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The spleen 365
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Massive splenomegaly in the UK is likely to be due to
one of the following: chronic myeloid leukaemia,
myelofibrosis, lymphoma, polycythaemia or portal
hypertension.
If the spleen is palpable, special attention must be
paid to detecting the presence of hepatomegaly and
lymphadenopathy (see Chapter32).
Splenectomy
Splenectomy is indicated under the following
circumstances.
Rupture: either from closed or open trauma or
•
from accidental damage during abdominal
surgery.
Haematological disease: haemolytic anaemia,
•
thrombocytopenic purpura.
Tumours and cysts.
•
•
Part of another operative procedure, for example
radical excision of carcinoma of the stomach, distal pancreatectomy, splenorenal anastomosis for
portal hypertension.
Complications ofsplenectomy
Gastric dilation
Following splenectomy, there may be a gastric ileus.
Swallowed air causes rapid dilation of the stomach,
which may tear ligatures on the short gastric vessels on
the greater curve of the stomach, which were tied during splenectomy; haemorrhage results. To prevent this,
a nasogastric tube is placed and regularly aspirated.
Thrombocytosis
Following splenectomy, the platelet count rises, often
to a level of 1000 × 10
time, the count falls but while it is high, the patient
isat a greater than normal risk of deep vein thrombosis and pulmonary embolus. Antiplatelet agents such
as aspirin are given as prophylaxis in addition to low
molecular weight heparin.
Post- splenectomy sepsis
One of the spleen’s functions is to clear capsulated
micro- organisms (such as Streptococcus pneumoniae,
Neisseria meningitidis and Haemophilus influenzae)
9
/L (normal is <400 × 109/L). In
from the bloodstream after they have been opsonized
by the binding of host antibodies to their surface as
part of the normal immune response. The spleen also
has important phagocytic properties, as well as being
the largest repository of lymphoid tissue in the body.
Splenectomy predisposes the patient, especially a
child, to infection with capsulated organisms such as
the Pneumococcus. The clinical course is of a fulminant bacterial infection, with shock and circulatory
collapse, termed ‘overwhelming postinfection’ (OPSI).
Prophylactic immunization with pneumococcal,
meningococcal and H. influenzae type B vaccines
should be administered, at least 2 weeks preoperatively when possible, or prior to hospital discharge as
part of an emergency splenectomy. In addition,
children should have prophylactic daily low- dose
penicillin at least until they reach 16 years of age.
Adults should have penicillin for at least the first
2 years after splenectomy, and lifelong once over
50 years of age. Other high- risk groups who should
receive daily antibiotic prophylaxis include those who
are
immunosuppressed, have had splenic irradiation,
or have previously had invasive pneumococcal disease, or who fail to develop an antibody response
following immunization. Annual flu immunizations
are also recommended to minimize the additional
risk of bacterial superinfection and special care is
required if the patient is to travel to malarial areas.
Patients presenting with infections who have
previously had a splenectomy should be treated
immediately with amoxicillin (or erythromycin if
penicillin allergic).
splenectomy
Ruptured spleen
This is the most common internal injury produced by
non-
penetrating trauma to the abdominal wall.
Itusually occurs in isolation, but may co- exist with
fractures of the ribs or rupture of the liver, the left kidney, the diaphragm or the tail of the pancreas.
Clinical features
Rupture of the spleen manifests in one of the following ways.
1
Immediate massive bleeding with rapid death from
shock. This results from a complete shattering of
the spleen or its avulsion from the splenic pedicle,
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and death from exsanguination may occur in a few
minutes. Fortunately, this is rare.
Peritonism from progressive blood loss. Following
2
injury, there are the symptoms and signs of progressive blood loss together with evidence of peritoneal irritation. Over a period of several hours
after the accident, the patient becomes increasingly pale, the pulse rises and the blood pressure
falls. There is abdominal pain, which is either
diffuse or confined to the left flank. The patient
may complain of pain referred to the left shoulder
tip or admit to this only on direct questioning.
