Breast cancer presents across a spectrum from silent, screen-detected lesions to symptomatic, advanced disease, requiring tailored diagnostic approaches including mammography, ultrasound, MRI, and biopsy, with critical emphasis on comparing serial imaging, maintaining low threshold for biopsy in pregnancy-associated cases, and recognizing that even non-palpable lesions with subtle imaging features warrant investigation to rule out malignancy.
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Webinae 9 - From Silent to Symptomatic: Spectrum of Clinical Presentation of Breast Cancer - How toAjouté :
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We'll be presenting three cases of a screen detected cancer with three different findings and how we tried to approach them for the diagnostic workup.
Over to Tisha please.
Thank you so much sir. Uh good evening everyone. I'm Dr. Tisha. Uh and uh today we'll be talking about screen detected breast cancer. Uh we are all aware that screen detected breast cancer present with unique set of challenges in terms of man uh diagnosis and management. They are often non-palable lumps. They are very subtle on imaging and have to have a very wide variety of >> recording in progress.
>> Hello. Am I audible?
>> Yes. Yes, you are.
>> Yeah. And they need uh very uh careful radiological and pathological correlation to help us with the treatment decision. So today we'll be discussing three such cases. The first case is that of a 68-year-old female.
She was asymptomatic and came to us for a regular health checkup. She was menopausal, hypertensive and had a strong family history of breast cancer.
Here is a mamogram from her left breast.
If we can appreciate the changes in the mamogram.
This is the tomo of the same patient which makes the changes more evident.
So what would you do in such case?
We went ahead with an ultrasound of the left breast where we can identify the lesion with peripheral vascularity as shown in the second image.
These are the findings of mamogram and ultrasound of the patient. It had a irregular speculated mass in the left breast upper inner quadrant close to 11:00 position measuring 10 into 8 mm bats 5 and the ultrasound gave irregular hypocoic lesion with peripheral vascularity in the left breast which was corresponding to the mamog giving by 4C.
>> So what would you typically do in such a case?
>> Any comments by the expert?
Dr. Ammon ma'am um if you >> Hi um it's a very typical finding we see on screening mamogram um you can see the speculated mass quite well you can see it better on tomographic images but on this case you can actually see it very well on the 2D image also the tomographic image just confirms it and when you do the ultrasound it's important to correlate it which they have said correlate it with the mamogram because this is a small mass and often you may see multiple small masses. So it's very important to correlate the ultrasound finding with the mamography finding to know that it's the same finding and this would be a birac case and ahead you would go ahead and biopsy this >> exactly Dr. Kusha what was the status of the nodes the axilla >> uh so they were enlarged but not uh enhancing >> uh can I just add so on ultrasound we can't talk about enhancing nodes so what we would talk about on ultrasound more than the measurement of nodes on ultrasound what is important is the cortical thickening in Indian population we often see enlarged nodes which can go up to 2 cm and can be very normal uh so it's important if the radiologist ologist hasn't told you that to ask them is there cortical thickening and is there abnormal cortical thickening. So uh it's not very sensitive but if there is grossly abnormal abnormal cortical thickening you can say that there's a possibility of a noral spread the possibility not sure and then you if you require you can biopsy it or not that depends on what your management is going to be like.
>> Yeah absolutely Dr. Ammon the ultrasound was normal as far as notes were concerned no significant lymphnopathy on either side.
>> Uh Dr. Prica uh can I just ask you a question because you mentioned that her mother had breast cancer. So uh what was her age when she was diagnosed her mother and was this lady the lady who you are presenting did she have any previous mamogram?
>> Uh no ma'am she had just come to us for a first like a regular health checkup.
This was there were no comparative mamograms that we had to compare it with previous >> mamog. Okay. Okay. So uh if there was is it important that is what uh basically we would like to understand. Is it important if she had a previous mamogram? It would be important to see if certain ch there basically to notice any interval changes like there could be previous asymmetry or like a calcification of sorts or something that she might have from probably a previous fibroid or something old uh fibroid. Definitely there will be a difference in the type of findings that we see on a mamog. But if she has been having a certain finding from a periodic time then uh we can still do a follow-up. But if there is a sudden interval change in her sequential mamogram then that is something we will have to pay more attention to.
>> Yes. So in this particular case I'm sure Dr. Aman ma'am will agree with me that this is a very very suspicious and it cannot be left just like that. But in case if there are very tiny uh you know areas of microalcification which might have been missed previously and if the present mamogram shows that there is an increase in the area uh covered by microalcification then that is very very important. Uh Dr. Raman ma'am can you uh would you like to add anything to >> yeah so when we are talking of specially screening mamogs and in India as with the occult screening mamogs they have to be read in conjunction with old mamography all the studies that they show with mamography picking up cancers is when they're reading screening mamograms in series not one mamogram alone so it's very important to have own mamograms to educate people to keep their own mamogs in because in India we don't all hospitals don't have packed systems where we have the old mamograms there and you're trying to look for subtle findings. You're going to see subtle findings in only when you have the previous mamograms. The easiest way to explain to young surgeons, radiologists or young residences when you look at CT scan of a brain, each brain looks very similar. There's just there's atrophy in a older brain or something else. But when you look at mamogs of different people, they're completely different. So there's no normal. The normal you see in a mamogram is the first mamogram of a patient. So that's why the old mamogs are so important to us. A finding like this, I wasn't too worried about old mamogs because it's a very suspicious finding.
If this finding with a speculated mass was there even on the old mamogram, I would still call it suspicious. It probably just didn't get called last time because it's very speculated. If the margins are smooth, rounded, and they had a old mamogram, it would change things. But this speculated mass is very suspicious. Whether she had it before or not, you would biopsy it.
>> Yes, >> absolutely. Dr. One at Maidanta we have a policy that the previous mamogram if it has been done in Maidanta we have all the records for the last 16 years but if they have been done outside we do ask but many times patient don't bring them or they have lost it or many times we are not able to compare but as a policy we try to compare with the old mamogram as much as possible. Yeah. So next >> I'm sure for the uh audience it is a very important take-home from so far what we have discussed is that whoever comes for screening mamogram uh whether it is normal or whatever you have to inform the patient to keep it safe and bring it at the time of next screening mamogram that is very important. So Dr. Disha please go ahead.
>> Yeah so like ma'am said it was very evident on ultrasound and we went ahead with a true cut biopsy. Now we'll move on and the finding were invasive ductal caroma. We'll go on to the next patient.
She was a 44 year old female patient who was a prospective liver donor asymptomatic came to us for clearance for liver donation.
>> Just a minute that actually we have a very large liver and kidney transplant program and all patients they come for certain departmental clearances including the female patients at dress department. If any patient who is above 40, we are doing a screening mamogram while the younger patients we just do clinical examination and clear them. So this is a patient. Go ahead Tashant.
>> Yes sir. So she was a 44 year old female prospective liver donor asymptomatic came to us for clearance. She was permenopausal and has no family history of breast cancer.
So here is her first 2D mamogram. uh here we can only appreciate some focal asymmetry in the upper outer quadrant.
On a tomo mamogram there is uh we can appreciate the architectural distortion.
>> Uh Dr. Raman, would you like to make a comment >> or or >> sorry, this is uh this is only the CC view. You can see the architectural distortion laterally. Do you have the oblique view to see if it's consistent or >> Yeah, it was consistent.
>> Yes, ma'am. It was consistent.
>> Yeah. So uh if there's an architectural distortion with this kind you'll go ahead and do an ultrasound and see if you can see anything there. You can do a spot compression view but with the tomosynthesis you can see the distortion pretty well. So I would just go ahead and do an ultrasound.
>> Yes ma'am.
>> So we went ahead and did an ultrasound ma'am but it was not giving any additional significant information as compared to a mamogram. In this case, it only showed an over hypo collision with cystic changes >> in the area of mamographic abnormality.
>> Yeah.
>> Yes, ma'am. There was no uh more correlation.
>> Okay.
>> So, uh simple cyst you saw in the area or you uh saw a lesion which had cystic changes.
Ma'am the uh the report said there was a lesion with cystic changes but uh not clinically correlating with the mamography.
>> So it wasn't at the same place they just saw this incident.
>> Yes ma'am.
>> Yeah. So in this uh I there are two things since she's a kidney donor you have to clear it. You can't uh so the thing is you can't say I'll follow this because she's a kidney donor. So you can either do a contrast enhanced mimography or you can do an MRI to rule it out.
Whichever you have, whatever facility you have in your hospital, >> you can do a stereotactic biopsy of our architectural distortion, but I would like to see it on the other view before I decide that because you need to see it's consistent on both views before you you need to be sure it's there on the mamogram before you put a needle inside.
If you're not sure and it's seen only on one view, probably a better idea to do an MRI or a contrast enhance meography and see if the lesion is real or not real.
Right ma'am. So we went ahead and got a contrast enhanced MRI done for this patient and we couldn't see the areas of enhancement as marked in the images.
There are multiple tiny cystic uh changes that we can appreciate.
So this was the report of the MRI focal areas of enhancement with multiple tiny cysts in the left breast upper outer quadrant close to 2:00 position and there were no other suspicious leisions in either breast. Uh this was given a bats 4.
>> So what next?
>> Dr. Shashank would you like to u uh comment or yeah >> uh we would want to discuss with the radiologist but a bats for religion herein there are two things first they would want to do a biopsy but probably give the clearance at the same time to proceed with the uh with the transplant program >> okay Dr. Ankita >> with a with a architectural distortion quite evident. Would you like to give a clearance without any tissue diagnosis or anything and with a non-mass enhancement in a in a MRI?
>> No sir, I would want to do a biopsy but what I'm trying to say is that that won't be an absolute contra indication to the transplant.
No, >> I think it is I think it is DCIS or LCI or or invasive carcinoma. I think we cannot give a clearance for liverp.
>> Yeah.
>> Right.
>> In which case I would want to go ahead with a stereotactic biopsy or if MR guided biopsy custo uh Dr. Ankita can we have a like is VAB effective in such cases? Pardon biopsy web v.
>> Yeah. Yeah. Let us see what we have done.
Any other opinion?
>> But uh we would prefer usually that when we are uh when we see such cases see we are a tertiary care center of malignancy. So usually we see incidentally detected bar for lesions with conccommatant other malignancies.
