Benign breast disorders

Benign breast disorders encompass a wide range of presentations and account for approximately 90% of breast outpatient referrals. Although the conditions discussed in this article are labelled ‘benign’, they can cause much anguish for the patient. A specialist breast clinician frequently has the privilege of being able to reassure patients in a single trip to the breast department and unburden them from their worry. One-stop breast clinics were designed to ensure that patients with worrying symptoms are promptly seen to aide early detection of breast cancer and optimize patient outcomes. The diagnostic multidisciplinary team consists of a specialist breast clinician, breast radiologist, pathologist and breast care nurses. Most patients with benign breast disorders can be reassured, with surgery limited to a few to aide definite diagnosis or as a last resort when conservative measures have failed. This is a comprehensive overview of benign breast disorders and covers all that is required for the MRCS examination and serves as a revision aide for FRCS candidates.     

Benign breast disorders

Benign breast disorders (BBDs) account for over 90% of referrals to rapid access breast clinics. Many women experiencing breast symptoms fear they may have breast cancer, and GPs, because of the sensitivities around the diagnosis of breast cancer, and the fear of a ?delayed’ diagnosis, have a low threshold for referral. It is also true that breast symptoms per se are poor discriminators between benign and malignant conditions, and clinical signs of breast cancer in the era of very high ‘breast awareness’ are subtle. The assessment of women with BBD consumes a substantial proportion of breast outpatient resources, yet most will only need a single multi-modality triple assessment. Although the exclusion of breast cancer is the primary concern of most women, they also seek an explanation of the aetiology of their breast symptoms and signs. A sound understanding of the anatomy, physiology and function of the breast is needed to manage this anxious cohort of women. In order to better understand BBD it is helpful to consider the following topics: congenital disorders; aberrations of normal development and Involution (ANDI); other miscellaneous problems. This article follows this format but in practice the majority of women with BBD fall within the ANDI framework.     

Benign breast disorders

Benign breast disorders (BBD) account for over 90% of referrals to rapid access breast clinics. Many women experiencing breast symptoms fear they may have breast cancer and GPs, because of the sensitivities around the diagnosis of breast cancer and the fear of a ‘delayed’ diagnosis have a low threshold for referral. It is also true that breast symptoms per se are poor discriminators of benign from malignant conditions and clinical signs of breast cancer in the era of very high ‘breast awareness’ are subtle. The assessment of women with BBD consumes a substantial proportion of breast outpatient resource yet most will only need a single multi-modality triple assessment. Although the exclusion of breast cancer is the primary concern of most women, they also seek an explanation of the aetiology of their breast symptoms and signs. A sound understanding of the anatomy, physiology, and function of the breast is needed to manage this anxious cohort of women. In order to better understand BBD it is helpful to consider the following headings: (i) congenital disorders; (ii) aberrations of normal development and involution (ANDI); (iii) other miscellaneous problems. This article follows this format but in practice the majority of women with BBD fall within the ANDI framework.     

Benign disorders of the male breast

Gynecomastia is the dominating problem of the male breast. Other diseases are rare but mimic the same conditions in women. Gynecomastia may occur at any age either as a primary event, when it is due to a minor hormonal unbalance, or secondary to other pathology (e.g., liver failure) or drugs. Treatment consists of assessment of cause and reassurance. In a minority of patients, treatment with drugs—such as danazol—or surgical resection is indicated.

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Resumen La ginecomastia es el problema dominante de la mama masculina. Otras entidades son poco frecuentes pero son mímica de las mismas condiciones patológicas que ocurren en las mujeres. La ginecomastia puede presentarse en cualquier edad como evento primario cuando se debe a un desequilibrio hormonal menor, o secundario a otra patología (por ejemplo, la falla hepática), o a fármacos. El manejo consiste en la valoración de la causa y en tranquilizar al paciente. En una minoría de los casos puede estar indicado el tratamiento con drogas—como el danazol—o la resección quirúrgica.

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Résumé La gynécomastie est le problème le plus fréquemment rencontré en matière de sein chez l'homme. Les autres maladies du sein chez l'homme sont rares mais ne diffèrent pas beaucoup de celles de la femme. La gynécomastie peut se voir à n'importe quel âge. Elle est soit primitive, due à un déséquilibre hormonal, soit secondaire à une autre pathologie (par exemple l'insuffisance hépatique) ou à des médicaments. Après bilan étiologique et tranquillisation du patient, seule une minorité de patients doit être traitée médicalement, essentiellement par le danazol, ou par la chirurgie.

     

Benign synovial disorders

Collectively, benign synovial disorders are not uncommon, and they may be seen in general orthopaedic practices. Symptoms are nonspecific, often delaying diagnosis. In fact, synovial chondromatosis, pigmented villonodular synovitis, synovial hemangioma, and lipoma arborescens often mimic each other as well as other, more common joint disorders in presentation, making diagnosis extremely difficult. It is important to diagnose these disorders correctly in order to provide appropriate treatment and avoid secondary sequelae, such as bone erosion and cartilage degeneration.     