On examination, the abdomen is generally tender, particularly on the left side. There may be
marked generalized rigidity, or it may be confined
to slight guarding in the left flank. Bruising of the
abdominal wall is often absent or only slight.
3
Delayed rupture. This may occur from hours up to
several days after trauma. Following the initial
injury, the concomitant pain soon settles. Then,
following a completely asymptomatic interval, the
signs and symptoms described above become
manifest. This picture is produced by a subcapsular haematoma of the spleen, which increases in
size and then ruptures the thin overlying peritoneal capsule with a resultant sudden, brisk
haemorrhage.
Spontaneous rupture. A spleen diseased by, for
4
example, malaria, glandular fever or leukaemia,
may rupture spontaneously or after only trivial
trauma.
Special investigations
The diagnosis of a ruptured spleen is a clinical one, and
an unstable patient must be resuscitated
and the surgeon proceed at once to laparotomy. In the
less acute situation, and only after resuscitation has
begun, the following investigations are useful.
•
Focused abdominal sonography for trauma (FAST)
(ultrasound) may reveal free fluid, an intrasplenic
aggressively
haematoma or a laceration of the capsule,
although the latter may be overlooked. Ultrasound
is increasingly used as a diagnostic tool in the
emergency department for such cases.
Computed tomography is the investigation of
•
choice in all cases of abdominal trauma, and will
demonstrate the laceration of the spleen and the
presence of intratraumatic injuries to other organs.
Chest X- ray may reveal associated rib fractures,
•
rupture of the diaphragm or injury to the left lung.
•
Urinalysis showing haematuria will suggest asso-
ciated coincidental renal damage.
abdominal fluid and identify
Treatment
Resuscitation is commenced with plasma expanders
initially and blood replacement as soon as blood is
available. Haemodynamically unstable patients with
positive FAST or CT scans should undergo immediate
laparotomy. If the spleen is found to be avulsed
or hopelessly pulped, emergency splenectomy is
required. If there is minor laceration of the spleen,
anattempt may be made to preserve it, especially in
children and young adults, in whom there is a greater
risk of post- splenectomy sepsis. This may be carried
out by using argon beam coagulation, sutures, fibrin
glues and/or topical haemostatic fibrin patches.
Having controlled the bleeding at laparotomy, it is
important to carry out a full examination to exclude
injury to other organs.
In haemodynamically stable patients with minor
injuries not requiring surgery and evidence of ongoing splenic bleeding, a non- operative approach
with angiographic embolization to control bleeding
may be considered.
Additional resources
Case 94: A severe abdominal injury
The lymph nodes
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andlymphatics
Christopher Watson
Learning objectives
✓ To know the causes of lymphadenopathy and the appropriate
management.
✓ To have knowledge of lymphoedema and its causes.
36
Enlarged lymph nodes are a common diagnostic
problem, so it is important to have a simple classification and clinical approach to their assessment.
The lymphadenopathies
The lymphadenopathies can be conveniently divided
into those due to local disease and those due to generalized disease.
Classication
Localized
1 Infective:
a Acute, for example a cervical lymphadenopa-
thy secondary to tonsillitis.
b Chronic, for example tuberculous nodes of
neck.
2 Neoplastic: due to secondary spread of tumour.
Ellis and Calne’s Lecture Notes in General Surgery, Fourteenth Edition.
Edited by Christopher Watson and Justin Davies.
© 2023 John Wiley & Sons Ltd. Published 2023 by John Wiley & Sons Ltd.
Companion website: www.wiley.com/go/Watson/GeneralSurgery14
Generalized
1 Infective:
a Acute, for example glandular fever (mononu-
cleosis), septicaemia.
b
Chronic, for example human immunodefi-
ciency virus (HIV), secondary syphilis.
The reticuloses: Hodgkin’s disease,
2
lymphoma, chronic lymphocytic leukaemia.
Sarcoidosis.
3
1
non- Hodgkin’s
Clinical examination
The clinical examination of any patient with a lymph
node enlargement is incomplete unless the following
three requirements have been fulfilled.