>> Yes. And uh we usually have uh you know some surgical intervention which is planned by the other uh other big management group. We don't usually let the virats over a lesion during the planner treatment. Of course this is an elective setting or donor setting so that things would be different. But when when the patient is undergoing treatment for another disease, what we try is to do either a solarized excision biopsy during the surgery while the patient is under G to save sort of time and save uh the patient the procedure. Uh understanding the fact that a 4A lesion is definitely not going to probably change the course of the treatment. Uh we do have to obviously discuss this with the radiologist and make sure that the index of suspicion is low that it is 4A and we also have a We have data from our center wherein we did uh most of these cases usually come with a PET scan. It's not that we have done a PET scan but when we do have a PET scan for the other malignancy and in the same patient incidentally detected for a lesion what we can do is actually check the uptake on the PET and what we've realized that those with an SUV of less than two have a very low chance of having any malignancy. So they've started to use that as another predictor of whether or not to really advise another inter intervention or let the course of treatment go on and this investigation can go on side by side >> right but I'm sure as Dr. Kupti also mentioned that uh and Rajiv Sar has also clearly said that uh you know biopsy especially in this setting because she is an elective and she's to go for liver donation probably a biopsy is definitely recommended and uh before we give a clearance for you know liver donation isn't it so >> which biopsy the the experts will recommend whether stereotactic or MRI guided So if you have MRG guided vacuum assisted biopsy, you could. If you don't facility with us, we have >> So it depends on what you're most confident you're seeing the lesion. If you're seeing it on tomography, well, you can do a tomography guided web >> and you don't need to do an MRI guided web. So it depends on where you're seeing your radiologist and let Tusha told what we have done.
>> Right. So for this patient we have done a tomo guided valve for the left breast.
As you can see we have also placed a clip in the area of the legion that is in the right side of the image.
So the result of the biopsy was fibrocystic disease with extensive lobular carcinoma and C2 present.
>> Okay. So Dr. Kisha u what was the indication of putting a clip? Can you uh tell us uh you know for the sake of the audience? Yes.
>> Yes ma'am. So uh the clip here it marks the location of the cancer. So a even after so after the lesion is excised using VA we still know where the uh lesion was present and depending on the biopsy we'll go ahead with the further treatment if there if the patient needs to uh depending on the case what is the report if the patient needs to receive any radiotherapy or uh so we'll know the exact location of where the cancer lesion was >> not for rad >> and for excision during if we want to excise after the new adent chemotherapy then also we can do like later on wireg guided wide local excision or uh stereotactic wire guided excision. So if the clip is in C2 we'll know the location of the lesion.
>> Yeah. So in this particular case in case if the biopsy comes out as cancer and you need to go for a wide local excision then that keep clip can be localized and uh that will guide you to perform the wide local excision.
>> Yeah.
>> Yes. Uh any any other question from the experts uh Dr. Ankita, Dr. Shashank, Dr. Trupti, Aman. Ma'am, >> can I just add one more thing? The clip also uh adds a detail because you've had an MRI finding with a tommo guided finding. If by chance uh whatever findings you got were discordant with the mamography findings when you said it didn't make up. If you repeat the MRI, you know that the lesion seen on the MRI was the lesion biopsy by the marker.
>> In case there's any discordance or something didn't your surgical finding, our radiology and pathological finding didn't meet up. You want to make sure that what you saw in the MRI was the same thing biopsied. So the marker or the clip or the marker whatever you call it also helps in that.
>> Correct. I think that's a very important point ma'am has made.
>> Yes.
>> Yeah. Any chances that we must have missed invasive component because it is fluid LCI is extensive. How sure we are that it is extensively sampled.
>> Dr. Tupi it was a VA.
>> It is a vacuum.
>> Yes I know. I know. But like have we addressed the entire thing like whatever was suspicious?
I mean even after VAP sometimes like when we see and in lobular there are such lesions that it cannot be detected on imaging. So there is always this thing that is very admixed very subtle kind of invasion. So that is why >> yeah purpose of biopsy is to have the representative tissue that we have definitely taken whether it has been completely excised or not or neither was the aim to completely >> Yes. Yes. Yes. Agreed.
>> Yeah.
>> Just because it is lobular with extensive this I was and radiologically not very sure.
>> Yes. And I'm sure uh it needs further you know attention. We cannot just leave it just like that. But uh today since we are not discussing the management part probably we will have to move to the third case.
>> Actually what we have done actually since her brother has undergone liver transplant and LCIS there is no immediate hurry to go ahead. So I said let the transplant patient your brother be settled maybe after 2 three weeks we will start working on the management.
Yeah. But Dr. Tusha just any comment on comedon necrosis on the estopath report.
>> Yes sir.
>> They have not mentioned about it. They have just said fibrocystic disease with extensive LCIS.
>> But sir I mean if if we are moving along those lines of ruling out disease then probably uh the presence of comedosis would have probably changed the plan of maybe planning oxygen. uh if it was a extensive LCIS with bombular process planning the excision at the same time when she's uh probably donating the organ.
>> I agree.
>> Yeah. So because just LCIS like what is the extent whether it is classical versus pleomorphic whether it is associated with necrosis and all will matter like what is the extent and whether it is high grade or not I think it needs many pathological uh features to be mentioned.
>> Correct. Absolutely.
>> Right now, next case.
>> Yes sir.
>> Uh so the third case is that of a 64 year old female uh who has been uh screening herself since 2020. Uh she presented to the breasttop for routine screening. She has strong family history and her mother died of breast cancer and she was diagnosed at the age of 75.
So here are the uh reports of her serial mamogram starting from 2020.
You will notice that uh there was an interval change in her mamogram in 2025.
This is our mamogram for 2024.
In 2025, you will notice uh micro calcification as marked on the image.
So what will you do next in this case?
So this was a very very small about 5 to 8 mm uh calcification which was not present because all these mamograms have been done at our center. So we could compare those mamograms with the old mamograms and this was a new finding this time.
>> So this um if I can answer this you you could do an ultrasound but I doubt you'll see it on ultrasound. You could just do it to confirm you can't see it.
And if you can't see it on ultrasound, you do a stereotactic vacuum assisted biopsy of the calcifications.
You could do an ultrasound just sometimes even with small calcifications there may be a little mass that you can pick up on ultrasound.
>> Yeah.
>> So here is the finding of a mamogram. uh there was interval changes small micro calcification at 4:00 position 6 into 5 mm by rat's 4C and on ultrasound it was showing uh small hypoquic leision and lobulated legion we could not do an MRI for this patient as the patient was sensitive to drugs the contrast so like ma'am said uh would you follow follow up this patient or go ahead with the biopsy.
We went ahead with a cedotactic wag for the left breast and you can see the excise sample on the right side which has the micro calcification and the result was highrade DCIS.
Um can we can I request Dr. Nita Dr. Anupma both of them have joined um Prisha Shank anyone to chip in and comment and uh >> yeah I just wanted to make a note out of the three cases Dr. Pratusha you have presented the cases very beautifully. Uh two of these cases had a strong family history. So we didn't go into the details of that but obviously for a lady with strong family history. Screening is one part uh and maybe we have to customize the screening frequency but in addition to that that lady should have been referred to a genetic uh counselor and have had a family a pedigree chart made and worked up counseledled for genetic testing as well.
>> Right sir.
So um in this particular case uh the last one what is the age of the patient >> uh at the time of diagnosis ma'am she's 60 uh 64 she has been coming since 58 years of age >> okay but um ma'am Dr. Aman um ma'am I think her mamogram is still looking quite dense isn't it?
>> Yes surprisingly surprisingly her mamogram is quite dense as per her age. Yeah, you do get sometimes you see 60 and 70 year olds with very dense breasts. It's not correct. It's not rare.
>> Yeah.
>> No, it's it's not rare.
>> But uh and since she did not have um she could not have MR you mentioned, right?
>> Yeah.
>> Since we have a mamog, we have a toomogram. So that's why we are able to detect these small lesions better today. Yeah. I think in this case with this type of calcifications you don't need an MRI you would still if you have routi it's a new group of heterogenous calcifications you have to biopsy it for DCIS you don't need to wait for the MRI >> okay and after the diagnosis of DCI if I can just comment I think Vali's concern is more about management in terms of how would we react later >> so this has come back as high-grade DCIS so we happy to size based on the mammo findings that we have versus you know in uh such a dense breast would we have anything else that could help us? Yeah, that is so after the diagnosis of DCIS especially in that small area I mean I would personally want to get uh go ahead with MRI before management to understand the real extent of the disease.
So I believe this lady was allergic to contrast from what the resident was.
Okay. So Aman is there anything else we could do?
>> No, she's allergic to contrast. She's probably MRI contrast. She's definitely allergic to the contrast we use in contrast enhance mimography. Do a tomography do a dedicate she did seem they did mention on the ultrasound two lesions. I don't know if those two hyper rounded lesions were seen on the prior ultrasounds or they're new lesions. If there were new lesions, I would definitely biopsy them also because one was at 1 2:00 and one was at 4:00 to just give you is there more disease somewhere else.
>> Right. Correct.
>> And we've had serial mamograms with a small group of calcifications. So I think if you if we don't have MRI, if you had MRI, great dense breasts to see the extent of disease, but if you didn't have MRI, localize it and if you get your margins clear, you're good. and probably just counsel the patient that that would be something.
>> Yeah.
>> Yeah. But I think what you said about the four:00 lesion also makes sense that one would definitely want to biopsy.
>> Yeah, you definitely biopsy everything you can see before you go in for surgery. So you have a better uh I think since we don't have an MRI to know what extent of diseases and you can counel the patient a lot better about what kind of surgery you would do.
>> Yes. Yes. Yes.
So just just one one sentence that since we are not discussing management today but since a question has been raised we did it widely excised margins were free and now the patient is in followup for more than one years we have just done a recent follow-up mamogram after one year and everything is okay >> okay >> what was the hisystopath on the oxygen >> same DCIS that and previously it was a bad grade DCI hormone negative hormone No receptor negative >> her two positive.
>> No, no, not her two positive.
>> So TN like triple negative negative >> probably. Yes. Yeah.
>> Okay.
So I think if the lesions are uh managed by one wide local excision then yes definitely but if they are wide apart one is in one quadrant and the other is in exactly opposite quadrant then what Dr. Raman ma'am and Dr. Nita are saying is that we have to biopsy each and every lesion so that patient can be you know offered an optimum surgery rather than you know just doing mastctomy or in case if it can be managed well within a single wide local excision then yes that makes sense but otherwise uh we need to biopsy are there any further questions from the experts for Dr. A >> no just a comment again coming back to the strong family history. I mean uh I understand that a breast conservation is absolutely on the charts but probably the counseling part if subject to her consenting if the genetic test were available and then uh that would also have been incorporated into uh the consultation part right >> in terms of what what breast surgery to be offered to the lady.
>> Right. Correct.
Yeah, >> I think one more thing is that although yes, all three cases were screen detected, we haven't anyway mentioned what were the clinical findings were they were any of them palpable at all. I think that's one important thing to mention in history examination.
>> No, in the in the very beginning she said actually these were all non-pelpable >> nonpelpable lesions.
>> Okay. All right. All right. All right.
