General Details:

32 years old married female

Symptoms/ Signs:

Lump in Left Breast since 15 days

Examination:

Definite single and palpable hard mass 2 cms in size in upper outer quadrant of left breast

No skin or nipple changes

No axillary lymph nodes

History:

No significant medical or gynaecologic or family history

Menstrual H/o – Normal

Diagnostics:

Management:

Surgery: Left Breast Wide Local Excision with Therapeutic Mammoplasty with Sentinel Node Biopsy with Right Side Reduction Mammoplasty

Discussion:

The tumour is in the upper quadrant at 12 o’clock position, 5-6 cms away from Nipple-Areola Complex

Markings are done in such a way that nipple, which is placed at around 25 cms from suprasternal notch, is lifted to around 20 cms and the wise pattern markings are done

The lower segment is de-epithelised completely

The tumour is widely excised by dissecting it on one side and cutting way beyond the edge

Shaved margins are sent for a frozen section

The tumour bed is marked with clips for identification by radiotherapist

The whole of the lower segment including infero-medial, infero-lateral pedicles and inferior pedicle is used to carry the NAC as the breast is not extensively reduced

Lymph node is dissected out and sentinel node is sent for frozen section through the same incision

The NAC on the lower pedicle is transported to fill-up the gap in upper quadrant

Pect Block (local anaesthesia) is given between both the Pectoralis muscles and between Pectoralis Minor and Serratus Anterior

The filler, which is the extension of the lower pedicle, is filled into the gap and the nipple is carried to the appropriate position

The nipple is sutured, first by interrupted sutures and then with continuous sutures

Similarly on the other side, the wise pattern is marked and a formal inferior pedicle is done with reduction to achieve 10% smaller size compared to the other breast

Care is taken to cut perpendicular down to the chest wall

A sliver of tissue is kept on the chest wall to try to preserve the nerves

NAC is carried on the inferior pedicle and the inferior pedicle is fixed to chest wall to prevent bottoming out later on and the two pillars are closed over the inferior pedicle

NAC is sutured and the skin is closed in two layers

Surgical Histopathology Report

Original tumour size – 2.5cm x 2.3cm x 2cm

IDC Grade II

Foci of DCIS solid and comedo type with high grade nuclei

Nodal involvement: 1/6 nodes positive for atypical or malignant cells

Post surgery

On tissue blocks:-

ER/ PR - negative

HER 2 - negative