Co-existent breast malignancy and contralateral primary axillary tuberculosis

Breast tuberculosis is an extremely rare entity representing less than 0.1% of all breast disease in developed countries1. Tuberculous infections within the United Kingdom have seen a steady decline with the highest rates present within North West London where infection rates reach 24.8 per 1000002. The presentation can mimic malignancy and lymphatic involvement of the breast both clinically and mammographically, with nodules within the upper outer quadrant, making accurate diagnosis challenging.3 Approximately 30% of breast TB cases present with axillary lymphadenopathy and a recent case series review of approximately 44 cases in London found that the most common presenting feature was a solitary breast lump in 87% of cases.4 We present a case of a patient presenting with primary malignancy and contralateral nodal disease highly suspicious for breast malignancy. Subsequent investigation led to the identification of synchronous localized cancer and tuberculous lymphadenitis. Synchronous presentation is uncommon and recognition and differentiation is vital as axillary lymph node metastasis is the most important factor in the staging of breast carcinoma and determining the subsequent oncological and surgical management.

Response to different medical treatment options for mastalgia in fibrocystic breast disease

Background: Fibrocystic breast disease is the most common type of benign breast disease and mastalgia is the most common symptom of fibrocystic breast disease. Various types of medical management are given as a gold standard treatment for that. The aim of this study was to compare the effects of different commonly used medical management options of mastalgia of fibrocystic breast disease on the quality of life of patients and their side effects as well. Methods: This quasi-experimental study was carried out in Out-patients Department of General Surgery, BIRDEM General Hospital, Dhaka, from July 2018 to June 2019. Total 45 patients with fibrocystic breast disease were selected according to the eligibility criteria and were allocated to two groups by alternative random selection. In non-pharmacological treatments receiving group, lifestyle modification advices along with evening primrose oil were given. On the other hand, in pharmacological treatment receiving group, bromocriptine and danazole were given according to some selection criteria of the patients. Response of treatments to each group and side effects were determined at one month, three months and six months follow-up respectively. Mastalgia was measured by visual analogue scale (VAS) score and quality of life was calculated by modified WHO-QOL scoring in each follow-up. Results: Patients had an average age of 30.24±6.93 years with a majority in the age group 31-35 years (33.3%). Most patients were married (64.4%), housewives (62.20%), from middle-class groups (62.20%), multiparous (57.78%) and the majority had absence of the family history of breast diseases (84.45%). Majority of them presented with cyclical mastalgia (57.78%), bilateral mastalgia (60%) and mastalgia with lumpiness (44.4%). Among the patients who received non-pharmacological treatment, mastalgia improved in 34.78% cases and patients received pharmacological treatment, mastalgia improved in 72.73% cases. Different domains of quality of life were improved significantly in patients who received pharmacological treatment. Though majority of the patients had side effects due to pharmacological treatment, they were well tolerated. Conclusion: Despite having various side effects, pharmacological management by danazol or bromocriptine was well tolerated to our patients and a dramatic improvement was observed on quality of life than the nonpharmacologically treated patients. BIRDEM Med J 2022; 12(1): 22-29

Effect of Anatomical and Physiological Factors on Ultrasonic Breast Imaging Reporting and Data System Score in Iraqi Women Presenting with Breast Lumps

BACKGROUND: Breast lumps are a common presentation that can be assess non-invasively using the ultrasonic examination. AIM: The study aimed to assess the effect of different anatomical and physiological factors on the outcome of ultrasonic scoring of breast lumps. METHODS: A total of 60 females presented with a breast lump on ultrasound assessment were randomly selected after their consent at the Clinic for Early Detection of Breast Cancer in Baghdad. The results were expressed according to the ultrasound breast imaging reporting and data system (BI-RADS) scoring. RESULTS: There was a statistically significant positive correlation between the BI-RADS score with breast size, age, postmenopausal state, and personal or familial history of breast disease. Most cases (46.7%) scored BI-RADS II, followed by scores of III (21.6%), 4 (16.7%), and V (15%). The upper lateral quadrant of the breast was the most commonly affected sites. Marital status, parity, and breastfeeding didn’t have statistically significant influence on the sores. CONCLUSION: Ultrasonic BI-RADS scoring of breast lumps provides an initial reliable tool for the management of breast disease. Higher scores are associated with increasing breast size, age, postmenopausal state, and personal or familial history of breast disease. Several anatomical, physiological, hereditary, and environmental aspects influence such factors.

