classification of carcinoma

The classification of carcinoma of the breast as outlined in the SRB Manual of Surgery includes the
following categories:

1. Based on Histopathology

Breast carcinomas are classified into invasive and non-invasive (in situ) types.

A. Non-Invasive Carcinomas (In Situ)

Ductal Carcinoma In Situ (DCIS):

Confined to the ducts without invasion of the basement membrane.

Precursor to invasive carcinoma if untreated.

Lobular Carcinoma In Situ (LCIS):

Confined to the lobules without invasion.

Considered a marker of increased risk for invasive cancer in both breasts.

B. Invasive Carcinomas

Invasive Ductal Carcinoma (IDC):

Most common type (~75–80% of invasive breast cancers).

Arises from ductal epithelium and invades the surrounding stromal tissue.

Invasive Lobular Carcinoma (ILC):

Second most common type (~10–15%).

Arises from lobules, often bilateral and multicentric.

Special Types:

Medullary Carcinoma:

Well-circumscribed, lymphocytic infiltration, better prognosis.

Mucinous (Colloid) Carcinoma:

Mucin-producing tumor, occurs in elderly women, good prognosis.

Tubular Carcinoma:

Small, well-differentiated tubular structures, excellent prognosis.

Papillary Carcinoma:

Rare, associated with DCIS, seen in older women.

Metaplastic Carcinoma:

Contains mixed epithelial and mesenchymal components, poor prognosis.

Inflammatory Carcinoma:

Presents with peau d’orange and erythema, aggressive behavior.

Paget’s Disease of the Nipple:

Malignant cells in the epidermis of the nipple, associated with DCIS or invasive carcinoma.

2. Based on Molecular Subtypes

Breast carcinomas can be classified based on receptor expression (ER, PR, HER2, and Ki-67 index):

Luminal A.

Luminal B.

HER2-Enriched.

Triple-Negative Breast Cancer (Basal-like).

Normal-Like.

3. Based on TNM Staging (AJCC/UICC Classification)

T: Tumor Size

Tis: In situ carcinoma (DCIS or LCIS).

T1: Tumor ≤2 cm.

T2: Tumor >2 cm but ≤5 cm.

T3: Tumor >5 cm.

T4: Tumor of any size with direct extension to chest wall or skin (including inflammatory carcinoma).

N: Regional Lymph Nodes

N0: No regional lymph node metastasis.

N1: Metastasis to movable ipsilateral level I or II axillary lymph nodes.

N2: Metastasis to fixed/matted axillary nodes or ipsilateral internal mammary nodes.

N3: Metastasis to infraclavicular, supraclavicular, or internal mammary nodes with axillary involvement.

M: Distant Metastasis

M0: No distant metastasis.

M1: Distant metastasis present.

4. Based on Grade (Histological Grading)

Using the Nottingham Grading System (Elston-Ellis modification of the Bloom-Richardson grading):

Grade 1: Well-differentiated.

Grade 2: Moderately differentiated.

Grade 3: Poorly differentiated.

5. Based on Clinical Presentation

Early Breast Cancer:

T1 or T2 with no or minimal nodal involvement (N0 or N1).

Locally Advanced Breast Cancer:

T3 or T4 with significant nodal involvement.

Metastatic Breast Cancer:

Presence of distant metastasis (M1).

6. Rare Types of Breast Carcinoma

Male Breast Cancer:

Rare, usually ductal carcinoma.

Phyllodes Tumor:

Can be benign, borderline, or malignant.

Breast Sarcoma:

Rare, arises from stromal tissue.

Clinical Importance

This classification provides a structured approach to diagnosing, staging, and managing breast
carcinoma. It helps tailor treatment strategies and predict prognosis based on tumor characteristics.

This summary aligns with the classification provided in the SRB Manual of Surgery.

Fibroadenoma
Fibroadenoma, as described in the SRB Manual of Surgery, is a common benign breast tumor seen
primarily in young women. It arises from the lobular stroma and represents a hyperplastic process
rather than a true neoplasm. It is often referred to as a "breast mouse" due to its mobility.

Etiology and Pathogenesis

Hormonal Influence:

Estrogen sensitivity plays a key role in its development.

Common in reproductive-age women, particularly in the second and third decades of life.

Origin:

Develops from the terminal duct-lobular unit (TDLU).

Stromal and Epithelial Components:

Comprised of a mix of stromal and epithelial tissue.

