36.4 Breast, Hernia and Skin and Soft Tissue: Benign Breast Masses, Breast Cancer Evaluation and Treatment, Groin and Abdominal Wall Hernias, Benign Skin and Soft-Tissue Tumors, Skin Cancers and Soft-Tissue Sarcoma

Why this area matters

Breast cancer is the most common cancer among Filipino women, and many present at a locally advanced stage, so early evaluation of a breast lump is a key skill. Groin hernias are among the most common elective operations, and incarceration is a frequent emergency. Skin cancers and sarcomas must be recognized so that the first excision is the right one.

Benign breast disease

• Fibroadenoma:
  • a smooth, firm, mobile, painless lump ("breast mouse") in women aged 15 to 35;
  • confirmed by ultrasound and core biopsy;
  • observed, or excised if large, growing or the patient prefers.
• Fibrocystic change: cyclic tenderness and nodularity before menses. Simple cysts are aspirated if symptomatic; bloody aspirate or a residual mass needs further evaluation.
• Intraductal papilloma: bloody nipple discharge from a single duct. Treated by duct excision.
• Phyllodes tumor: a rapidly enlarging fibroepithelial tumor, usually in women aged 40 to 50, that may be benign or malignant. Treated by wide local excision with clear margins; no axillary dissection, because it spreads by blood.
• Fat necrosis: follows trauma or surgery and can mimic cancer, so biopsy is needed.
• Mastitis and breast abscess: see postpartum care. Abscesses are drained by aspiration or incision.
• Gynecomastia in men: physiologic at puberty and old age, or caused by drugs (spironolactone, cimetidine), liver cirrhosis or testicular tumors.

Breast cancer

• Risk factors:
  • female sex and increasing age;
  • BRCA1 and BRCA2 and family history;
  • early menarche and late menopause, nulliparity, late first pregnancy;
  • hormone therapy;
  • obesity after menopause;
  • alcohol;
  • chest irradiation;
  • atypical hyperplasia and lobular carcinoma in situ.
• Evaluation (triple assessment):
  • clinical examination;
  • imaging: ultrasound for women under about 35 years, mammography with ultrasound for older women, reported with BI-RADS categories (4 to 5 need biopsy);
  • core needle biopsy for histology and ER, PR and HER2 status.
• Signs of malignancy: a hard, irregular, fixed lump, skin dimpling, peau d'orange, nipple retraction, bloody discharge and axillary nodes.
  • Inflammatory breast cancer (dermal lymphatic invasion) mimics mastitis but has no fever, and is treated with neoadjuvant chemotherapy first.
  • Paget disease of the nipple is an eczematous nipple lesion over an underlying cancer.
• Types:
  • ductal carcinoma in situ (calcifications on mammography): excision with or without radiotherapy;
  • invasive ductal carcinoma, the most common;
  • invasive lobular carcinoma, often multifocal and bilateral.
• Staging (TNM): clinical examination and imaging (CT, bone scan) for locally advanced disease.
• Treatment:
  • surgery: breast-conserving surgery plus whole-breast radiotherapy, with survival equal to mastectomy in suitable patients, or mastectomy (with reconstruction);
  • axilla: sentinel lymph node biopsy for clinically node-negative patients, and axillary dissection for proven node involvement (risks: lymphedema, nerve injury);
  • systemic therapy by subtype:
    • hormone receptor-positive: tamoxifen (premenopausal; risks of endometrial cancer and VTE) or aromatase inhibitors (postmenopausal; bone loss) for 5 to 10 years;
    • HER2-positive: trastuzumab (cardiotoxic, so monitor the ejection fraction) with chemotherapy;
    • triple-negative: chemotherapy, and immunotherapy in some;
  • neoadjuvant chemotherapy for locally advanced or inflammatory cancer.
• Male breast cancer: linked to BRCA2. It presents as a subareolar mass and is treated by mastectomy.
• Screening: mammography (every 1 to 2 years from 40 to 50, by guideline), clinical breast examination and breast awareness.

Hernias

Groin Hernias: Inguinal Anatomy, Hesselbach's Triangle & Differential Spectrum

Groin hernias represent protrusions of intra-abdominal contents through defects in the abdominal wall of the inguinal and femoral regions.

Anatomy of the Inguinal Canal & Hesselbach's Triangle

The inguinal canal extends obliquely downward and medially between the deep (internal) inguinal ring (an evagination of transversalis fascia) and superficial (external) inguinal ring (a triangular slit in the external oblique aponeurosis).