Childhood renal disorders in Nigeria

The common childhood renal disorders in Nigeria are post-infectious acute glomerulonephritis (PIAGN), nephrotic syndrome, hypertension, congenital anomalies and urinary tract infection. Children with PIAGN often present with hypertension, circulatory overload and hypoalbuminaemia. Nephrotic syndrome is characterized by a paucity of minimal change and a poor prognosis. Posterior urethral valves and hydronephrosis are the most frequent congenital anomalies. Children with congenital anomalies present late with advanced disease. The commonest malignancy is nephroblastoma, but Burkitt's lymphoma of the kidney also occurs. Both acute and chronic renal failure present depressing and distressing clinical problems, with an aggressive course and a high morbidity and mortality. Poor soclo-economy has adverse effects on the presentation, management and follow-up of Nigerian children with renal disorders.     

Benign breast disease

Benign breast disease (BBD) accounts for the majority (90%) of referrals to a breast clinic. It therefore represents a significant part of a breast surgeon's workload. With a solid understanding of the causes for BBD and the use of triple assessment to exclude breast cancer, a great deal can be done to accurately diagnose the condition and provide adequate explanation and treatment options. These patients are very anxious about their condition and need to be managed in the setting of a multidisciplinary team. With an increase in patient awareness and expectations the number of such referrals is expected to increase.     

Benign Intrathoracic Tumours: A Population Survey in Northern Finland

Benign intrathoracic tumours are uncommon, but their occurrence in unselected populations is poorly defined. We reviewed all cases of suspected intrathoracic tumour in a population (440,000) in northern Finland during 1990 through 1992. Diagnostic investigations included fiberoptic bronchoscopy and computed tomography in all cases. Of the 653 intrathoracic tumours, 36 were benign. The male/female ratio in these 36 cases was 1.25; the mean age was 54 years. Twenty-three of the lesions were symptomless, found at health check or examination for other disease. Bronchoscopy did not confirm the diagnosis of any benign tumour. Thoracotomy was considered necessary in most cases and histologic diagnosis was therefore available in 24 (67%). Hamartoma was the most common benign lung tumour. This prospective study in an unselected population confirms previous findings in surgical series concerning benign intrathoracic tumours and their histology.     

Anesthesia in neuromuscular disorders. Part 2: specific disorders

The neuromuscular disorders described are divided into four groups: motoneuron diseases, peripheral neuropathies, disturbances of neuromuscular transmission and myopathies. In motoneuron diseases problems mainly result from respiratory insufficiency and the predisposition for aspiration caused by progressive muscular weakness. Depolarising muscle relaxants may elicit myotonic reaction and massive hyperkalemia. In contrast to non-depolarising muscle relaxants there may be an extreme hypersensitivity. In peripheral neuropathies the cardiac function is often limited whereby dysautonomia may enhance cardiovascular instability. The negative inotropic effect of anaesthetic agents must be observed with care and patients with higher degree of AV blocks may need a cardiac pacemaker during general anaesthesia. The Charcot-Marie-Tooth-Syndrome is characterized with a high sensitivity to thiopental. Disturbances of neuromuscular transmission frequently cause respiratory problems The fluctuating weakness of bulbar and respiratory muscles may impair swallowing and can lead to recurrent aspirations. Due to the reduced number of acetylcholine receptors the sensitivity to non-depolarizing muscle relaxants is elevated and the response to succinylcholine is reduced. Drugs reducing neuromuscular transmission such as antibiotics and beta-blockers may enhance these symptoms and should be avoided. In progressive muscular dystrophies the anaesthetic risk is mainly dependent on cardiac and respiratory impairment. Administration of succinylcholine leads to the risk of hyperkalmic cardiac arrest. Patients with metabolic myopathies are also at risk due to the involvement of cardiac muscle but respiratory problems are less frequent. Muscle metabolism should be supported by administration of substrates depending on the underlying disorder. In membrane disorders muscle rigidity (myotonic reactions) or weakness may lead to respiratory insufficiency. In addition to the depolarising muscle relaxants also anticholinesterase drugs, hypothermia and dyskalaemia can evoke myotonic reactions.     

Benign breast disease and breast cancer risk: morphology and beyond

Evidence from clinical follow-up studies has indicated that there is a relationship between the presence of histologically proven benign breast disease and breast cancer risk and that the level of risk varies according to the histologic category of benign breast disease. In particular, proliferative lesions without atypia are associated with a 1.5- to 2-fold increase in risk, whereas atypical hyperplasias are associated with a fourfold to fivefold increase in breast cancer risk. A number of clinical factors appear to modify the risk associated with these lesions, including the time since biopsy, menopausal status, and family history of breast cancer. Recent studies have begun to evaluate the potential role of biologic, molecular, and genetic markers in assessing breast cancer risk in patients with benign breast disease. Additional information derived from clinicopathologic follow-up studies, epidemiologic studies, and molecular and genetic studies will provide new insights into benign breast disease and breast cancer risk.     