Often encapsulated by a thin pseudocapsule.

Clinical Features

Presentation:

Single or multiple, painless, firm, and well-defined breast lump.

Mobile and not attached to skin or underlying tissue.

Typically 2–3 cm in size but can grow larger (giant fibroadenoma >5 cm).

Location:

Can occur in any quadrant of the breast but is commonly found in the upper outer quadrant.

Symptoms:

Generally asymptomatic.

May cause cosmetic concern or anxiety due to fear of malignancy.

Types of Fibroadenoma

Simple Fibroadenoma:

Uniform architecture with no cellular atypia.

No increased risk of breast cancer.

Complex Fibroadenoma:

May show calcifications, sclerosing adenosis, or cystic changes.

Slightly increased risk of breast cancer (~1.5–2 times).

Diagnosis
Clinical Examination:

Well-circumscribed, mobile, non-tender lump.

Imaging:

Ultrasound:

Hypoechoic, well-defined lesion with smooth margins.

Useful in younger women with dense breast tissue.

Mammography:

Well-circumscribed, round, or oval density.

Not routinely performed in young women.

Fine-Needle Aspiration Cytology (FNAC):

Confirms benign nature.

Shows stromal and epithelial components.

Core Needle Biopsy:

Performed if malignancy is suspected or the diagnosis is uncertain.

Management
Observation:

Small, asymptomatic fibroadenomas can be observed with regular follow-up.

Surgical Excision:

Indications:

-Size >2–3 cm.

-Rapid growth (to rule out phyllodes tumor).

-Atypical features on imaging.

-Patient anxiety.

-Suspected malignancy.

Procedure:

Excisional biopsy (lump excision) with preservation of breast tissue.

Cryoablation:

Non-surgical technique for selected cases.

Freezes and destroys the fibroadenoma using ultrasound guidance.

Prognosis

Excellent prognosis as fibroadenomas are benign.

Recurrence can occur after excision, especially in younger women.

Complex fibroadenomas require careful follow-up due to the slightly increased risk of malignancy.
Differential Diagnosis

Phyllodes tumor (similar in presentation but can grow rapidly and recur).

Breast cyst.

Fibrocystic changes.

Malignant breast tumors (less common in young women but must be excluded).

Key Points

Fibroadenomas are the most common benign tumors of the breast.

They are hormone-sensitive and may regress post-menopause.

Treatment is tailored based on size, symptoms, and patient preference.

Complex fibroadenomas warrant closer monitoring due to their association with a slightly increased
risk of breast cancer.

This summary reflects the detailed explanation provided in the SRB Manual of Surgery.

Mammography, as explained in the SRB Manual of Surgery, is a specialized

radiological examination of the breast. It is the gold standard imaging modality for
the early detection, diagnosis, and screening of breast cancer, particularly in
asymptomatic women.

Types of Mammography

Screening Mammography:

Used in asymptomatic women for early detection of breast cancer.

Recommended for women aged 40–50 years and older, depending on regional
guidelines.

Diagnostic Mammography:

Performed in symptomatic patients (e.g., those with a lump, nipple discharge, or

skin changes).

Includes additional views or magnification for better evaluation.

Technique

Standard Views:
-Cranio-Caudal (CC) View: Breast is compressed horizontally, capturing tissue from
the nipple to the chest wall.

-Mediolateral Oblique (MLO) View: Breast is compressed diagonally to visualize

the upper outer quadrant and axillary tail.

Compression:

Breast tissue is compressed to reduce thickness and improve image quality.

Minimizes radiation exposure.

Additional Views:

Magnification, spot compression, or lateral views may be used for better

visualization of suspicious areas.

Indications

Screening:

Early detection of breast cancer in asymptomatic women.

Diagnosis:

Evaluation of breast lumps, nipple discharge, or skin changes.

Postoperative follow-up of breast cancer patients.

Preoperative Staging:

To assess tumor size, extent, and multifocality.

Monitoring:

Follow-up after breast-conserving surgery or radiation therapy.

Findings on Mammography

Normal Breast Tissue:

Dense in younger women, more fatty in older women.

Benign Lesions:

Well-circumscribed, round or oval masses (e.g., fibroadenoma, cysts).

Calcifications: Coarse or popcorn-like (typical of benign conditions).

Suspicious Lesions:

Spiculated masses with irregular borders.

