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Background Mastalgia often impairs the physical, social, and sexual lives of women. It may manifest in both cyclical or acyclical patterns. The psychoneurotic association of mastalgia has been claimed for a long time in various available literature. Several treatment options have been used and are available in the market for mastalgia, but no specific guidelines are currently in place at the global or local levels. This study aims to evaluate the psychological status and effectiveness of various treatment options in women presenting with mastalgia. Methods This study was conducted in the General Surgery outpatient department from February 1 to November 30, 2021, at King George's Medical University, Lucknow, India. Females of all age groups presenting to the General Surgery outpatient department with unilateral/bilateral breast pain and/or chest wall pain were considered for this study. Pregnant patients, those with a history of allergy to drugs, or those who were lost to follow-up were excluded from the study. The psychological status of patients was assessed using the Depression Anxiety and Stress Scale (DASS-42) scale. Pain assessment was performed using a visual analog scale (VAS). Patients were divided into five categories: (i) isolated chest wall pain, (ii) isolated breast pain, (iii) both chest wall and breast pain, (iv) pain with an associated lump(s), and (v) pain and tenderness isolated over the lump, and two groups: Group-A: VAS≤4, and Group-B: VAS>4. Group B patients in Category iv were randomized into two groups: topical non-steroidal anti-inflammatory drugs (NSAIDs) or evening primrose oil+vitamin E. The next line of treatment was tamoxifen 10mg followed by danazol 100mg followed by ormeloxifene 30mg. Results The mean age of 106 participants enrolled was 31.59±10.52 years. The mean scores, using the DASS-42 scale, for depression, anxiety, and stress were 7.31±8.53, 7.08±6.57, and 11.15±8.07, respectively. The depression, anxiety, and stress scores had no significant correlation with pain scores (p =0.84, 0.99, and 0.97 for depression, anxiety, and stress, respectively), or duration (p=0.69, 0.66, and 0.85 for depression, anxiety, and stress, respectively). Twenty-nine of 43 patients (67.44%) responded to topical NSAIDs as first-line treatment, and out of the remaining, 6.98% responded to evening primrose oil + vitamin E, 18.60% to tamoxifen, and 4.65% to danazol. Twenty-nine of 32 patients (90.63%) responded to evening primrose oil+vitamin E as first-line treatment, while 6.25% and 3.12% responded to tamoxifen and danazol, respectively. Conclusions Both topical NSAIDs and evening primrose oil + vitamin E were found effective first-line treatment options in the majority of patients. Hence, it is always advisable to start such patients on topical NSAIDs, or evening primrose oil + vitamin E, before switching over (if no resolution of pain is reported with these drugs) to higher and more severe treatment options. The duration or severity of pain did not correlate with the psychological condition of the patient.
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Background Marjolin's ulcer or scar carcinoma is a rare disease arising from the conversion of chronic scar into malignancy. Studies show Marjolin's ulcer squamous cell carcinoma has more chances of lymph nodal metastasis and is more aggressive with a worse survival rate. To date, no established guidelines exist for managing regional lymph nodes in cases of Marjolin's ulcer with clinically N0 nodes. Observation vs elective node dissection remains an option. In developing countries, long-term follow-up is not consistently leading to the risk of patients being kept on observation for regional nodes; presenting late with inoperable regional nodes is possible. This study aims to identify clinicopathological factors of lower extremity Marjolin's ulcer, which are associated with a high risk of inguinal lymph node metastasis. Identifying such risk factors may help provide a rationale for performing elective nodal dissection instead of observation in high-risk cases. Material and methods All clinically N0 lower extremity Marjolin's ulcer cases, more than 3 cm in size, treated at King George's Medical University, India, during the last five years, have been included in this study. Demographic, clinical, and pathological data of eligible patients were retrieved from institutional records. Various clinical and pathological factors were studied and correlated with lymph node positivity, and the strength of the correlation was tested using statistical methods. Factors correlated strongly