A patient presenting painful chest wall swelling: Tietze syndrome

World J Emerg Med. 2019; 10(2): 122–124.

Kohei Sawada

Department of Emergency, Critical Care and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama-shi, Okayama, 700-8558, Japan

Hiromi Ihoriya

Department of Emergency, Critical Care and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama-shi, Okayama, 700-8558, Japan

Taihei Yamada

Department of Emergency, Critical Care and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama-shi, Okayama, 700-8558, Japan

Tetsuya Yumoto

Department of Emergency, Critical Care and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama-shi, Okayama, 700-8558, Japan

Kohei Tsukahara

Department of Emergency, Critical Care and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama-shi, Okayama, 700-8558, Japan

Takaaki Osako

Department of Emergency, Critical Care and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama-shi, Okayama, 700-8558, Japan

Hiromichi Naito

Department of Emergency, Critical Care and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama-shi, Okayama, 700-8558, Japan

Atsunori Nakao

Department of Emergency, Critical Care and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama-shi, Okayama, 700-8558, Japan

Department of Emergency, Critical Care and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama-shi, Okayama, 700-8558, Japan

Received 2018 Mar 15; Accepted 2018 Aug 20.

Copyright : © 2019 World Journal of Emergency MedicineThis article has been cited by other articles in PMC.

Dear editor,

Patients frequently visit the emergency room with acute chest pain. While some potentially life-threatening disorders may cause the pain, in approximately 80% of cases, the chest pain source is benign, and musculoskeletal chest pain accounts for nearly 20%–50% of those cases.[1–6] Thus, pain caused by benign and pathological conditions of the chest wall encountered in the emergency department is sometimes incorrectly attributed to angina pectoris or pleuritic and other serious cardiopulmonary diseases.

Tietze syndrome is an inflammatory ailment characterized by chest pain and costochondral junction swelling with unknown cause. Tietze first described the syndrome in 1921 as a non-suppurative, benign, painful superior chondrosternal joint swelling. We report a case of Tietze syndrome in a 41-year-old male experiencing acute chest pain. Pain caused by this disease is frequently referred to the emergency department and occasionally misdiagnosed as pleurisy, angina pectoris, or other severe cardiopulmonary disorders. Our report may help raise awareness of the clinical presentation and the management of this disease among emergency physicians. Emergency physicians must be aware that musculoskeletal chest pain causes are frequent but often overlooked.

CASE

A 41-year-old man without traumatic episode presented to our emergency room complaining of acute-onset anterior chest pain. His past medical history was unremarkable without diabetes mellitus, but the patient reported smoking and alcohol consumption on a regular basis. The patient stated that the severe pain felt like a stabbing knife and was unlike any pain experienced before.

On physical examination, his temperature was 36.4 °C, blood pressure 134/73 mmHg, pulse rate 78 beats/minute, and oxygen saturation 99% on room air. He was oriented and coherent in conversation. The patient had swelling of the third chondrosternal joints and tenderness on palpation. Initial electrocardiogram was normal without ST-segment elevation or depression. No arrhythmia or abnormal T-wave change was detected. His laboratory data was unremarkable and his white blood cell count and serum troponin level were normal. Radiographs were examined to rule out pulmonary and cardiovascular causes and were found to be normal. Chest computed tomography (CT) showed minimal focal enlargement of the left second chondrosternal joint without fracture (). Based on clinical and radiological findings, Tietze syndrome was diagnosed. A non-steroidal anti-inflammatory drug (NSAID) was administered. After a few days, the NSAID relieved the pain. Twelve months after the first visit, the patient no longer experienced chest pain during exertion or rest, and restriction of joint movement and swelling over the chondrosternal joints were gone.

The patient had swelling of the second chondrosternal joints and tenderness on palpation (black arrow, left upper panel). Chest computed tomography (CT) showed minimal focal enlargement of the right second chondrosternal joint without fracture (white arrow).

DISCUSSION

Tietze syndrome usually presents in both male and female adults under the age of 40. The source of this condition is not known. No causal link has been found between Tietze syndrome and occupation, geography, or ethnicity; however, there have been clustered cases. Results of the few pathological studies conducted vary from no unusual findings to degradation and swelling of the costal cartilage with associated minimal inflammation of the perichondrium.[7]

One differential diagnosis for Tietze syndrome is costochondritis, a more common condition characterized by tenderness and pain of the chondrosternal joints without swelling.[8] The term costochondritis is used interchangeably with costosternal syndrome and chest wall syndrome, and definitions are not consistent.[9] These syndromes are all characterized by pain and local tenderness at the costochondral or chondrosternal articulations, or even at the xiphoid process, but without the inflammation and swelling seen in Tietze syndrome. Many patients are left untreated and undiagnosed, possibly leading to further unnecessary examinations or cost.

Diagnosis is a clinical one, as there are no characteristic laboratory or radiographic findings. Full characterization of the chest pain is needed regarding site, onset, radiation, and exacerbating and relieving factors. Reproducible chest wall tenderness helps to rule out acute coronary syndrome in patients with acute chest pain in an early stage of the evaluation process.[10] Manual palpation of pain and motion of muscles and joints of the chest wall and cervicothoracic spine are important; however, pain localization does not help with differential diagnosis, since pain localization of acute coronary disease does not differ from that experienced by patients with chest wall syndrome, gastroesophageal reflux disease, or psychogenic chest pain. Interestingly, one study showed that the final diagnosis in patients presenting acute chest pain in the emergency room were chest wall syndrome in 46. 6%, acute coronary disease in 14.8%, and psychogenic disorders in 9.5%. Gastroesophageal reflux disease and hypertension were seen in 3.5% and 4.0% of the patients with chest pain, respectively.[11]

Thus, this diagnosis of Tietze syndrome is based on ruling out other possibly life-threatening health issues affecting the chondrosternal joints, such as tumors and pyogenic and rheumatoid arthritis, after careful case history, physical exam, and test results analysis.[12] Obviously, acute injuries or trauma including rib contusion or fracture and muscular strains should be excluded. Physicians can confirm a musculoskeletal diagnosis using clinical examination alone, an important part of which is reproducing the pain by movement or palpation over the pain-originating structure. Differential diagnosis between Tietze syndrome and chest wall tumors is often difficult, especially in a patient with a history of malignant disease that frequently metastasizes to the bone. CT or bone scintigraphy is not specific enough to confirm malignant or other benign costochondral junction disorders. A report of a patient with Tietze’s syndrome and squamous cell carcinoma of the mediastinum with unknown primary site invading the anterior chest wall and sternum has been published.[13] Clinicians should more closely follow patients with Tietze syndrome and should consider early diagnostic biopsy in cases of increasing swelling size.[1] Treatment strategies comprise manual therapy and administration of anti-inflammatory agents and analgesics either orally, topically, or by injection. Focal local anesthetic injection alone may also be a useful therapeutic and diagnostic tool. As mentioned above, careful follow-up is critical.

CONCLUSION

Chest wall syndrome constitutes the most common etiology of chest pain seen in primary care. Emergency physicians must be aware of the management and clinical presentation of Tietze syndrome to avoid further unnecessary anxiety, time, and expense.

Footnotes

Funding: None.

Ethical approval: Not needed.

Conflicts of interest: The authors declare that there are no conflicts of interest regarding the publication of this paper.

Contributors: KS proposed the study, analyzed the data and wrote the first drafts. All authors contributed to the design and interpretation of the study and to further drafts.

REFERENCES

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unusual presentation of an aggressive mediastinal tumour

BMJ Case Rep. 2009; 2009: bcr05.2009.1890.

Reminder of important clinical lesson

Abdul Majid Wani

¹Hera General Hospital, Medicine, Makkah, 21955, Saudi Arabia

Waleed Mohd Hussain

¹Hera General Hospital, Medicine, Makkah, 21955, Saudi Arabia

Mohamad Ibrahim Fatani

¹Hera General Hospital, Medicine, Makkah, 21955, Saudi Arabia

Ahmad Qadmani

¹Hera General Hospital, Medicine, Makkah, 21955, Saudi Arabia

Mohannad Hemdi

¹Hera General Hospital, Medicine, Makkah, 21955, Saudi Arabia

Sadia Hanif

¹Hera General Hospital, Medicine, Makkah, 21955, Saudi Arabia

Mubeena Akhtar

¹Hera General Hospital, Medicine, Makkah, 21955, Saudi Arabia

Mazen G Bafaraj

²Umul Qurah University, Makkah, 21955, Saudi Arabia

¹Hera General Hospital, Medicine, Makkah, 21955, Saudi Arabia

²Umul Qurah University, Makkah, 21955, Saudi Arabia

Abstract

The majority of patients with primary mediastinal lymphoma are symptomatic at the time of diagnosis and commonly have fever, weight loss and/or night sweats. Symptoms due to compression of adjacent mediastinal structures are infrequent, but may include pain, dyspnoea, stridor, or superior vena cava syndrome. Local infiltration into the chest wall, pleura and pericardium is not uncommon.

In the present report, two interesting cases of chest wall swellings that in fact were extensions of primary mediastinal lymphoma are given. Histopathology of the tumour was large B cell lymphoma (CD20+). The first case was in a 23-year-old woman, with dramatic onset but a good outcome. The second was in a 34-year-old Pakistani woman, with insidious onset and poor outcome due to extent and invasion by the tumour. Interesting CT images are presented showing chest wall and left supraclavicular swelling.

Background

All left supraclavicular swellings need investigation for lesions other than metastases from the stomach, testicles, ovaries, pancreas and so on. Chest wall swellings may not always arise from constituents of the chest wall but may represent an extension of the mass inside. Acute presentation of aggressive lymphomas is not unusual, and tissue biopsy is essential to establish the diagnosis and plan treatment. Surgery has no role in the treatment of mediastinal lymphoma, and symptoms may not be present at presentation.

Case presentations

Case 1

A 23-year-old woman presented with a 2-week history of swellings on the chest wall and left side of the neck. The patient gave a history of a mild, boring pain in the left parasternal region but no experience of fever, weight loss or night sweats and she denied any personal or family history of tuberculosis. The pain was relieved by analgaesics such as paracetamol and ibuprofen initially, but became continuous and was only relieved by tromadol. Examination revealed an average woman with a firm to hard mass of 5×5 cm on the anterior chest wall adjacent to the sternum, slightly painful on pressure (), and a left supraclavicular lymph node 3.5×4 cm, firm, non-tender and mobile (). Complete blood counts were normal, and the erythrocyte sedimentation rate was 115 mm/h. Serum transaminases were normal as was serum lactic dehydrogenase and uric acid. The possibility of a tumour arising from chest wall structures was considered with the following differential diagnoses ().

Anterior chest wall swelling and left supraclavicular swelling.

Table 1

In view of the left supraclavicular lymph node, other possibilities were discussed ().

Table 2

Differential diagnoses of left supraclavicular masses

However, x ray of the chest showed a large mediastinal mass, which on CT scanning was revealed to be a large mass extending beyond the anterior chest wall and sternum (), encasing the adjacent vessels. Sections at the level of the neck revealed left supraclavicular swelling consistent with a lymph node. Fine needle aspiration of the masses and a mediastinascopic biopsy were inconclusive. A CT scan of the abdomen revealed hepatosplenomegaly, but bone marrow aspiration was negative for any infiltration. An incisional biopsy of the chest wall mass proved it to be a diffuse large cell B cell lymphoma (CD 20+) (). The patient was diagnosed as having a primary mediastinal lymphoma of the aggressive non-Hodgkin’s type. The patient was given cyclophosphamide, vincristine, doxorubicin, prednisolone and rituximab (CHOP-R) chemotherapy and is so far doing well.

CT scan of the chest and mediastinum showing tumour extension beyond the sternum and contiguous with chest wall swelling.

Biopsy of mass showing large cell lymphoma (H&E stain).