>> No clinical findings.
>> No clinical findings. Yeah.
So, uh can anyone from the expert um summit or tell us something more about how differently could this have been done or is that perfectly all right?
>> Yeah. Yeah. Anupa.
>> Yeah. Uh the last case actually I didn't hear the first one so can't say uh the last case you know uh for such screen detected micro uh we usually just directly do a wire localization and wide excision only because it is financially more viable for the patient first to do uh if you do a tomo guided web that costs money then the high highrade DCIS then a wide local excision with a wire lock so it is kind of double procedure So just for the sake of uh you know saving the finances of the patient which is a very common and a very important uh thing for us uh we do only one procedure which is wire localization and wide local both for diagnosis as well as therapeutic. Yes, I think uh you know the logistics concern, the financial concerns are definitely important but whenever we talk about the ideal way of you know investigating then surely uh the way it has been actually investigated is the way to go but depending on the patient's circumstances and the financial conditions we have we can actually modify the way we manage the patients. Uh Dr. Thisha Dr. Dr. Anupma has also mentioned that when we do wide local excision or especially when you have done a vacuum assisted VA what is that particular thing which is very important to understand that the right area has been sampled or taken out or excised especially when you are actually sampling or excising microalcifications >> um post the specimen.
>> So whenever we do whenever we do any biopsy from micro calcification, we always do a specimen mamogram.
>> Yes.
>> And that is what we have done to see whether we have taken out representative tissue or not. That that's that's always a a rule of thumb that for all microclassification we must do a specimen number.
So whether it is the course or the vacuum assisted you know specimen or said even if we have to do wireg guided excision >> yes >> we must do a mamogram of that specimen so that it corresponds to the findings on the original mamogram >> correct okay Dr. Brishi >> can I just add something >> yes yes Dr. Yeah. So specimen mamography is one thing but I also feel that a detailed hystopathological report is must like whatever legion we say we have to quantify especially in lab. So when it is usually detected for the like uh mamography detected things and all like if we are seeing calcification or not because some calcifications are also different type like one we can easily see and one doesn't take up the stain but on polarizer or maybe on deeper sections we get so I think as a pathology part also we have to quantify the legion give exact high grade low gradede features like if it out of multiple things in how many sections we are giving some exact quantification mention of calcific ification wherever possible.
>> So if I can ask >> how do you quantify tumor size on a VAB?
>> Yeah. So like for example like uh we had this case where you have LCIS. So at least when you have like for example multiple fragments of tissue bits or you have four five sections. So at least we can say like if it is an occasional fosi or if we see multiple fossai across all different sections. So like that kind of subjective uh like quantification is must or you can say out of the total things what percentage it is like sometimes you have like multiple sections but an occasional forai >> like that kind of thing because then we have yeah correlate with the imaging findings if whatever is suspicious we have taken it out or not.
>> Okay. Okay. So you may not be able to give us the exact size but whether uh the imaging uh abnormality has been properly represented in the Yeah, that is the thing.
>> Yeah.
>> Um so uh now I think we are ma'am are you saying saying something?
>> No no I'm just asking you whether we should move on.
>> Yeah we should move on to the next session. Uh Suni can you please stop sharing the screen? Yeah, thank you so much faculty for your great input. Thank you. Thank you Dr. >> Thank you Dr. Tisha. Great presentation.
>> Uh now we'll move to towards the next session and uh we'll have another interesting case presentation on fil tumor which usually mimics fibroidema but has a very different clinical course as well as management. So for that we have Dr. Bsha who is resident at department of surgery PGI rutak. Uh I would also like to have the pleasure of introducing our panel of experts.
Dr. Nikita Nay ma'am is there after spending quite some time at PMI. She is now at Apollo Navi Mumbai. Uh Dr. Aman Dtari ma'am is senior radiologist at PD Hinduja Mumbai. Dr. Chupti Pai ma'am is professor molecular onopathology at TMH.
Dr. Anketa Dash, assistant professor and consultant breast ontolastic surgery at TMH and Dr. Shashank Nigam who is uh consultant surgical oncologist and breast disease specialist at luck. So over to you Dr. Vashra >> and we also have Dr. Anupma.
Um yeah we have ma'am with us and we are also going to get benefited by her presence.
>> Yeah. So they are the >> Yeah.
Dr. Va over to you. Please go ahead.
Uh good evening ma'am.
>> Good evening. Good evening. Go ahead.
>> I'm Dr. Ba from junior resent 3 from PJMS rot. I'm going to present a case of atypical breast lump.
So this is a case of 35 year years old female resident of rot 12 past homemaker and belonging to a lower middle soioeconomic status by modified kopuswami scale. She presented to the OPD with chief complaints of lump in her right breast for 3 years.
History of presenting illness. Patient was apparently well 3 years back when she noticed a lump in her right breast while bathing. Initially it was of 2 into 2 cm size which then grad gradually progressed to a size of 4 into 4 cm over a period of 2.5 years and then suddenly it increased to a size of 8 into 8 cm as gestured by the patient in last 3 months. This lump is not was not associated with pain her pain in her right breast or nipple discharge. Not associated with evening rice fever, night sweats or chronic cuff and there was no history of chroma as well. There was no history of overlying skin changes over the lump site or over the nipple areola complex.
There was no nipple retraction or itchy lesions over nipple are aola complex.
There was no history of any other swelling in same or opposite breast in axilla or in neck region. There is no history of upper limb edema or lesions over upper limb or chest wall. There was no history of suggestive of distant metastasis such as backachche, headache, luring of vision, abnormal body movements, abdominal distension, yellowish discoloration of skin and eyes, shortness of breath and blood in sputum. There was no history of excessive bleeding per vaginum as well.
Past history, there were no similar episodes in past and patient is not a known case of any chronic illness.
There's no history of any blood transfusion or known drug allergy or no prior surgical intervention history.
Personal history patient is vegetarian by diet. She is having she was having normal sleepwake cycle and normal bowel bladder habits and no history of any substance abuse or oral contraceptive pills intake history.
Family history. There was no history of similar complaints in family and there was no history of any cancer or cancer related deaths in family.
Menstrual and obstatric history. A patient attained her minar at 13 years of age and initial cycles were irregular for two years and then she attained regular cycles after that and the cycles were lasting for 3 to 5 days occurring at an interval of 28 to 35 days soaking around 1 to two pads per day and with no excessive dispmenoria or excessive passage of clothes. Patient was ma patient got married at 22 years of age and her obstatric formula is par 2 live issues two and abortion zero. She had her first child birth at the age of 24 years and it was a girl child which was by who was by normal vaginal delivery and the baby was breastfed for 2 years.
The second child was at the age of 27 years. It was a male child by normal vaginal delivery and was breastfed for 2 years and currently her last menstrual period was on 23rd May 2026.
Ma'am, should I continue with the examination part?
>> Yes, please. Okay. or unless the experts want to ask any questions.
>> Okay ma'am.
>> Um >> I think at history maybe you could have a provisional um >> yeah ma'am >> impression of what the diagnosis is.
Yeah ma'am. My patient 35 years old female uh with she of lump in her right breast for 3 years which has suddenly increased to a size of 8 to 8 cm in past 3 months is probably a case of benign breast disease.
>> Sorry. Why do you think it's benign breast disease? Because it's increased significantly in size.
>> Yes ma'am. uh ma'am first considering the age of the patient the patient is 35 years old and second she's having sudden increase in size of uh in size but the swelling which the patient is having is not associated with any other changes like nipple retraction though the size of the swelling is very large but she's not having any other changes like nipple retraction which usually is seen in case of malignancies >> yeah but that Someone your examination the patient's history alone may not be effective enough to answer that >> on probing the patient the patient told about that there was no history of nipple retraction >> so again patient will not be able to answer that herself >> yes >> that I think if you are looking at signs of breast cancer then that is something that you would look at after your examination not during your in history and I think the history of a sudden change from 3 to 8 cm is something that does not point to a benign lesion.
>> So I I'm not convinced that this is a benign lesion for you to be able to say benign. You have to be able to say that this is a lesion that probably needs to be evaluated to rule out a malignancy because of the sudden increase in size.
I would be I would be more comfortable saying that I want to rule out some sort of malignant transformation whether it's inner foids whether it's malignancy or some sort of cystic degeneration because there is a sudden increase in size which is what is concerning in the history.
I'm not happy to say this is benign. I mean everybody else can uh also opine on that please >> early actually what Dr. Nita is saying he's absolutely right. Uh Dr. Shashank um you want to say anything?
>> Yeah, completely agree with Dr. Nita ma'am. Uh in if you talk about differentials uh we would suspect malignancy and moving forward we first step would be to exclude malignancy and that kind of stay certainly suspicious and cancers or malignant transformations as ma'am said would be at the top of our list that we need to exclude in here.
Yes. And Dr. Barsha when you said that since the lesion I mean when she since she had felt this lump 3 years ago that does not rule out that it cannot be cancer because there are obviously not in this particular case but there are very slow growing cancers which are there especially in elderly women who have who usually come with a history that oh I've noticed this lump couple of years ago. So the duration of symptoms alone should not be you know uh taken to rule out presence of malignancy here.
>> Okay.
>> Okay.
>> Although I must say that you have uh done a great job of taking a very exhaustive history.
uh but uh you know uh when you talk about clinical exam I mean clinical history when you look at each and individual uh you know symptom and the progression of the symptoms at the end of your clinical history taking before you examine what Dr. Nita rightly mentioned was since it has been there for last 3 years and suddenly it has grown in size there is no history of trauma there is no history of any fever or anything which is suggesting that it could be infection or uh responsible for sudden increase in size then it has to be taken uh you know it has to be obviously thoroughly uh examined and investigated. So you could say that I would like to investigate before saying that oh this could be benign based on the duration of the symptoms.
>> Okay.
>> Okay. Yeah. Please go ahead.
>> So proceeding with the examination part.
The patient was examined in a well-lit room after taking informed consent and maintaining the adequate privacy of patient. Patient was conscious, cooperative and well oriented to time, place and person. Her pulse rate was 82 beats per minute in right radial artery good in volume regular rhythm no radiorial or radiomoral delay blood pressure was 128 by 70 mm of mercury taken in right arm in sitting position at the level of heart respiratory rate was 14 breaths per minute and patients BMI was 31.2 2 kg per meter squared which was falling under mild obesacity.
Palar etherus sinosis clubbing lympadinopathy and edema was absent.
Systemic examination the central nervous system examination higher mental functions were normal. Sensory and motor examination was within normal limit.
Respiratory system examination showed bilateral equal air entry and no added sounds. In cardiovascular system examination, S1 is too heard and there were no additional murmurss heard. In per abdomen examination, the abdomen was non distended, soft and non- tender and there was no organo megali.