with inguinal lymph node positivity were identified as high-risk factors. Results A total of 66 patients with lower extremity Marjolin's ulcer had no preoperative pathologically confirmed inguinal lymph nodes documented by ultrasonography and fine needle aspiration cytology. All patients underwent surgery for primary, followed by elective, inguinal lymph nodal dissection. The majority were males (n=51/66; 71%), and the most common age group was 30-50 years (n=40/66; 60%). The leg was the most common site (n=31/66; 47%). The least common site was below the ankle (n=14/66; 22%). Maximum dimension ranged from 3 cm to >15 cm, with the majority between 6 and 10 cm (n=40/66; 56%). Extension beyond the scar site was present in 24% (n=15/66) of patients. Most of the lesions in this study were well differentiated, 85% (n=56/66), and moderately differentiated, 15% (n=10/66), and none of the lesions was poorly differentiated. Perineural invasion, lymphovascular invasion, tumor necrosis, and extension below subcutaneous tissue were present in 82%, 14%, 28%, and 26%, respectively. Of 66 patients, 21.2% (n=14/66) had pathological nodal disease after elective nodal dissection. Perineural invasion (p<0.0001), depth of lesion (p<0.0001), and tumor necrosis (p=0.0002) had a statistically significant correlation with node metastasis. On ROC curve analysis, 7.5 cm was the cut-off size, above which chances of nodal metastasis increased significantly. Conclusions Marjolin's ulcer patients with no preoperative positive nodes may be segregated into high-risk and low-risk groups as per their risk of harboring cancer cells in regional lymph nodes. Those having one or more of the following risk factors should be classified as high risk: dimension more than 7.5 cm, presence of perineural invasion, tumor necrosis, and deep tumors extending below subcutaneous tissue. We recommend that such patients undergo prophylactic regional lymph node dissection instead of observation during primary surgery.
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A man in his mid-50s presented with heaviness in the right lower abdomen for the last three months. Ultrasonography (USG) showed an intra-abdominal mass in the right iliac fossa. Contrast-enhanced CT (CECT) revealed a well-defined circumscribed mass near the ileocaecal junction, with a hypodense center, surrounded by a hyperdense periphery and well-defined capsule. A lower midline laparotomy was performed. Intraoperatively, a white, firm, smooth ball-like mass was found, lying freely in the abdomen. Histopathology revealed fatty tissues surrounded by a calcified shell, which was further surrounded by proteinaceous material. Such peritoneal loose bodies (PLBs) are free masses in the abdomen, with variable sizes. These are asymptomatic, unless they compress any nearby viscera, as was in our case. The objective of this case report is to make surgeons and radiologists aware of this rare entity, which can be a source of confusion in a case of mass in the abdomen.
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INTRODUCTION: Tumors of facial skin are common in upper part of central subunit of face. Defects after resection require a flap, which is pliable, thin, and has a good colour match. Among the various local flaps available paramedian forehead flap is a good option. PATIENTS AND METHODS: Patients reconstructed with paramedian forehead flap during the period from January 2015 to March 2020 were included in the study. Data regarding the demographic, clinical characteristics, and treatment details was recorded, and analyzed for postoperative complications and cosmetic outcomes. RESULTS: Paramedian forehead flap reconstruction was performed in 37 patients who were resected for tumor involving upper central subunit of face. Median age of patients was 57 years. Male to female ratio was 1.4:1. All tumors were resected with a negative margin. Nodal disease was managed by superficial parotidectomy only (4/37), superficial parotidectomy along with supra-omohyoid neck dissection (6/37) and modified neck dissection (1/37). In five patients additional buccal mucosa graft was used to reconstruct conjunctiva. Additional flaps were required in two patients in whom nasolabial and mustarde flaps were used. Partial flap loss occurred in one patient. There was no major flap loss. Surgical site infection developed in only one patient, who had partial flap loss. On subjective assessment, nearly 60% patients described their appearance as good. CONCLUSION: Facial reconstruction in area of dorsum of nose and medial aspect of both eyelids using paramedian forehead flaps is a simple and quick procedure.
