Tumour (Arbuda)

Detailed description of Arbuda and their co-relation with different tumours)

1. Lecture on Arbud or Tumour By- Dr. Alok Verma

2. Arbuda गात्रप्रदेशे क्वचिदेव दोषाः सम्मूर्च्छिता मांसमभिप्रदूष्य | वृत्तं स्थिरं मन्दरुजं महान्तमनल्पमूलं चिरवृद्ध्यपाकम् ||१३|| कुर्वन्ति मांसोपचयं तु शोफं तमर्बुदं शास्त्रविदो वदन्ति |१४| Su.Ni . 11 The vitiated doshas in whole body goes to mansa dhatu and produces, oval, fixed, painless/less painful, mass with deep rooted and slowly growing without suppuration causes swelling, may known as Arbuda .

3. Types वातेन पित्तेन कफेन चापि रक्तेन मांसेन च मेदसा च ||१४|| तज्जायते तस्य च लक्षणानि ग्रन्थेः समानानि सदा भवन्ति |१५| Raktaj: दोषः प्रदुष्टो रुधिरं सिरास्तु सम्पीड्य सङ्कोच्य गतस्त्वपाकम् ||१५|| सास्रावमुन्नह्यति मांसपिण्डं मांसाङ्कुरैराचितमाशुवृद्धिम् | स्रवत्यजस्रं रुधिरं प्रदुष्टमसाध्यमेतद्रुधिरात्मकं स्यात् ||१६|| रक्तक्षयोपद्रवपीडितत्वात् पाण्डुर्भवेत् सोऽर्बुदपीडितस्तु |१७|

4. Mansaj : मुष्टिप्रहारादिभिरर्दितेऽङ्गे मांसं प्रदुष्टं प्रकरोति शोफम् ||१७|| अवेदनं स्निग्धमनन्यवर्णमपाकमश्मोपममप्रचाल्यम् | प्रदुष्टमांसस्य नरस्य बाढमेतद्भवेन्मांसपरायणस्य ||१८|| मांसार्बुदं त्वेतदसाध्यमुक्तं... |१९| ..साध्येष्वपीमानि विवर्जयेत्तु | सम्प्रस्रुतं मर्मणि यच्च जातं स्रोतःसु वा यच्च भवेदचाल्यम् ||१९|| These arbuda develops due to blunt injury/ hit by closed fist. These are painless, smooth margins, nonsuppurative , hard,fixed , skin colured . This happen usually in the people who ate lots of mans. These are Asadhya, even if the sadhya arbuda is present on marma sthan, continuous discharging, present in shrotasa and fixed then these became asadhya.

5. Few terms यज्जायतेऽन्यत् खलु पूर्वजाते ज्ञेयं तद ध्यर्बुद मर्बुदज्ञैः | यद्द्वन्द्वजातं युगपत् क्रमाद्वा द्विरर्बुदं तच्च भवेदसाध्यम् ||२०|| Medoj : न पाकमायान्ति कफाधिकत्वान्मेदोबहुत्वाच्च विशेषतस्तु | दोषस्थिरत्वाद्ग्रथनाच्च तेषां सर्वार्बुदान्येव निसर्गतस्तु ||२१||

6. Arbuda Samanya chikitsha Upnaah with the doshs samaka medicine accordingly. Raktavsechana ( Shringa,Alabu,Jaluka , siravedha ) Vaman and Virchana Ksharkarma Lekhana karma Agnikarma Shastra karma If there is wound then treatment of vranachikitsha .

7. TUMOUR Definition Tumour or Neoplasm is the growth of new cells which proliferate without relation to the need of body. This occurs due to abnormal reproduction or abnormal differentiation . The term tumour must be used for the new growth only nor for any swelling.

8. Few terms should clearly understood in respect to tumour…………….. Metaplasia: There is change in one well differentiated tissue in to other differentiated cells. This usually occurs due to chronic irritation. For e.g. Squamous Metaplasia occurs as simple columnar epithelium of gall bladder changes in to squamous epithelium, which is precancerous condition. Dystrophy : This is defined as a disorder, usually congenital, of the structure, function of any organ or tissue. Term dysplasia may be used sometime for the abnormal development of the tissue. Anaplasia: This is a condition where, collection of the cell, which does not resembles to any kind of tissue. Teratoma: These are the tumors arising form the totipotent cells, i.e. the cells which are capable to differentiate in to any kind of tissue. That’s why in teratoma there is presence of all three Germ layer (Ectoderm, mesoderm, endoderm).

9. Classification Tumours are broadly classified as Benign and Malignant. Benign : Any capsulated tumour, which has no tendency to invade the surrounding tissue. These Tumours proliferates slowly and have little evidence of mitosis. The cell are usually well differentiated. Malignant: Invasiveness is the characteristic feature of malignant Tumours. The edge is therefore ill-defined in contrast to well defined in benign tumours. The term cancer is exclusive for it’s invading property.