Per vagina and perctile examination were within normal limit.
Local examination was done in sitting position in lying down position in semi-reumbent and in bending povert position with hands by side hands above the head and hands above waist region.
Left breast examination was done first and which was within normal limit.
On inspection of right breast bilateral breast spendulus in shape and the right breast was slightly at a lower level and more tootic than the left breast.
There was a fullness noted in outer quadrant of right breast. There were no engorged veins, redness, discharge over the skin of right breast and there was no ulceration, fungation, pudior or dimpling occurring or nipple retraction over right breast.
On examination of nipple, the right nipple was slightly at a lower location than the left nipple and there was no discharge from the right nipple and the surface of nipple was normal. that that is there were no cracks or fissures or ulcer over the right nipple. Uh bilateral areola were symmetrical with no discharge or lesion or redness over the nipple areola. There were no nodules on chest or right upper limb, no right upper limb edema or no pullness in the neck region.
On palpation, all inspector findings were confirmed. There was no local rise of temperature.
We noticed a solitary non- tender mobile firm irregular lobulated well-defined 9 into 9 cm lump with no fixity to underlying chest wall or muscle and skin in lower outer quadrant of right breast.
There was no auxiliary supraclavicular and cervical lympodinopathy noted.
Uh this is the image of the patient that we can see. We can see the fullness and outer quadrant of the right breast. In these images, the green part marked is showing the tumor site.
Uh ma'am, this is all about the examination part.
>> Okay.
>> Should I think? Yeah, I think uh you should now wait for the for our um experts to know uh discuss this case with you further.
>> So Dr. >> the first question sorry >> go ahead Dr. Ankita then maybe we can ask Dr. Shashank I think I was asking the same thing at this point the first question to any resident is always what is your provisional diagnosis?
>> Yes Dr. Versa for you >> considering the history and examination part in mind uh ma'am my first diagnosis will be more towards the benign pathology in this case as ma'am said that b on the bas basis of history we can consider malignancy as our first diagnosis um then concluding the examination part I think uh benign pathology fits more toward in this case as this mass is 9 into 9 cm cm and there is fullness in the outer quadrant of right breast with no nipple changes and this patient is on examination we got loulation and irregular surface of the lump and this lump was mobile so I think I can consider benign breast disease as my first diagnosis after examination part >> shank >> yeah and Would malignancy be in your list of differentials or or not at all?
>> Yes, malignancy will be in my list of differentials.
>> Okay. So, I mean the points in favor of you calling it a benign disease probably are only two. One that absence of nipple retraction which which a lot of breast cancers early breast cancers up you won't have it and secondly you are basing your uh first differential probably because of its loated margin.
So for younger age women a lot of times uh triple negative breast cancers would mimic. So I would still want you to have a word of caution uh while keeping those differentials uh with the kind of largest lump both uh even if it is if it is a fibropthenial lesion with the kind of history of rapid progression and the size I would be more tilted towards calling it maybe a borderline or malignant fluidities visav keeping a malignancy in my list of differentials as well.
>> Okay. I'm sorry I'm Yeah.
>> Yeah. Sorry Ankita if I may. Um I don't think you can say benign breast disease at any point of time in this.
>> I can consider phot is not a benign breast dis.
>> So when you say benign breast disease foids is not a benign breast disease.
Benign foids is not a benign breast disease.
Cysto saroma does not come under what we qualify as benign breast disease. So I think you're getting a little swayed with the fact that you know what the diagnosis is and you're using the word benign breast disease. Benign breast disease is something which is fibrocystic disease which is fibroadinomomas sclerosing adinosis things like that.
Cysto saroma fyoids is not a benign breast disease. Your differentials at her age with a lobulated margin with an increase in size which is so rapid needs to be able to say >> I think this over.
>> Yeah.
>> Yes. Yes ma'am. So yes that's exactly what I was coming to actually. I think when you're saying benign, you're including fellows. I know in a lot of textbooks and uh you know you might get confused that they do come under the spectrum of benign but they're really not benign because the first thing is a phenotant and that is really a very very hystopathological diagnosis. It's not something that you could possibly tell clinically. So you we we all especially such a large lump uh if you there's nothing else if you say the word benign breast disease apart from a fellows what else can really grow to a 9 cm lump in a 35 year old over the span of 3 months.
So the first diagnosis will be fess or if not foes then even a malignancy even an invasive ductal carcinoma can sometimes present like that without any skin changes.
So uh you do have to call it malignant.
I know the age goes against it and as residents we were often told that when the younger age your first differential should not be malignancy but that's not the case in the face of such red flags clinically.
>> Yes and uh Dr. Vsha when you talk about benign breast disease Dr. Ita has very clearly told you that then you can talk only about fibroadinoma or as she mentioned sclerosing adinosis and all those things or those fibrocystic uh you know what we call it but in this particular case this is a very large tumor with a typical history that it has grown in size the age is corresponding a large giant fibroid can be there but this is not the age where usually the patients present present with they are much younger. But in this particular case looking at the overall clinical history, the progression of the disease and the clinical findings, this definitely cannot be labeled it as a benign breast clump. Okay.
>> Okay ma'am.
>> Okay. Uh ma'am may I please ask a question?
>> Yes please you can. uh ma'am keeping the mobility of the lump and nodularity of the lump in mind can we say that this is more point uh this is pointing more towards tumor >> so again uh you know Dr. Dr. Ankita also mentioned that large triple negative breast cancers also can present like that you know uh especially in younger women they can have a central necrosis and they can present with large uh tumors. So only the fact that the tumor is mobile it is not fixed to the skin uh you can rule out cancer. It is not like that. Obviously not like that.
>> Okay. Thank you.
So um should she proceed or uh Dr. Sha Shank any anything >> would you like to ask any? Yeah.
>> Yeah. I mean keeping myself as a resident in her place I understand where she is kind of fumbling. Uh what we have been always told taught in our residencies is truly age is not probably not in favor. The lawity is not in favor. But with the kind of rapid progression and the fact that lot of breast cancers are actually happening at a younger age, we would need to keep we can probably start with our differential one as a fibroacial legion with malignant transformation. But a close differential would always in such a scenario be a malignancy. So I mean we have to probably if if it it is to be told to an examiner differential one and differential two have to be told in the same go because the I mean with the examination history so far both the possibilities are very close.
>> Okay sir.
>> So please go ahead. How did you uh evaluate her?
>> Okay ma'am.
uh after this clinical examination part we went ahead with the investigation part that is radiological investigation.
We advised ultrasound and mamography to this patient. On ultrasound we got uh this finding that a lobulated multic lesion with thick internal septations and intracystic solid component seen out quadrant of right breast measuring 9.1 into 8.4 cm. Internal Echos are also seen within the cystic component on color mode. No significant viscularity noted within the region.
>> No evidence ofopathy noted.
>> And the final impression of ultrasound report was very complex breast system right that is four lesion.
Uh further we advised me which shows Uh >> go ahead Dr. Visha.
>> Uh on mammography we got this report that is breast density ACR a radiodense lobulated lesion measuring 9 to 7 cm in outer quadrant without calcification and speculations.
So we can see in the image the upper part is the uh uh cran craniocodal uh medial oblique view and the um uh this part uh upper part is showing the cranioal view and lower part is showing the medial oblique view. So we can very well identify the illusion lesion in the outer quadrant of right breast in this image which is showing lobulation and uh radio density on further uh on further we advised MRI to this patient which showed well definfined hetrogenously enhancing solid cystic mass lesions in right breast measuring 9.3 into 8.6 into 7.2 cm lesion. The cystic component shows internal fluid level. The solid component shows area of diffusion restriction on ADC map. Left breast was normal and there were no enlarged lymph nodes seen. Uh the chest was normal.
Visualized lungs and mediasum appears normal. Bilateral pectoralis mus were grossly normal and there was no evidence of skin thickening noted and there was no nipple retraction seen. Visualized lungs and mediastum normal. So the final impression of CMR breast was uh complex right breast cyst favoring fo corresponding >> Dr. Va.
>> Yes ma'am.
>> Can I ask if mamography and sonography was so clear in this patient why did you do an MRI? uh ma'am MRI was advised in this patient to see the malignant transformation as diffusion restrict uh that diffusion restriction on MRI can tell about tell us about the malignant transformation in phot advised otherwise usually in phot MRI is not as such indicate >> this does not typically fit into the indication for MRI actually there are very a specific indication for doing an MRI and this really doesn't fit into that.
>> Uh yes ma'am the MRI was not uh actually not indicated in this case but we just advised to see whether it is showing type CV or not to see the malignant transformation.
I don't uh an MRI would not be very specific to see malignant transformation with such a large as you would need a biopsy to figure out if it's malignant or not. I don't think the MRI would add a lot of value. That's the whole thing.
You may see something but to say uh be specific and say that this is definitely malignant after your ultrasound findings and would be very unlikely. That's all. I know people do an MRI but it doesn't add much value to it before a biopsy or before a final uh therapeutic or surgical thing.
>> Ma'am, can you >> addition to the contrast mamogram? That was the contrast mamogram as well, right?
>> Yes, ma'am.
>> It was a regular mamogram. It wasn't a contrast enhance. It was it was just a very dense.
>> Did you go back to the manual page?
>> Yes, ma'am.
So this is not this is a regular mamog ma'am the MR was contrasted.
>> Okay. All right. All right. Okay.
>> Ma'am can we um uh you know tell our audience as to what are the indications for MRI especially in the situation where we are clinically suspecting uh it to be a filoids tumor.
So if you're suspecting a filoids tumor between a mamography and ultrasound uh on ultra on mamography you just see a mass most likely circumscribed sometimes it's a large mass and you can see lobulations in a foid tumor you see multiple cystic spaces unequal sizes on ultrasound that's or you see catsifications and you see lot of heterogenicity or of the mass on ultrasound that's one of the uh area when we see that we raise the possibility of a foid tumor. This tumor increased in size very rapidly and so clinically also you were thinking of that but there are many times where you may not think of it clinically as a foids tumor but we come it comes back as a foid tumor and the imaging findings are pretty classical on ultrasound. Uh MRI doesn't add much to the diagnosis >> to the diagnosis of a filoids tumor per se. Uh so there are no reasons if I'm seeing a ma there's a palpable mass in a young lady we are seeing typical findings on an ultrasound which may be a filoids tumor we would go ahead and biopsy it an MRI is not recommended for it people do it for different reasons but it's not one of the recommendations for a breast MRI according to the ACR guidelines or any guidelines you look worldwide >> correct ma'am is there any situation where you would suggest uh MRI in the case of recurrent filoids.
>> So recurrent malignant. So when it's malignant filoids the whole right now we're not sure it's malignant or not.
>> No no no not in this particular case.