The area drained by the involved lymph nodes has
1
been searched for a possible primary source of
infection or malignant disease. There are four
important points to remember.
a Cervical lymphadenopathy. In addition to
examining the skin of the head and neck, the
inside of the oropharynx together with the
1
omas Hodgkin (1798–1866), Curator of Pathology, Guy’s
Hospital, London, UK.
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larynx should be examined for chronic sepsis
or malignant disease.
Inguinal lymphadenopathy. If a patient has an
b
enlarged lymph node in the groin, the skin of
the leg, buttock and lower abdominal wall
below the level of the umbilicus must be scrutinized, together with the external genitalia
and the anal canal.
c
Testicular tumours drain along their lymphat-
ics, which pass with the testicular vessels to the
aortic lymph nodes, and not to the ingui-
paranal lymph nodes.
Virchow’s node
d
2
is a prominent node in the left
supraclavicular fossa arising from malignant
disease below the diaphragm, such as gastric
carcinoma, with secondaries ascending the
thoracic duct to drain into the left subclavian
vein (Troisier’s sign
3
). A supraclavicular node
may also signify spread from intrathoracic, testicular or breast tumours.
The other lymph node areas are examined, as
2
enlarged lymph nodes elsewhere would suggest a
generalized lymphadenopathy.
3
The liver and spleen are carefully palpated; their
enlargement will suggest a lymphoma, sarcoid or
glandular fever.
Special investigations
In many instances, the cause of the lymphadenopathy
will by now have become obvious. The following
investigations may be required in order to elucidate
the diagnosis further.
•
Examination of a blood film may clinch the diag-
nosis of glandular fever or leukaemia.
Chest X- ray may show evidence of enlarged medi-
•
astinal nodes or may reveal a primary occult
tumour of the lung, which is the source of disseminated deposits.
• Serological tests: an HIV antibody test is performed
if infection is suspected; syphilis may be confirmed by specific treponemal antigen tests.
2
Rudolf Ludwig Karl Virchow (1821–1902), Professor of
Pathology in Würzburg and later Berlin, Germany. He
described the nodes in association with gastric carcinoma
(1848).
3
Charles Émile Troisier (1844–1919), Professor of Pathology,
Paris, France. He described the sign in connection with
other types intra- abdominal cancer (1889).
• Ultrasound of a lymph node may be able to determine whether it has a normal morphology or is
suggestive of malignant infiltration.
•
Lymph node biopsy: ultrasound- guided needle
core biopsy, or surgical removal of one of the
enlarged lymph nodes, may be necessary for
definite histological proof of the diagnosis. This is
particularly so in Hodgkin’s disease and nonHodgkin’s lymphoma.
Computed tomography (CT) scan of the neck,
•
chest, abdomen and pelvis may be required to
determine the stage of any lymphoma, or to identify the primary tumour.
•
X- ray of cervical nodes may show spotty calcifica-
tion typical of tuberculous nodes.
Lymphoedema
Lymphoedema results from the obstruction of
lymphatic flow, owing to inherited abnormalities of
the lymphatics, their obliteration by disease or their
operative removal. It is characterized by an excessive accumulation of interstitial fluid. Affected individuals are prone to infections (cellulitis) in the
affected areas together with lymphangitis. The
causes of lymphoedema may be divided into primary and secondary.
Primary lymphoedema
There are two autosomal dominant inherited forms
of lymphoedema, both are more common in
women.
Type 1 (also known as Milroy disease,
•
5
Milroy
disease and primary congenital lymphoedema) is very uncommon and is often associated
with a mutation in the FLT4 gene, which encodes
vascular endothelial growth factor receptor
3(VEGFR- 3), VEGF being important in lymphangiogenesis. It is characterized by onset soon after
birth with lower limb swelling.
• Type 2 (also known as Meige syndrome
most common primary lymphoedema, and is
associated with mutations in FOXC2, a forkhead
family transcription factor gene. It is characterized
4
William Forsyth Milroy (1855–1942), Professor of Medicine,
University of Nebraska, Omaha, NE, USA.
5
Max Nonne (1861–1959), Neurologist, Hamburg, Germany.