Case 2

Case 2 was a 34-year-old Pakistani woman, who presented with non-productive cough, fever and weight loss of 6-months duration. Examination revealed an average build woman with a tender subcutaneous mass anterior to the sternum and cervical and axillary lymphadenopathy. An x ray of the chest showed mediastinal widening; complete blood counts were normal, and the erythrocyte sedimentation rate was 102 mm/h (first hour). CT of the chest revealed a huge lobulated mass with areas of necrosis, eroding the sternum and extending subcutaneously (). There was left-sided pleural effusion but no hepatosplenomegaly and no bone marrow involvement. A lymph node biopsy revealed a large cell lymphoma (CD 20+). The patient was subjected to radiotherapy to decrease the tumour bulk, but unfortunately died of a massive bout of bleeding from the upper respiratory tract due to invasion of the trachea by the tumour.

CT scan of the chest of patient 2 showing a mediastinal mass eroding the sternum and encasing mediastinal structures, with areas of necrosis.

Differential diagnosis

See .

Treatment

Patient 1 was given CHOP-R chemotherapy and is so far doing well. Patient 2 was treated with radiotherapy

Outcome and follow-up

Patient 1 is doing well after 1 year of treatment. Patient 2 unfortunately died of a massive bleed.

Discussion

The anterior mediastinal compartment is anterior to the pericardium and includes lymphatic tissue, the thymus, the extrapericardial aorta and its branches, and the great veins. Masses in the anterior compartment are more likely to be malignant than those found in the other mediastinal compartments. Lesions most commonly found in the anterior mediastinum are thymomas, germ cell tumours, lymphomas, intrathoracic thyroid tissue lesions and parathyroid lesions.¹

Although patients with disseminated systemic lymphoma often have involvement of the mediastinum, 5% to 10% of patients with lymphoma present with primary mediastinal lesions. Primary mediastinal lymphoma accounts for 10% to 20% of primary mediastinal masses and is the second most common primary anterior mediastinal mass in adults. ² Most mediastinal lymphomas are seen in the anterosuperior mediastinum, with the remainder being found in the middle mediastinum.

Primary mediastinal Hodgkin’s lymphoma occurs predominantly in the third and fourth decades, and is usually of the nodular sclerosing variety.³ Non-Hodgkin’s lymphoma is found in all age groups but is more common in women in the third and fourth decades.²

The majority of patients with primary mediastinal lymphoma are symptomatic at the time of diagnosis and commonly experience fever, weight loss and/or night sweats. Symptoms due to compression of adjacent mediastinal structures are infrequent, but may include pain, dyspnoea, stridor, or superior vena cava syndrome. Local infiltration into the chest wall, pleura and pericardium is not uncommon.³ Our patient presented with swelling of the chest and a swelling in the neck in addition to chest pain. The diagnosis is initially suggested by radiographic studies demonstrating a lobulated mass in the anterosuperior mediastinum. Tissue confirmation of the diagnosis is mandatory, and may be accomplished by excision of an enlarged cervical or supraclavicular lymph node (if present), mediastinoscopy, mediastinotomy or thoracotomy. Fine needle aspiration biopsy usually does not provide adequate tissue to establish the diagnosis.

Treatment of mediastinal Hodgkin’s lymphoma consists of chemotherapy and/or radiotherapy. The 5-year survival rate has improved dramatically over the past 20 years, and is currently approximately 75%.

Mediastinal lymphoma is usually a locally invasive tumour where surgical resection can play no role. In rare cases where a tumour is identified that is readily resectable, complete excision with adjuvant therapy may be indicated because favourable results with this approach have been previously reported with lymphomas at other extranodal sites.

In contrast to the improved results in patients with mediastinal Hodgkin’s lymphoma, mediastinal non-Hodgkin’s lymphoma is still associated with a poor prognosis. If treatment is followed as per international prognostic index (IPI) the outcome is variable, and the lower the index at the start of treatment the better the 5-year disease free survival rate; the higher the IPI, the worse the 5-year disease free survival rate.⁴

Learning points

• All left supraclavicular swellings need investigation for lesions other than metastases from the stomach, testicles, ovaries, pancreas and so on.

• Chest wall swelling may not always arise from the constituents of chest wall, but may represent an extension of the mass inside.

• Acute presentation of aggressive lymphomas is not unusual, though symptoms may not be present at presentation.

• Tissue biopsy is a must to establish the diagnosis and plan treatment.

• Surgery has no role in treatment of mediastinal lymphoma.

Acknowledgments

We acknowledge the support provided by Mrs Manal Karima (postgraduate education and training director) and Ms Mecciya Hadi Majrooshi (senior secretary of hospital administration).

Footnotes

Competing interests: None.

Patient consent: Patient/guardian consent was obtained for publication.

REFERENCES

1. Davis RD, Jr, Oldham HN, Jr, Sabiston DC., Jr Primary cysts and neoplasms of the mediastinum: recent changes in clinical presentation, methods of diagnosis, management and results. Ann Thorac Surg 1987; 44: 229. [PubMed] [Google Scholar]2. Sekiguchi N, Nishimoto J, Tanimoto K, et al. Primary mediastinal large B-cell lymphoma: a single-institution clinical study in Japan. Int J Hematol 2004; 79: 465–71 [PubMed] [Google Scholar]3. Kerry J. Savage primary mediastinal large B-cell lymphoma. Oncologist 11: 488–95 [PubMed] [Google Scholar]4. Wilder RB, Rodriguez MA, Medeiros LJ, et al. International prognostic index-based outcomes for diffuse large B-cell lymphomas. Cancer 2002; 94: 3083–8 [PubMed] [Google Scholar]

Painful chest wall swelling | Postgraduate Medical Journal

A 70 year old man, a non-smoker, presented with a painful swelling over the right sternoclavicular joint and low grade continuous fever for a period of two months. The patient had been empirically started on antituberculous therapy on the suspicion of tuberculous osteomyelitis, but his fever and swelling persisted.

On clinical examination, a hard and tender swelling was present over the right sternoclavicular joint. The swelling was fixed to the underlying bone, but not to the overlying skin. The patient did not have any skin lesions. Examination of his respiratory system revealed no abnormality. Examination of other systems was unremarkable.

Blood investigations showed a haemoglobin concentration of 160 g/l. The total white blood cell count was 10.5 × 10⁹/l with 72% polymorphonuclear cells, 26% lymphocytes, and 2% eosinophils. ELISA testing for HIV infection was negative. Other haematological and biochemical parameters were within normal limits.

Fine needle aspiration cytology of the swelling showed a few red blood cells, polymorphonuclear cells, lymphocytes, and a few epithelioid cells in a necrotic background. No granulomas or giant cells were seen.

Computed tomography (plain and contrast) of the thorax revealed a right sternoclavicular and first costoclavicular joints arthropathy with subchondral sclerosis and abnormal periarticular soft tissue mass. A technetium-99 bone scan was done (shown in fig 1) which revealed the diagnosis.

Questions

(1)

What does the bone scan show?

(2)

What is the diagnosis and name the associated syndrome.

Answers

QUESTION 1

The bone scintigraphy shows an increased radiotracer uptake in the region of the right sternoclavicular joint and the manubrium sterni (“bullhead” sign). Increased uptake was also seen in the region of the left knee joint, the left ankle joint, D9 thoracic vertebrae, and the posterior end of the left eighth rib.

QUESTION 2

The diagnosis is sternocostoclavicular hyperostosis (SCCH).1 The associated syndromes are called SAPHO syndrome (an acronym for synovitis, acne, pustulosis, hyperostosis, and osteitis),1
2 CRMO (chronic recurrent multifocal osteomyelitis),1
2 ACW syndrome (anterior chest wall),2 or PAO (pustulotic arthro-osteitis). 1
3

Discussion

SCCH is observed mainly in young and middle aged adults, and is rarely seen above 60 years of age.1 Bone and joint involvement are the commonest findings. Patients present with pain and swelling of gradual onset, most commonly involving the medial end of the clavicle and the manubrium sterni. Involvement of only one clavicle and the adjacent part of the manubrium sterni are also a frequent event. The ribs are similarly involved, with changes occurring in the anterior costochondral junction and/or in the posterior costal arch, leading to limitation of the thoracic cage mobility.1 The swelling might also present as a solitary neck mass or as thoracic sinus formation.4
5 Flat bones like the ileum, the mandible, long bones, or spine could also be involved in the disease process.1 The involved bone shows sclerotic changes with periosteal, articular, or periarticular inflammation.1
2

The skin involvement in SAPHO and PAO is usually in the form of palmoplantar pustulosis, palmoplantar pustular psoriasis, or severe acne known as acne conglomerata or acne fulminans. Though skin involvement is a common feature, the absence of skin lesions at the time of presentation is only apparent because the skin lesions may have been transitory, or may develop decades after the bony manifestation. The patient may have other manifestations like thoracic outlet syndrome, thrombosis of the subclavian vein, or superior vena cava syndrome.1

Diagnosis can be made by radiography. Bone scintigraphy using radiotracer material like technetium-99 is the imaging modality of choice. It reveals hot spots in the areas of increased uptake. “Bullhead” sign refers to increased uptake by the medial end of the clavicles and manubrium sterni, corresponding to a bull’s head. This sign is a typical and a highly specific manifestation of SSCH syndrome and helps to confer the diagnosis.1 Also a bone scan is able to detect early bone involvement, which would not yet be seen radiographically. Ultrasonography, computed tomography, and magnetic resonance imaging contribute little to the identification and location of the lesion. 1

There are no specific markers for these syndromes. Blood counts are usually normal. A moderate increase in C reactive proteins, erythrocyte sedimentation rate, and alpha-2 and gammaglobulins may be present. Histopathological examination of the biopsied tissue shows hyperostosis. Later in the course of the disease an infiltrate of mononuclear cells, lymphocytes, plasmocytes and a few multinucleated cells may be seen.1 Various theories have been postulated regarding the aetiopathogenesis. A reactive osteomyelitis is potentially triggered by saprophytes or caused by infectious agents like Propriobacterium acne, which has been found at the site of a lesion in many cases. The link with seronegative spondylarthritis also suggests a genetic predisposition, loosely associated with HLA-B27.

The treatment involves the use of anti-inflammatory drugs. The duration of treatment has not been standardised. Corticosteroids may be used in the most severe form. Colchicine and sulphasalazine may prove to be successful. 1 Thus the recognition of SCCH syndrome is essential to differentiate this benign condition from other serious involvements like bacterial osteomyelitis, infectious spondylodiscitis, Ewing’s sarcoma, and Paget’s disease.5 This can protect an individual from unnecessary therapeutic procedures and unnecessary medications.1
3

Final diagnosis

Sternocostoclavicular hyperostosis.

Learning points

• Sternocostoclavicular hyperostosis (SCCH) is a benign condition that involves bones and joints.

• SCCH is seen in the young and middle aged, rarely in old age.

• Associated syndromes include SAPHO, PAO with skin involvement.

• Diagnosis is by bone scan with classical “bullhead sign”.

• Treatment consists of anti-inflammatory drugs, rarely in severe cases with steroids.

• SCCH should be considered in the differential diagnosis of bacterial osteomyelitis, Paget’s disease, Ewing’s sarcoma, and infectious spondylodiscitis.

Pericarditis – Managing Side Effects

Chemocare.com

Care During Chemotherapy and Beyond

What Is Pericarditis?

Pericarditis is an inflammation (redness and swelling) of the thin,
protective membrane that surrounds the heart, and keeps it in its proper anatomic
location. The thin, loose tissue will allow the heart to change in size, and move
with each heartbeat. Inflammation of this membrane may cause chest pain.