>> In a recurrent foids sometimes if you don't pick them up on ultrasound often if it's a recurrent fillids you also have lot of scars because they have already done surgery. So that becomes when there's scarring it's always trickier for us on ultrasound and mimography and then there's a tiny lesion sitting on the scar. you're not sure if there's a recurrence at the scar. So that time MRI helps a lot and MRI is very good for differentiating scarred lesions what we see on ultrasound because we see a lot of shadowing on scars and seeing a recurrence. Recurrence MRI is very good but at the first place I don't think it's needed.
>> Yes, >> in this case I don't think it was needed done or not but I don't think it added any value per se. That's my opinion.
>> Absolutely. Dr. Versa uh I think uh it is clear for you now.
>> Yes ma'am.
>> So MRI has not added any additional clinical information to what you have already received by doing a clinical examination ultrasound and yes mamography is that so >> yes ma'am.
>> Okay so please go ahead.
>> Okay ma'am so skipping this part.
>> Yeah. U then we went ahead with the true cut biopsy core biopsy from the right breast lump which showed fibroalaginous tissue with mixoid stroma with glands and leaf like pattern and the findings were suggestive of foids tumor.
>> Can I just add one thing? So in a lesion that is this large when you're doing the biop and so hetrogenous on ultrasound when you're doing the biopsy it's very important the needle takes samples from multiple areas the cystic areas the solid areas especially to get a foids because sometimes in a smaller lesion between fibroid and foids gets very difficult for the pathologist so in a heterogenous lesion when you do the biopsy it's very important to take samples from different parts of the tumor that's very important more than in an MRI or anything else >> can Can I Can I make a small comment?
>> Yes sir.
>> Since since this is a cystic solid lump though it is a very big lump. I will ask my radiologist to do the biopsy and ultrasound so that he can take the appropriate samples from the solid area and cystic area. If I do a clinical biopsy I may take insufficient sample either from the cystic area or something. So in a filoid suspected filid I will definitely like to do an ultrasound guided biopsy as was told that it should be taken from various areas both cystic and solid so that maybe I think the accuracy of the biopsy may increase.
>> Yes sir. Dr. Ki uh can you Dr. Ki are you there?
>> Yeah yeah yeah. Uh so can you please uh tell our audience about how uh can you you know comment upon whether it is a foids tumor or a fibroadinoma or in case if it is a foids tumor whether it is a benign borderline or malignant uh especially on true biopsy what are the limitations and uh so pathological considerations uh when we diagnose such a case. Yeah. So it is always a nightmare and always because these lesions are very heterogeneous and in biopsy it gets very difficult to capture everything like in such clinical scenario. So I it would have been great if you could have put the hisystopathology images uh >> so that >> you have put >> Yeah. Can you just >> uh this is the final hisystop slides ma'am that I got.
>> Oh okay. So this is a very high power.
So it would have been so you know like there are subtle features like when you get different coursees so one at low power at 1x or 2x when we see when we see lot of small small fragmented bits it is one indirect way to say it is a filid tumor because it is like a leaf like structure and a very solid cystic when you do biopsy you tend to get very smaller smaller things. Now here if you see you see this leaf like kind of fronts but at this power we cannot say.
So what do we see? We see stromal cellularity. So fibroepithelial so epithelial component and the fibrous stromal component. So we see how much part of biopsy is occupied by the stromal stroma. So when you see very scanty epithelium lot of stroma lot of cellularity it is like a filid tumor. If you see lot of epithelial component very less of stroma then it is like a too much struggle for us. Sometimes in in this kind of heterogeneous uh things you know you get lot of areas resembling fibroidoma. Just having a leaf like architecture doesn't mean it is fil tumor. We have to focus on the stromal elements. Stromal overgrowth. What do you mean by stomal overgrowth? Where very less of epithelium and under a lens of microscope you just see this stroma.
Even if it is bland you see only stroma or you see heterologus elements like you see cartilagenous things you see very high-grade round cells in this stromal cells or you see necrosis tumor necrosis. So these are certain findings.
Now here just looking at it I still cannot call it fil tumor at this part.
So when you take hystopathology image you know you take low power image so that you see how much is the stromal component or you take high power images to see what kind of cells are there in the stroma whether there is nuclear atypia whether there are mitosis.
So we see stomal overgrowth stomal cellularity stomal nuclear atypia mitosis all these things we will have to look at and it is a very tricky diagnosis. Now this is a 35 year old.
Sometimes you have this adolescent age group like 12 to 18 less than 20. It is very difficult to say and you must have seen like most of the time we give this differential and we say that exact characterization possible on the oxygen specimen.
>> Absolutely.
>> Absolutely. Because this is what we usually get that this is a fibroepithelial lesion and the most probable differential based on whether it is a stromal proliferation or epithelial proliferation whether it is number one filid tumor or fibroidoma that is what is the usual way the coronetal biopsies reported isn't it Dr. Yes. Yes.
>> Yeah.
>> Right.
>> Unless we see very high grade features, it is very easy to call malignant. But this heterogeneous where the differential is between the cellular fibroid and benign fils, it gets very difficult.
>> Correct. Correct.
>> Uh other experts u just want to hear Dr. on uh how difficult it is to differentiate a malignant filidis with a saroma.
>> Yes. Yes, that is another thing. So one spectrum is difficulty between fibroid, cellular fibroid and benign fils and other difficulty is when you just see the stomal component whether it is a malignant filids versus it is a saroma or whether it is metablastic carcinoma sarcomid. Always in the in this scenario when you see just so sto we look at the history of the patient like whether it was a repeated thing initially someone called it fils benign fils or fibroid there is a repeated history of lump excision or you see on imaging finding it is like a well circumscribed solid cystic mass and then always on biopsy if these things are there we end up giving a differential and we still say on resection also you know sometimes we have to take 30 40 sections and in one section we get the epithelial component. So it is that tricky. So everything in that condition we take clinical picture imaging picture and still on hystopathology we have to give the differentials. Some IC's help like A1 A3 if it is diffusely positive it is a type of a sarcomid carcinoma or if it between too much stoma even if you see some dilated epithelial component your first differential will be a uh like um uh this saroma in a background of malignant fils.
>> Okay.
So uh thank you Dr. Is that clear Dr. Va to you?
>> Yes ma'am.
>> Okay. Um anything further Dr. Shashan, Dr. Ankita, Dr. Nita, I think Dr. Nita is not feeling well.
I think at a resident level I guess one more thing is just that until you're sure it is a saroma or a fil or an IDC and even otherwise the only one thing to follow is when you're doing a biopsy. Of course, now we don't always chase biopsy scars, but as far as possible to try to keep the biopsy in the center of the lump, which is especially difficult in mobile lumps and totic breasts and the same is when you're getting uh when you're getting an ultrasound guided biopsy uh to make sure that this is conveyed conveyed to the radiologist as well because it is convenient to put the probe on top and the needle from the side. But if it is conveyed to them, they can also manage to put the core biopsy in a way that it's within the resection and not an eccentric scar.
>> Correct. I think that's a very important point. uh from the management point of view it is very very important especially to you know have a good uh cosmetics I can see some uh raise of hand uh Mr. Manau uh do you want to say something Mr. Mana >> Hi Dr. Vali I am Dr. Natasha.
>> Oh, hi. Hi. Hi, Dr. Natasha. Please, please go ahead. Sorry, I could not recognize you from your name. Please go ahead.
>> Laptop of my resident only.
>> Yeah.
>> So, what I want to say that is R is a government institute. She's my resident only. I told you.
>> So, ours is a government institute and our residents are going accompanying the patient to the radiology department.
>> Okay.
>> And they are taking by their own this uh biopsy. They are just showing us putting the probe over the lump and uh our residents are taking the biopsy core biopsy.
>> Okay.
>> We are taking care of that part also >> and okay. Uh so for everyone else uh let me introduce Dr. Nityas Sha. She is the head of surgery at PG Rotak and she is the mentor and guide of Dr. Versa. So that's a that's a great thing Dr. Dr. Nityasa that your residents are performing the biopsies themselves of course uh with the use uh with the help of your radiologist that's a great way of learning how to perform uh you know proper guided biopsies um any anything uh else from the other experts for Dr. Versa >> uh I would just like to make a comment here that uh uh you know uh for smaller lumps or vague uh lumps we advise ultrasound guided biopsies. I mean that is the usual trend and for larger lumps the residents and everybody does it in the clinics only in the OPDS but I have seen the diagnosis being missed even from larger lump core biopsies because you know the the core biopsy targets the center which is necrotic and you get a negative biopsy. So my recommendation would be to advise ultrasound guided core biopsies even for the larger lumps and Dr. Rajie Vagaral also mentioned the same thing. Yeah. Yeah. So what Dr. Nityasha said was that the residents go to the ultrasound suite, the radiologist guides them and these residents perform the biopsy. That is what she mentioned.
>> Yeah, it's in our institute that we are uh for all kinds of lumps small big we are taking ultrasound guided biopsy and we don't have the facility of mamography guided basically stereotactic we don't have so ultround guided only. Yeah, I think mamographic or stereotactic biopsy is very rarely required in especially in our kind of scenario where majority of the patients present with symptotomatic uh you know breast cancers. So yes um if we are okay with uh moving on should we uh >> Dr. Dr. Shashan Dr. Gita we should okay >> yeah thanks Dr. Versa great presentation uh Dr. Preshi >> Yes ma'am ma'am >> thanks Dr. Versa uh now we'll move towards the last presentation which will be on pregnancy associated breast cancer uh complex condition and a challenging diagnosis in India. So pregnancy associated breast cancer includes the breast cancer which are diagnosed during pregnancy or one year postpartum. Usually the diagnosis is delayed because of the changes in breast associated with pregnancy and most of these cases are diagnosed in advanced stages. So uh I would like to invite our next speaker Dr. Akanga Sarawa. She is fellow breast surgery at Ruby Hall Clinic. She is associated with Dr. Anukma Manima. Over to you Dr. Akanga.
>> Good evening everyone. Myself Dr. Kansa.
Uh today I'm going to present two short cases which is pregnancy associated breast cancer. First will be early breast cancer case and the second would be LAC. Uh I would like to share my screen ma'am.
Yeah it is visible. Please do it on slideshow mode.
>> Yeah.
>> Yeah. Okay.
>> Is it visible?
>> Yes.
>> Yes it is.
>> Okay. uh first case is early breast cancer in pregnancy. A clinical review of ductal carcinoma in C2 arising within a fibroid in a 33 year old gestational patient at 16 weeks of ANC.
Uh history of present illness. A 33 year old female presented at 16 weeks of ANC at our OPD with primary complaints of bilateral breast lumps which were present since her teenage years. It it was painless in nature and stable in size. Uh her personal history she did not have any co-orbidities. Family history was negative for breast, ovarian, pancreas, colon and prostate cancer. Uh she was on annual mamography uh for long-term duration as there was a benign chemical presentation her uh should I move on to physical examination ma'am?