4
Nonne–
6
) is the
The lymph nodes andlymphatics 369
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by lymphoedema that is particularly severe below
the waist. It has been arbitrarily divided into lym-
phoedema praecox, which develops between
puberty and the age of 35, and the less common
lymphoedema tarda, which develops in adult life.
There are three principal pathological processes
affecting the lymphatic channels in congenital lymphoedema: aplasia, hypoplasia and varicose dilation
(megalymphatics).
Secondary lymphoedema
Secondary lymphoedema develops where a previously normal lymphatic system has been damaged. It
affects more than 200000 people in the UK, with one
in 6000having primary lymphoedema
•
Post- inflammatory: the result of fibrosis obliterat-
ing the lymphatics following repeated attacks of
streptococcal cellulitis, particularly when the lymphatic drainage is already compromised.
• Filariasis: Filaria bancrofti
7
infects lymphatics; a
chronic inflammatory reaction is set up with
consequent lymphatic obstruction. There is gross
lymphoedema, especially of the lower limbs and
genitalia, often called elephantiasis.
•
Following radical surgery, particularly after block
dissection of the axilla, groin or neck in which
extensive removal of lymphatics is performed.
Post- irradiation fibrosis.
•
•
Malignant disease: late oedema of the arm after
axillary clearance and radical mastectomy is often
indicative of massive recurrence of tumour in the
axilla occluding the residual lymphatic pathways.
Obesity is also a cause of secondary lymphoedema.
•
Special investigations
• Lymphoscintigraphy involves injecting a radiolabelled protein subcutaneously and monitoring its
movement through the lymphatics. It will confirm
lymphatic obstruction.
• Magnetic resonance imaging may be used to confirm
the cause of obstruction in secondary cases.
• CT scan may also detect disease in proximal
lymphatics.
6
Henri Meige (1866–1940), Professor of Medicine, Hôpital
de Salpêtrière, Paris, France.
7
Joseph Bancroft (1836–1894), Physician and Public Health
Ocer, Brisbane, Australia.
Box 36.1 A swollen leg
Generalized disease
•
Cardiac failure.
•
Nephrotic syndrome.
•
Liver failure.
Venous disease
•
Venous thrombosis*.
•
Deep venous insufficiency.
•
Arteriovenous fistula,* e.g. Klippel–Trenaunay
syndrome
Lymphatic disease
•
Primary lymphoedema*.
•
Secondary lymphoedema,* e.g. filariasis,
malignant infiltration, following surgery or
irradiation to lymphatics.
*
Also may cause unilateral upper limb swelling.
8
.
*
Differential diagnosis
The diagnosis of lymphoedema depends first of all on
the exclusion of other causes of oedema, for instance
venous obstruction, cardiac failure or renal disease,
and, second, on demonstration of one of the causes
mentioned above (Box36.1). It was previously taught
that lymphoedema could readily be differentiated
from other forms of oedema on the simple physical
sign of absence of pitting in the lymphoedematous
limb. However, lymphoedema of acute onset will initially pit on pressure, although it is true that, when it
becomes chronic, the subcutaneous tissues become
indurated from fibrous tissue replacement and pitting
will not then occur. However, oedema of any nature, if
chronic, will have this characteristic.
Treatment oflymphoedema
Conservative
The recommended treatment is decongestive lymphatic therapy (DLT). This involves four components:
8
Maurice Klippel (1858–1942), French Neurologist,
Salpêtrière Hospital, Paris, France. Paul Trenaunay (b. 1875),
French Neurologist and junior colleague of Klippel at the time
of its description. e syndrome involves multiple congenital
venous malformations producing varicose veins together
with hypertrophy of bones and soft tissues and extensive
cutaneous haemangiomas, usually aecting the lower limbs.
370 The lymph nodes andlymphatics
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• Exercise, using muscles in the affected limb to
promote fluid drainage. It is also important to
reduce weight if overweight.
•
Manual lymphatic drainage, a massage technique
to stimulate the flow of lymph to reduce swelling.
