Aetiologic factors in breast cancer

◼️Geographic

Breast cancer is more common in developed western counteries, it account for 3-5% of all deaths, whereas in developing counteries the incidence is lower and account for 1-3% of all deaths. It was found to be rare in japan.

◼️Age

Breast cancer is extremely rare below the age of 20 years, but thereafter, the risk steadily increasea until it becomes 20% at 90 years.

◼️Gender

Males represent less than 0.5% of all cases of breast cancer.

◼️Genetic

Breast cancer is more common in women with a family history of breast cancer,, breast cancers that are due to a specific mutation represent about 5% of all cases, and they will be discussed later in details.

◼️Diet

It was found that there is a link to diets with low phytoestrogens, also high alcohol consumption increase the risk.

◼️Endocrine

Estrogenic drive seems to increase the risk of breast cancer, it was found that nulliparous women are more likely to have breast cancer, also having the first child at an early age is protective, breastfeeding in protective, also late menarche and early menopause seem to be protective.
The role of oral contraceptive pills and hormonal replacement therapy is controversial, it seems that the benefits from these treatments outweight the small putative risk.

#Breast

Phyllodes tumor

◼️Previously known as serocystic disease of Brodie, but also known as cystosarcoma phyllodes.

◼️They may reach massive size (see picture above), and may cause pressure necrosis and ulceration of the overlying skin (note the ulcerations in the picture above), despite all this they remain mobile on the chest wall, and you can insert a probe between the tumor and the skin (usually not fixed).

◼️Phyllodes tumors are usually of the benign type,, only very rarely they are malignant.

◼️Histology is variable, some tumors show low malignant potential, resembling a fibroadenoma, some show high mitotic index which is worrying.

◼️The name cystosarcoma phyllodes, is really out of character, because these tumors are rarely cystic, and very rarely act like a malignant sarcoma.

◼️Treatment can be done by enucleation or wide local excision, but if the tumor is massive, recurrent or of the malignant type, mastectomy is indicated.

#Breast

Duct ectasia/Periductal mastitis

◼️The pathology, is a dilated duct with surrounding periductal inflammation.
◼️The pathogenesis is unclear, the classic event is that dilatation of a large lactiferous duct takes place, then a green or brown secretion fills up the dilated duct, and becomes stagnant, it may discharge from the nipple.
◼️This stagnation initiate irritation of surrounding tissues, and lead to periductal mastitis, abscess formation (see figure yellow arrow), this abscess may open into the skin leading to a fistula (black arrow).
◼️Sometimes these inflammatory changes causes an indurated subareolar mass, which mimics carcinoma.
◼️Eventually, fibrosis takes place and causes a slit like nipple retraction (white arrow).
◼️Smoking clearly increases the risk, some say because it causes an arteriopathy which is an aetiologic factor, others say that it increase virulence of commencal bacteria, either ways, cessation of smoking clearly increase chance of long term cure.

#Breast

Mondor's Disease

◼️The above image is a mondor's disease under the right breast.

◼️It is a thrombophlebitis of the superficial veins of the breast and anterior chest, also reported to involve the arm.

◼️In absence of infection or injury, the cause of this disease is obsecure.

◼️The Pathognomonic feature, is a thrombosed subcutaneous cord of vein usually attached to the skin, when the skin overlying the breast is stretched, a narrow shallow groove appear along side the cord.

◼️Differential diagnosis include lymphatic permeation from an occult breast carcinoma.

◼️No treatment other than restricting arm movement is needed, it resolve on its own in few months without complication, recurrence or deformity.

◼️Some case reports suggested association of mondor's Disease with breast cancer, although this is probably a coincidental event.

#Breast

TNM staging and Manchester staging of breast cancer.

#Surgery

Manchester staging of Breast cancer:

Stage I:
-Mobile tumour in the breast; no deeper fixation; skin if involved lesser the size of the tumour; lymph node spread is absent.

Stage II:
-Same as stage 1 with mobile discrete axillary nodes.

Stage III:
-Fixed to pectoralis major or skin involvement more the tumour size or fixed/adherent node.

Stage IV:
-Tumour fixed to chest wall, involvement same or opposite supraclavicular nodes, opposite axillary nodes, opposite breast, cancer en cuirasse, distant blood spread.