>> Yes. Um unless there are any questions from you said annual mamography but it is annual annual sonography. She was on annual sonography.
>> Okay. Okay.
Go ahead. Go ahead please.
>> Okay. On a physical examination on her left breast there was lump located at 2:00 position measuring 2 is to 2 cm in dimension. It was mobile firm and pose.
On her right side, a lump was at 9:00.
It measures 1 is to 1 cm. It was mobile, soft inconsistency and painless in nature. Bilateral lymph nodes was not enlarged or neither suspicious. Uh there was no enlargement at supra cavicular regions also. Should I move on? Ma'am, >> why not?
>> Even at this particular point, are there any questions for Dr. Akanga?
Yeah, I'm still stuck to uh to the annual sonogram uh that this lady was advised earlier. I mean mean is what should be the normal practice for uh for a lady who has uh currently uh clinically by all parameters fibroid once examined and tested would would should she be put on an annual sonogram schemes sort of thing?
Uh >> yes sir. Uh we should take the annual sonograph just to check the interval changes. Is there any uh increase in the size or anything abnormal we are seeing inside the sonography.
>> Uh I would disagree. Uh yeah ma'am >> uh I just wanted to ask since how long has she been uh undergoing ultrasound and was there any history of biopsy of any of these lesions in the past?
No ma'am, she was uh she since uh she was on the follow up since uh 2020 something.
>> 2020. So last five six years I suppose.
>> Yes. Yes. She had those lumps since her teenage years but she was on followup uh since 2020.
>> Okay. And did did any of these ultrasounds mention any increase or in the size and what bide category was mentioned in those ultrasounds?
>> Uh ma'am those were uh it was stable lumps. There was no interval changes seen in those and uh it was by two one or three. Uh in her previous sonography there was virates two or three.
>> Two or three. Okay. So can we uh request Aman ma'am to tell us about how do we uh you know follow patients who have breds three lesions. Uh ma'am >> yeah so uh one I whether they were biops it makes a difference whether these were ever biopsied or not. Uh if they were biopsied usually if there are uh lump masses like this that we are seeing which we think are fibroadnomomas and they've been proven fibroids. If they're proven fibroids then we if on a core needle biopsy we've done it we are sure you've done a good biopsy with a 14 gauge needle the pathologists show it's only a fibroidoma we generally follow it for 6 months up to a year if they've never been biopsied say if a patient has multiple lesions in both breasts and you can't go ahead and biopsy four four lesions in each breast and just biopsied one we usually follow them for at least 2 years so in 6 months 6 months and a year usually in breast if things are stable for 2 years the chances of malignancy are less. However, in our country with so much um variation in where the ultrasound is done with people a lot of patients and a lot of clinicians more than in radiologists a lot of clinicians will send it to us for a yearly ultrasound but in the west they're followed for 2 years once it's labeled for 2 years if shown stability we don't usually follow them again. If a patient is getting pregnant, very often we may decide to do an ultrasound before pregnancy because often in pregnancy lesions increase. So you want to just prove that there fibomas and we just see want to see the epigenicity of it to make sure that it's not changing during pregnancy if there's an increase.
>> Correct.
>> So Dr. Akanga, one question for you. um since the lumps uh she presented with were for last couple of years. So why did she come to you? Was there a reference from her gynecologist? Was she referred to you for breast examination by her gyneitician or she came on her own? Did she notice any change? What was the scenario here?
>> Uh she was actually living in a Poland ma'am and she was with my name ma'am.
She was on a followup uh since her long since long years. Then one of the sonography showed virates 4A which was done at the Poland. So they did a biopsy there also uh which was suggestive of DCIS. Then she came back to India as she was pregnant. So she came back to India again and uh we have done her investigations again as there was mismatch >> uh in the previous uh reports and her recent reports.
>> Okay. So she is uh I mean she was staying somewhere else Poland you said and there she was re-evaluated during her pregnancy and biopsied also. Okay.
Which side? Right side or left side?
>> Left side. Left side.
>> Left side. for at the left side >> and it was the same lesion that they call for a or it was a different lesion in the breast.
>> It was the same leion 2:00 lesion. It was the same lesion they called for same size biopsy.
>> Yeah ma'am it was of the same size 2 is to 2 cm. And did they have the old ultrasounds to compare it?
Because that's the most important thing.
And if we call something benign or not, a BATS 2 or three, if you're seeing a lesion that's even slightly lobulated or slightly different and we have nothing to compare it, then we would recommend a biopsy at 4A. Even if it looks maybe a fibroid or a 4A, we might put it as a 4 A. So that changes a lot if they had the original images to compare or not.
Uh ma'am actually she was at the so we told her original reports of the uh sonography so we did everything again at our center.
>> Okay.
>> Okay. Okay.
Any questions uh from the experts?
>> Okay. Uh uh Dr. If she had not gone to Poland and if you had um you know the ultrasound done here itself and it was reported as BY 3 like the previous uh you know uh ultrasound reports would you have done anything further?
I would have uh I would like to keep her on close followup >> during your pregnancy, right?
>> Yes.
>> Okay.
>> Uh can I just add if it was a Bats 2 that went to a BATS 3, I would be worried if for 5 years she's been on BATS 2 and we've seen no increase, I would ask the radiologist, why have you jumped to a BART 3 now?
>> Yes.
So what are the uh you know indications for you know evaluating further that is what I think Dr. Raman ma'am is trying to tell you that if there is any change in terms of BAD category or uh change in the size or appearance or any additional new lesion especially in the scenario that the lady is pregnant. All of this is to be taken uh you know further and uh evaluated to rule out a pregnancy associated breast cancer.
Isn't it? Then the question is by Shali is it the same ideologist who has said by two or three or it is a different ideologist. Many time many times there is a difference of opinion in various ideologist. Somebody says two the same legions somebody says three.
>> That is true. That is true. So uh Ammon ma'am what how how do you guide us? what should we do if there is any uh change of opinion in terms of ID category?
>> So if you're following a lesion, if you've seen if you're following something in 6 month, it's always good to go back to the same place where you did it.
>> Yes, >> the technique is the same. The machines uh better ultrasound machines, few measurements, some people a millimeter plus minus is intervariable uh observer variability is there. So what someone else calls two, someone else may call three. It's a very subtle difference.
It's a question of two a percent here and there. Uh so I think when you're following lesions, it's important to go to the same person. And it's very important for that person. If you go to a new person, they have all the images, not just the reports with measurements because you don't want to just see measurement. You want to see what it looks like, how the margins have changed, if the heterogenicity inside has changed. There a lot of things we see differently. And also often these small lesions when they're 1 cm and all there may be a second 1 cm lesion there which someone may not have seen. So it's very important for the same person to see it and you have distance from the nip. a lot of other things that we need to put in the report if it's going to be followed by someone else. The depth because it's very it's for 1 cm lesions as a radiologist it's very easy to miss one and find a new one and think that it's the same one that it was there before and it's completely different.
>> Absolutely. Um my question uh to Dr. Akanga will be that in case if she did not have any past such history and she came to you with a breast lump in her second trimester of pregnancy and you find a lump in her breast and it is reported as by red 3 on ultrasound.
How do you proceed?
>> Whether it's a new region ma'am or it's a previous region only. No, no, no. She comes to you now for the first time.
There is no past history, no past record of having, you know, undergone any uh breast imaging. You find a lump, you do an ultrasound and you find a bat 3 report and she's say 16 week pregnant.
How do you proceed? Or is there any other question from the experts Dr. Shashang, Dr. Uh Ankita >> ma'am I would want exactly this question and this is a very good question that we have put up right now.
>> Yes.
>> So I mean if a lady comes with a new onset lump labeled as bats 3 how would Dr. Akancha want to proceed with that one?
uh I will assess her clinically whether there is any signs of malignancy I could see and then I will uh like to see her uh sonography plans and then uh is there any past history or any family history I would like to rule out and I would like to keep her in my close followup so that uh uh whether there is any interval changes or any enlargement on the rapidly enlarging in the size of that lump because pregnancy can mask the symptoms of benign as well as the malignant cases. Uh so rather than jumping directly to the core biopsy I would like to observe her first and if it is uh keeps on increasing rapidly then I would like to go to a core biopsies.
>> Um can we ask Dr. Anupma uh what is her take on this particular >> Anupa are you there? Yeah. Yeah. Yeah.
Yeah.
>> So this lady the particular problem was that when she came from Poland with a bira 4A report on sonography and a DCIS report on core biopsy from there.
>> No. Um sorry I'm asking a very different situation not particularly this case.
Okay. Um um a young lady uh 2 weeks uh to second trimester pregnancy comes to you for the first time with no past history but a palpable lump and ultrasound shows that it is a bira uh lesion. So in that situation would you considering the fact that she's pregnant would you know change your approach to that lump differently or what?
>> No I would keep her under very close followup. I would explain to her the uh importance of not missing the follow-ups and the possibility of SOS doing a core biopsy if I notice any change clinically or in imaging.
>> How frequently would you follow her up in that situation?
>> So 3 months is general but I would also explain to her that the lump is likely to increase anyways because of pregnancy related changes. Even the benign lumps are likely to increase.
>> Yes. So obviously if she notes any difference she has to come even earlier than 3 months >> right. Uh Ammon ma'am do you have any different take on how do we >> if you if the surgeon or the gyneak told me this is a new palpable lump and unless I could very classically with every feature call it a fibroid or a cyst. If I had even a slightest doubt I would biopsy it. In today's day and age I would biopsy it.
miss too much pregnancy unused. A biopsy in a second trimester is a very simple procedure. It doesn't cause any harm to the patient. It decreases the stress of everyone around >> and if it's a new palpable lump I don't think I would wait unless it was a very classical simple cyst or a very classical fibroid which even if it was a classical fibroid the reason that it's become palpable I think the chances of me biopsying it is higher because any any lobulation anything heterogenicity there are a lot of features when we call it a fiboma there are at least five to eight features if it didn't take every box I would buy I would be I would be happier biopsying it than following it because I would not want to miss a pregnancy in this cancer because they're very we do see them missed very often >> right right uh Dr. Ankita Dr. Nita um any inputs from your side?
Yeah, I just wanted to um ask if sorry I got missed that person but uh a mamogram we have established that we can do right >> we can do a mamogram but uh if it wouldn't change so generally in a in a pregnancy you can do a mamogram the mamogram uh radiation to the bellies but what we generally always start with an ultrasound if it's suspicious I biopsy it and if it's malignant then we would end up doing a mamogram because you need to If it comes back as a fibroid, I don't need to do the mamogram. So then I wouldn't do the mamogram. So I generally tend to biopsy the lesion before I do a mamog in a pregnancy.