10. Comparison S.N. Character / factor Benign Malignant 1 Age At any age Usually after 40 yrs 2 Size Usually small, may be enormous Usually large size 3 Growth Slow growing, expansile type of growth, progress of growth is irregular tend to cease. Rapidly growing, invasive type, progress is relentless till death. 4 Histology Well differentiated, well formed stroma with little tendency of bleeding and necrosis. Cells regular few mitosis. Poorly differentiated, sometime anaplastic, poorly formed stroma with high tendency of bleeding and necrosis. Often numerous mitosis. 5 Fixity Not fixed to nearby structure Usually fixed 6 Surrounding structure Not involved Involving to surrounding structure is characteristic. 8 Metastasis Never Frequent 9 Cause of death Usually not fatal, death may occur due to mechanical pressure. Combination of mechanical and destructive effects, secondary infection, starvation, blood loss, etc.

11. Classification of malignant cancer Classification on the basis of growth of cancer: Carcinoma-in-situ. Locally malignant tumour Dormant cancer Latent cancer

12. Varieties of benign and malignant tumour Tissue origin Benign Malignant Epithelium Covering epithelium Squamous Squamous- cell papilloma Squamous- cell carcinoma Transitional Transitional- cell papilloma Transitional- cell carcinoma Columnar Columnar - cell papilloma Adenocarcinoma 2. Compact secreting epithelium Adenoma, if cyst then cystadenoma Or papillary cystadenoma. Adenocarcinoma if cyst cystadenocarcinoma 3. Others epithelium Basal cell carcinoma, salivary and mucous gland tumour are different from both benign and malignant. Connective tissue Fibrous tissue Fibroma Fibrosarcoma

13. Tissue origin Benign Malignant Nerve sheath Fat Smooth muscles Striated muscles Cartilage Bone Osteoblast Osteoclast Meninges Lymphoid and hematopoietic tissue Neurofibroma Lipoma Leiomyoma Rhabdomyoma Chondroma Osteoma Osteoclastoma Meningioma Benign Lymphoma Neurofibrosarcoma Liposarcoma Leiomyosarcoma Rhabdomyosarcoma Chondrosarcoma Osteosarcom Malignant osteoclastoma Meningiosarcoma Lymphosarcoma . Fetal trophoblast Hydatidiform mole Chorion- epithelioma Embryonic tissue Totipotent cells Notochord Benign Teratoma ------------------ Malignant teratoma Chordoma Hamartoma Melanotic Angeiomatic Benign melanoma Benign angioma Malignant melanoma Angiosarcoma

14. Etiological factors of malignant tumour Although the exact etiology of cancer is unknown, but there are few predisposing factors to develop cancer. The cause is not one for all cancers. Hydrocarbons Sex hormones Radiations Viruses Co-carcinogens Heredity Chronic irritation Trauma Diet Geography

15. Spread of malignant tumours There are six various routes of spread of malignant tumours………. Local or direct spread Invasion by lymphatics Through blood vessels Through serous cavities Natural passages Inoculation

16. Some benign tumours Papilloma Lipoma Adenoma Fibroma Hemangioma Neurofibroma

17. Papilloma It is common benign sessile or pedunculated tumour containing layers of skin. It may be arises form epithelial surfaces may be epidermis or mucous membranes. It contains blood vessels and lymphatics. The various examples:- From epidermis- papilloma of skin Squamous cell type Congenital, infective papilloma or infective warts, soft papilloma, keratin horn Basal cell type Senile warts on trunk, face, arms and arm pits From mucous membrane Squamous: tongue, cheek, lips, esophagus etc. Transitional: pelvis of ureter, Bladder Columnar: colon, rectum, stomach, small, intestine From wall of duct From wall of cyst Treatment Excision may be form for the cosmetic reason. In Infective warts of HPV antiviral therapy may help up to some extent but excision is the ultimate option.

18. Adenoma This is benign tumour of glandular tissue. Usually arises from secretory gland. Adenoma are usually encapsulated, causes pressure atrophy over surrounding structure. Adenoma arises from secretary glands of mucous membrane becomes, pedunculated then called Polyps. Commonly found in large intestine & rectum. These often tends to be malignant. Adenoma found in glandular structure as breast, prostate, salivary glands and other endocrine glands. These tumors tend to be malignant. There are two variants: Fibroedenoma found in breast Cystadenoma found in ovary, pancreas, parotid gland & kidney. Treatment Complete excision.

