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Dcis case presentaion
- 1. Presentedby: Ms. Donisha K Johnson M.Sc. Medical Technology, SemII Imaging Sciences
- 2. Breast Cancer “Ductal carcinoma in-situ”
- 3. CASE A 58 year old female patient electively admitted to a tertiary care hospital with H/O of lump in left breast since two weeks
- 4. Patient posted for Wide excision of lump DAY 1: 1st July 2020
- 5. Personal Demographic History • Name: Mrs. Ann Felix • Age: 58 years • Gender: Female • Department: Obstetrics & Gynaecology • Consultant: Dr. Pearl • Hospital ID: AA2020196 • IP No.: IPR0072707 • Date and time of Admission: 01st July 2020 10:24 AM
- 6. History of presenting illness -Patient presented with left sided breast lump since 2 weeks gradually Increasing in size. -The lump is irregular in shape, tender and immobile, occasionally painful -There is no discharge from the nipples and no skin changes involved -Mammography performed showed a 2.2 x 1.7 cms irregular nodular lesion in the outer and upper quadrant of the left breast under BIRADS III category. -Trucut biopsy showed Focal ductal carcinoma in situ. -Now admitted for surgical intervention and management.
- 7. Past History Medical History Family History Obstetric History Personal History Past Medical history: Hypertension on treatment since 10 years Past Surgical history: no history of any surgery Current medications: LnBloc- 10 mg on OD since 10 years Allergies: No known allergies Patients’ mother has hypertension and Diabetes mellitus Menstrual history: menopause OBH: P2L2- FTND –L1- Female – 29 years -L2- Male- 27 years Married life: 30 years 1st child from 5 siblings Occupation: Laboratory technologist Patient is non-smoker and non- alcoholic Patient has no addictions of drugs
- 8. Family History of Breast Ca 1st Generation Maternal 1st Generation Paternal 2nd Generation Patient Breast Cancer No Cancer
- 9. Clinical examination Temperature: 98.3 F Pulse: 94 b/min Blood Pressure: 120/90 mmHg SpO2: 98% on room air (RA) Vita l Sign s
- 10. General Examination Pallor - No Pale color found on the skin and conjunctivae of the eyes. Icterus – No yellowish pigmentation found on the skin, tissue and body fluids. Cyanosis – No bluish discoloration are seen on the Lips, Nose, Cheeks and Oral cavity. Clubbing – No clubbing seen in Fingernails and Toenails. Lymphadenopathy – Swelling in the left axillary lymph nodes. Edema – No swelling on the hands and feet
- 11. Height -174 cm Weight – 83 kg BMI – 27.04 kg / m2 PHYSICAL APPEARANCE
- 12. Clinical Breast Examination: Inspection • Symmetry- Size, Shape, Position Both breasts are symmetrical in size, shape and position • Skin No visible skin abnormalities , no nodules, no ulceration, no texture difference, no dimpling, no skin discoloration, enlarged veins • Nipples and areolae Nipples present at both sides. Not retracted , no accessory nipples, nipples dark brown in color, central in position, no discharge is seen • Hands by the side/raisedabove head Axillary lymph node enlargement seen , no distended veins and no muscle wasting
- 13. Clinical Breast Examination: Palpatation of Lump • Temperature Warm • Tenderness Present on left breast • Site Left upper outer quadrant • Size 2 x 2 cms • Shape Round • Margin Irregular • Relation to skinand underlying muscles Hard, immobile and fixed Palpate Circles Wedges Lines
- 14. Systemic Examination Respiratory system Inspection Shape of the Chest – Bilaterally symmetrical and Elliptical in cross section. Movement of the chest – Equal on both side No abnormalities on the chest • No Tracheal deviation are present. No Abnormalities in Upper respiratory system. Palpation Surface temperature is afebrile. No abnormalities in Apical Impulse. Percussion Percussion done on entire lung field., No any dullness are found. Auscultation No Abnormal sounds
- 15. Systemic Examination Cardiovascular system Inspection No abnormalities on the chest JVP is normal Palpation No any abnormalities in apex beat. Thrill and Heave are absent. Percussion No abnormalities found in percussion done on 3rd,4th and 5th intercoastal space Auscultation Heart sounds are normal.
- 16. Systemic Examination Per Abdomen system Inspection No any abnormal signs are seen on the abdomen Palpation Superficial and deep palpation are done and no abnormalities are found. Percussion Percussion over the abdomen was given and no Fluid thrill Found. Auscultation Bowel sound are heard. No abnormal sounds are present.