Causes of Pericarditis Include:

• Infection – From a bacteria or a virus, which causes inflammation; rheumatic fever,
  or tuberculosis
• Cancers – causing inflammation of the pericardium from spreading of lung, breast,
  renal cell cancer; Hodgkin’s disease, and lymphoma
• Certain Immune diseases – such as Systemic Lupus Erythematosus (SLE, or Lupus)
  can cause pericarditis
• Injury to the heart muscle – from radiation therapy to the chest area, drugs, or
  a heart attack (myocardial infarction) – can cause pericarditis
• Sometimes the cause is unknown

Symptoms of Pericarditis:

• Chest pain is most often sharp or burning in character
• Pain may start in the chest, and spread to the throat, jaw, shoulder blades, or
  arms (left or right). However, you may feel symptoms of
  palpitations instead of pain.
• You may experience a feeling of chest heaviness, or tightness. There may be increased
  pain when you take a deep breath, or change positions (especially when you lean
  forward).
• You may have nausea, sweating, or dizziness associated with your chest pain. It
  may also cause you to feel short of breath. Your chest pain may spread to the stomach,
  and feel like indigestion.
• Some people may feel terribly excruciating chest pain, and others may experience
  a mild discomfort. The severity of the symptom does
  not indicate how severe the damage to the heart muscle may be.
• Pericarditis may cause you to be overly
  tired, or very weak (fatigued). It may be hard for you to do any kind of your normal
  activities.
• You may experience sudden or gradual shortness of breath, either at rest or while
  performing any type of activity. This may include walking to the door, or climbing
  stairs.

Things You Can Do About Pericarditis:

• The goal of treating pericarditis is to identify
  and treat the cause of your symptoms. If pericarditis is due to a bacterial
  infection, you will most likely receive intravenous (IV) antibiotics in the hospital.
  Non-steroidal Anti-Inflammatory (NSAIDS) medications, or aspirin, will likely be
  given to decrease the inflammation of the lining of your heart, and provide comfort.
• If you smoke, be sure to quit. Smoking can increase the chance of developing chest
  pain and heart disease.
• Make sure to exercise, under the supervision of your healthcare provider. Walking,
  swimming, or light aerobic activity may help you to promote the flow of oxygen in
  your lungs and blood, thus reducing your symptoms. Discuss with your
  healthcare provider how you can maintain your optimal level of functioning during
  this illness.
• Eat a well -balanced meal, limiting salt intake, high fat and high cholesterol foods.
• Make sure you tell your doctor, as well as all healthcare providers, about any other
  medications you are taking (including over-the-counter, vitamins, or herbal remedies).
  Do not take aspirin or products containing aspirin unless your healthcare provider
  permits this.
• Remind your doctor or healthcare provider if you have a history of diabetes, liver,
  kidney, or heart disease.
• Notify your healthcare provider if you have a family history of heart disease, stroke,
  high blood cholesterol, or high blood pressure, in a first or second-degree relative.
• If you are ordered a medication to treat your pericarditis,
  do not stop taking any medication unless your healthcare provider tells you to.
  Take the medication exactly as directed. Do not share your pills with anyone.
• If you miss a dose of your pericarditis medication, discuss
  with your healthcare provider what you should do.
• Use relaxation techniques to decrease the amount of anxiety you have. If you feel
  anxious, place yourself in a quiet environment, and close your eyes. Take slow,
  steady, deep breaths, and try to concentrate on things that have relaxed you in
  the past. Such techniques may lessen symptoms of pericarditis.
• If you experience symptoms or side effects, especially if severe, be sure to discuss
  them with your health care team. They can prescribe medications and/or offer
  other suggestions that are effective in managing such problems.
• Keep all your appointments for your treatments.

Drugs That May Be Prescribed by Your Doctor:

Your doctor or healthcare provider may prescribe certain drugs to help your heart
muscle work more effectively, or to control your symptoms of pericarditis.
These may include:

• ACE inhibitors – These drugs work by opening, or dilating, your
  arteries. They will lower your blood pressure, and improve blood flow to your
  kidneys, and throughout your body, thus lessening your symptoms.
  Your healthcare provider may also prescribe these medications if you have diabetes
  or protein in your urine, to protect your kidneys. Some examples of this medication
  may include: enalapril maleate (Vasotec^®), lisinopril
  (Zestril^®), and fosinopril sodium (Monopril^®)
• Antibiotics – If your doctor or healthcare provider suspects that
  a bacterial infection has caused your pericarditis (not a viral), he or she may
  order antibiotics, usually intravenous (IV). If you are prescribed antibiotics,
  you may need to be admitted to the hospital unit for evaluation.
• Antianxiety medications: If you have symptoms of anxiety,
  which might be aggravated by your symptoms of pericarditis, your healthcare
  provider may prescribe an Anti-anxiety medication, called an anxiolytic.
  These medications will help you to relax. These may include lorazepam (Ativan^®), or alprazolam (Xanax^®).
  It is important to take these medications only when you are feeling anxious. Do
  not operate heavy machinery, or drive an automobile while taking these. If these
  medications do not control your symptoms, discuss this with your doctor.
• Aspirin – Depending on your overall health status, your healthcare
  provider may prescribe aspirin as a “blood thinner”, or to relieve your pericarditis.
  Aspirin works by preventing platelets in your blood from forming blood clots (anti-platelet).
• Beta-blockers – can be used to slow down your heart rate,
  and improve blood flow through your body, thus lessen symptoms of pericarditis.
  You may take this drug if you have been diagnosed with irregular heartbeats, or
  high blood pressure. Some examples of this medication may include: Metoprolol (Lopressor^®), propranolol (Inderal^®),
  and atenolol (Tenormin^®).
• Calcium Channel Blockers – These medications may be given to treat
  chest pain, high blood pressure, or irregular heartbeats. A few common drugs include
  verapamil HCL (Calan^®), and diltiazem (Dilacor
  XR^®).
• Nitrates – such as nitroglycerin, work to increase blood flow to
  the heart. They also decrease the work of the heart by dilating (expanding) the
  arteries, thus lessening your symptoms. You may take
  this during an episode of chest pain, if your doctor has determined that it is safe.
• Non-steroidal anti-inflammatory (NSAID) agents – Such as naproxen
  sodium and ibuprofen may provide relief of pain. If you are to avoid NSAID drugs,
  because of your type of cancer or chemotherapy you are receiving, acetaminophen
  (Tylenol^®) up to 4000 mg per day (two extra-strength
  tablets every 6 hours) may help. It is important not to exceed the recommended daily
  dose of Tylenol^®, as it may cause liver damage.
  Discuss this with your healthcare provider.
• Do not stop any of these medications abruptly, as serious side effects may occur

When to Contact Your Doctor or Health Care Provider:

Call your doctor with the following symptoms:

• Fever of 100. 5° F (38° C), chills, sore throat (possible signs of infection).
• Sudden or gradual shortness of breath, chest pain or discomfort; swelling of your
  lips or throat should be evaluated immediately
• Feel your heartbeat rapidly (palpitations), and have not noticed this before
• Any new rashes on your skin, especially if you have recently changed medications
• Any unusual swelling in your feet and legs, or weight gain of greater than 3 to
  5 pounds in 1 week.

Note: We strongly encourage you to talk with your health
care professional about your specific medical condition and treatments. The information
contained in this website is meant to be helpful and educational, but is not a substitute
for medical advice.

Chemocare.com is designed to provide the latest information about chemotherapy to patients and their families, caregivers and friends. For information about the 4th Angel Mentoring Program visit www.4thangel.org

Chest Wall Cancer – Brigham and Women’s Hospital

Comprising less than five percent of all thoracic malignancies, cancers of the chest wall are rare and difficult to treat. Chest wall tumors can develop in the bones, soft tissues and cartilage of the chest cavity, which contains the heart, lungs and other organs. These tumors typically involve invasion or have metastasized from adjacent thoracic tumors, and are malignant in more than half of cases.

The most common chest wall cancer is sarcoma of the chest wall, including:

Other chest wall cancers include metastatic cancer, desmoid tumor and neurogenic tumors.

Tumors in the chest wall typically manifest as painful, quickly growing and easily palpable masses. Surgery is often necessary, and may be followed by plastic surgery reconstruction to recreate a normal appearance.

Physicians and surgeons at the Brigham and Women’s Hospital (BWH) Lung Center provide comprehensive, specialized care for patients with chest wall cancer. As the thoracic surgical and pulmonary medicine specialists for Dana-Farber/Brigham and Women’s Cancer Center, our physicians collaborate with other specialists to provide patients with a highly informed diagnosis and a cohesive treatment plan.

What are the risk factors for chest wall cancer?

While chest wall cancer is rare, factors contributing to an increased risk for chest wall cancer include:

• Advanced age, as certain chest wall cancers are more prevalent among elderly
• Previous radiation to the chest
• Living in certain parts of the world
• History of a previous cancer

What are the symptoms of chest wall cancer?

The most common symptoms of chest wall cancer are:

• Chest pain
• Swelling in the chest
• A mass or lump protruding from the chest
• Muscle atrophy
• Impaired movement

Sometimes chest wall cancer does not exhibit any symptoms. About 20 percent are found incidentally on chest X-rays. For that reason, it is important that you regularly see your physician and alert him or her should you notice any irregularities.

How is chest wall cancer diagnosed?

To diagnose your chest wall cancer, our specialists will carefully review your medical history and conduct a full physical examination. He or she will likely order additional tests, including:

Our thoracic radiologists confine all their work to reading radiographic studies of the chest. They are highly skilled at recognizing chest wall cancers and patterns of spread. Our pathologists are internationally recognized as research leaders in the accurate diagnosis of rare sarcomas. The ability to provide a definitive diagnosis is invaluable to our multi-specialty treatment team.

What are the treatment options for chest wall cancer?

Specialists at Brigham and Women’s Hospital offer both conventional and novel therapies for the treatment of chest wall cancer, personalized to each patient. Depending on your medical history and the stage of the cancer, your treatment may include chemotherapy, radiation therapy and/or surgery.

What are the non-surgical treatment options for chest wall cancer?

Although a traditional surgical approach is still needed for complex chest wall cancers, Brigham and Women’s Hospital has pioneered and refined the most advanced surgical treatments for chest wall cancer, including intraoperative chemotherapy. Surgery for chest wall cancer is typically used in conjunction with a combination of other treatments, including:

• Chemotherapy involves anticancer drugs that aim to kill cancer cells throughout the entire body. Chemotherapy is often used before or after surgery, although it can be used alone in advanced cases.
• Radiation therapy uses high-energy rays to shrink or kill cancer cells. It is often used alongside chemotherapy before and after surgery.

What is chest wall cancer surgery?

The purpose of surgery is to remove all visible disease. We also strive to preserve function of the chest and arms so patients can continue to enjoy activities important to them, including golf and other sporting activities. Surgical options for chest wall cancer include:

Chest wall resection and reconstruction is the primary surgical option for chest wall tumors. This surgery involves the removal of one or more ribs to extract the tumor, followed by reconstruction to recreate a normal appearance after invasive surgery. This can involve prosthetic materials and/or rotation of muscle flaps.

Video-assisted thoracic surgery (VATS), a minimally invasive procedure that involves the insertion of a thoracoscope (small camera) and surgical instruments into small incisions in the chest to remove the tumor.

What can I expect?

A multidisciplinary team will work with you every step of the way, from diagnostics through evaluation, to create a cohesive and comprehensive treatment plan. Our unique approach features same day consultations with multiple specialists and fosters seamless, expert care. Your medical condition will be closely monitored and managed to promote optimal lung functioning and an improved quality of life.

If you require surgery, you will meet with your healthcare team first for pre-operative information and tests. On the day of your surgery, you will receive care from surgeons, anesthesiologists and nurses who specialize in thoracic surgery and interventional pulmonary procedures. After surgery, you will recover in our designated thoracic post-surgical care unit where you will receive comprehensive care by an experienced surgical and nursing staff.

Team-based care

Chest wall cancer patients benefit from the wide range of specialists at The Lung Center, including thoracic surgeons, medical and radiation oncologists, pulmonologists and imaging experts. This collaboration ensures comprehensive diagnosis and targeted treatment for patients.

Any recommended surgery or procedure will be performed by an experienced, board-certified surgeon, in collaboration with the treatment team including nurses and physician assistants, all of whom specialize in taking care of patients with chest wall cancer.

How do I book an appointment or find directions?

What other resources can I read on thoracic cancer?

Learn more about thoracic cancer topics in our health library.

Visit the Kessler Health Education Library in the Bretholtz Center for Patients and Families to access computers and knowledgeable staff.