Microcalcifications: Clustered or linear branching, suggestive of malignancy.

Architectural distortion or asymmetry.

Other Features:

Skin thickening or nipple retraction.

BI-RADS Classification

Mammography findings are categorized based on the Breast Imaging Reporting

and Data System (BI-RADS):

Category 0: Incomplete – additional imaging required.

Category 1: Negative – no abnormality.

Category 2: Benign findings.

Category 3: Probably benign – follow-up advised.

Category 4: Suspicious – biopsy recommended.

Category 5: Highly suggestive of malignancy.

Category 6: Known malignancy.

Advantages

Detects breast cancer at an early, asymptomatic stage.

Differentiates between benign and malignant lesions.

Useful for monitoring response to therapy.

Limitations

False Negatives:

Occurs in dense breasts (common in younger women).

Small or subtle cancers may be missed.

False Positives:
Leads to unnecessary biopsies or anxiety.

Radiation exposure, though minimal, is a consideration in younger women or

during pregnancy.

Complementary Imaging

Ultrasound:

Useful for dense breasts or differentiating cystic from solid masses.

MRI:

High sensitivity, used for high-risk patients, preoperative staging, or unclear

mammography findings.

Indications for Screening Mammography

Women aged 40–50 years (annually or biennially depending on regional

guidelines).

High-risk women:

Family history of breast cancer.

BRCA1 or BRCA2 mutation carriers.

Conclusion

Mammography remains a cornerstone of breast cancer screening and diagnosis. Its

ability to detect early-stage cancers significantly improves prognosis. However, it
is essential to complement it with other imaging modalities when necessary,
especially in younger women with dense breast tissue. Regular mammography
screening has been shown to reduce breast cancer mortality.

This explanation is based on the SRB Manual of Surgery.

Thyroid storm, as described in the SRB Manual of Surgery, is a rare but life-
threatening complication of untreated or inadequately managed hyperthyroidism.
It is characterized by an acute exacerbation of hyperthyroid symptoms and
systemic decompensation, requiring immediate recognition and management.

Etiology and Precipitating Factors

Thyroid storm typically occurs in patients with underlying Graves’ disease or toxic
multinodular goiter, triggered by stressors such as:

1)Surgical stress:

-Particularly thyroidectomy without adequate preoperative preparation.

2)Infections:

-Respiratory or urinary tract infections.

3)Trauma:

-Including burns or injuries.

4)Cardiovascular events:

-Myocardial infarction or stroke.

5)Iodine exposure:

-Contrast agents, amiodarone, or radioactive iodine therapy.

6)Uncontrolled hyperthyroidism:

-Non-compliance with antithyroid medications.

Pathophysiology

Thyroid storm is caused by an acute surge in thyroid hormone (T3 and T4), leading
to:

_Increased metabolic rate.

_Adrenergic overstimulation.

_Multi-organ dysfunction.

Clinical Features

1)General Symptoms:

High fever (>38.5°C).

Profuse sweating.

2)Cardiovascular Symptoms:

Tachycardia (may exceed 140 bpm).

Atrial fibrillation or other arrhythmias.

Congestive heart failure.

3)Neurological Symptoms:

Agitation, restlessness, confusion.

Delirium, seizures, or coma in severe cases.

4)Gastrointestinal Symptoms:

Severe diarrhea, nausea, vomiting.

Jaundice (in advanced stages due to hepatic dysfunction).

5)Other Symptoms:

Weight loss.

Muscle weakness.

Diagnostic Criteria

1)Clinical Diagnosis:

Based on history and clinical presentation.

Laboratory confirmation of hyperthyroidism (elevated free T4 and suppressed

TSH) supports the diagnosis but is not required for initiating treatment.

2)Scoring Systems:

Burch-Wartofsky Point Scale:

A scoring system to assess the likelihood of thyroid storm based on symptoms and
signs.

Management

Thyroid storm is a medical emergency requiring intensive care with the following
principles:

1. General Supportive Care:

Hospitalization in ICU.

Fluid and electrolyte management.

Cooling measures for hyperthermia.

2. Control of Thyroid Hormone Levels:

Antithyroid Drugs:

Propylthiouracil (PTU):

Preferred as it inhibits peripheral conversion of T4 to T3.

Loading dose: 600–1000 mg orally, followed by maintenance doses.

Methimazole:

Alternative to PTU, except in the first trimester of pregnancy.

