Category: Medicine Hat News

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Breast Lump Evaluation

A breast lump in a woman or a man is an important clinical finding – never to be ignored. It is also a source of anxiety for the patient and his or her family.

The usual questions are: What is it doctor and what investigations are required to check for cancer?

Investigations of a breast lump starts with a history and physical examination. Physical examination is best done between seven to 10 days from the first day of the menstrual cycle.

The clinical history will establish how long the lump has been present. Whether there has been any change. And if there is a previous history of breast biopsy or breast cancer.

Risk factors for breast cancer will be noted (patient’s age and family history). Absence of risk factors does not decrease the probability of cancer.

Examination of the breasts will confirm the presence and establish the character of the lump. Hard, irregular, tethered or fixed, or painless lump may be suggestive of cancer. Axillary (armpit) and neck areas are checked for lymph glands. The predictive value of physical examination (to say whether the lump is benign or malignant) in experienced hands is about 75 percent.

Mammograms in younger women are not very helpful. But after mid-30s the value of mammography increases. Quite often mammography can clarify the nature of the lump. It can also detect non-palpable lumps.

The overall level of sensitivity of mammography in palpable breast cancers may be no more than 82 percent. It may be even lower in premenopausal women. A negative mammogram in the presence of a persistent lump does not exclude malignancy.

Fine-needle aspiration biopsy done in the office can establish whether a breast lump is solid or cystic. When the lump is solid, cells can be aspirated for examination under a microscope. If fluid is obtained during aspiration and the lump disappears then it is cystic.

In a cystic lump, if the fluid is not bloody then no specimen needs to be sent for examination and no further investigation is necessary. Bloody fluid may be suggestive of cancer and should be sent for microscopic examination.

Fine-needle aspiration biopsy should provide satisfactory specimen for microscopic examination in 90 percent of the cases with an accuracy rate of 95 percent to detect presence of cancer cells.

When physical examination, mammography, and microscopic examination of aspirated specimen indicate cancer then the probability of this being confirmed by surgery is more than 99 percent. If all three tests are negative then the lump being cancerous is less than one percent.

Core-biopsy, where a bigger sample (a core of tissue) is taken from a breast lump, has 90 percent predictive value for breast cancer. A negative biopsy may make it unnecessary to do an open surgical biopsy.

Ultrasound of the breast lump is an alternative method to distinguish a cyst from a solid lump. Ultrasound is useful when a non-palpable lump is seen on a mammogram.

Nuclear medicine techniques (Miraluma scan) have been used to evaluate breast cancer. Its predictive value for cancer is around 80 percent for a palpable lesion and 50 to 70 percent for a non-palpable breast lump found on mammography.

Whenever reasonable doubt remains about cancer (since none of the tests have a one hundred percent accuracy rate), a surgical open biopsy is undertaken.

Only about one in every five to 10 breast biopsies leads to a diagnosis of cancer. But every breast lump should be investigated thoroughly.

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Rectal Pain (Proctalgia Fugax)

A doctor putting on his glove. (iStockphoto/Thinkstock)
A doctor putting on his glove. (iStockphoto/Thinkstock)

A patient asks: I have pain in my rectal area and I have been told that I have proctalgia fugax. What is this condition and how can I get some relief?

There are at least six common causes for rectal and anal pain: pruritus (itch), external thrombosed hemorrhoid (a blood clot), prolapsed internal thrombosed hemorrhoids, fissure (tear), abscess, and fistula (tunnel).

Proctalgia fugax is not part of the list as it is not that common. But unfortunately it is not that rare either. It occurs in about 14 percent of healthy people. Seventy five percent of these are women.

Proctalgia fugax falls under the category of “unexplained rectal and anal pain”. Other conditions under this group are levator ani syndrome and coccygodinia.

Let us try and understand some anatomy first.

Colon ends in the pelvis to become sigmoid, rectum and anus. Sigmoid and rectum act as storage area for fecal matter. At a socially convenient place, the anal sphincters (valves) relax to allow us to defecate.