19. Fibroma It is a rare tumour. It consists of collections of fibroblasts between which there is variable amount of collagen. It is of two types hard or soft. Hard fibroma has more common collagen, whereas the soft fibroma is predominantly cellular. Many fibroma are combined with other mesodermal tissue such as fat, muscles, nerve sheath. Treatment Complete excision.

20. Lipoma This is most commonest in all benign tumours. It is composed of fat cells of adult type. It can occur anywhere in the body, that is why also called as universal tumour or ubiquitous tumour. The commonest site are subcutaneous tissue trunk, back of neck, limbs. There are three variety:- Encapsulated variety Diffuse variety Multiple lipoma

21. Complication A lipoma when present long time may undergo certain changes. This is particularly true in cases of lipoma in the subcutaneous tissue of the thigh, buttock or retroperitoneal lipoma. These changes may be- Degeneration Saponification Calcification Malignant or sarcomatous changes.

22. Variety of Lipoma Lipoma can occur in different anatomical situations… Subcutaneous Sub fascial Intermuscular lipoma Sub-serous lipoma Sub-mucous lipoma Intra- articular Sub-synovial lipoma Periosteal lipoma Extradural lipoma Intra-glandular lipoma

23. Subcutaneous Lipoma Pathology Clinical feature History Age Duration Symptoms Examination Position color Temperature & tenderness Size & shape Surface Consistency Trans-illumination test Mobility “slip sign” + ve

24. Treatment Cleaning & Draping Linear incision Separate from adjoining tissue Keep stay suture if required Little traction by stay suture Extract mass with capsule Achieve heamostasis Pour antibiotic solution Close cavity Close skin with interrupted

25. Hemangioma A development malformation of blood vessels it is not typical tumour. It may be considered as example of Hamartoma. Hamartoma is development malformation which consists tumour like overgrowth in which the particular body tissue is arrange, haphazardly, usually with an excess of one or more of it’s components. The large number of lesions fall in the general category of hamartoma. These lesions are benign pigmented moles, majority of angioma, and Neurofibroma. There are three types of hemangioma Capillary hemangioma Venous or cavernous hemangioma Arterial or Plexiform hemangioma

26. Capillary hemangioma There are three variety of capillary hemangioma— Strawberry angioma Port-wine stain Salmon patch

27. Strawberry angioma (strawberry naevus ) Characteristics: A typical history of appear a red mark after 1to 3 weeks of birth. Gradually increase in size and becomes like strawberry in few months. Usually involve subcutaneous tissue, skin, muscle and rarely sub mucous. On examination a swelling slight protrude from skin, sessile, dark red lesion. The swelling is compressible , apulsatile , the surface is irregular may covered with scabs on ulceration. After first birthday hemangioma starts regresses and disappear before age of 8-9yrs.

28. Port wine stain Characteristics: It present since birth and remain for rest of life. Size increases in proportion to the body surface area. Most commonly present on face, shoulder, neck and buttock. Colour is deep purple-red which later on becomes pale. Lesions are flat no elevation color diminishes on pressure and reappear on releasing pressure.

29. Salmon patch Characteristics: Present since birth and disappear before 1 st birthday. Mostly seen over forehead or occiput or anywhere in midline of body.

30. Treatment Wait and watch, as most of capillary hemangioma disappear in 7-8 yrs. If patient insisted, cosmetic treatment includes Excision of lesion with skin graft Carbon Dioxide snow application Injection of hot water, hypertonic solution or sclerosant X-Ray therapy Injection of steroids.

31. Venous/cavernous hemangioma It consist of multiple dilated venous channels. It is spongy swelling. Characteristics: It is present since birth and does not show any tendency to involusion but it may goes larger with time. These are usually bluish colour as content is venous blood. These are non-pulsatile. Compressibility present. Common site are face, cheek, ears, mucous membrane of lips, tongue may be in the organs, like liver, kidney and brain.

32. Treatment Conservative treatment More often conservative treatment is enough. Injection of sclerosing agent in to lesion. In this respect 3% sodium morrhuate is quit effective. The injection is given once week for few times up to 6 weeks if necessary. Cauterization may be effective in hemangioma. Surgery Surgery is better treatment if swelling is small and localized. The feeding vessels are first ligated and whole lesion is excised. Diathermy may be used to control hemorrhage.

33. Spider naevus It is solitary dilated skin arterioles feeding a number small branches which grows in radial manner. It is an acquired condition associated with some generalized disease. Such lesions are presents on face, trunk and arms. Compressibility present Usually associated with chronic liver disease ( cirrhosis, tumour) and tumours producing estrogens.

34. Arterial or Plexiform Hemangioma It is a type of congenital arteriovenous fistula. These swelling are pulsatile and arteries and veins become arterialized. Feeling like a bag of pulsating earthworms. Treatment Ligation of vessels. Therapeutic embolism of the feeding artery After ligation of feeding vessels excision of the lesion with diathermy.