Access a complete directory of patient and family services.

Complications of Lupus | Michigan Medicine

Topic Overview

Some people who have lupus (systemic lupus erythematosus, or SLE) develop complications with internal organs, such as the kidney, heart or lungs.

Living with lupus

Most people with lupus are able to continue their usual daily activities. You may find that you need to cut back on your activity level, get help with child care, or change the way you work because of fatigue, joint pain, or other symptoms. You may find that you have to take time off from daily activities entirely.

Most people with lupus can expect to live a normal or near-normal life span. This depends on how severe your disease is, whether it affects vital organs (such as the kidneys), and how severely these organs are affected.

Lupus usually does not cause joint damage or deformity, which may happen in people who have rheumatoid arthritis, another autoimmune disease.

Medicines used to treat moderate to severe lupus have side effects. It can be difficult to tell what problems are part of the natural course of the disease and what problems are due to effects of medicines used to control the disease.

In the past, lupus was not well understood. People who had lupus died younger, usually of problems with vital organs. Now that the disease can be treated more successfully, life expectancy with lupus has increased significantly.

Birth control, pregnancy, and lupus

Hormones such as estrogen and prolactin are sometimes used for hormone therapy, birth control, and as part of fertility treatments. Studies do not agree on whether taking hormones increases the risk for lupus or for lupus symptom flares. If you are thinking about taking hormones, talk to your doctor about the risks and benefits of this treatment.

Lupus doesn’t typically affect a woman’s ability to conceive. But if you are having a lupus flare or are taking corticosteroid medicines, you may have irregular menstrual cycles, making it difficult to plan a pregnancy.

It is not clear whether women have more lupus flares during pregnancy. But there does seem to be an increased risk to the developing fetus.^{footnote 1} The risks are decreased if the woman avoids becoming pregnant during a period of active lupus activity. So it’s a good idea for women who have lupus to use effective birth control when lupus is active. If you plan to have a baby or are already pregnant, it is very important that you and your doctor discuss how lupus may affect your pregnancy.

Kidney problems

Kidney problems affect many people who have lupus. These problems usually don’t cause any symptoms, but some people may notice swelling in their legs or ankles (due to fluid retention) that they have not had in the past. The first sign of kidney problems is often abnormal urinalysis findings, such as protein, blood, or white blood cells in the urine or granular or red cell casts (clumps of red blood cells or kidney cells).

In a few cases, kidney problems are so severe that the kidneys stop working properly or fail completely. Depending on how severe kidney damage is, treatment can include strong medicines to control the lupus, kidney dialysis, or a kidney transplant.

Heart problems

Heart problems caused by lupus include:^{footnote 2}

• Inflammation of the sac around the heart (pericarditis). This is the most common lupus-related heart problem.
• Hardening of the arteries that supply blood to the heart muscle. People with lupus are at increased risk for plaque deposits in arteries (atherosclerosis) that may cause coronary artery disease. They are also likely to develop plaque deposits at an earlier age than people who do not have lupus.
• Diseases of the heart valves. A few people with lupus may have slightly thickened heart valves, which makes them more susceptible to infections of the damaged valves (endocarditis), blood clots, or heart failure. Some people with damaged heart valves may need surgery to replace the valves.
• Inflammation of the heart muscle (myocarditis), which is uncommon but may lead to problems with the heartbeat or heart muscle. Myocarditis can cause serious heart problems, such as dilated cardiomyopathy and heart failure. With these problems, the heart can’t pump blood as well as it should.

Lung problems

About 1 out of 3 people who have lupus develop inflammation of the tissue around the lungs.^{footnote 1} Sometimes this causes no symptoms. At other times it causes painful breathing, coughing, or chest pain that is worse with a deep breath (pleurisy). Many people with lupus have chest pain when they breathe. When this pain is not caused by pleurisy, it is commonly caused by inflammation of the chest muscle, cartilage, or ligaments, or of the joints that connect the ribs to the breastbone (costochondral joints). In these cases, the lungs may not be affected.

Less common lung problems with lupus include fever, cough, and inflammation of the lung tissue (acute lupus pneumonitis). Some people with lupus produce an antibody that causes their blood to clot more easily (antiphospholipid antibody). These people may be at risk for clots in the lung (pulmonary emboli). An unusual complication is the buildup of fluid in the lungs (pulmonary edema), caused by heart or kidney problems.

Blood-related problems

Blood-related problems are common in people who have lupus, but they do not always cause detectable symptoms. These problems, which in a few cases are severe and even life-threatening, include:

• Changes in red blood cells, which carry oxygen; white blood cells, which fight infection; and platelets, which help the blood clot.
• Anemia caused by the destruction of red blood cells (hemolytic anemia), low white blood cell count (leukopenia), or low platelet count (thrombocytopenia). Anemia can be caused by both lupus and the medicines used to treat it.
• Changes in organs related to circulation, such as the spleen or lymph nodes.
• Production of antibodies that attack certain blood-clotting factors, causing the blood to clot easily. These antibodies are produced by about 1 out of 3 people who have lupus.^{footnote 1} They can cause a condition, called antiphospholipid antibody syndrome, which can lead to mild or severe blood-clotting complications.

Nervous system problems

Neurological (nervous system) problems associated with lupus include:

• Mild memory loss, trouble concentrating, and errors in insight and judgment.
• Headaches, which are common but are usually related to stress and tension. Migraine headaches occur in many people who have lupus.
• Nervous system problems that cause vision disturbance, dizziness, muscle weakness in the face, arms, or legs, or loss of temperature or pain sensation in the feet, hands, arms, or legs (cranial or peripheral neuropathy).
• Seizures. They may be caused by problems with blood pressure, infections, or inflammation in blood vessels in the brain.
• Strokes, ranging from mild to severe.

Mental health problems

The physical and emotional stress of coping with a chronic illness can make it difficult to maintain good mental health.

• Many people with lupus become anxious, depressed, or both.
• Psychosis, a mental-behavioral disorder in which a person may have delusions (firmly held but false beliefs) or hallucinations (false perceptions) or both, is seen in some people who have lupus. It can be caused by the disease or by medicines such as tranquilizers, corticosteroids, or opioid pain relievers.
• Manic behavior, including unusually high levels of energy and activity, difficulty sleeping, and irritability, can occur as a result of corticosteroid treatment for lupus. It is usually not serious and goes away when the medicine is discontinued.

Digestive system problems

Problems in the digestive system are not common with lupus but may include:

• Abdominal (belly) pain, often with nausea and vomiting.
• Enlargement of the liver.
• Inflammation of the pancreas (pancreatitis).
• Inflammation of the sac surrounding the intestines (peritonitis).
• Indigestion.
• Difficulty swallowing.
• Dry mouth.

Reminder of an Uncommon Diagnosis

Lack of awareness about isolated tubercular osteomyelitis of the sternum resulted in a delay in diagnosing the condition in an eleven-year-old girl who presented with a gradually increasing swelling over the sternum. Radiological, histological, and microbiological investigations helped diagnose the condition and the child responded well to antitubercular therapy (ATT) and surgical debridement. The report provides a brief description about the various management options available.

1. Introduction

With only a handful of childhood cases of tubercular osteomyelitis of the sternum described in the literature [1–3], many pediatricians have not had the opportunity to see and manage such cases. This communication describes a case afflicted with the condition with an aim of increasing awareness about tuberculosis of the sternum.

2. Case History

An eleven-year-old girl was admitted with complaints of a gradually increasing circular nonpainful swelling (diameter 10 cm) over the sternum for the past 3 months (Figure 1). There was no history of local trauma or other symptoms such as fever, rash, or swellings over the body or bleeding from any site. There was no contact with tuberculosis. The patient had received oral analgesics, antipyretic agents, and antimicrobial agents during the intervening period. The patient’s vital parameters were stable (pulse: 82/min, respiratory rate: 22/min, and BP: 108/64 mmHg) and anthropometric measurements were within centiles (weight: 30 kg, between 5th and 25th percentile; height: 129 cm, between 95th and 97th percentile; charts provided by the Centers for Disease Control, Atlanta). This child with BCG scar had no pallor, cyanosis, icterus, petechiae, ecchymoses, or lymphadenopathy. There were no swellings over the skull. The systemic examination was not contributory. The firm, nontender swelling with erythematous surface extended from manubrium to the sternal body. The child was investigated with the possible clinical diagnoses of tuberculous osteomyelitis and Langerhans cell histiocytosis.

The child’s hemogram was normal (hemoglobin concentration: 10.4 gm/dL; total leukocyte count: 10800/mm³; platelet count: 347000/mm³; no abnormal cells on the peripheral smear). Raised erythrocyte sedimentation rate (50 mm at one hour) and positive Mantoux test (2 tuberculin units, induration: 16 mm) supported a diagnosis of tuberculosis, despite a normal chest radiograph and sputum smear negative for acid-fast bacilli (AFB). The test for human immunodeficiency virus (HIV) antibodies was negative. Fine needle aspiration cytology (FNAC) showed a cellular smear with intact and degenerated polymorphs, lymphocytes, and macrophages on caseous necrotic background suggestive of a cold abscess. The CT scan of the chest and thorax showed a lytic lesion of the manubrium sternum with an overlying soft tissue (Figure 2) without any evidence of pleural effusion, enlarged mediastinal lymph nodes, or parenchymal lesions. The patient was started on four-drug intensive antitubercular therapy (ATT) consisting of isoniazid, rifampicin, pyarzinamide, and ethambutol in appropriate doses. The lesion was subjected to debridement and curettage. The debrided material demonstrated fragments of fibrocollagenous tissue bits with granualation tissue and foci of caseous necrosis with the presence of epithelioid cells and granulomas with Langerhans type of giant cells without any malignant cells on microscopic examination. The material obtained at debridement grew Mycobacterium tuberculosis on culture with the organism being susceptible to the first-line antitubercular drugs. The FNAC and biopsy tissue sent for cartridge-based nucleic acid amplification technique (CB-NATT) were returned as the tissues had undergone degeneration. The ATT was continued and the child demonstrated complete resolution and healing of the lesion at follow-up visit 2 months later. At the last follow-up visit six months into the treatment, it was noted that she remained asymptomatic and had gained 5 kg. It is planned to continue ATT for a total period of 12 months.

3. Discussion

Isolated tubercular osteomyelitis is quite rare in children [1–3] and we suspect that consequent nonfamiliarity with the condition was responsible for the diagnosis getting delayed by over three months. It can occur through reactivation of latent foci formed during the initial hematogenous or lymphatic dissemination of tubercular organisms or by extension from adjacent and contiguous mediastinal lymph nodes [4]. The delay in the diagnosis can be hazardous as it has the potential to cause serious complications such as secondary infection, fistula formation, spontaneous sternum fracture, compression or erosion of large blood vessels, tracheal compression, or extension of sternal abscess into the mediastinum, subcutaneous tissue, or pleural cavity and infiltration into the bone marrow [4].

Tubercular osteomyelitis of the sternum presents with local symptoms like swelling [1, 2, 4–7], discharge [2, 7, 8], or ulcer [4] with [4, 6, 8, 9] or without [3] associated pain. Systemic manifestations such as cough [5, 7], fever [1, 2, 5, 8], night sweats [6–8], weight loss [2, 5–8], malaise [6], and fatigue [6], even when reported, are generally less dramatic. Injury to the local site has been reported as a trigger in a few cases [7, 10].

