malignancy on final pathology, suggesting that observation may be a safe alternative to surgical excision. Further research is warranted to determine which patients can be safely managed conservatively.     

Electrolyte disorders in the critically ill

Electrolyte disorders are extremely common in the critically ill patient. Competent analysis and management of these is essential in providing quality intensive care. This article provides a review of and guide to the aetiology, analysis, and management of major electrolytes disorders in the critically ill.     

Sleep disorders in Parkinson’s disease

Sleep disorders in Parkinson's disease (PD) are frequent and have numerous etiologies. Both nighttime sleep disturbances and daytime sleepiness can occur. The key to effective treatment is appropriate diagnosis. A careful interview of the patient and his or her bed partner provides direction for additional evaluations. Referral to a sleep specialist for quantitative studies is necessary to evaluate for rapid eye movement (REM) sleep behavior disorder, sleep apnea, periodic limb movements, and other sleep disorders. Excessive daytime sleepiness may be attributed to interrupted nighttime sleep or daytime medications (particularly the dopamine agonists) or it may be intrinsic to PD. When the diagnosis is established, treatment is directed toward the primary sleep disturbance. Fragmented sleep due to recurrence of PD symptoms may improve with the use of long-acting preparations of carbidopa/levodopa. Sleep apnea is treated using continuous positive airway pressure, and REM sleep behavior disorder may improve using pharmacologic interventions, although controlled trials are lacking. Restless legs syndrome and periodic limb movements during sleep are treated with direct dopaminergic agonists at bedtime. Excessive daytime sleepiness related to the use of direct dopaminergic agonists may improve with dosage reduction or discontinuation. Stimulants such as modafinil may provide modest benefit.     

Are risk factors for breast cancer similar in women with inflammatory breast cancer and in those with non-inflammatory breast cancer?

PURPOSE: The aim of the study was to compare reproductive factors in patients with inflammatory breast cancer (IBC), and with non-inflammatory breast cancer (non-IBC). The study was performed in two centers: one French including 49 IBC patients and 140 non-IBC and another Tunisian including 97 IBC and 139 non-IBC. Unconditional logistic regression was used for the analyses. PATIENTS AND METHODS: The French IBC patients had a lower educational level, a higher body mass index and a longer cumulative duration of breast-feeding, and they included a greater proportion of non-European women, than the non-IBC patients. In the multivariate analysis, only breast-feeding duration remained associated with the IBC status (P=10(-3)). These results could not be verified in the Tunisian series, because the duration of breast-feeding was unavailable in this center. RESULTS: This study suggests that the etiology of IBC might be different of that of non-IBC.     

Liposuction in Benign Symmetric Lipomatosis,Sense or Senseless?

Benign symmetric lipomatosis is a rare form of typical fat distribution in the shoulders, the arms, and the neck that can compromise the respiratory, nutritional, and psychological status of the patient. Alcoholism, malignant tumors of the upper airways, endocrine tumors, hypothyroidism, diabetes, and hypertriglyceridemia are often associated with its occurrence. Surgical removal via lipectomy or liposuction can give good cosmetic results, although recurrences often occur. Liposuction has become the first choice to treat this disorder in patients with smaller masses. We have operated on four such cases in which liposuction failed and surgical excision had to be performed. We present a summary of the clinical characteristics of all four patients and discuss the different treatment options.     

Objective analyses of mastalgia in breast clinics: Is breast pain questionaire a useful tool in a busy breast clinic?

The aim of this study was to investigate the feasibility of use of breast pain questionnaire (BPQ), a short, focussed and robustly designed tool to assess severity of mastalgia and its impact on quality of life, in a busy breast clinic. Seventy-four consecutive women completed BPQ prior to their consultation with a Breast Surgeon. Based on the BPQ score, mastalgia was graded as mild (score 0-100) in 26%, moderate (score 101-200) in 59% and severe (score >200) in 15% of patients. In 93% of patients breast pain lasted for more than 5 days and visual analogue score (VAS) was more than 3.5 in 82% of patients. The breast pain was described as mild (12%) discomforting (55%), distressing (22%) excruciating (3%) or horrible (8%). All results are presented as median (interquartile ranges). Out of maximum possible 100, overall pain rating was 17(9-31), percent sensory component was 21(12-33) and percent affective component was 0(0-17). The percent VAS was 60(40-80), percent pain index was 40(40-60) and quality of life score (maximum possible 60) was 20(0-40). Of maximum possible score of 360, total breast pain was 137(99-180). In conclusion BPQ can be used routinely in a busy breast clinic as a quick, user-friendly and reliable tool to assess the degree and severity of breast pain in order to provide an organised approach to the management of mastalgia.     

Results of breast conserving surgery in clinical stage I–II breast carcinoma

Background  

The role of breast conserving surgery with radiotherapy is well established and has become a widely used procedure in breast cancer. Patient selection, a multidisciplinary approach, and expert surgical technique are important factors to avoid locoregional recurrence. The aim of this study was to analyse the outcomes of patients treated with breast conserving surgery in stage I–II breast cancer.     