Factors associated with mammographic breast density among women in Karachi Pakistan

Background There are no studies done to evaluate the distribution of mammographic breast density and factors associated with it among Pakistani women. Methods Participants included 477 women, who had received either diagnostic or screening mammography at two hospitals in Karachi Pakistan. Mammographic breast density was assessed using the Breast Imaging Reporting and Data System. In person interviews were conducted using a detailed questionnaire, to assess risk factors of interest, and venous blood was collected to measure serum vitamin D level at the end of the interview. To determine the association of potential factors with mammographic breast density, multivariable polytomous logistic regression was used. Results High-density mammographic breast density (heterogeneously and dense categories) was high and found in 62.4% of women. There was a significant association of both heterogeneously dense and dense breasts with women of a younger age group < 45 years (OR 2.68, 95% CI 1.60–4.49) and (OR 4.83, 95% CI 2.54–9.16) respectively. Women with heterogeneously dense and dense breasts versus fatty and fibroglandular breasts had a higher history of benign breast disease (OR 1.90, 95% CI 1.14–3.17) and (OR 3.61, 95% CI 1.90–6.86) respectively. There was an inverse relationship between breast density and body mass index. Women with dense breasts and heterogeneously dense breasts had lower body mass index (OR 0.94 95% CI 0.90–0.99) and (OR 0.81, 95% CI 0.76–0.87) respectively. There was no association of mammographic breast density with serum vitamin D levels, diet, and breast cancer. Conclusions The findings of a positive association of higher mammographic density with younger age and benign breast disease and a negative association between body mass index and breast density are important findings that need to be considered in developing screening guidelines for the Pakistani population.

Diagnostic Accuracy of Nipple Discharge Fluid Cytology: A Meta-Analysis and Systematic Review of the Literature

Background Nipple discharge is the third most frequent complaint of women attending rapid diagnostic breast clinics. Nipple smear cytology remains the single most used diagnostic method for investigating fluid content. This study aimed to conduct a systematic review and meta-analysis of the diagnostic accuracy of nipple discharge fluid assessment. Methods The study incorporated searches for studies interrogating the diagnostic data of nipple discharge fluid cytology compared with the histopathology gold standard. Data from studies published from 1956 to 2019 were analyzed. The analysis included 8648 cytology samples of women with a presenting complaint of nipple discharge. Both hierarchical and bivariate models for diagnostic meta-analysis were used to attain overall pooled sensitivity and specificity. Results Of 837 studies retrieved, 45 fulfilled the criteria for inclusion. The diagnostic accuracy of the meta-analysis examining nipple discharge fluid had a sensitivity of 75 % (95 % confidence interval [CI], 0.74–0.77) and a specificity of 87 % (95 % CI, 0.86–0.87) for benign breast disease. For breast cancer, it had a sensitivity of 62 % (95 % CI, 0.53–0.71) and a specificity 71 % (95 % CI, 0.57–0.81). Furthermore, patients presenting with blood-stained discharge yielded an overall malignancy rate of 58 % (95 % CI, 0.54–0.60) with a positive predictive value (PPV) of 27 % (95 % CI, 0.17–0.36). Conclusions Pooled data from studies encompassing nipple discharge fluid assessment suggest that nipple smear cytology is of limited diagnostic accuracy. The authors recommend that a tailored approach to diagnosis be required given the variable sensitivities of currently available tests.

A PROSPECTIVE STUDY TO COMPARE THE EFFICACY OF THREE TREATMENT MODALITIES ON BENIGN BREAST DISEASE VIZ. EVENING PRIMROSE OIL (EPO), DANAZOLAND CENTCHROMAN

Background: Breast pain among women, with or without lump is common complaint and a cause of signicant anxiety and fear of breast cancer. Breast feeding is additionally one of the reasons for non-cyclic pain, brocystic breast disease is otherwise called broadenosis. Material and Methods:This is prospective study in the Department of General Surgery, Indira Gandhi Institute of Medical Sciences, Patna, Bihar. Conclusion: Centchroman is a selective anti estrogen effective in the treatment of brocystic disease. Centchroman is effective in reducing the sizes of breast lumps, providing relief from mastalgia and in curing cyclical and noncyclical breast pain in the premenopausal women.

Principles of surgery

This chapter examines the principles of surgery. It begins by explaining the process of history taking and case presentation, and outlining the common surgical symptoms. The chapter then looks at the process of examination and investigation of the patient. It details the evaluation of breast disease, the neck, the abdomen, pelvic disease, peripheral vascular disease, and the skin and subcutaneous tissue disease. The chapter also considers preoperative care, pre-optimisation of the patient, perioperative care, and post-operative management. Finally, it discusses the management of the critically ill surgical patient. The first step is recognising compensated critical illness (e.g. shock compensated by tachycardia and peripheral shutdown or respiratory failure compensated by unsustainable respiratory effort). The surgical team should consider using critical care services for both elective and emergency surgical patients.