The diagnosis of the condition is generally delayed by months [1, 2, 4–6, 8, 9]. Besides, the paucity of experience with the condition among doctors, the nonspecific nature of initial symptoms, paucibacillary nature of the disease, analgesic and anti-inflammatory drugs providing partial or short-lasting relief of main symptoms, and antimicrobial agents providing some relief in the presence of a secondary bacterial infection contribute to this delay. Chest radiographs (especially the anteroposterior views) may not show bone lysis, sclerosis, periostitis, osteoporosis, osteopenia, or sternal fracture [9] in the initial stages and these normal radiographs may pose diagnostic problems for the practitioners. Most physicians consider pyogenic infections, malignancy (including lymphoma or metastatic cancers), granulomatous lesions (sarcoidosis, actinomycosis, and fungal infections), and Brodie’s abscess in the differential diagnosis [9]. Ultrasonography can demonstrate the presence of soft tissue enlargement along with sinus formation [4]; the extent of bone and joint destruction [9] can be seen on the CT scan, even when the chest radiograph is normal. The CT scan can help detect mediastinal lymph nodes, which could be the underlying cause for sternal involvement. The HRCT may additionally help detect a parenchymal lesion not visualized on the chest radiograph. The MRI scan demonstrates abscess formation, bone marrow invasion [4], and the extent of the soft tissue mass even better than the CT scan. However, these imaging modalities and radionuclide scan can only define the extent of involvement and demonstrate the presence of complications. Only histopathological and microbiological investigations can help identify the etiology.

Antitubercular therapy is the mainstay of treatment and may be the only therapeutic modality needed to treat the condition [1, 2, 4]. Generally, the duration of ATT is 9 months; however, it can last for a longer period in children with extrapulmonary disease at the discretion of the treating physician [11]. We decided to prescribe ATT for 12 months in view of the sternum being an unusual extrapulmonary site. Nonresponse to medical treatment (persistence of discharge, nonhealing of ulcer, or persistence of constitutional symptoms) or presence of a large ulcer obviously mandates surgical intervention. As stated earlier, the need for histological or microbiological confirmation of diagnosis might necessitate debridement or aspiration. A school of thought proposes that such surgical intervention in all cases might promote healing, avert formation of a draining sinus, and prevent recurrence [3].

The diagnosis of isolated tubercular osteomyelitis of the sternum in children is a rarity even in India, where tuberculosis is endemic, resulting in delayed diagnosis. Fortunately, the child did not suffer from any complications and responded well to the first-line ATT. This case report with a brief overview of management modalities will serve as a reminder to doctors about this diagnosis and help minimize the delay in diagnosis and management. It should also be mentioned that judicious use of appropriate newer diagnostic techniques such as cartridge-based nucleic acid amplification techniques, heminested, cartridge-based real time PCR, and line probe assays can also help expedite the diagnostic process and provide clues regarding presence of a drug-resistant infection. Hopefully, these will ensure that children would be spared of unwarranted antibacterial therapy, repeated aspirations, and possibility of extension or complications of the disease.

Competing Interests

None of the authors has any competing interests in publishing this report.

Authors’ Contributions

Pradnya Joshi was responsible for the collection of data, literature search, interpretation of data, clinical care, preparation of the first draft, and approval of the final draft. Sandeep B. Bavdekar was responsible for the collection of data, literature search, interpretation of data, clinical care, intellectual inputs for improvement of the draft, and approval of the final draft. Sushma U. Save was responsible for the collection of data, interpretation of data, clinical care, intellectual inputs for improvement of the draft, and approval of the final draft.

Acknowledgments

The authors wish to thank Dr. RM Bharmal, Dean, TN Medical College and BYL Nair Charitable Hospital, Mumbai, for permitting them to use hospital records for publishing this report.

90,000 Breast cancer treatment at the EMC Cancer Center in Moscow

The EMC Institute of Oncology carries out comprehensive diagnostics and treatment of breast cancer according to modern American and European protocols (NCCN and ESMO) using modern methods of surgery, chemotherapy, targeted and hormonal therapy, and radiation treatment. For our patients, this is a unique opportunity to gain access to the best breast cancer treatment methods without going abroad. The decision on the treatment tactics for each patient is made at an interdisciplinary consultation (tumor board) with the participation of a chemotherapist, surgeon, mammologist, radiologist, histologist, mammologist; if necessary, an oncopsychologist is invited to the consultation, as well as related specialists.From the moment of initial treatment to the operation, no more than 10-14 days pass, which is extremely important in the treatment of malignant diseases.

Breast cancer risk factors

Breast cancer is the most common cancer in women in most of the developed countries of the world.

The incidence is especially high in Europe and North America. In Russia, breast cancer also ranks first in the structure of oncological pathology in women. According to statistics, 55 thousand people get sick with breast cancer in our country every year.women.

The presence of risk factors does not mean that a woman will definitely develop breast cancer. But knowledge of individual risk factors can help identify the disease at an early stage, when the disease is successfully treatable.

Breast risk factors include:

• Age: The risk of breast cancer increases between the ages of 45-50

• Weight: being overweight is a risk factor for postmenopausal cancer, but an increased body mass index is associated with a lower risk of premenopausal breast cancer

• Increased estrogen level

• High density breast tissue

• Hormone replacement therapy in menopause (long-term, more than 5 years, taking combined estrogen-progestin drugs in women aged 50-79 years)

• Reproductive factors: early onset of menstruation and late menopause, late labor and their absence, lack of breastfeeding

• Heredity is one of the main risk factors.About 90,039 10% of 90,040 of all breast cancers are associated with inheritance of mutations in the BRCA 1 and BRCA2 genes. In women with mutations in these genes, the lifetime risk of breast cancer is 50 to 85%.

Lifestyle and dietary habits are also associated with increased risk, in particular:

• Reduced physical activity

• Smoking

• Alcohol consumption

• Eating red meat more than 5 times a week.According to research, it increases the risk of developing hormone receptor positive breast cancer in premenopausal women.

According to some reports, a diet high in fruits and vegetables, as well as foods containing soy, may slightly reduce the risk of breast cancer. The role of antioxidants in reducing morbidity has not been proven. The effect of caffeine on morbidity has also not been scientifically proven.

Environmental Factors:

• Radiation therapy to the chest area in the past (for example, in the treatment of Hodgkin’s lymphoma)

• Working the night shift, according to some reports, is a risk factor for developing breast cancer, which may be associated with a lack of the hormone melatonin, the production of which occurs only at night.

Symptoms of breast cancer

In countries with a developed screening system, mammography is the result of mammography in the majority of patients with breast cancer. But in 90,039 30% of 90,040 cases, a palpable tumor is found in between regular mammographic examinations, such cases even got their name – “interval cancers” of the breast.

The “classic” signs of a breast tumor are a solid, immobile single formation with irregular edges.However, these signs do not allow judging the nature of education. Locally advanced cancer symptoms may include:

• enlargement of lymph nodes in the armpit

• skin thickening, orange peel effect.

Warning signs also include a visual change in the nipple – for example, retraction, discharge from the nipple.

How to protect yourself from breast cancer?

Breast cancer screening

Unfortunately, the above symptoms are often a sign of a common process.Therefore, for the early diagnosis of cancer, regular screening is important – this is a study that identifies the disease before its clinical manifestations.

Breast cancer screening starts at age 40-45 years and is carried out annually or every two years (international expert organizations give different recommendations). Therefore, in each individual case, the beginning of the examination and their frequency is best determined with a doctor.

The main research method adopted as a diagnostic standard is digital mammography.

Screening for women at risk begins earlier, usually 5 years before the age at which the next of kin was diagnosed with the disease. For women with a genetic predisposition, our clinic has developed special screening programs. According to international recommendations, they include contrast-enhanced magnetic resonance imaging, alternating with breast ultrasound every 6 months. We also carry out molecular genetic diagnostics – a test for the presence of BRCA 1 and 2 gene mutations.

Diagnosis of breast cancer

Diagnosis of breast cancer includes:

Clinical examination is important, but its role is insignificant for the early diagnosis of breast cancer, since palpation does not allow detecting small tumors or deeply located neoplasms.

Breast ultrasound is performed for women at any age. Ultrasound is an “operator-dependent” method, so it is important that the study is performed by a qualified specialist using modern equipment.Ultrasound is only an additional research method in the diagnosis of breast cancer.

Digital mammography is the main method for diagnosing breast cancer. EMC performs digital mammography with tomosynthesis – a layer-by-layer image of breast tissue. It has been proven that this technique increases the efficiency of breast cancer diagnostics by 20% in comparison with conventional mammography. Digital mammography has age restrictions and cannot be used for diagnostics in women under 40 years of age.

Important pathognomonic, i.e. a characteristic feature of breast cancer is the visible accumulation of microcalcifications in the image. Even those cases when there is no tumor node as such on a mammographic image, but there is only an accumulation of calcifications in a limited area, are an indication for a diagnostic and treatment procedure – sectoral breast resection, since the tumor can be X-ray negative and among these calcifications a malignant tumor – cancer in situ (non-invasive cancer).

MRI of the mammary glands with contrast is a highly informative method for diagnosing the mammary glands. The method is used in women with high breast density with suspected breast cancer based on mammography results, as a screening in young women with a genetic predisposition to breast cancer and in other difficult diagnostic cases.

The final method for diagnosing breast cancer is a breast tumor biopsy.

Fine-needle puncture biopsy (when a tumor is punctured with a thin needle of a medical syringe and the resulting cell material is sent for cytological examination) is not always sufficient for a diagnosis.For a full diagnosis and selection of the correct treatment tactics, it is necessary to perform a CORE biopsy, when tumor tissue is taken under local anesthesia of the skin of the gland for subsequent histological examination.

CORE biopsy is performed on an outpatient basis and allows to determine not only the histological structure of the tumor, but also to conduct an immunohistochemical study to determine the most important characteristics of the tumor: the presence or absence of hormonal receptors, the HER 2 / neu receptor, as well as the Ki-67 marker – the proliferation index, or the growth rate of tumor cells.

EMC Histology Laboratory has the highest marks of the independent quality control organization for immunohistochemistry NordiQC in the field of breast cancer diagnostics. If necessary and at the request of the patient, the diagnosis is verified (revision of histological preparations) in leading European and American oncological clinics.

Turning to the EMC Institute of Oncology, you can be sure that all the necessary diagnostic and therapeutic procedures will be carried out according to modern international standards.If pathological areas are found and a biopsy is necessary, it is performed on the day of the first visit, that is, immediately after the mammography. This approach not only saves you time, but also reduces unpleasant waiting and anxiety before the procedure.

Staging breast cancer

After the diagnosis is made, it is necessary to determine the extent of the tumor process, since cancer has a tendency to metastasize. Even a small tumor can give distant metastases to other organs.The approach to treatment and the prognosis of the disease depend on the stage.

The standard of examination is determined by the most frequent sites of breast cancer metastasis. As a rule, this is:

• regional lymphatic evils (axillary, supra- and subclavian intramammary lymph nodes),

• lungs,

• second mammary gland,

• liver,

• bones.

Screening for breast cancer staging may include:

According to statistics, PET / CT for breast cancer in at least 90,039 30% 90,040 cases changes the initial treatment tactics, allowing you to choose a personalized and effective treatment for each patient.

At EMC, PET / CT examination is carried out by qualified radiologists using modern equipment using high-quality radiopharmaceuticals of our own production and in the shortest possible time.Since 2016, patients registered or permanently registered in Moscow can undergo PET / CT for newly diagnosed breast cancer free of charge under the compulsory medical insurance policy if there is a referral from an oncologist.

If the patient complains of dizziness, unreasonable sudden headaches, a feeling of double vision, after excluding high blood pressure and orthostatic collapse, an MRI scan of the brain is performed.

Assessment of the defeat of axillary lymph nodes in breast cancer

One of the main sites of breast cancer metastasis are axillary lymph nodes located in the axillary region.Lymph node involvement is one of the most important factors in determining the long-term prognosis for breast cancer and the choice of treatment tactics.

• If tumor cells are detected in the lymph nodes, then there is a high likelihood of further spread of the tumor to various organs and tissues, therefore, in this case, adjuvant (postoperative) systemic chemotherapy is recommended for most women.

• In the absence of lymph node involvement, systemic therapy is prescribed less frequently, especially with small tumor sizes, as well as with other prognostically favorable factors (for example, with estrogen receptor-positive tumors).

In the meantime, adjuvant hormone therapy is given to all women with estrogen receptor-positive tumors, even in the absence of lymph node involvement. Hormone therapy has fewer side effects compared to chemotherapy and significantly reduces the risk of cancer recurrence in the future.

