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Therapeutic Mammoplasty With Sentinel Node

    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:

  • Digital Mammography with 3D tomosynthesis:

    Cluster of branching microcalcifications seen in lower inner quadrant of left breast.

    Findings s/o high grade DCIS with comedo necrosis. BIRADS IV lesion.

  • Sonomammography:

    24x16mm hypoechoic lesion with multiple tiny calcifications at 9’o clock position

  • FNAC showed Malignant Breast Lesion.

    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

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