Compression garments, custom made, to move
•
fluid out of the affected limb and prevent it
reaccumulating.
•
Skin care to avoid any infection that may worsen
the lymphatic compromise. This includes avoiding
insect bites, careful nail care, wearing gloves for
manual tasks, avoiding phlebotomy and venous
cannulation in affected limbs, avoiding sun burn,
hot baths, saunas, steam rooms and sun beds.
Surgery
In severe cases, surgery may be appropriate. There
are three options:
Debulking, removing excess skin and subcutane-
•
ous tissue.
Liposuction, removing subcutaneous fat. This is
•
not a cure, but rather debulks the limb after
which compression garments should be worn
again.
•
Provision of alternative lymphatic drainage,
bypassing obstructions, such as by tunnelling a
tongue of omentum down to the inguinal nodes,
to provide drainage along mesenteric lymphatics
to the thoracic duct, bypassing obstructed iliac
nodes. Unfortunately, the results are poor. Other
techniques, such as lymphovascular anastomoses, have also been disappointing.
Additional resources
Case 95: A painless lump in the neck
Case 96: Swollen legs in a young woman
The breast
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Eleftheria Kleidi
Learning objectives
✓ To know about benign and malignant breast disease.
✓ In particular, to be able to recognize the features of breast cancer and
have knowledge of its management.
Developmental
anomalies
Accessory nipples andbreasts
Extra nipples or breasts may develop along the milk
line extending from the axilla to the groin. Accessory
nipples, called polythelia, are usually found just
below the normal breast. Accessory breast tissue,
called polymastia, is most commonly found at the
axilla. They are influenced by circulating hormones,
and the nipples may discharge during lactation.
37
Unilateral failure is associated with Poland2 syndrome,
which presents with concurrent underdevelopment of
the pectoralis muscle and is more common in males.
Asymmetry can be treated by a combination of ipsilateral breast augmentation and contralateral breast
reduction.
Tuberous breasts
This can be unilateral or bilateral and consists of a
narrow breast base with a relatively wide areola, so
that the breast looks like an hourglass. Cosmetic surgery might be considered for correction of this anomaly in adulthood.
Hypoplasia or absence
ofthebreast
Although asymmetry of the breasts is normal, complete failure of development of the breast, called
amastia, may occur and is often associated with chest
wall defects. Bilateral developmental failure may be
associated with ovarian failure or Turner syndrome.
1
Henry Hubert Turner (1892–1970), Endocrinologist and
Professor of Medicine, University of Oklahoma, Norman,
OK, USA
Ellis and Calne’s Lecture Notes in General Surgery, Fourteenth Edition.
Edited by Christopher Watson and Justin Davies.
© 2023 John Wiley & Sons Ltd. Published 2023 by John Wiley & Sons Ltd.
Companion website: www.wiley.com/go/Watson/GeneralSurgery14
Nipple inversion
This may be primary (present since birth) or
secondary to duct ectasia or a carcinoma of the
breast. If of recent onset (see later in this chapter),
then the process is more appropriately called nip-
1
ple retraction. Primary indrawn nipples may cause
problems during lactation but are of no other
significance.
2
Sir Alfred Poland (1822–1872), Surgeon to Guys and latterly
Moorelds Hospitals. He described the condition when he
was still a student based on his dissection of the body of a
convict.
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Ductules or acini
Lobule
Terminal duct
Adipose tissue
Segmental duct
Lactiferous duct
Lactiferous sinus
Nipple
Paget’s disease
Nipple adenoma
Papillomas
Hyperplasia
Most carcinomas
Fibroadenoma
Cysts
Traumatic fat necrosis
Figure37.1 Anatomical features of the breast. Adapted from Koeppen BM, Stanton BA (2008) Berne and Levy
Physiology, 6th edn. St Louis, MO: Mosby (Elsevier).
different structures (Figure37.1). Ninety per cent of
Symptoms ofbreast
disease
There are five common symptoms of breast disease
that warrant urgent attention:
New, discrete lump.
•
• Nipple discharge– blood- stained, or spontaneous
single duct, or persistent.