Examination of axillary (axillary) lymph nodes

Examination of the axillary lymph nodes is carried out by visual examination, palpation of the lymph nodes by an oncologist, ultrasound and biopsy.With proven damage to the lymph nodes, they are removed during the operation – axillary lymph node dissection.

Sentinel node biopsy is performed in early-stage patients with no signs of lymph node involvement. In this case, the first lymph node on the way of the lymph outflow from the tumor (the so-called “sentinel”) is removed, and its histological examination is carried out. EMC is one of the few clinics in Russia where sentinel lymph node biopsy is performed for breast cancer.

If no metastases are found in the sentinel lymph node, the risk of affecting the remaining lymph nodes is minimal. In this case, the diagnosis of the remaining lymph nodes or their removal is not required.

Thus, the procedure allows you to obtain important information for the staging of the disease, while avoiding serious complications, in particular, lymphatic edema of the arm – lymphedema, which often occurs as a result of extended axillary lymph node dissection.

Stages of breast cancer

Non-invasive breast cancer

The earliest stage of breast cancer is called in situ cancer.The term “in situ” means “in situ”.

Ductal carcinoma “in situ” (non-invasive ductal carcinoma) is a non-invasive malignant neoplasm that develops in the mucous membrane of the mammary gland ducts.

The primary treatment for ductal carcinoma “in situ” is the surgical removal of the affected breast tissue. The volume of tissue to be removed depends on the size of the affected area and the mammary gland, the degree of malignancy of the tumor, and the general condition of the patient.Most women undergo organ-preserving treatment – removal of a small area of ​​the breast – lumpectomy followed by radiation therapy. In older patients with a small tumor and a low grade of malignancy, only surgical treatment can be performed, without radiation. For extensive ductal carcinoma, a mastectomy may be recommended, during which a sentinel lymph node biopsy is usually performed.

Patients with in situ ductal carcinoma do not receive chemotherapy.Hormone therapy is prescribed for women with estrogen receptor-positive tumors. The main hormone therapy drugs for premenopausal women are antiestrogens. For postmenopausal women, aromatase inhibitors are prescribed.

Lobular carcinoma in situ (lobular carcinoma) is not a cancer in the literal sense of the word, but rather is considered a precancerous condition in which abnormal cells are found in the lobules of the breast.

Women who have been diagnosed with lobular carcinoma in situ should consult with a specialist about receiving treatment to reduce the risk of developing invasive cancer. Regular health monitoring, annual mammography, MRI and periodic breast examinations are required.

Stages of invasive breast cancer

Stage 1 and 2 breast cancers are called early stage or localized cancers.

Stage 1 breast cancer – tumor less than 2 cm, without affecting the lymph nodes.

Stage 2 breast cancer – the tumor has spread to the axillary lymph nodes and / or the tumor is larger than 2 but less than 5 cm.

Stage 3 breast cancer – Also called locally advanced cancer. It is characterized by a large tumor (more than 5 cm in diameter), extensive metastasis to the axillary (axillary) lymph nodes (when more than 10 lymph nodes are affected), the involvement of intramammary, supra- and subclavian lymph nodes.

In stage 3 cancer, the tumor can invade the skin and muscle tissue under the breast.

Inflammatory breast cancer – a fast-growing type of tumor that causes redness and inflammation of the breast belongs to stage 3 cancer, even with a small tumor and no lymph node involvement.

Stage 4 breast cancer – the tumor metastasizes to distant organs – bones, lungs, liver, etc. In this case, the size of the initial tumor and the degree of damage to the lymph nodes can be any.

Factors influencing the treatment of breast cancer

Today, the treatment of breast cancer is personalized, it depends not only on the stage of the disease, but also on the molecular biological subtype of cancer – a set of molecular characteristics of the tumor.An immunohistochemical study makes it possible to answer the question of whether the tumor contains receptors for estrogen and progesterone, the HER2 / neu receptor, and what is the proliferative index of the tumor Ki-67.

Generally speaking, tumors that express sex hormone receptors and do not express HER2 / neu receptors have a more favorable clinical course. These tumors tend to respond well to hormone therapy and are associated with a better prognosis.

If the HER2 / neu receptor is expressed in the tumor, the woman is prescribed targeted therapy with Herceptin for one year.

Triple negative breast cancer is a tumor that lacks receptors for estrogen, progesterone and HER2 / neu. As a rule, these are tumors with a high Ki-67, i.e. with a high proliferation index – this means that cells are dividing very quickly. This tumor is considered the most unfavorable and has an extremely high metastatic potential. But, on the other hand, such tumors are most sensitive to chemotherapy.

The molecular biological subtype of the tumor also suggests the most common sites of cancer metastasis.Triple negative tumors most often metastasize to the central nervous system, such as the brain. Therefore, when a woman with triple negative breast cancer complains of gait instability, dizziness, she must undergo an MRI of the brain. Hormone receptor-positive breast tumors are more likely to metastasize to the skeletal system.

The modern genetic analysis Oncotype DX (Oncotype), USA is available to the patients of the EMC Oncology Institute. Based on the analysis of the expression of a group of genes, the test makes it possible to assess the individual risk of cancer recurrence in a patient with an early stage of breast cancer and to make a decision on the need for chemotherapy.

Treatment of breast cancer stage 1 and 2

Treatment of patients with stage 1 and 2 breast cancer is almost identical with minor differences. There are two main surgical methods for treating localized breast cancer: mastectomy (removal of the breast) or organ-preserving surgery (removal of only the tissue affected by the tumor, or lumpectomy).

Organ-sparing treatment consists of organ-sparing surgery followed by radiation therapy, which reduces the risk of cancer recurrence.

However, there is a category of patients who do not need radiation therapy after breast-conserving surgery – these are elderly patients with small hormone-positive tumors, without involvement of the lymph nodes.

In the world’s leading cancer centers, 60% of 90,040 patients with early stage breast cancer undergo organ-preserving treatment. According to the results of numerous studies, there were no significant differences in survival rates after mastectomy and organ-preserving treatment, which allows us to consider these approaches equally effective.

EMC also favors organ-preserving treatments. In the process of breast-conserving surgery, additional correction of the volume and shape of the breast (lifting, reduction in size, correction of the other breast) can be carried out to achieve an optimal aesthetic result. This is called the oncoplastic approach.

If breast removal is unavoidable, skin-preserving mastectomy and mastectomy with preservation of the nipple-areola complex may be performed. We offer our patients all the most modern options for immediate or delayed breast reconstruction, including lipomodeling (correction using one’s own adipose tissue).

Operations are performed by a highly qualified surgeon with experience in leading European cancer centers Iskra Daskalova (Ireland).

New advances in breast cancer treatment

Radiation therapy for breast cancer

Radiation therapy at EMC is carried out on the latest generation TrueBeam Varian linear accelerators, which allow targeted irradiation of the tumor with minimal impact on the surrounding tissues.Such equipment has been installed in only a few dozen of the world’s leading oncology clinics. The specialists of the department, under the guidance of the chief radiotherapist of Moscow, Dr. Nidal Salim, carry out radiotherapy treatment according to modern international protocols.

For the first time in Russia, EMC has introduced a unique method for treating early stage breast cancer – organ-preserving surgical treatment with simultaneous intraoperative radiation therapy using the Xoft system (USA).The revolutionary technology allows radiation therapy to be carried out in one session right during the operation, which significantly shortens the treatment time and minimizes the side effects of radiation.

Systemic drug therapy for breast cancer

Adjuvant therapy is a systemic anticancer treatment that is carried out after surgical treatment. The goal of adjuvant therapy is to prevent the growth of cancer cells that may have spread throughout the body. Adjuvant systemic therapy is offered to most women with stage 2 disease and some patients with stage 1.

There are three main types of adjuvant systemic drug therapy for breast cancer:

• Chemotherapy. The decision on the need for chemotherapy is made by the oncologist based on many factors, including the stage of the disease, the degree of differentiation of the tumor, the presence of hormonal receptors, etc. The main drugs in the treatment of breast cancer are doxorubicin or adriamycin, cyclophosphamide, or cyclophosphamide and taxanes.The taxane group includes docetaxel and paclitaxel.

• Hormonal (endocrine) therapy. Conducted for patients with estrogen receptor-positive tumors, regardless of stage. Reduces the risk of cancer recurrence by 50% . There are two main types of hormone therapy that are used in adjuvant treatment: antiestrogens and aromatase inhibitors.

• Anti-HER2 therapy. Recommended for patients with tumors expressing the HER2 / neu receptor.Trastuzumab and pertuzumab are used as targeted drugs.

EMC oncologists-chemotherapists carry out all types of systemic drug therapy of any complexity level, use the latest drugs and methods of treating oncological diseases. The drugs are administered through the central venous access port in comfortable wards. At the end of the chemotherapy or targeted therapy session, the patient can go home. At the request of the patient, a special cold helmet is used during the treatment, which allows you to preserve the hair during the chemotherapy process.

Treatment of stage 3 breast cancer (locally advanced cancer and inflammatory cancer)

Stage 3 cancer is usually treated with a combination of chemotherapy, surgery and radiation therapy. Hormone therapy and targeted therapy with trastuzumab (Herceptin) may also be used. In most cases, systemic drug treatment is given before surgery, this is called neoadjuvant therapy. For locally advanced cancer, mastectomy is more often performed than breast-conserving treatment, and virtually all patients receive radiation therapy after surgery.

Treatment of breast cancer stage 4 and

In recent years, significant progress has been made in prolonging the life of patients with metastatic breast cancer, while maintaining the quality of life during treatment. Treatment methods are used that reduce the severity of symptoms and at the same time have minimal side effects on the body. As a rule, treatment tactics involve the judicious use of systemic therapy. Surgery and radiation therapy can also be used for local treatment of, for example, bone metastases, brain, spinal cord and skin metastases.

Prognosis for breast cancer

Five-year survival rate for breast cancer is:

• at 1 stage – 95%

• at 2A stage – 85%

• at stage 2B – 70%

• at 3A stage – 52%

• at 3B stage – 47%

• at 4 stages – 18%

Most breast cancer relapses occur within the first five years of diagnosis, especially in hormone receptor-negative tumors.

After a course of breast cancer treatment

Treatment is followed by a follow-up period. At this time, the patient regularly visits the doctor, the frequency of visits is determined by the doctor for consultations. In addition, it is necessary to undergo mammography annually so that in the event of a recurrence of a neoplasm, it can be diagnosed and treated at an earlier stage.

90,000 98% of women can be cured of breast cancer if the disease is detected at an early stage

As world statistics show, if breast cancer is detected at the first stage, then in 98% of cases, with appropriate treatment, you can completely get rid of the disease.At this stage, the neoplasm does not exceed two centimeters in diameter and can be easily removed.

As the stage of cancer increases, the chance of recovery decreases. In the second stage of the disease, the size of the tumor ranges from two to five centimeters in diameter, cancer cells are present in 4-5 lymph nodes. If you learn about a malignant breast tumor in the second stage, then the chance of recovery is 93%.

“At the third and especially the fourth stage, getting rid of the neoplasm of the mammary glands is much more difficult.Therefore, it is important to be attentive to breast health and to regularly visit a doctor, ”said Guram Kvetenadze, head of the department of breast surgery and reconstruction of the Moscow Research Center for Science and Technology. Loginova DZM.

The Metropolitan Department of Health recalled that breast cancer is the most common cancer in women, and also urged them to undergo regular breast examinations by medical specialists. The optimal frequency is considered to be once every two years.If the doctor finds any changes, then it is necessary to make a diagnosis in accordance with the recommendations of the doctors.

From October 19 to November 3, on weekends, 71 medical organizations of the DZM will wait for patients for a free breast health check-up. Women from 18 to 39 years old are offered to undergo an ultrasound examination, and women over 40 – mammography. On Saturdays, doctors will have an appointment from 9:00 to 18:00, on Sundays – from 9:00 to 15:00. Pre-registration is required by the contact phone number of the organization.