Note:
-Manchester staging and Columbia classification are obsolete (not used now).

#Surgery

Glasgow vs Ranson criteria in AP.

#Surgery

Indications for surgery in AAA:
-Asymptomatic aneurysm more than 5.5 cm.
-Growth rate more than 0.5 cm/year.
-Painful, tender aneurysm.
-Thrombosed aneurysm, aneurysm with distal emboli.

Indications for surgery in PAD:
-Claudication.
-Rest pain.
-Ischemic ulceration.

•ACUTE GASTRIC DILATATION

-It is an enormous acute dilatation of stomach with atonic gastric wall without peristalsis.
-Stomach distends enormously occupying most of the abdomen and pelvis causing sequestration of lots of fluid resulting in hypovolaemia.

#Surgery
#Stomach

•Causes of Acute Gastric dilatation:

1-After major surgery (abdomen,. neurosurgery).
2-Trauma, burns.
3-Retroperitoneal haematoma.
4-Electrolyte imbalance.
5-Other causes: Anorexia nervosa, bulimia, polyphagia, drug abuse, diabetes, anaesthesia, debilitating diseases, spinal cord diseases, muscle dystrophy.

#Surgery
#Stomach

•HYPERTROPHIC PYLORIC STENOSIS

-There is increased risk of developing the condition if new- born gets erythromycin or azithromycin in first 14 days after birth.

#Medicine
#Pediatrics

•Ultrasound abdomen (very useful) in PS:

-Doughnut sign.
-Pyloric muscle 4 mm or more in thickness.
-Length of pyloric canal >14 mm.
-Cervix sign on long avis, target sign on short axis.

#Medicine
#Pediatrics

•Precancerous lesions of Gastric Cancer:

1•H. pylori infection, chronic gastritis
2•Pernicious anaemia
3•Intestinal metaplasia
4•Adenomatous polyps more than 2 cm
5•Agammaglobulinaemia
6•Benign gastric ulcer
7•Previous gastric surgery
8•Stomach remnant (stump carcinoma)
9•Menetrier’s disease.
10•Benign gastric ulcer.

#Surgery
#Medicine

DUODENAL BLOW-OUT 5%:

-It is a very serious complication of Billroth II gastrectomy, occurs usually on 4–5th day after surgery.

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#Stomach

DUMPING SYNDROME(Post-cibal Syndrome):

-It is common in females, seen after Billroth II surgery.

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#Stomach

•EARLY DUMPING SYNDROME:

-It is common and more severe type Incidence is 10% Vasomotor symptoms appear immediately after food, lasts for 30-40 minutes, aggravated by bulky food.
-It is relieved by lying down, aggravated by more food.

-Clinical features: Sweating, tachycardia, colicky pain and diarrhoea, Hypotension and features of hypovolaemia.

#Surgery
#Stomach

•LATE DUMPING SYNDROME:

-It is of less severe type Incidence is 5% It usually occurs 2 hours after meal.
-It is relieved by glucose and aggravated by exercise.

-Pathogenesis: Due to initial hyperglycaemia insulin secretion is stimulated which in turn leads to hypoglycaemia.

-Clinical features: Tremor, fainting, nausea, Features of hypoglycaemia.

-Treatment: Symptoms are less severe and so treated conservatively, by giving glucose and food.

#Surgery
#Stomach

•Mackler triad (esp. in Boerhaave syndrome) in Esophageal Perforation:

1-Vomiting and/or retching
2-Severe retrosternal pain that often radiates to the back
3-Subcutaneous or mediastinal emphysema:
crepitus in the suprasternal notch and neck region or crunching/crackling sound on chest auscultation (Hamman sign).

#Surgery

•Extra-esophageal symptoms (respiratory )of GERD:

1-Reflux-induced Asthma.
2-Chronic Cough.
3-Aspiration pneumonia.
4-Recurrent laryngitis.
5-Pulmonary fibrosis.
6-Hiccups.
7-Pharyngeal & laryngeal irritation horsiness of voice.
8-Otitis media.

#Medicine

•Complications of Barrett’s oesophagus:

1-Ulcerations and stricture
2-Dysphagia
3-Bleeding
4-Perforation
5-Adenocarcinoma of O-G junction (25 times more common).

#Surgery