>> Okay. But if it's looking clinically suspicious and we feel nodes and ultrasound is also looking suspicious especially in second.
>> When you're talking about nodes and all you're talking of a malignancy straight off that's >> you can always you can always biopsy and then do the mamogram in 3 days.
>> It's not going to change. It means you still get a complete picture. When in doubt do a biopsy.
>> Yes, when in doubt do a biopsy. And especially uh Dr. Dr. Aman has rightly pointed out that if there are uh certain features which are not really ticking the box for a fibroidoma especially in the situation where there is a pregnancy associated uh clinical situation then I would also rather do a biopsy because ultrasound guided biopsy does not uh put the lady in or the baby in any harm. So it will in fact give us a peace of mind and uh you know we can surely uh give her a great confidence that it is not malignancy which we are dealing with here. In fact is not going to contribute anything in this case 16 week pregnancy the breast are slightly edimeatus young patient I don't think memo is going to contribute much and if I can add something more I mean following if we if we were to put this lady on surveillance uh the radiologists are only going to find it much difficult each time because of the other uh pregnancy related breast changes that would set in so I mean I would want to hear Dr. Raman uh how tough it would be with the increasing age of pregnancy uh localizing this legion >> uh increase with ultrasound we'd still see it well we see other changes in the breast you see a lot of vascularity you see a lot of ducks you see hypercogenicity because of uh the breast changes in pregnancy we'd still be able to see the lesion well but just following a lesion I think puts a if it's a especially because it's a palpable lesion just puts a lot of anxiety on the patient as well as the doctors around >> and it is a simple it's a very safe procedure doing an ultrasound guided coral biopsy if it was not a safe procedure then it's a different it's very safe it takes hardly 10 15 minutes there's no side effects per se you're doing it early enough nothing happens so I would rather do a biopsy and as Dr. The mamogram does not add anything.
That's why we don't do the mamogram before we do a biop. If the biopsy comes back as malignant, it's a different question. Then you would definitely do a full then you need the whole workup.
Then you're talking for malignancy. The chances of this coming back as a fibroid is high. But we want to prove that it's a fibroid. So we don't need to look at it during the rest of the pregnancy per se.
>> Correct. Correct. Yes ma'am. Thank you.
Uh I think Dr. Akanga should proceed because we have still one more case. So Akanga please go ahead.
>> Okay ma'am.
uh during a diagnostic ultrasound. This was from Poland. Targeted USG finding was left press 2:00 upper outer quadrant region sus with suspicious features which was categorized as bids 4 a uh and then they did a USG guided core biopsy uh which was done at also at Poland which was suggestive of this was a final uh true cut biopsy report from outside it was suggestive of presence of ductal carcinoma without clear features of stroal imaging cytoologically the cells are well differentiated low grade in two ducts they have seen a focal necrosis and proliferative changes with morphology of artypical ductal hyperraia present IC was P63 positive CK4 positive ER positive PR positive and her two negative final diagnosis was ductal carcinoma in C2 solid type of mammary gland >> uh Dr. I >> Yes.
Um how often do you come across um you know such a uh you know pathological situation when there is uh presence of DCIS in a fibroid uh and how >> very rare like we do see uh like colonization of so we see a typical fibroid and then we see it is colonized with fluoride sclerosing adinosis and in sclerosing adinosis there is DCIS or there there is fluoride LC CIS which is colonizing fibroid. So though rarely but we do see but here in the hystopathology there is no mention of fibroid only.
>> Yeah there is no mention I think clinically and radiologically it looked like a fibroid. However uh the corn needle biopsy mentioned only DCIS Dr. Akanga is that correct?
>> Yes ma'am. Yes ma'am.
>> Okay. So it was not in the background of fibroid. So it is just a DCIS but >> but then like you saw a very well-formed mass like a F.
>> Yeah. So maybe because DCS was seen they didn't I don't know like pictures would have been more >> go ahead Aka go ahead the further will guide it >> clarify. Okay go ahead.
Then uh we did a repeat USG at our center which was suggestive of bilateral fibroids associated with small adenotic nodules. And then we again also did a core biopsy as there was no biopsy blocks available from her previous biopsy. So we did it again at our center which was this is the core biopsy slide and which was suggestive of benign pro proliplative breast lesions with mark usual hyperclavia. No definitive evidence of DCIS or IDC is identified.
ER shows heterogeneous expression. Uh at our center we did not see any DCIS ma'am or any typical hypleia also seen. So because there was Should I move on?
>> Yeah.
>> Yeah.
>> Then we did as there was uh no mismatch between two hisystopathological reports, we uh did a left wide local excision during her second trimester. Uh post-operative monitoring confirmed a safe recovery with stable fetal cardiac activity and progress.
uh then after the wide local excision her final hisystopath suggestive of ductal carcinoma in C2 grade two arising entirely within a pre-existing left fibroid growth pattern shows plastic solid at cribform patterns and associated comedon necrosis receptor profiling was proved to be strongly positive for estrogen receptors and her surgical margins were clear all margins were clear it was confirmed successful complete local excision Uh these are two slides which showed the uh I'll get back to my slide now.
This is the DCIS component we can see here and this is the fibroid component we can see here. Actually you know this looks like lot of this is uh can I I don't think so there is one fibroidoma and then on the other side it is like a fluorid sclerosing edinosis and in that there are few fosa of this epithelial hyperplasia. So it is this entire thing is not DCIS. This is what I can make out from this picture.
Uh am I audible? I don't think I the DCI this is all like a sclerosing adinosis and in that there are few forai which be this is a very low power for me to see.
So this is what I was saying is sometimes you get like a FA and then you get sclerosing adinosis and then inside you get some um like ADH or DCIS.
>> Okay.
>> Yeah. So it would be very interesting to see ER in this case. So you know >> strong positive.
>> Uhhuh. What it is?
>> It is strongly positive for ER positive.
>> Okay. Okay. Okay.
>> Okay. So you know sometimes the intensity is strong but we have to see whether it is heterogeneous or whether it is diffusely seen.
>> So just the absence of CK56 in some cases is not sufficient. In papillary in papillary legions yes CK56 is very helpful but in certain other lesions no it is uh like for example you have columnar cell alteration atypical columnar cell alteration CK56 is often negative. So ER will be very helpful in this cases and also in pregnancy related now there is lot of lactational changes which make the cells look very atypical.
So that also we have to be aware of.
Yeah.
>> Okay. Okay. Okay. So in this situation probably um I'm sure Dr. Anukma has done a great you know um care of this because the margins and everything are clear.
But is it suggested that uh Dr. that we should get a pathology reviewed elsewhere also.
>> Yeah. Or maybe like just if you have a scanned images just we can see because this is a very low power for me to comment on anything but definitely I think there is a reviewed >> and huh sorry it was reviewed in two different centers apart from ours. So three times it has been reviewed. Yeah.
>> Okay.
>> Okay. And none of them called like it is clarosing edinosis also which is colonized by >> no DCIS was confirmed >> DCIS must be there but I am saying like as as I was saying like no quantification like not everything which is looking cellular looks DCIS to me here it is definitely there is this sclerosing edosis and most of the time it comes hand in hand with this fibroid and all this and then there are some fosi which has DCIS or LCIS Yes.
>> Okay. So, you know, from a surgical point of view, we don't really focus much on sclerosing addin alsos. So, I really don't remember whether the report had that >> but DCIS was definitely there that I remember very well. We reconfirmed and rechecked it because she was pregnant and we had to plan her further treatment.
>> So, that was for sure. But as you are saying, yes, sclerosing adenosis uh it would be important to know that.
>> Okay. I'm sure this is a very interesting and a great uh you know way the patient was managed of danopma. Uh I think we should move to the next case.
Uh Dr. Akanga.
>> Yes ma'am. Yes sir.
>> Because we have only uh 15 minutes now left.
>> Yes ma'am. The second case is pregnant.
Uh second case was LBC a 39year-old second grabida in her second trimester presenting with rapidly growing right breast mass. She has no known coorbidities.
Uh her present history of present illness was she was 39 year old G2 P1 L1. Uh gestation at the time of pres presentation was 24 weeks. Her chief complaints was painless right breast lump which was growing over the time of 2 months. lump first notice at the seventh week of gestational. She ignored it as she was breastfeeding her first child. Uh it then evolved to a painful rapidly enlarging mask. She then consulted a gynecologist which advised epenacy which was uh which showed a panic cells. Uh then she was referred to a breast surgeon. Uh her family history was her maternal grandmother has carcinoma but the details was unknown.
On clinical examination she uh sorry her menstrual and obstetric history was anarchy was 13 years. Her first pregnancy was as 37 years which was a late maternate age. The mode of delivery was C-section. The now the baby is the first child is 2 years old. she was uh it was adequately breastfed and being shortly before this pregnancy her current pregnancy she's second rabbit conceived at the age of 39 years uh and the uh uh I would like to move on to a clinical presentation should I continue ma'am >> please go ahead please go ahead >> yes ma'am on inspection there was generalized pure orange across the entire right breast surface on palpation there was 12 is to 10 cm hard irregular mass which was mildly tender which involving the all four quadrants. Uh the T stage was T4B. Fixity the lump was fixed to overly skin mobile relative to underlying pectoralis major muscles. Uh right axillary status was 4 to 3 cm fixed mass. It was non- tender and there was no supraclavicular nodes palpable.
Systemically there was no nothing significant.
uh then we did a primary investigation as she was pregnant just a moment uh let us ask our experts whether they want to you know intervene here and uh before you move ahead uh Dr. Shashank Dr. um Ankita with the clinical history and presentation do you have any questions for Dr. Kanga >> um >> I think in this case it's quite clear that this we're dealing with an LABC so we have to ask very specific and leading questions for sites of malignancy because of course the metastatic workup that we can do in this patient is going to be very limited. So we have to be very very uh the threshold uh has to be very low for us to pick up any symptoms for symptom directed metastatic workup.
>> Yeah Dr. Akanga I have one question uh considering the fact that uh the lump really was very big it progressed rapidly she's in a second trimester her age at uh you know conception is 39 years all of that uh definitely pointing towards you know malignancy history clinical examination is there any other differential you would like to consider here as she was breastfeeding it uh there might be a galactosal or a breast absess or it can be a lactating edoma but uh uh after seeing her clinically there was clinical signs of malignancy like enlargement of lymph nodes and today orange appearance so it was clearcut a malignancy.
>> Yeah. So clearly it the first you know clinical assessment would be of breast cancer. However rarely very rarely in this situation mastitis also because she has been lactating and all that but definitely we have to rule out that uh it is cancer.