Open diagnostic days at cancer hospitals and lectures at the School of Women’s Health will take place on 19 and 26 October.

Events within the framework of the World Day Against Breast Cancer are held in 79 medical organizations of the Moscow Department of Health from October 12 to November 3. A complete list of activities is available on the website https://mosgorzdrav.ru/rmj

90,000 How is breast cancer in women treated?

Treatment for breast cancer depends on the nature of the tumor and its size, and includes surgery (surgical procedure) and cancer treatment, which may include radiation, chemotherapy, anti-hormonal treatment and biological treatment.A combination of several treatments will be prescribed according to the nature of the tumor and, in most cases, only after the final results of the operation have been obtained.

In any case, the treatment will be selected for each patient individually, depending on the nature of the tumor and its spread to the lymph nodes and on the type of operation, as well as taking into account her personal wishes.

What is the purpose of the surgical treatment?

The goal of breast cancer surgery is to remove the entire tumor, including healthy tissue around it, and check the lymph nodes in the armpit area.

Sometimes the removal of the breast is partial, sometimes it is necessary to remove the entire breast, and in both cases we are talking about relatively simple operations that last about an hour and are performed under general anesthesia. Since we are not talking about abdominal surgery, very often you can be discharged the very next day and very quickly return to your usual way of life. After conservative surgery (“partial excision” or “lumpectomy”), an additional course of radiation is usually required. After complete breast removal, radiation is required only in some cases.

Conservative breast removal (lumpectomy) : The purpose of the operation is to remove the tumor and maintain the shape of the breast. If we are talking about a small tumor, it is enough to remove only it so that the shape of the breast is preserved, except for a small scar, which is almost invisible in appearance.

When it comes to a large tumor or a small breast, sometimes a plastic surgery technique should be used to achieve the aesthetically optimal results, the so-called “oncoplastic repair”.This operation is considered more complex and sometimes additional surgery is required to give symmetry to the second breast.

In cases in which the tumor is not palpable, but only detected on tomography, a suspicious formation should be noted before surgery, usually with the introduction of a thin wire into the tumor. Such a mark is carried out under local anesthesia (like a biopsy) with full consciousness, under ultrasound or mammography, the day before the operation, or just before it.

Complete breast removal : In case of a relatively large tumor, or if the patient and doctor agree that no additional radiation is required, a mastectomy is performed, a complete resection of the breast.In most cases, it is possible to preserve the membrane, including the nipple, and make immediate reconstruction, most often with silicone implants and biological tissue. This part of the operation is performed by the plastic surgeon immediately after the completion of the resection.

Sometimes even in these cases an additional course of radiation is required, very often it becomes clear after the operation.

Surgical removal of lymph nodes under the mouse: As part of breast cancer surgery (and in some cases, when it comes to precancerous conditions), the lymph nodes-follicles should be checked.These nodes are located in the armpit area, and the breast tissue passes into them. To identify suspicious lymph nodes, mark them with a small amount of radioactive material (isotope), which is injected around the chest from one day to the hour of the start of the operation and / or injection of a small amount of blue dye around the tumor during the operation itself. Through a small incision in the armpit, suspicious follicles can be found and removed and sent for microscopic examination to check for cancer cells.

Today it is customary to remove only the lymph nodes affected by the disease. It is important to note that the absorption of the substance in the lymph nodes is not a sign of the spread of cancer cells, but only helps the doctor to remove the necessary nodes for examination during the operation.

If it is known that the tumor has spread to the lymph nodes even before the operation, biopsies of the follicles are not necessary and it is recommended to remove the nodes in the armpit using a method called “axillary dissection”.This is done through an incision in the armpit and requires the resection of the fatty tissue in the armpit within defined anatomical boundaries. This is because it is very difficult to distinguish between injured and healthy lymph nodes with the naked eye. Usually, about 10-20 lymph nodes are removed during surgery and drainage is left for accumulating lymph fluid for several days. Axillary dissection is associated with an increased risk of developing lymphoedema, that is, lymphatic chronic swelling of the forearm, especially if a course of radiation in the armpit is performed after the operation.There are special instructions designed to reduce the percentages of the risk of lymphadema, and it is important to remember that only less than 10% of those who underwent axillary disc dissection complained of lymphadema in the future.

Irradiation during surgery : In women over 55 years of age who have developed a tumor less than 2 cm in size, without involvement of the lymph nodes, radiation during the operation can, in most cases, be dispensed with. In Israel, treatment is carried out with an apparatus called Intrabeam, it emits radiation, which passes through a special applicator inserted into the hole formed after the removal of the tumor.Irradiation prolongs the operation by an additional hour, but basically saves the further course of irradiation (in about 10-15% of such cases, it turns out that irradiation during the operation is insufficient and therefore external irradiation should also be added).

Who treats breast cancer?

The treatment of breast cancer is a multidisciplinary field of medicine and is carried out by radiologists, surgeons, pathologists and oncologists, each in their own field, but acting in concert with regard to consultation and treatment.Usually, radiologists are actively involved in the early stages of diagnosis and perform most biopsies. In the next step, if the diagnosis is confirmed, the treatment will be taken by surgeons who will decide on the type of surgery and oncologists who will decide on radiation or chemotherapy or other treatment. Sometimes you will be asked to irradiate the tumor first to reduce its size.

In addition, nurses are involved in the treatment, genetic counselors, psychologists and social workers as needed.

Breast cancer

Breast cancer is a malignant tumor in the area of ​​the breast.

It is the most common cancer in women and most often occurs after age 40. In about 1% of cases, men develop it. Only one breast is initially affected.

Regular scheduled mammography and self-examinations allow timely diagnosis of breast cancer. In the early stages, the disease responds well to treatment.

Russian synonyms

Breast cancer.

Synonyms English

Breast cancer, Cancer of the breast.

Symptoms

In the early stages, breast cancer is often asymptomatic; palpation of the breast may reveal a lump.

Breast cancer symptoms:

• chest lump;
• changing the size, shape, contours of the breast;
• nodules, ulcers, “orange peel” on the skin of the breast, redness, peeling of the skin;
• nipple discharge;
• inverted nipples, areola deformation, nipple position change.

General information about the disease

Breast cancer is a malignant tumor formed from cells in the breast.

The mammary gland consists of 15-20 lobules located radially in relation to the nipple. They are surrounded by loose connective and adipose tissue. Each lobule is a tubular gland with a milk duct opening at the top of the nipple with milky pores. The nipple is intended for breastfeeding and is surrounded by an areola, a pigmented area in the form of a circle that outlines the nipple.

Breast cancer is the most common cancer among women. Its prevalence increases with age, starting at 40 years old, and peaks at 60-65 years old. In 1% of cases, breast cancer occurs in men. Typically, only one gland is affected.

In cancer, healthy breast cells become cancerous. Normally, cells, appearing in the right amount, die off at a certain time, giving way to new ones. Cancer cells begin to grow uncontrollably without dying off in due time.As a result of the accumulation of these cells, a tumor is formed. Cancer cells can metastasize – spread beyond the primary focus. In particular, breast cancer most often spreads to the lymph nodes, liver, lungs, bones, brain and skin.

The development of breast cancer is associated with genetic mutations, hereditary predisposition, obesity, with the effects of hormonal or radiation therapy.

The main types of breast cancer are distinguished according to the types of cells affected.

• Epithelial cancer. In most cases, cancer affects the epithelial cells of the breast that line the milk ducts or lobules. In this type of cancer, the tumor can be located within the ducts or lobules, without spreading to other tissues, this form of cancer is called ductal carcinoma in situ and lobular carcinoma in situ. However, over time, cancers in the ducts and lobules of the breast can spread beyond these areas, affecting nearby tissues and forming metastases.This form of cancer is called invasive ductal cancer and invasive lobular cancer.
• Paget’s disease. In this type of cancer, ductal cancer affects the skin covering the nipple and areola, and is combined with inflammatory skin lesions. At the same time, Paget’s malignant cells are present in the epidermis.

Stages of breast cancer

1) Cancer tumor up to 2 cm in size is located within the mammary gland.

2) A cancerous tumor, 2 to 5 cm in size, spreads outside the breast, affecting the axillary lymph nodes located on the same side as the tumor.

3) The cancerous tumor increases, the cancer spreads beyond the breast, nearby tissues, intrathoracic lymph nodes can be affected.

4) Cancer spreads outside the breast, affecting the axillary region and intrathoracic lymph nodes. Supraclavicular lymph nodes, lungs, liver, bones, brain may be affected.

Who is at risk?

• Women after 40 years. The risk of developing breast cancer increases with age, peaking at 60-65 years.

• Women who have already had cancer of one breast – the risk of developing cancer of the second breast in this case increases.
• Women who start menstruating before age 12 and women with late menopause (after age 52). The longer your period lasts, the higher your risk of getting sick.
• Women with a hereditary predisposition to breast cancer.
• Women with a genetic predisposition to the development of the disease.With a mutation in the BRCA1 and BRCA2 genes, the risk of developing breast cancer is significantly increased.
• Obese women. Adipose tissue promotes the production of estrogen, which can stimulate the growth of certain types of breast cancer.
• Never gave birth to women, as well as women who gave birth to their first child late (after 30 years).
• Women undergoing hormone therapy after menopause – permanent cessation of menstruation.
• Women who have undergone radiation therapy.

Diagnostics

Routine self-examinations and mammograms help to detect breast cancer in the early stages and subsequent successful treatment. All women over the age of 40 are advised to have a mammogram at least once every two years.

If breast cancer is suspected, mammography is first performed, the level of tumor markers is determined, and ultrasound is additionally performed. The diagnosis is confirmed by biopsy. Then studies are carried out aimed at determining the stage of the disease and identifying metastases.

Laboratory research

Tests for tumor markers in the blood:

Tumor markers are proteins that can be elevated in association with the development of cancer. However, their concentration can be increased in a healthy body as well. Therefore, the determination of the level of tumor markers is used as an auxiliary method for diagnosing cancer, for diagnosing relapses of the disease and assessing the effectiveness of its treatment.

Other research methods

• Mammography is an X-ray examination using specially designed equipment.It allows you to establish the presence of a tumor, determine its size and location.

• Ultrasound diagnostics (ultrasound). The data obtained in the course of the study complements the results of mammography.
• Biopsy – involves taking a tissue sample for subsequent laboratory examination. Only it allows you to confidently diagnose breast cancer and determine its type.
• Magnetic resonance imaging (MRI) and computed tomography (CT).
• After detection of breast cancer, its stage is established, metastases are detected. Can run:

• Healthy breast mammography;
• chest x-ray;

• densitometry (scanning of bones to measure their density) – in case of suspected metastasis of cancer in the bone.

• Identification of mutations in the BRCA1 and BRCA2 genes. Women with these mutations are 60-80% more likely to develop breast cancer.

Treatment

Taking into account the characteristics of the organism, stage and type of cancer, the optimal strategy for its treatment is selected.

• Surgery. In most cases of breast cancer treatment, the entire breast is removed in an operation called a mastectomy. A mastectomy may involve removing breast tissue – lobules, ducts, adipose tissue, and skin, including the nipple and areola – or it may be radical, when the major muscles of the chest and surrounding lymph nodes are excised along with the breast tissue.

• Radiation therapy (can be done before and after surgery). It can be external and internal, with external radiation acting from the outside, with internal (brachytherapy), a special device filled with radioactive material is placed next to a cancerous tumor.

• Chemotherapy – taking drugs to destroy cancer cells. It can be combined with other treatments.
• Hormone therapy – blocking the release of estrogen and progesterone, which stimulate tumor growth.Sometimes it is used after surgery, in conjunction with radiation and chemotherapy.

Prevention

• Early diagnosis of breast cancer. Regular mammography is recommended. You can also conduct a self-examination of the breast, consisting in a thorough palpation and examination. If you find seals, you should immediately consult a doctor.
• Refusal of hormone therapy after menopause (complete cessation of menstruation).
• Maintaining a normal weight. Obesity increases your risk of breast cancer, so you need to maintain a healthy weight through proper diet and exercise.
• Physical activity for at least 30 minutes every day.
• Conducting a genetic study to identify mutations in genes (BRCA1 or BRCA2) to determine the risk of developing breast cancer.