Impact of schizophrenia and related disorders on mortality from breast cancer: A population-based cohort study in Denmark, 1995–2011

ObjectivesTo investigate overall and breast cancer-specific mortality in early-stage breast cancer patients with and without schizophrenia or related disorders.MethodsWe used Danish national registers to identify all women with no prior history of cancer or organic mental disorders, who were diagnosed with early-stage breast cancer 1995–2011. Logistic regression models were used to calculate the odds ratios (ORs) for not being allocated to guideline treatment. Cox regression models were used to compute hazard ratios (HRs) for overall and breast cancer-specific deaths among women allocated or not allocated to guideline treatment.ResultsWe identified 56,152 women with early-stage breast cancer diagnosed in 1995–2011, of whom 499 women also had been diagnosed with schizophrenia or related disorders. The likelihood of women with schizophrenia or related disorders for not being allocated to guideline treatment was increased (adjusted OR, 1.50; 95% confidence interval (CI), 1.15–1.94). The adjusted HR for all-cause mortality was 1.55; 95% CI, 1.32–1.82 and 1.12 (95% CI, 0.98–1.50) for breast cancer-specific mortality; women allocated to guideline treatment had an adjusted HR for breast cancer-specific death of 1.42 (95% CI, 1.11–1.82). The adjusted HR for death due to unnatural causes was 3.67 (95% CI, 1.80–7.35).ConclusionThe survival of women with schizophrenia or related disorders after breast cancer is significantly worse than that of women without these disorders. These patients are less likely to be allocated to guideline treatment, and, among those who are, mortality from both breast cancer and other causes is increased.     

Is breast conservation superior to mastectomy in early stage triple negative breast cancer?

PurposeCompare overall survival (OS) and breast cancer-specific survival (BCSS) outcomes of breast conservative therapy (BCT) and mastectomy in a large cohort of patients with early-stage triple negative breast cancer (TNBC), using a propensity score-based matching approach.MethodsSurveillance, Epidemiology, and End Results (SEER) database was used to study the role of RT in early stage TNBC. Primary end points were OS and BCSS. Cox proportional hazard regression models and Kaplan-Meier plots were used to generate the desired outcomes. Propensity score matching was done to minimize bias.Results12,761 patients with T1-2N0M0 TNBC as their first malignancy were retrieved. Of these 7237 had lumpectomy with RT, and 5524 had mastectomy only. Age, race, marital status, tumor laterality, grade and stage, and receipt of chemotherapy were prognostic variables for OS and BCSS. Among 4848 matched subjects, the 5-year OS was significantly higher in patients with lumpectomy and RT (89%) compared to mastectomy alone (84.5%) (p-value <0.001). Similarly, BCSS was significantly higher in patients with lumpectomy and RT (93%) compared to mastectomy alone (91%) (p-value <0.001). On subgroup analysis, patients who are younger than 40 had similar survival outcomes after either mastectomy alone or lumpectomy with RT. However, those who are older than 60, have any grade or T stage had better survival outcomes with lumpectomy and RT.ConclusionsOverall, lumpectomy followed by RT is associated with better OS and BCSS compared to mastectomy in T1-2N0M0 TNBC patients. Further research is needed to determine the optimal treatment strategy for specific patient subgroups.     

Can breast surgeons read mammograms of symptomatic patients in the one-stop breast clinic?

AIM: To establish how accurate surgeons were when compared to the radiologists in interpreting symptomatic mammograms in one-stop clinics. METHODS: The surgeons were asked to write their opinion on the mammograms which was compared with the radiologists' report. 144 patients were involved in the study and the data were analysed by McNemara's test for paired categorical data. RESULTS AND CONCLUSIONS: Surgeons were accurate in interpreting most of the mammographic findings. However, they underestimated the presence of benign calcification which was statistically significant. Surgeons can, therefore, be involved in double reading of mammograms in symptomatic breast disease patients and improve the sensitivity which has been the case in double reading by radiologists in the breast screening programme.     

Benign esophageal strictures--outcomes of coloesophagoplasty in Surgical Clinic II Timişoara

Esophagoplasty is obviously a proper choice of treatment; postoperative outcomes should be very good because of benign type of lesions, but morbidity-mortality are high due to the complexity of the intervention. Our purpose is to emphasize the utility of coloesophagoplasty like a very feasible surgical option, based to our short and long term outcomes. This paper relies on the retrospective analysis of all cases admitted to II-nd Surgical Clinic Timisoara in a 20 years period (1983-2002), having coloesophagoplasty for benign esophageal stenosis. There were performed 45 such interventions (16 men, 29 women); the mean age was 35.7 years (15-68 years). The pathology included postcaustic lesions (42 cases), peptic lesions (2 cases) and esophageal leiomyoma (1 case). Postoperative morbidity occurred in 22.6% of patients. The graft functionality was good and very good in 86.6% of patients at discharge. Postoperative mortality was 6.6%.     