>> Go ahead. Go ahead.
Then we did a primary whiskey sound which showed a hypoic solid mark subcutaneous edma consistent with the orange appearance multiple enlarged nodes with maintained fatty high the left breast and axilla was unremarkable.
Then we did a core biopsy which showed IDC grade three. Her IFC status was triple positive. She was ER positive. PR positive her two positive KI 67 index was 75%. Her initial clinical staging was CT4 P N2A M0 it was a stage 2 3B Dr. Kanga I can see that uh the clinical size which you mentioned was nearly 12 cm did you or did I oh okay okay uh no no clinical finding clinical >> yes ma'am I'll go back to clinical finding >> yeah it was uh >> 12 10 cm And the ultrasound shows it to be a 5 cm.
>> Yeah ma'am because she first went to a gynecologist which suggestive her epenny until the time she came to us it was progressed to this clinically it was 12 to 10 cm the ultrasound was done 1 month before.
>> Okay. So before coming to you the ultrasound was done.
>> Yeah.
>> Okay. Okay. Okay. So Dr. Do we have a recent ultrasound report as well? I mean did you do a repeat ultrasound when she came to you with that kind of progression?
>> No sir. Uh we did not repeat ultrasound.
We directly proceed to 4 biopsy.
No, but because my question is with regards to the auxiliary findings finding a 4x3 cm fixed nodal mass which turns out on ultrasound as reactive with fatty hilum I mean we need to discuss with our radiologist once again probably can you move on to the USC findings once again the next time please So multiple enlarge notes but with maintained fatty hila that's clearly a very u non-concordant uh you know ultrasound uh result but probably this was done uh Dr. Shashank this was done before the patient came to them.
>> Yeah I agree ma'am just just to highlight it to Dr. Rakanch and other other trainees that if if the imaging shows a palpable node which turn which is on imaging uh looks like a reactive node we should probably uh the the final clinical stage would have to we will have to incorporate the radological findings and thereby probably keep it as n0. If you had to rely on this report as the final report then the clinical staging would be n0 >> but obviously >> I I I don't think in a multiple enlarged nodes even if they have a fatty hilum I'll put it a clinical stage is n0 clinically enlarged nodes is n1 >> uh I think probably the ultrasound what you really need to know on the nodes is the cortical thickening or then if the fattyum is >> if their nodes are enlarged if the cortical thickening which if there are multiple enlarged nodes they can have a fatty but the cortical thickening is probably increased which has not been mentioned in this report. Yes, absolutely. Repeat the ultrasound to see I mean the way the picture is it looks like the nodes are enlarge. If you are feeling them we are probably going to see cortical thickening >> and any tumor which is more than 5 cm with a pud orange and clinically 10 cm enlarged nodes I cannot ignore those nodes >> right uh Dr. Raman here um is there any role of mamogram although on the side of the symptom the lesion is pretty large and you know >> we would still do a mamogram one you want to see if there are any it's an IDC you want to see any calcifications that are extending beyond the mass just to have an idea and also the opposite breast >> opposite breast >> you want very important to just make sure there's nothing happening in the opposite breast because you're probably going to treat it with newagen chemotherapy so you want to make sure there's nothing going on there >> correct >> so I would do a mamog As in a case like this, we would do a mamogram and ultrasound. We would have probably repeated the ultrasound.
>> Yeah. And with proper shielding of the baby, >> shielding of the Yeah.
shielding of the abdomen and talking to the before in shielding educ just talking to the patient, talking to her about the radiation and telling her about the low risk and everything else.
>> How how how old the pregnancy was?
>> Dr. Yes sir.
>> Uh >> 24 weeks 24 weeks >> 24 weeks >> 24 weeks >> 24 weeks yeah >> Dr. Anita uh do you have any question at this stage for Dr. Akanga >> that um when we said that she said it was a nodal mass a 4 cm nodal mass which was fixed.
>> Yeah.
>> You're not audible actually. Am I audible now?
>> Yes, you are.
>> Yes.
Uh, >> no. We lost you again.
>> I'm sorry. Can you hear me now?
>> Hello.
>> Hello.
>> Yes. Can you hear me now?
>> Uh, not really clearly, but please go ahead ask question.
thing is having a clinically fixed nodal mass is a very clear N2 disease. So uh we could very safely say that and yes like uh Dr. Aman also said a mamogram would be necessary with an abdominal shield and it's absolutely safe and essential in picking up calves. I just wanted to also say that maybe it would have also helped us in the previous case. We do do mamogs for our pregnant patients with abdominal shield. um you know of course only if there is any suspicious finding to look for calcifications for DCIS. So uh yeah I would agree with uh ma'am here that a mamogram over here is absolutely safe and probably essential.
>> Yes. Uh now that we've got a diagnosis and we know that it is a locally advanced uh breast cancer in a 24 uh week um pregnant lady. So what is the next uh you know investigation which uh one needs to do here Dr. Akanga?
>> Uh ma'am we would like to proceed a core biopsy here and the systemic evaluation to look for >> core biopsy you have already performed you have told us that it is a invasive ductal carcinoma. Yes. Now the workup bit the systemic workup is it necessary and how would you do it?
>> Yes ma'am. She is a stage three uh she so I would like to do a systemic workup and she has also nodal mass so systemic workup in late uh higher stage of uh resta we would have to do a system >> so uh aman ma'am >> yeah so you could >> go ahead >> no no no you please I wanted your u you opinion an ultrasound. So you cannot you cannot use any contrast. So you cannot do an MRI with contrast or you cannot do a PET CT or CT with contrast. So you do an ultrasound abdomen or you do a chest X-ray. You can do an non-contrast MRI but it wouldn't find much stuff for you.
So you probably just go with this at least till the end of pregnancy.
Um I'm sure she has mentioned everything and we have come to a logical conclusion uh that it is a um you know locally advanced uh case. Obviously we are not going to discuss the management here but if there are any further questions which our uh you know audience would uh want to know or if the experts also would like the audience to know please uh >> uh just like to add here that uh chest sex and ultrasound abdomen of course are um the the modalities for metastatic workup that we would use but we have to also very be very careful that we're checking the LFPS for any raised alkaline phosphotase and asking for any specific bony sites which are painful persistent focal bony pain so in that case it is an indication to an MR of the spine since we can't do anything else at this point do you agree with what Dr. on the side.
>> Yeah, exactly. Following up climos and carefully evaluating for any systematic symptoms uh would be essential. And just wanted to make a a general comment on the fate of pregnancy associated breast cancers. This last case is a classical presentation wherein this lady probably with a greater awareness could have had been diagnosed at a much earlier stage.
But I mean that is how a lot of pregnancy associated breast cancers go on unnoticed until they have gone to this kind of picture wherein the prognosis is obviously um >> absolutely absolutely so uh the whole objective of putting these two cases uh Dr. Anukma mentioned uh in the beginning itself was that we have to not miss cancers in pregnancy because there are so many uh you know fallacies in clinical examination especially in a lady who is pregnant with engorged breast and all we are more likely to miss uh you know any suspicious finding uh in um pregnancy. So that is very important that the patient who presents with any breast related symptom rather she or she may not be presenting with any breast related problems but it is important for uh us all of us to examine the breasts of a pregnant lady at regular intervals throughout the pregnancy and educate the pregnant women to do breast self-examination and report any breast related changes if they happen to notice to their gynecologist or to the breast specialist uh nearby.
So this is very important uh for us to diagnose pregnancy associated breast cancers at early stage. Um if there are no further questions then uh Dr. Rajiv sir, Dr. Goel, Dr. Preshi, any anything else which we have probably not discussed because we have already uh overshot by 4 minutes.
any any comments by Anukuma for the last case. She is the mentor of the fellow.
>> Uh yeah. So basically the same thing uh only diagnostic difficulties a lot more in pregnancy associated breast cancers and uh in the first case of course I think the take-home message is that uh even if there are multiple bilateral fibroatinomas be very very careful especially during breast c especially during pregnancy. And in the second case even such a large lump many a times gets missed or misdiagnosed because it is not suspected. We still have lot of doctors you know who tell them hair types. So patients still come to us with that check but during pregnancy that's a very common uh way scenario.
>> Yeah. So we really have to keep our antenna up basically and be extremely sure that we have ruled out malignancy during pregnancy.
>> Agreed. Agreed.
>> Dr. Shashang Dr. Ankita any uh >> yes ma'am I mean I mean for pregnancy breast cancer the lad is already under a followup. I mean those are kind of missed opportunities and as you have rightly pointed out yourself that I mean pro it is already there but it is not being practiced. Every gynecologist with for every OBS visit for every NC visit needs to have a mandatory breast examination and lot of majority of those are not even examined. The patient brings it to the notice of the physician. the physician would outrightly because it is associated with pregnancy would exclude it and not even bother to examine and and I mean so I mean the luna is the bridge that we need to fill up is is huge in in this scenario >> the problem is that we have to sensitize the gynecologist about breast problems before saying any breast lump that there's nothing to worry it is either duty gut or it is benign I think the most important thing is to sensitize the gynecologist that this breast lump should be evaluated by the proper person because they are unfortunately missing a lot of cancers in the early.
>> Yeah.
>> In my center the moment patient says breast the gynecologist says nothing to do with us you go there >> right.
Uh yes um anything or else we wrap up today's session Dr. Preshi?
>> Yes ma'am. So great presentations by all the presenters and now I would request you to give both of >> that's a great job. I really enjoy doing that. Uh so at the outset I would like to thank all our young presenters and their mentors. So thanks to Dr. Tisha, Dr. Vsha and Dr. Akanga for such wonderful and painstaking efforts at uh you know collecting the history the images and the pathology. Thank you so much. You have been great. Uh and Dr. Anupma, Dr. Nityasha Trajuser of course for guiding them and mentoring them. Uh all thanks go to my expert colleagues Dr. Shashank, Dr. Ankita, Dr. Nita she was unwell but she joined. Thank you so much Dr. Nita uh Aman ma'am Dr. Tripi everybody thank you so much I thank my team Dr. Rajiv sir Dr. Goyel sir Dr. Preshi Dr. Safala and last but not the least I thank all my audience to be consistently with us in all the webinars and encouraging and motivating us to carry on with these uh efforts uh you know and Dr. the entire team of Mighty Duo especially Sunnidi who has been always there uh in helping us you know uh manage these webinars without any technical flaw without any technical glitch. So thank you so much and I'm sure we will come up with uh uh our next webinar very soon. we'll announce the uh topic and we would rather seek your consistent support and uh you know presence in these webinars.
So have a wonderful night and have a great day. Thank you so much. Thanks for being with us consistently all the time.
Thank you Dr. Tupi. Sorry I forgot to answer you. Sorry. Sure.
>> Thank you so much and have a great night. Send two.
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