- 17. Systemic Examination Central nervous system and neuromuscular system Patient is conscious and oriented Clonus absent No reflex abnormalities hyperreflexia/hyporeflexia/areflexia due to CNS metastasis or electrolyte disturbance
- 18. Routine Investigations • COMPLETE HAEMOGRAM • FT4/TSH • HIV, HBSAG, VDRL,HCV • CREATININE • URICACID • PT/APTT • HBA1C • LFT • BLOODGROUP • URINE ROUTINE • ECG • CHESTX-RAY
- 19. TEST PARAMETERS RESULT REFERENCE HB 14.1 gm/dl 11.5-16.5 gm/dl RBC 4.45 million/cumm 3.8-6 million/cumm PCV 39.7% 36-47% MCV 89.2 fl 80-95 fl MCH 31.8 pg 26-34 pg M.C.H.C 35.6% 31-38% PLATELET COUNT 2.75 Lakhs/cumm 1.5-4.5 Lakhs/cumm TOTAL COUNT 8029 cells/cumm 4000-11500 cells/cumm Neutrophils 58% 40-75 % Lymphocytes 37% 20-40 % Monocytes 4% 2-12 % Eosinophils 1% 0-6 % Basophils 1% 0-2% 30th June 2020
- 20. TEST PARAMETERS RESULT REFERENCE FREE T4 10.33 pmol/L 9.0 – 19.04 pmol/L TSH 2.458 uIU/mL 0.2 – 8.5 uIU/mL Serum creatinine 0.82 mg/dl 0.6-1.2 mg/dL Uric acid 6.40mg/dl Upto 5.7 mg/dL FBS 100 mg/dL 75- 100 mg/dL HbA1C- Glycosylated HB% 6.50 % 4.8-5.6 % Prothrombin Time 17.0 seconds 11.0- 15.0 PT Control 13.2 seconds ------- PT-INR 1.27 seconds 0.8-1.2 seconds Activated Partial Thromboplastin Time 34.9 seconds 17.8- 39.8 seconds Aptt control 31.5 seconds ------ 30th June 2020
- 21. TEST PARAMETERS RESULT REFERENCE V.D.R.L Non Reactive HIV 0.09 Non reactive less than 1 HBsAg 0.25 Anti HCV 0.06 Non reactive less than 1 (LFT) TOTAL BILLIRUBIN 0.85 mg/dl 0.2-1.3 mg/dl Direct bilirubin 0.18 mg/dl 0.0-0.3 mg/dl Indirect bilirubin 0.67 mg/dl Aspartate Amino Transferase (SGOT) 29 U/L < 31 U/L Alkaline Phosphatase (ALP) 92 IU/L 25-140 IU/L Alanine Amino Transferase (SGPT) 41 U/L < 31 U/L 30th June 2020
- 22. TEST PARAMETERS RESULT REFERENCE Routine Urine Analysis Appearance Slightly Cloudy Colour Yellow Glucose Negative Bilirubin Negative Ketone Negative Specific Gravity 1.030 1.01-1.035 pH 6.0 4.6-8.0 Urobilinogen Normal Pus cells 0-2 cells/hpf 0-5 / hpf RBCs Nil 0-2 / hpf Epithelial cells Occasional 0-2 /hpf Crystals and casts Nil 30th June 2020
- 23. Special Investigations • Mammography • Histopathologic examination • USG of abdomen & pelvis • 2D-ECHO
- 24. Mammography: is a dedicated radiographic technique for imaging the breast • Screening Mammography • Diagnostic Mammography
- 26. Standard Views Cranio-caudal view (CC) Medio-lateral oblique view (MLO)
- 28. Radiological Anatomy Of Breast
- 29. Image Assessment: breast composition; Mass/Calcifications; Architectural distortion; BIRADS classification: widely accepted risk assessment tool, scale ranges from 0 to 6.