Recommended analyzes

• Complete blood count
• Serum creatinine
• Calcium in serum
• Aspartate aminotransferase (AST)
• Alanine aminotransferase (ALT)
• CA 15-3
• CA 125
• CYFRA 21-1
• CA 72-4
• Cancer embryonic antigen (CEA)
• Breast cancer gene 1 (BRCA1).Identification of the 185delAG mutation (violation of the protein structure)
• Breast cancer gene 1 (BRCA1). Detection of 4153delA mutation (protein structure disorder)
• Breast cancer gene 1 (BRCA1). Identification of 5382insC mutation (protein structure disorder)
• Breast cancer gene 2 (BRCA2). Detection of 6174delT mutation (protein structure disorder)

Breast cancer prevention | GAUZ “Regional Clinical Dermatovenerologic Dispensary”

Breast cancer is a malignant tumor of the glandular tissue of the breast

How breast cancer develops
Breast cancer develops in the same way as any other malignant tumor in the body.One or more cells of the glandular tissue, as a result of the mutation in them, begin to divide abnormally quickly. They form a tumor that can grow into adjacent tissues and create secondary tumor foci (metastases).

Causes and risk factors
Unfortunately, scientists do not yet have complete information on the causes of breast cancer. There is a list of risk factors that affect the likelihood of a tumor, but some are diagnosed with the disease in the absence of these factors, while others remain healthy if many of them are present at once.Nevertheless, scientists still associate the development of breast cancer with certain circumstances that most often precede its appearance.
These include:
• old age;
• use of hormonal drugs;
• trauma to the mammary glands;
• a history of breast cancer;
• diagnosed with breast cancer in one of the relatives;
• Exposure to radiation, such as radiation therapy given to treat another type of cancer;
• excess weight;
• early onset of menstruation and later – menopause;
• absence of children or late (after 35 years) first childbirth;
• smoking and alcohol abuse;
• diabetes mellitus;
• work on schedule with night shifts.

Symptoms of breast cancer
Quite often, early breast cancer is asymptomatic. But in some cases, there are signs indicating the presence of a disease, and they can be noticed.
First of all, the symptoms that should be alerted include lumps in the mammary glands, next to them or in the armpit. In 9 cases out of 10, seals are benign, but this can be established for sure only on examination by a mammologist.
It is worth checking your breasts yourself for nodules or any other changes once a month, at the end of your period. Home diagnostics are most conveniently done while taking a bath or taking a shower. Any changes that have been detected should be reported to the doctor as soon as possible.

Symptoms of breast cancer include:
1. Skin hardening
2. Skin retraction area
3. Skin erosion
4. Skin redness
5. Nipple discharge
6.Ripple-type breast deformity
7. Skin swelling
8. Vein enlargement
9. Nipple retraction
10. Breast symmetry violation
11. Lemon peel symptom
12. Palpable node inside the breast.
70% of breast cancer cases are self-diagnosed by patients as a result of breast self-examination.
If these symptoms appear, as well as any other changes in the mammary glands (for example, unusual or painful sensations), you should immediately consult a mammologist.

How to avoid breast cancer
Doctor’s advice:
• In winter and spring, you need to take preparations containing vitamins A, B1, B2, C, E and trace elements – iodine, selenium.
• Iodine deficiency can be replenished with seafood. There is a lot of iodine in cod liver. It is found in small amounts in potatoes.
• It is very important not to overwork yourself, to avoid nervous shocks.
• Physical training, water hardening procedures normalize sleep and activity of the nervous system.
• It is not recommended to use TV, computer, mobile phone no more than 20 hours a week.
• Alcohol abuse, smoking, chemical deodorants have a negative impact on health.
• For the timely detection of deviations in the state of health, all women must visit the examination room of the polyclinic once a year.
• At the age of 35-49 years, it is necessary to undergo special examination methods (mammography, ultrasound examination) annually, after 50 years – once every six months.
• It is equally important to limit the intake of high-calorie foods, introduce more fruits and vegetables to the menu, especially cabbage, carrots, pumpkin, zucchini, lettuce, flaxseed oil

• Women of any age need to regularly, every month, conduct breast self-examination

When examining in front of a mirror with hands down and up, pay attention: whether there is retraction (or, on the contrary, a bulge that has appeared) of the skin area, retraction of the nipple or shortening of the areola radius, changes in the size or shape of one of the mammary glands, discharge from the nipples or ulcers, etc.
Continue inspection by turning right and left. With your fingertips, in a circular motion clockwise and counterclockwise, feel the mammary glands from the nipple region to the periphery of the gland.
Do the same while lying on your back.
When feeling the left breast, place a small pillow under the left shoulder blade, and the palm of the left hand under the head. And vice versa.
To identify discharge from the mammary gland, you need to examine the linen, slightly squeeze each nipple.

If you adhere to these recommendations, then many fears can be avoided.

90,000 Benign Breast Tumors | ChUZ “KB” Russian Railways-Medicine “them. ON. Semashko “

Benign breast tumors – breast formations that arise as a result of a violation of normal growth and reproduction of cells and are characterized by slow growth, do not grow into the surrounding tissues and do not give metastases.

Benign breast tumors include:

1. Fibroadenoma
2. Intraductal papilloma
3. Lipoma

Do you suspect a breast tumor?
You can get advice and make an appointment by phone.:
+7 (499) 266-98-98

1. Fibroadenoma is a benign breast tumor originating from fibrous breast tissue.

The cause of the development of fibroadenoma may be trauma to the breast or hormonal imbalance.

Clinical manifestations of fibroadenomas. These tumors are defined by palpation as mobile, painless, round-shaped seals with clear boundaries. Sizes can range from the size of a pea to the size of a lemon.It occurs more often in young women aged 20 to 35 years.

Fibroadenomas rarely become malignant, with the exception of leaf-shaped fibroadenomas of the mammary gland, which, in the absence of timely treatment, can degenerate into sarcoma.

Diagnosis of fibroadenomas is carried out according to ultrasound, mammography, cytological examination and, of course, clinical data (examination by a specialist).

Treatment . In the presence of fibroadenoma up to 1.0 cm in size, dynamic observation is possible (mammography and ultrasound control).The indication for removal of fibroadenoma is the rapid growth of education, large tumor size, suspicion of breast cancer. Sectoral resection of the mammary gland or enucleation of fibroadenoma is performed.

2. Intraductal papillomas – benign breast tumors that grow inside the gland, and are characterized by the appearance of formations (papillomas), consisting of connective tissue papillae containing vessels. Intraductal papillomas can be single or multiple.

The causes of intraductal papillomas can be hormonal disorders occurring at any age from puberty to postmenopause.

Clinical manifestations. Intraductal papillomas tend to disintegrate, and therefore, the main manifestation is bloody or brownish-green discharge from the mammary gland. Sometimes there is discomfort in the chest or soreness when squeezed.

Diagnosis of intraductal papillomas is based on clinical manifestations, examination data, as well as ductography data – X-ray examination of the breast with the introduction of a contrast agent into its ducts.

Treatment of intraductal papillomas is only surgical. this type of benign breast tumor can degenerate into cancer. The main method of surgical treatment is central sectoral resection.

3. Lipoma is a benign breast tumor growing from adipose tissue. Usually round and soft in texture. Lipomas can grow to a significant size and cause displacement of the surrounding tissues. Small lipomas may not show clinically.Denomination occurs in very rare cases. Treatment of lipomas is only surgical. The indications for surgery are rapid tumor growth, pain, suspicion of degeneration into cancer.

At the Private Educational Institution “Clinical Hospital” Russian Railways-Medicine “them. ON. Semashko ” room for early detection of breast diseases was opened. Reception is conducted by highly qualified specialists – mammologists who are engaged in the diagnosis and treatment of all types of breast pathology, including benign breast tumors.The clinic is equipped with modern diagnostic equipment, has its own clinical diagnostic laboratory, which allows you to quickly establish an accurate diagnosis and prescribe the necessary treatment.

90,000 Breast cancer, breast tumor

Breast cancer risk factors

Breast cancer (mammakarcinoma) is a malignant neoplasm that develops from the glandular tissue of the breast against the background of precancerous pathologies (mastopathy and fibroadenoma).The causes of this formidable disease are not fully understood. However, oncologists have found a causal relationship between a woman’s high estrogen levels and her predisposition to breast cancer.

risk factors for breast cancer include:

• early onset of menstruation;
• first birth after 30 years;
• late menopause;

90,013 are over 50 years old;

• diagnosed infertility;
• hormonal correction of menopause with the use of estrogens and gestagens;

90,013 obesity;

• family inheritance.

Breast cancer symptoms

A malignant tumor of the breast has no specific symptoms, which additionally complicates the early diagnosis of the disease. Therefore, any atypical manifestations (discharge from the nipples, changes in the appearance of the breasts, the appearance of seals, redness, swelling, etc.) should force a woman to see a doctor.

Self-examination performed by women and girls on certain days of the menstrual cycle plays a huge role in the early diagnosis of breast cancer.Also, breast cancer can be detected on time by regular examinations by a mammologist, which are mandatory for all middle-aged and older women. If close relatives suffered from breast cancer pathologies, it makes sense to do a test for tumor markers in order to, if not completely eliminate the threat, then at least be more attentive to yourself.

Medical statistics

Breast cancer is the most studied and most common form of cancer in women (23% of all cancer pathologies detected in the beautiful half of humanity.In addition, even men sometimes suffer from breast cancer (1% of cases): gynecomastia is a risk factor for them.

Diagnosis of breast cancer abroad – in Germany

Successful treatment of breast cancer requires early detection of tumors of any etiology. For this, in diagnostics, first of all, modern mammographs that work with low doses of radiation are used. This is an informative way to visualize the structure of the breast, allowing you to detect and initiate treatment for even a very small breast tumor.In Germany, the cost of modern mammography is around 95 euros.

Additionally, sonography can be used – examination of the mammary glands by means of ultrasound in order to determine the type of tumor. During sonography, cysts and other benign neoplasms are easily detected.

MRI is used to clarify tumor operability and for visual control over the effectiveness of preoperative treatment abroad.

Treatment of breast tumors and breast cancer in Germany – complex

• surgical operation (local or radical), the volume of which directly depends on the stage of the tumor process;
• methods of conservative treatment – immunological, hormonal (in the case of a hormone-positive tumor), radio and chemotherapy.In the later stages of the disease, additional methods can be used before surgery to reduce staging, reduce tumor volume and achieve a palliative effect.

In cancer centers in Germany, preference is given to low-traumatic organ-preserving operations, during which lymphostasis is not disturbed and only a part (lobe) of the affected breast is removed. Treatment of advanced breast cancer involves a radical mastectomy with the obligatory removal of the “sentinel” lymph nodes.Radiotherapy is required to avoid metastasis and tumor recurrence from single cancer cells.

Cost of breast tumor treatment in Germany

The price of breast cancer treatment depends on the degree of tumor affection of the mammary glands, as well as the type of tumor and the required range of diagnostic and therapeutic services. For example, the cost of one course of chemotherapy ranges from 1900 -3400 euros (depending on the medication). The exact cost of breast cancer treatment, surgery can be clarified by calling our medical center, or by using the application form for treatment.

MedHaus offers the best clinics for breast cancer treatment

In Germany at your service – more than 45 private and public medical institutions , including:

Here you can undergo a full screening, as well as receive adequate surgical treatment for breast cancer in Germany and an optimal course of restorative procedures. Mandatory monitoring of the success of treatment for breast cancer pathologies is performed every 12 weeks. It includes a test for tumor markers, as well as an examination of the chest, internal organs and bones of the skeleton.

Specialists of the medical center “MedHaus” consult in absentia on the diagnosis and treatment of breast cancer in cancer centers in Germany. The consultation is carried out during working hours, within a couple of hours after you send your medical documents to our e-mail.

We advise for free!

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