Boundaries of Hesselbach's Triangle (Site of Direct Inguinal Hernias):

• Medial Boundary: Lateral border of the rectus abdominis muscle.
• Lateral (Superolateral) Boundary: Inferior epigastric vessels (artery and vein).
• Inferior Boundary: Inguinal ligament of Poupart (thickened lower edge of external oblique aponeurosis).

Incarceration versus Strangulation

• Reducible Hernia: Hernial contents can be returned spontaneously or manually into the peritoneal cavity.
• Incarcerated Hernia: Hernial contents are physically trapped within the hernia sac and cannot be reduced. No vascular compromise is present yet.
• Strangulated Hernia: Blood supply to the incarcerated viscus is occluded (arterial and venous compromise), producing ischemia, gangrene, and perforation. Clinical signs: Extreme tenderness, persistent severe pain, warm erythematous overlying skin, high fever, marked leukocytosis, and peritonitis. Contraindication: Forceful manual reduction (taxis) of a strangulated hernia is strictly contraindicated because reduction of nonviable gangrenous bowel into the abdominal cavity precipitates catastrophic intra-abdominal sepsis and peritonitis. Emergent operative exploration is mandatory.

Hernia repair and other hernias:

• Inguinal hernia repair:
  • tension-free mesh repair (Lichtenstein) or laparoscopic repair (TEP, TAPP);
  • complications are recurrence, chronic groin pain (ilioinguinal nerve), seroma, testicular atrophy and infection;
  • femoral hernias are repaired promptly because of the strangulation risk.
• Special hernias:
  • Richter hernia: only part of the bowel wall is trapped, so it can strangulate without obstruction;
  • Littre hernia: contains a Meckel diverticulum;
  • sliding hernia: a viscus (colon, bladder) forms part of the sac wall;
  • obturator hernia: thin elderly women, with obstruction and the Howship-Romberg sign (medial thigh pain on hip rotation);
  • Spigelian hernia: through the semilunar line below the arcuate line;
  • incisional hernia: after laparotomy, repaired with mesh;
  • umbilical hernia in adults: repaired because of incarceration risk, especially in cirrhosis with ascites, which is controlled first;
  • epigastric hernia: through the linea alba.
• Pediatric hernias:
  • inguinal hernias (patent processus vaginalis, more common in preterm babies) are repaired promptly by herniotomy, because incarceration is common in infants;
  • umbilical hernias usually close by 4 to 5 years.

Skin and soft tissue

• Benign lesions:
  • lipoma: soft, mobile, lobulated;
  • epidermal inclusion (sebaceous) cyst: has a punctum and can become infected; excise the whole sac;
  • dermoid cyst: along lines of embryonic fusion, such as the outer eyebrow;
  • neurofibromas;
  • hemangiomas of infancy, which proliferate then involute (propranolol for problematic ones);
  • keloids.
• Basal cell carcinoma:
  • the most common skin cancer;
  • a pearly papule with telangiectasia and a rolled edge, which may ulcerate ("rodent ulcer");
  • on sun-exposed skin of the face;
  • locally invasive, rarely metastasizes;
  • treated by excision with margins (Mohs surgery for facial lesions).
• Squamous cell carcinoma:
  • arises from actinic keratosis, chronic ulcers and scars (Marjolin ulcer), arsenic exposure and immunosuppression;
  • can metastasize to nodes;
  • treated by wide excision.
• Melanoma:
  • ABCDE features: asymmetry, irregular border, color variation, diameter over 6 mm, evolution;
  • acral lentiginous melanoma (palms, soles, nails) is the most common type in Asians, including Filipinos, and is often diagnosed late;
  • prognosis depends mainly on Breslow thickness, ulceration and nodal status;
  • diagnosed by excisional biopsy with narrow margins;
  • treated by wide local excision with margins based on thickness (1 cm for 1 mm or less, up to 2 cm for thicker tumors), with sentinel node biopsy for intermediate thickness;
  • immunotherapy and targeted therapy (BRAF) for advanced disease.
• Soft-tissue sarcoma:
  • suspicious features: a mass larger than 5 cm, deep to the fascia, enlarging or painful;
  • evaluated by MRI followed by core needle biopsy, planned along the future incision; never "shell out" a suspicious mass;
  • common types are liposarcoma and undifferentiated pleomorphic sarcoma, and rhabdomyosarcoma in children;
  • spread by blood, most often to the lungs, so a chest CT is part of staging;
  • treated by wide excision with negative margins, with radiotherapy for high-grade or large tumors, and limb-sparing surgery where possible.