• Nipple retraction or distortion of recent onset.
• Altered breast contour or dimpling.
• Nipple changes suspicious of Paget’s disease.
Other common symptoms that require further investigation include persistent asymmetrical nodularity,
pain (mastalgia), and a family history of breast cancer.
all lumps in the breast will be one of the following:
Cyst.
1
2 Fibroadenoma.
3
Carcinoma of the breast.
In addition, the following less common causes need
to be considered.
Trau ma: fat necrosis.
1
2 Other cysts:
3 Other tumours:
A lump inthe breast
When considering the different pathologies of the
breast, it is helpful to think in terms of its anatomy
and the pathology which is associated with the
3
William Featherstone Montgomery (1797–1859), Professor
of Midwifery, Dublin, Ireland
Terminal duct
lobular unit
Anatomic
structures
Lesions
a Galactocele.
b Abscess.
c Cystadenoma.
d Retention cyst of the glands of Montgomery.
e Fibrocystic changes (presenting as prominent
nodularity).
a Ductal papilloma.
b Sarcoma (extremely rare).
3
The breast 373
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c Hamartoma.
Lipoma.
d
Uncommon chest wall swellings may rarely be
confused with breast swellings. Examples of such are
rib swellings (e.g. tumour, Tietze’s syndrome or tuberculosis), superficial thrombophlebitis (Mondor’s
4
disease
) and abscesses.
Management
The diagnosis of discrete breast lumps is based on a
triple assessment that comprises the following.
Clinical examination.
1
2 Radiological imaging:
Mammography, usually in patients over 40 years.
a
b Ultrasound, both diagnostic and to guide
biopsy.
c
Magnetic resonance imaging, useful in sympto-
matic patients with breast implants in whom
ultrasound is not diagnostic. It is also used
when there is discrepancy on the findings
between clinical examination and mammogram and/or ultrasound. MRI is usually performed as a second-
3 Biopsy, usually ultrasound- guided:
a
Core biopsy: investigation of choice for the
assessment of breast and axillary abnormalities.
Vacuum- assisted biopsy (VAB), mostly used in
b
areas of microcalcification to obtain a larger
amount of tissue and optimize the possibility
of adequate sampling of the area.
c Punch biopsy: when the abnormality is on the
skin, i.e. ulcerating lesion or rash/eczema.
Fine- needle aspiration cytology, is hardly ever
d
used to assess breast abnormalities; it is still
used in some units to assess the axillary nodes.
The predictive value for benign disease when all three
components of the triple assessment are benign is 99%.
If there is discordance between any of the three tests,
open biopsy or further investigations are considered.
line investigation.
b Intraductal carcinoma; (ductal carcinoma
insitu, DCIS).
Trauma.
c
d
Paget’s disease (rare).
Invasive carcinoma (very rare).
e
2
Clear, single duct: benign intraductal papilloma.
3
Multicoloured (often multiductal): duct ectasia
(discharge commonly yellow, brown or green).
Milky: galactorrhoea: may follow lactation but can
4
also be drug induced or a manifestation of hyperprolactinaemia (or, occasionally, hypothyroidism).
Purulent: breast abscess, periductal mastitis.
5
Management
Nipple discharge is usually physiological when nonspontaneous. The majority of cases of spontaneous
nipple discharge are benign, and this symptom is
rarely a presenting feature of breast cancer, even
when bloodor blood- stained discharge requires further investigation; if a lump is present, it should be managed by triple assessment (see earlier in this chapter). In the
absence of a lump, the management of discharge is as
follows:
stained. Spontaneous, clear, single- duct
Multicoloured, multiductal
discharge
If clinical examination and imaging are normal, a
diagnosis of duct ectasia is likely and no further treatment is required. If the symptoms are distressing,
total duct excision (Hadfield’s procedure
considered.
5
) can be
Clear single- duct discharge
If triple assessment is normal, the diagnosis is likely
to be an intraductal papilloma and excision of the
affected duct (a microdochectomy) is indicated.
Bloody nipple discharge
Discharge fromthe nipple
1 Blood- stained:
a Benign intraductal papilloma, when blood
arises from a single duct.