Iodine Therapy (administered 1 hour after antithyroid drugs):

Lugol’s iodine or potassium iodide to inhibit thyroid hormone release.

3. Adrenergic Blockade:

Propranolol:

Controls tachycardia and symptoms of adrenergic overstimulation.

Dose: 60–80 mg orally every 4–6 hours or IV for severe cases.

Esmolol:

Short-acting beta-blocker in critically ill patients.

4. Steroid Therapy:

Hydrocortisone:

100 mg IV every 6–8 hours.

Reduces T4 to T3 conversion and manages adrenal insufficiency.

5. Treatment of Precipitating Cause:

Antibiotics for infections.

Appropriate measures for other triggers (e.g., surgery, trauma).

Complications

Cardiovascular collapse.

Multi-organ failure.
Death if untreated.

Prognosis

With timely diagnosis and appropriate management, mortality can be significantly

reduced.

Untreated thyroid storm has a high mortality rate (~20–30%).

Prevention

Adequate preoperative preparation with antithyroid drugs and beta-blockers

before thyroid surgery.

Early treatment of hyperthyroidism.

Avoidance of iodine-containing drugs in hyperthyroid patients.

Key Points

Thyroid storm is a hypermetabolic state requiring immediate intervention.

Early recognition and multidisciplinary management are critical to reducing

morbidity and mortality.

Patients with a history of hyperthyroidism should be carefully monitored during

stress-inducing events.

This explanation aligns with the description provided in the SRB Manual of
Surgery.

Pheochromocytoma, as described in the SRB Manual of Surgery, is a rare

catecholamine-secreting tumor arising from the chromaffin cells of the adrenal
medulla or extra-adrenal paraganglia. It is a significant cause of secondary
hypertension, and the condition can be life-threatening if left untreated. Below is a
detailed explanation based on SRB:

Etiology

Origin: Tumor of neural crest-derived chromaffin cells.

Location:

Majority (90%) are adrenal in origin.

Extra-adrenal tumors (paragangliomas) occur in sites such as the organ of

Zuckerkandl, bladder, or carotid body.

Epidemiology

Rare; accounts for 0.1-0.5% of cases of hypertension.

Equal sex distribution.

Most cases occur between the ages of 30-50 years.

Pathophysiology

Pheochromocytomas secrete catecholamines (epinephrine, norepinephrine, and

sometimes dopamine), leading to:

Persistent or paroxysmal hypertension.

Tachycardia.

Hypermetabolism.

Excessive stimulation of alpha and beta adrenergic receptors.

Clinical Features

Classic Triad:

Episodic headache.

Sweating (diaphoresis).

Palpitations.

Other Symptoms:

Sustained or episodic hypertension.

Anxiety, tremors, flushing.

Abdominal pain or mass.

Hyperglycemia (due to catecholamine-induced gluconeogenesis).

Triggers: Physical activity, emotional stress, surgery, certain foods (tyramine-rich

like cheese and wine).
Diagnosis

Biochemical Tests:

Elevated plasma-free metanephrines and urinary catecholamines/metanephrines.

Hyperglycemia may also be noted.

Imaging:

CT or MRI of the abdomen for adrenal tumors.

MIBG (metaiodobenzylguanidine) scintigraphy for extra-adrenal and metastatic

tumors.

Provocative Tests:

Rarely used now due to risks of hypertensive crises.

Genetic Testing:

Recommended for familial syndromes (e.g., MEN 2, von Hippel-Lindau,

neurofibromatosis).

Treatment

Preoperative Management:

Alpha-adrenergic blockade (e.g., phenoxybenzamine) for 10-14 days to control

blood pressure and prevent intraoperative crises.

Beta-blockers (after adequate alpha-blockade) to manage tachycardia.

Surgical Management:

Definitive treatment: Adrenalectomy (laparoscopic or open).

Special care is taken during tumor manipulation to prevent catecholamine surges.

Postoperative Care:

Monitoring for rebound hypotension or hypoglycemia.

Regular follow-up for recurrence.

Prognosis

Surgical removal is curative in most cases.

Recurrence occurs in 10-15% of cases; hence, long-term monitoring is essential.

Key Points

"Rule of 10s" (applicable in older studies):

10% are extra-adrenal.

10% are malignant.

10% are bilateral.

10% occur in children.

This rule has been updated with recent insights, showing a higher frequency of
familial syndromes.

Let me know if you'd like further clarification!