Anal canal is surrounded by two circular muscles known as internal and external sphincters. Rectum is surrounded by and held in place by pelvic floor consisting of a group of muscles called levator ani. Coccyx is the tail end of the spine, not too far from the anal canal.

Proctalgia means pain in the rectum. Fugax means flying, fleeting, momentary like a fugitive – trying to elude justice!

Proctalgia fugax is an intensely painful spasm in the rectal area that begins abruptly and lasts for several minutes. It can begin during sleep, defecation, urination, or intercourse. The character of the pain has been compared to a charley horse.

Sharp cramp or stabbing pain may awaken the patient from sleep. It lasts less than 30 minutes and may radiate to the coccyx or perineum. It may only occur once a year or several times a week. Pain may be severe enough to cause sweating and palpitation. There may be a desire to have a bowel movement, yet pass no stool.

It is thought that a sudden spasm of the levator muscle complex or the sigmoid colon can result in proctalgia fugax.

It is believed that people who frequent the toilet are at greatest risk. Professionals, managers, and perfectionists are more likely to be afflicted. Stress and anxiety plays a role in precipitating the pain.

The diagnosis is based almost entirely on the patient’s symptoms. Clinical examination is usually negative. Patients should undergo flexible sigmoidoscopy to screen for other causes of ano-rectal diseases. Careful pelvic and prostate examinations should be undertaken. Ultrasound or CT scan of the pelvis may be necessary.

Patients with levator ani syndrome experience pain for hours to days. The pain is most often constant or rhythmic and may be likened to sitting on a ball or feeling like a ball (or corncob) was inside the rectum. Pain may be caused by defecation, sexual intercourse, sitting for long periods, and stress or anxiety. The pain is probably due to spasm of the pelvic floor muscles.

Coccygodynia is a cramp or ache in the tailbone and typically results from injury to the coccyx or arthritis. Movement of the coccyx can reproduce the pain.

Pain from proctalgia fugax, levator syndrome, and coccygodynia may be hard to differentiate.

Treatment is often unrewarding. Some of the measures worth trying are: reassurance, hot baths, bowel regimens, message therapy, perineal strengthening exercises, pain killers, anti-inflammatory, muscle relaxants, topical nitrates, tranquillizers, calcium channel blockers, acupuncture, and psychiatric evaluation.

Unfortunately, proctalgia fugax is one of the many medical conditions for which there is no good explanation or treatment.

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Constipation and Laxatives

Constipation continues to be a problem for up to 30 percent of the population.

This is not something new. Even during the time of Hippocrates, people were worried about their bowel movements. It was recognized then that eating unrefined foods gave better bowel movements and better health.

Dictionary defines constipation as difficult, incomplete, or infrequent evacuation of dry hardened feces from the bowels. For some it means straining to have a bowel movement, to others a process of passing hard stools, or infrequent passage of stools, or inability to defecate at will.

A study of healthy people in Great Britain found that 99 percent of the population had between three bowel movements a week and three bowel movements a day.

Constipation is associated with (not necessarily caused by) inactivity, low calorie intake, number of medications being taken, low income, and a low education level. Constipation is also associated with depression as well as physical and sexual abuse, says an article in Gastroenterology.

Constipation can be due to slow transit of low quantity of stool which fails to stimulate the colon to move in orderly fashion. There may also be uncoordinated movement of the colon near the rectum or dysfunctional pelvic floor which causes pseudo-obstruction.

The Gastroenterology article says that about 60 percent of patients with constipation have irritable bowel syndrome with normal colonic transit time (or slightly delayed only). About 30 percent have pelvic floor dysfunction (with or without slow transit), and 10 percent has slow transit only.

Management of constipation starts with history and physical examination, review of patient’s current medications, basic blood work and investigation of the colon to rule out bowel blockage.

If everything is normal then constipation may be easily corrected by increasing dietary fiber (bran, cereal, fresh fruit, and vegetables), intake of liquids and increasing physical activity.

If this fails then use of laxatives (agents which promote evacuation of the bowel) become necessary. Commonly used laxatives are described here briefly.

Bulk forming agents (psyllium, methylcellulose) are considered the safest. They work like a sponge – they soften stool by holding water in the fecal matter.

