Paget Disease of Breast

Paget Disease of Breast

Paget Disease of Breast is an eczema like condition due to underlying carcinoma.

Differentiation between Eczema and Paget's Disease of Breast:-

Paget disease of the breast starts from the nipple and spreads towards the areola of the breast.

Whereas the normal eczema starts from the periphery and involve the areola and nipple.

In benign eczema patient can have evidence of eczema anywhere else in the body.

Nipple Destruction is very characteristic in Paget Disease of Breast.

Treatment of Paget Disease with a Breast Lump is Modified Radical Mastectomy.

Treatment of Paget Disease with no Lump is Total Mastectomy.

 

Post Auricular Dermoid Cyst

Post Auricular Dermoid Cyst

                            

Post Auricular Dermoid Cyst

Post Auricular Dermoid Cyst-Incision for Excision

Post Auricular Dermoid Cyst-Excision

Post Auricular Dermoid Cyst is type of Sequestration Dermoid,  in which the epidermal cells are sequestrated to deeper layers of tissues. Hence it is also called Epidermal Cyst.

Sequestration Dermoids are seen close to the mesodermal derivatives like bone. Hence it is possible to get indentation of  the underlying skull bone and even an intracranial extension.

Sequestration Dermoids are seen along the line of embryonic fusion. Other examples of Sequestration Dermoids are External Angular Dermoid and Submental Dermoid.

Age group:-

The second or third decades of life.

Clinical Features:-

Painless Swelling with a smooth surface and soft consistency. Indentation of the underlying bone may be appreciated.

Soft cosisitency of a dermoid cyst is due the tooth paste like pultaceous material composed of sebum and desquamated epithelial cells with or without hair.

Complications of Dermoid Cyst:-

• Infection
• Ulceration
• Mechanical compression to adjacent structures

Investigations-

Plain X Ray Skull- to assess bony erosions.

CT Scan Head- if  intracranial extension is suspected.

Treatment

Surgical Excision under appropriate anesthesia.

Peau d’ orange Appearance in Carcinoma Breast

Peau d’ orange Appearance in Carcinoma Breast

Dimpling of the skin over the breast is due to involvement of the Cooper’s ligaments.

Blockage of the dermal lymphatics of the breast due to malignancy results in oedema of the skin.

Skin dimpling along with odema of the skin is the cause of Peau d’ orange Appearance ( Orange peel ) in Carcinoma breast.

Significance of Peau d’ orange Appearance in Carcinoma breast:-

Peau d’ orange Appearance is considered as skin involvement in Carcinoma breast and hence affects the stage of the disease.

NB:  Mere dimpling of the skin over the breast will not affect the stage of the disease as it is not considered as skin involvement.

Skin involvement in Carcinoma breast means presence of any one of the following:-

1.     Peau d’ orange Appearance

2.     Skin Ulceration

3.     Skin nodules

Benign condtions producing Peau d’ orange Appearance:-

Mastistis

Radiation

Hematocele

Hematocele

Causes of Hematocele:- Trauma (Cricket ball injury, Road Traffic Accidents etc), Iatrogenic ( Aspiration of a Hydrocele-Not recommended), Testicular neoplasms.

Clinical Features:- Painful swelling of scrotum with history of Trauma.

Investigations:-Doppler Ultra Sound Scan to assess the vascularity and architecture of the testes.

Treatment:- Scrotal Exploration and evacuation of blood clots.

Important:- Viability  of the testes is confirmed. Small linear lacerations are sutured, severely shattered testis requires orchidectomy.

Complications:- Infection, Atrophy of testes due to pressure haematoma.

 

Simple Mastectomy, Total Mastectomy and Modified Radical Mastectomy

What is Simple Mastectomy, Total Mastectomy and  Modified Radical Mastectomy for Carcinoma Breast?

Simple Mastectomy

Surgical removal of the whole of breast tissue superficial to  the pectoral fascia is called Simple Mastectomy. That means superficial fascia is left behind or not removed.

Total Mastectomy

Surgical removal of the whole of breast tissue including the pectoral fascia is called Total Mastectomy.

Modified Radical Mastectomy

Surgical removal of the whole of breast tissue including the pectoral fascia and level I, II and III axillary lymph nodes is called Modified Radical Mastectomy.

In other words Modified Radical Mastectomy is Total Mastectomy with Axillary clearance of lymph nodes.

Indication of Simple Mastectomy

Simple Mastectomy is done for Metastatic Breast Disease. It is also called Toilet Mastectomy. The purpose of doing Simple Mastectomy in Carcinoma Breast with metastasis is to prevent fungation and local ulceration of the tumor.

Indication of Total Mastectomy

Indication of Total Mastectomy is Paget Disease of the Breast with no palpable lump.