4
Henri Mondor (1885–1962), Professor of Surgery, Hôpital
Salpêtrière, Paris, France.
When blood is present, a focused central breast
ultrasound is performed and a mammogram (for
women over 40 years). If imaging is normal, and the discharge persists, a microdochectomy is recommended if
a single duct can be identified; a total duct excision is
5
Georey John Hadeld (1923–2006), Surgeon, Stoke
Mandeville Hospital, Aylesbury, UK.
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performed if a single duct cannot be clearly identified.
Cytology of the nipple discharge is no longer recommended, as the results do not impact management.
Bloody nipple discharge can be seen in up to 20% of
women in pregnancy and lactation, due to the hypervascularity of the ducts. This is usually benign and
resolves spontaneously. Triple assessment is still
warranted: if bloody discharge persists, the recommended management is the same as above, usually
after delivery.
Pain inthe breast (mastalgia)
It can be separated into true and extramammary
breast pain. True breast pain is further divided into
cyclical and nontom of breast cancer.
cyclical. Mastalgia is rarely a symp-
Extramammary breast pain
It is likely the most common cause of breast pain and
is usually unilateral. Any irritation of the intercostal
nerves that innervate the breast (T3referred pain. Careful clinical examination, also in the
lateral positions, can differentiate extramammary
from true breast pain. Common causes include:
•
Musculoskeletal chest wall pain, usually derives
from the pectoralis major muscle or the ribs.
Tietze’s syndrome,
cartilage of the second, to fourth costochondral
junctions is another cause of chest wall pain.
Intercostal neuralgia due to trauma or underlying
•
pleuritic pain, gallbladder disease or herpes zoster
can be a less common causes of extramammary pain.
•
Spinal disorder like arthritis or spondylitis, is also a
less common cause.
Patients with extramammary breast pain are reassured once the cause is identified and their treatment
is symptomatic and cause directed.
6
which is costochondritis of the
T5) can cause
Cyclical mastalgia
therapy [HRT]) and other medications. Diet high in
caffeine and/or in fat had been previously considered a
risk factor but convincing evidence is lacking. In the
absence of any focal findings on clinical examination,
mammography may be offered for screening for patients
over 40 years old.
Management
Initial management consists of reassurance and primary measures, which include a supportive bra and
local or oral antihormonal medications might also be required, such
as an alteration to, or introduction of, the OCP or HRT.
Evening primrose oil containing γ(GLA), and/or dietary modifications are no longer
recommended, as they have not proven effective in
trials; however, some clinicians still use them due to
the small benefit in some women.
Second- line management for cyclical mastalgia, if
symptoms persist after 6months may be considered,
taking into account the potential side effects:
•
Tamoxifen, an oestrogen receptor antagonist; at
low dose for 3months.
Danazol, an androgen with antigonadotrophic
•
and anti-
inflammatory agents. Adjustment of
linolenic acid
oestrogenic effects.
Non- cyclical mastalgia
In one- third of women with true breast pain, this will
be non- cyclical. Causes include:
Breast infection: mastitis and abscess.
•
• Benign breast conditions: breast cysts, duct ecta-
sia, Mondor’s thrombophlebitis.
Trauma or prior breast surgery.
•
• Hormonal therapies, usually HRT.
• Carcinoma of the breast: an uncommon present-
ing symptom.
Management is directed towards the precipitating
factor, along with the primary measures mentioned earlier in this chapter for cyclical mastalgia, if indicated.
Cyclical mastalgia is caused by hormonal changes
during the menstrual cycle. It is usually bilateral,
diffuse, worse premenstrually and relieved following
menstruation. It is more common in younger women.
Risk factors include hormonal preparations (oral
contraceptive pill [OCP] or hormone replacement
6
Alexander Tietze (1864–1927), Surgeon, Breslau, Germany.
Traumatic fat necrosis
Aetiology
Fat necrosis may be associated with a history of
trauma and is a common result of seat belt injury or
surgical trauma. Its importance lies in its ability to
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