35. Neurofibroma These tumour arises from the connective tissue of the nerve sheath. This is a development disorder and is often considered as hamartoma and not a typical tumour. Such disorder often runs in families. Majority of the Neurofibroma arises from endoneurium, the innermost connective tissue layer of nerve fiber. There are two varieties of Neurofibroma. Local Generalized

36. Local Neurofibroma Single Neurofibroma is usually found in the subcutaneous tissue, found in extremities on median nerve, ulnar nerve etc. Clinical feature Swelling is main feature may accompany paresthesia and pain on pressure. The swelling is smooth with well defined margin on skin with subcutaneous tissue. Mobility is only sidewise from the axis of nerve fiber. These Neurofibroma may also occur other than skin, like cranial nerve, dorsal nerve root of ganglion, intramuscular and sometime bones. May goes in to cystic degeneration or malignant change s Treatment Excision of lesion without injuring nerve is treatment of choice, sometime removal is not possible then that particular section of nerve is removed followed by end to end anastomosis of nerve is good option. Recurrence may happen after resection.

37. Generalized Neurofibroma Also known as Von Recklinghausen’s disease of nerve. There are multiple Neurofibroma arising from the cranial, spinal or peripheral nerve. This is autosomal dominant inherited disease. This arises from endoneurium. Von Recklinghausen’s disease of bone*

38. Clinical feature There are multiple nodules of varying size can be seen over face, neck , trunk and limbs . Majority of the Neurofibroma present since birth, number and size increases as age progresses. The nodule vary in consistency from soft to hard. Each nodule has clear margins. The other neurological abnormalities are not common. Often the skin over nodule becomes hyper pigmented. Sometime some skeletal deformities also present. In Approx 5% cases malignant changes may be present.

39. Treatment The number of Swellings are numerous so, excision of all is almost impossible, but the swelling can be excised if it is painful, large, causing mechanical discomfort and having pressure effect. The swelling but be excised and send for HPE, if malignant changes are suspected. No medical cure is available till now.

40. Some less common Neurofibromatosis Plexiform neurofibromatosis Elephantiasis neurofibromatosa Cutaneous neurofibromatosis. Plexiform neurofibromatosis Cutaneous neurofibromatosis Elephantiasis neurofibromatosa

41. Malignant tumours Malignant tumours of skin and epidermis are Basal cell carcinoma Squamous cell carcinoma Malignant tumours of secreting epithelium or underlying glands are Glandular carcinoma Malignant tumours of transitional epithelium Transitional cell carcinoma The melanomas

42. Basal cell carcinoma This is a locally invasive carcinoma of the basal layers of epidermis. This is low grade malignancy. White, Elderly people are usually affected, more commonly in males. It may be ulcerative (rodent ulcer), Nodular or Cystic type. Commonly This arises from the basal layer of epidermis but some time it may arise from basal cells of hair follicle and sweat glands. It spread with local invasion, it destroys the tissue comes in contact with. That is why this tumour is called rodent ulcer.

43. Clinical feature Main complain is chronic painless, non-healing ulcer, later may be itch. These ulcers are deep so may bleed due to erosion of vessels. After being secondary infected it may cause pain. Most common site is face and other are outer/inner canthus of eye, nose, nasolabial fold or fore head. As the common presence of tumour on face also called as tear ulcer. Tumour always starts with nodule, later on the center of nodule undergoes in necrosis and develops the ulcer. Treatment Radiotherapy Surgery Cryosurgery Local chemotherapy laser

44. Squamous cell carcinoma This is carcinoma of squamous cell of the skin. This carcinoma may be starts from the skin or may be arises from any pre- existing lesion like- Longstanding chronic ulcer. Senile keratosis Bowen’s disease Leukoplakia Skin expose to irradiation. Chronic skin lesion as lupus vulgaris, eczema, warts. It may also develop from pre-existing basal cell carcinoma.

45. Site This tumour can develop any place in body where there is squamous or transitional epithelium Anywhere in skin as face, dorsum of hand, feet, etc Junction of skin and mucous membrane e.g. Lips, nostril, eyelids, genitals. Mucous membrane lined by stratified squamous epithelium. e.g. Tounge , mouth, esophagus, vagina. Occasionally seen in layers having columnar epithelium for e.g. bronchus, gallbladder. After metaplasia it may be occur in various organ like kidney, ureter and urinary bladder.

46. It is of two types Proliferative Ulcerative Spread Local Lymph Blood Clinical feature Usually seen above 40 yr Have Occupational relation Usually painless, nodule or ulcer. May have enlarge lymph nodes Treatment Surgery Radiotherapy