The treatment of Paget Disease of the Breast with a palpable lump is Modified Radical Mastectomy.

Indication of Modified Radical Mastectomy

Indication of Modified Radical Mastectomy is Early Breast Carcinoma and Paget Disease of the Breast with a palpable lump.

Different levels of Axillary Lymph Nodes

Axillary Lymph Nodes are broadly classified in to Level I, II and III nodes.

Level I axillary lymph nodes are the nodes located lateral to Pectoralis minor muscle.

Level II axillary lymph nodes are the nodes located beneath  or over the  Pectoralis minor muscle.

Level III axillary lymph nodes are the nodes located medial to Pectoralis minor muscle.

Types of Modified Radical Mastectomy

Patey’s Modified Radical Mastectomy :- Pectoralis  major muscle is  preserved and Pectoralis minor removed               

Scanlon’s Modified Radical Mastectomy :–   Pectoralis minor muscle is divided but not removed.             

Auchincloss’ Modified Radical Mastectomy :– Pectoralis minor is retraced but not divided.

Auchincloss’ Modified Radical Mastectomy is widely practiced nowadays.

Halstead’s Radical Mastectomy

In Halstead’s Radical Mastectomy both Pectoralis  major and Pectoralis minor muscles are removed along with the whole breast and the axillary lymph nodes.

What are the structures removed in Modified Radical Mastectomy (MRM)?

Whole of the breast tissue including the axilliary tail, along with the Tumor, Nipple Areola complex, Skin and the Level I, II and III Axillary lymph nodes are removed.

                                                 Images Courtesy: Madurai CME 2013



Follicular Carcinoma Thyroid

Follicular Carcinoma Thyroid

Follicular Carcinoma Thyroid

Pulsatile tumor in the scalp and a thyroid swelling is typical of Follicular carcinoma thyroid.

Follicular carcinoma is diagnosed histologically based on the capsular and vascular invasion.

The capsular and vascular invasion cannot be better appreciated in a Fine Needle Aspiration Cytology (FNAC).

Hence the type of Thyroid malignancy which cannot be diagnosed with FNAC is Follicular Carcinoma Thyroid.

Haematogenous spread is more common in Follicular Carcinoma Thyroid.

Clinically skull metastasis is pulsatile in nature because of the increased vascularity.

Hurthle Cell Tumor is a variant of Follicular Neoplasm.

The cell of origin of Follicular Carcinoma Thyroid is the Follicular epithelium of the gland.

Follicular Carcinoma Thyroid is grouped under Differentiated Thyroid Cancer.

Differentiated Thyroid Cancer is the only human cancer where age of the patient is included in the tumor staging system.

Surgical Treatment of Follicular Carcinoma Thyroid is Total Thyroidectomy, Functional Neck Dissection for the nodal disease and Radio Iodine ablation with suppression of TSH.

Functional Neck Dissection means removal of all the lymphatics and lymph nodes on the affected side of neck with preservation of Sterno Cleido Mastoid Muscle, Spinal Accessory Nerve and Internal Jugular Vein.

The treatment of metastasis in Follicular Carcinoma Thyroid is Radio Iodine Therapy.

For Radio Iodine Therapy, the whole of thyroid tissue must be removed surgically. If there is some remnant thyroid is left, the metastasis will not take up the radio iodine.

Thyroid Stunning Effect

Scanning dose of I¹³¹ used for thyroid scan can cause damage of follicular cell resulting in decreased uptake in the thyroid remnant or metastasis. This can inturn impair the therapeutic efficacy of subsequent I¹³¹ therapy.This is called thyroid Stunning Effect.

Stunning effect occurs at the cellular level.

Higher the dose of I¹³¹, more the incidence of Stunning

The following methods are used to avoid stunning:-

-Use smaller dose of Iodine ¹³¹ for diagnosis

-Use of Iodine ¹²³

-Shorter interval between diagnostic and therapeutic doses, that is less than 72 hours.

                                               Image Courtesy: Madurai CME 2013

 

Omental Metastasis – Carcinoma Ovary

Omental Metastasis – Carcinoma Ovary

Omental Metastasis – Carcinoma Ovary ( Black Arrow)

Exfoliated malignant cells from the ovary  first reach the para colic gutter. The negative pressure associated with respiratory movement causes upward migration of the tumor cells towards diaphragm.

Omental metastasis typically occurs along the attachment of mesentery with the bowel because of the increased vascularity of the region required for the tumor angiogenesis.

Hence as a part of Cytoreductive surgery for advanced ovarian carcinoma Gastro colic omentectomy is also done along with Hysterectomy and Bilateral Salpingo Oophorectomy.