Benign breast disease in the postmenopausal woman

Breast symptoms are surprisingly common in the postmenopausal period, especially (but not only) when taking hormonal therapy. All of the common conditions of the premenopausal period may be seen. Clinical examination is usually easier and more precise in the postmenopausal woman. The importance of accurate clinical observation is stressed, as a diagnosis can usually be made in this way, supplemented by mammography and aspiration cytology where reliable services exist.

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Resumen Síntomas mamarios son sorprendentemente comunes en el período postmenopáusico, especialmente (pero no exclusivamente) cuando la paciente toma terapia hormonal; todas las alteraciones patológicas comunes en el período premenopáusico pueden ser observadas también en el postmenopáusico. En tanto que clínicamente la frecuencia de estas alteraciones disminuye en forma dramática después de la menopausia, histológicamente se hacen más frecuentes con el avance de la edad hasta constituírse en hallazgo casi universal. El examen clínico es generalmente más fácil y certero en la mujer postmenopáusica. Se hace énfasis sobre la importancia de la observación clínica meticulosa, puesto que usualmente por su intermedio puede ser establecido el diagnóstico con el complemento de mamografía y citología por aspiración cuando se dispone de tales servicios.

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Résumé La pathologie du sein est étonnemment fréquente chez la femme postménopausique, surtout (mais pas exclusivement) lorsqu'elle est sous traitement hormonal. Toute la pathologie de la période préménopausique peut se voir. L'examen clinique est plus facile et plus précis chez la femme ménopausée. L'importance de l'inspection clinique est soulignée, la plupart des diagnostics n'y résistent pas. L'examen est ensuite complété par la mammographie et la cytologie par ponction.

     

Surgical management of achalasia in Zaria, Northern Nigeria

BACKGROUND: Achalasia of the cardia is generally considered a rare disease. Because the cause is uncertain, treatment is palliative and directed at relieving distal oesophageal obstruction. In developed countries, several treatment options are available, but in developing countries, achalasia is usually treated by open surgical myotomy. We reviewed the outcome of management of achalasia in our patients and the influencing factors. PATIENTS AND METHODS: We retrospectively reviewed all adult patients treated for achalasia between 1991 and 2006. Diagnosis was based on clinical symptoms and barium swallow examination. The severity and frequency of dysphagia were determined before and after treatment. Barium examination was repeated 2 weeks after surgery or when the patient had recurrence of dysphagia, regurgitation or heartburn. Treatment was by modified Heller's operation, transabdominally without complementary antireflux procedure. Logistic regression modelling was performed to identify factors predictive of poor outcome. RESULTS: There were 47 patients, 31 (66.0%) males and 16 females, mean age (+/- standard deviation (SD) 34.6+/-9.8 years. All patients presented with dysphagia, which was severe in 31 cases (66.0%) and moderate in 14 (29.8%). Preoperative maximum oesophageal diameter ranged from 34 to 89 mm, mean 67.4+/-12.7mm. In 30 (63.8%) of the patients, the maximum diameter was >70 mm. Postoperative maximum diameter ranged from 28 to 72 mm, mean 37.5+/-8.2 mm (p=0.001). The mean preoperative diameter of the narrowest distal oesophagus was 4.6+/-2.5 mm, compared with the postoperative figure of 11.6+/-1.8 mm (p=0.015). Following surgery, 41 (87.2%) patients had complete relief of dysphagia, regurgitation and heartburn. Four patients continued to have heartburn after surgery. Patients with severe dysphagia or preoperative oesophageal dilatation >70 mm had the greatest likelihood of incomplete relief of symptoms after treatment. CONCLUSION: Achalasia can be accurately diagnosed on the basis of clinical symptoms and barium swallow examination. A modified Heller's operation provides lasting relief of symptoms. Patients with severe preoperative dysphagia or oesophageal dilatation are more likely to have poor outcome of treatment.     

Benign breast tumours in an African population

A detailed prospective clinical study of 238 women presenting with benign breast swellings in the South Eastern equatorial rainforest of Nigeria clearly shows that 94% of lesions were due to two disorders, fibroadenomas and bacterial infections, and that they affected mostly young women in the peak of their reproductive life. Fibroadenoma which accounted for disease in no less than 69% of the women was multiple in 8%, bilateral in 11%, and was considered giant in size in 5% of the cases; by contrast, fibroadenosis was rare, accounting for swellings in only eight patients. Bacterial infections, chronic pyogenic mastitis and tuberculosis together caused breast swellings in 25% of the women studied. In tropical Africa, multiple chronic discharging sinuses suggest tuberculosis of the breast.