Sympathetic activity in breast cancer and metastasis:partners in crime

The vast majority of patients with advanced breast cancer present skeletal complications that severely compromise their quality of life.Breast cancer cells are characterized by a strong tropism to the bone niche.After engraftment and colonization of bone,breast cancer cells interact with native bone cells to hinder the normal bone remodeling process and establish an osteolytic“metastatic vicious cycle”.The sympathetic nervous system has emerged in recent years as an important modulator of breast cancer progression and metastasis,potentiating and accelerating the onset of the vicious cycle and leading to extensive bone degradation.Furthermore,sympathetic neurotransmitters and their cognate receptors have been shown to promote several hallmarks of breast cancer,such as proliferation,angiogenesis,immune escape,and invasion of the extracellular matrix.In this review,we assembled the current knowledge concerning the complex interactions that take place in the tumor microenvironment,with a special emphasis on sympathetic modulation of breast cancer cells and stromal cells.Notably,the differential action of epinephrine and norepinephrine,through eitherα-orβ-adrenergic receptors,on breast cancer progression prompts careful consideration when designing new therapeutic options.In addition,the contribution of sympathetic innervation to the formation of bone metastatic foci is highlighted.In particular,we address the remarkable ability of adrenergic signaling to condition the native bone remodeling process and modulate the bone vasculature,driving breast cancer cell engraftment in the bone niche.Finally,clinical perspectives and developments on the use ofβ-adrenergic receptor inhibitors for breast cancer management and treatment are discussed.     

Complications in immediate breast reconstruction using Strattice™

Introduction

Immediate breast reconstruction (IBR) is becoming increasingly popular. Implant-based IBR has a lot of benefits over autologous IBR but also carries the disadvantages associated with implant use. Acellular dermal matrix, such as Strattice?, has been used as an alternative approach to provide implant coverage.

Methods

All cases of implant-based IBR using Strattice? performed between 2009 and 2011 at the North Tees and Hartlepool Breast Unit were reviewed to assess the outcomes, complications and impact on adjuvant therapy with the use of Strattice? in IBR.

Results

Twenty-one implant-based IBR utilising Strattice? in 17 patients were reviewed, four were bilateral procedures. Ten patients had complications, nine of whom required a clinical intervention for these complications. Four patients had a foreign body reaction associated with a seroma. Five patients had a wound breakdown with eventual loss of the implant and one patient had an early contracture following radiotherapy. Four patients requiring adjuvant radiotherapy had a delay in starting treatment. Three out of six patients requiring adjuvant chemotherapy had a delay in commencing treatment, and three patients experienced delays between cycles resulting from complications.

Conclusions

Strattice? may offer an alternative solution to problems in implant-based reconstruction but there are concerns regarding the development of complications associated with this. Complications may delay adjuvant therapy. Further studies should investigate the impact on adjuvant therapy, when using Strattice? in IBR. Level of evidence: Level IV, therapeutic study.     

Is Calcification in the Regional Lymph Nodes a Benign Feature in Patients with Lung Cancer?

World Journal of Surgery - Calcified lymph nodes (LNs) on computed tomography (CT) in patients with lung cancer are generally considered to be a benign feature. However, few studies have evaluated...     

Pregnancy-associated breast cancers: Do they differ from other breast cancers in young women?

The impact of pregnancy in the physiopathology of pregnancy-associated breast cancer (PABC) is still unclear. We compared the characteristics of PABCs and breast cancers not associated with pregnancy (non-PABCs) in terms of their loco-regional invasion and histological phenotype. We conducted a retrospective chart review on women less than 43 years of age treated for breast cancer from January 1, 2004 to December 31, 2010. We compared age at diagnosis, loco-regional invasion and histological data. We recorded 282 breast cancers in 276 patients. Forty-one tumors (14.5%) were PABCs. PABC patients were significantly younger than non-PABC patients. Compared with the non-PABCs, PABCs were twice more frequent advanced tumors (T3-4) and have twice more frequent HER2 over-expression and hormone negative status. The more aggressive histological profile observed in the PABCs, especially in post-partum tumors and women older than 35 years of age, seems to be a direct consequence of the association with pregnancy.     

Benign prostatic hyperplasia in a 23 year old man with progeroid syndrome

Introduction

Progeroid syndromes are characterized by accelerated aging and early development of diseases typically associated with aging. Premature development of tumors including BPH, maybe observed in these patients, which can lead to significant bladder outlet obstruction.

Management of impulse control disorders in Parkinson’s disease

Impulse control disorders (ICDs) are a set of behaviors, including pathologic gambling, hypersexuality, compulsive shopping, compulsive eating, and punding, which are now recognized to occur in a subset of patients with Parkinson's disease (PD). Although the underlying pathophysiology of these behaviors is poorly understood, they appear to be associated with the use, and sometimes overuse, of dopaminergic agents prescribed for the treatment of the motor symptoms of PD. At present, there are limited data to support any particular therapeutic strategy. Approaches worth considering in the management of the PD patient with an ICD include reduction or discontinuation of dopamine agonist therapy, trials of various pharmacologic agents, psychosocial interventions, and deep brain stimulation of the subthalamic nucleus. However, the management of each patient must be tailored for the particular clinical setting, and the development of evidence-based treatment strategies awaits future prospective studies and randomized controlled trials.