- 30. • BI-RADS 0, inconclusive results requiring further mammography; • BI-RADS 1: no areas of architectural distortion, suspicious calcifications, or masses (tumor was absent); • BI-RADS 2: simple cysts, secretory calcifications, calcified fibroadenomas, implants, fat- containing lesions, and intramammary lymph nodes (benign tumor); • BI-RADS 3: a solitary mass of punctate calcifications, or a circumscribed and non-palpable mass, or focal asymmetry (probably benign); • BI-RADS 4: suspicious for malignancy • BI-RADS 5: highly suggestive of malignancy
- 31. Patient underwent mammography examination with relevant preparations Patient was explained about the procedure beforehand Bilateral breasts were examined the examination took about 15 mins The images were sent to the radiologist for reporting
- 32. Mammogram report Fibro fatty tissues noted in both breasts Irregular well defined homogenous nodular opacity lesion measuring 2.2 x 1.7 cms noted in outer and upper quadrant of the left breast Retro mammary spaces is clear bilaterally , nipple and areolar regions appear normal ; skin and subcutaneous tissues are normal; Left axillary lymph node with benign morphology Mammogram of both breast were performed, Cranio- caudal and Medio-lateral oblique views are obtained Impression: Irregular nodular lesion in upper and outer quadrant in left breast suspicious for malignancy, BIRADS ‘III’ category Suggested sonomammogram and FNAC for further evaluation 24th June 2020
- 35. Ultrasound-guided Tru-cut needle biopsy is a well- tolerated and reliable procedure for providing a tissue diagnosis of malignancy before definitive treatment, and obviating the need for formal excision biopsy of lesions for which there is a low index of suspicion.
- 36. Histopathology test report Tissue fixation: Adequate Macroscopy description: Specimen contains of four grey- white bits of tissue, measuring 0.3 to 0.7 cms in two sections named A,B Microscopy Description: Block ‘A’- the section depicts tissue cores comprising of fibrous and adipose tissue components. A single tiny bit shows two compressed ductal structures which are lined by epithelial cells showing moderate nuclear atypia, hyperchromasia and absent nucleoli Within intact basement membrane – suggestive features of Ductal carcinoma in situ (DCIS). There is dense periductal lymphoid infiltration, no evidence of invasive malignancy Nature of the specimen: Trucut Biopsy Clinical Data: K/C/O left breast lump Specimen identified by patients’ name and accession number on the container; 26th June 2020
- 37. IMPRESSION: Focal Ductal Carcinoma In Situ, intermediate grade NHS BSP Category- B4 Section ‘B’ – the section reveals fibro adipose tissue components and skeletal muscle fibers of normal morphology with separate small fragment of tissue shows a few ductal/lobular tissue lined by bilayered epithelial membrane- within normal limits. No features of malignancy
- 39. USG of Abdomen and pelvis Kidneys: both kidneys normal Right kidney: 8.0 cm Left kidney: 8.2 cm Pelvi-calyceal systems: Normal Bladder: Normal Uterus: anteverted and normal Ovaries: Normal Impression: Fatty liver, no other significant abnormality detected Liver: shows increased parenchymal echogenicity Spleen: Normal Portal venous system: Normal Hepatic veins: Normal Biliary system : Normal Pancreas: Normal 30th June 2020
- 40. Chest X-ray report Chest X-ray PA View Findings • Bilateral lung fields are clear • The cardio mediastinal contours are within the normal limits • The hila are normal • Bilateral costophrenic angles are normal • Bony thorax appears normal Impression: No significant abnormality detected 30th June 2020
- 41. 2D ECHO Normal cardiac chambers Normal valves Normal RV and LV systolic functions Mild pulmonary hypertension No clot/RWMA 30th June 2020 ECG ECG showed normal rhythm
- 42. Physician opinion sought for fitness for surgery With routine pre-operation procedures and with prior consent the patient underwent Wide excision of left breast lump under general anesthesia
- 43. WIDE EXICISION OF LUMP DONE UNDER GA ● Lump in upper outer quadrant of left breast was removed with skin over tumor unto deep muscle ● Around more than 1 cm margin given in all directions with medial margin excision ● Drain placed, wound closed in layers ● The specimen sent for HPE
- 44. POST- PROCEDURE TREATMENT • Patient withstood the procedure well • Patient treated with IV fluids, IV antibiotics, antiemetics, analgesics, PPI’s and other supportive medications • Treatment given: • Inj. Taxim 1 gm IV/ATD 1-0-1 • Inj. PAN 40mg IV/ 1-0-1 • Inj. PCT 100ml IV STAT • Inj. Emeset 1 amp IV STAT • Inj. Tramazac 1 amp 1-1-1 • Tab LN BLOC 10 mg 0-0-1 • Ward stay was uneventful hence was discharged in stable condition with drain in situ the following morning ( 02/07/2020)
- 45. Condition of patient during discharge : Patient was stable, wound healthy and dressing was done Advice on discharge: Tab. Taxim- O 200 mg 1-0-1 x 5 days Tab. Ultracet 1-1-1 x 5 days Tab. Pan 40 mg 1-0-1 x 5 days Drain care
- 46. Thank You