Stool softeners (docussate sodium) soften faces by lowering the surface tension of fluids in the bowel which seems to allow more water to remain in the stool.

Stimulants (senna, bisacodyl, cascara, castor oil) act by increasing the colonic muscle contractions. Long term use of these agents is discouraged because of the theoretical risk of damaging the nerve centers in the colon.

Lubricants like mineral oil (liquid paraffin) is chemically inert and not digested in the gut. It probably acts by lubricating the bowel. It may interfere with absorption of fat soluble vitamins such as A, D and K. Sometimes aspiration of liquid paraffin may cause pneumonia.

Lactulose is a synthetic disaccharide. It is not absorbed in the gut. Its mode of action as a laxative is not clear.

Magnesium and phosphate containing agents are considered saline laxatives. They work by drawing water into the large bowel. They should be used with care in patients with kidney and heart problems.

This is only a short list of common laxatives. There are numerous other off the counter laxatives which are used and abused by the general public. For most patients proper use of laxatives is all that is required. For a small minority, our options should go beyond laxatives and include behavioral treatment as well as new drugs.

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Thyroid Nodule

Recently, I saw a young lady with a lump in the neck. . The lump moves with swallowing. That means it is in the thyroid gland

The young lady wants to know: Is it cancer? Why did she get it? What can be done about it?

Thyroid lumps or nodules are tumors, most of which are benign. But some are malignant and invasive cancers.

A solitary nodule, within an otherwise apparently normal gland, is of more concern than a thyroid gland with multiple nodules which is known as a multi-nodular goiter. Multi-nodular goiters are usually benign.

Thyroid nodules are more common in women. Single nodule is four times more common in women than men.

About 42-77 percent of nodules are simple cysts (colloid nodules); 15 -40 percent are benign tumors (adenomas); and only 8 – 17 percent are cancers. In men, the frequency of cancer in the thyroid nodule is more than 50 percent by 70 years of age.

Radiation treatment to the neck, or any radiation exposure near the thyroid gland, increases the risk of developing nodules. These nodules tend to develop long after the radiation exposure. Family history of thyroid cancer increases the likelihood of thyroid nodule being malignant.

How do we investigate a solitary thyroid nodule?

To start with, only one blood test is required –thyroid stimulating hormone (TSH) level – to check if the thyroid is functioning normally or is over-active.

If the thyroid function is normal then the next line of investigation is a fine-needle aspiration (FNA) biopsy. In nine reports (comprising 9119 patients) the FNA showed benign tumor in 74 percent of patients, malignant tumor in four percent, indeterminate results in 11 percent, and inadequate biopsy specimen in 11 percent, says an article in the New England Journal of Medicine (NEJM).

If the TSH is suggestive of an over-active thyroid nodule or the FNA biopsy result is indeterminate then a radio-nuclear scan should be performed to further check the status of the nodule. If it is “hot” – then it is overactive.

Ultrasound is a good test for thyroid lumps. It can tell us if there is more than one nodule; if the lump is solid, cystic or mixed; and it is the best method to determine the size of the nodule.

What is the treatment of solitary thyroid nodule?

If the nodule is hyper-functioning then it requires medical treatment. Surgery is rarely indicated.

If the needle biopsy is clearly benign and there are no other symptoms suggesting pressure to the surrounding structures, like difficulty breathing or swallowing, then the nodule can be observed with or without thyroid hormone therapy. The nodule may enlarge, shrink or disappear.

Main indications for surgery are: malignant or indeterminate FNA biopsy results, local symptoms, or the gland is so big that it changes the appearance of the neck.

The NEJM article says that in six reports (10,850 patients) the rate of surgery for a solitary thyroid lump varied from 14 to 61 percent.

Why such a big variation in the rates of surgery? For three reasons: differing rates of accuracy of FNA biopsy results among centers, surgeon’s own preference and differing views on whether patients with unclear FNA results should routinely undergo surgery.

So, a solitary thyroid nodule is not always malignant. But it should not be ignored. Appropriate investigations should be done to rule out cancer.

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