Locally advanced breast carcinoma (LABC) is characterized by a rapidly progressing breast lump (typically >5 cm) with skin involvement (ulceration, peau d'orange appearance), and ipsilateral axillary lymph node involvement, classified as T4B N1 M0 in TNM staging. The clinical presentation includes a 55-year-old postmenopausal woman with a 10 cm breast lump, axillary swelling, and nipple ulceration. Diagnosis involves detailed history taking (risk factors: age, early menarche, late menopause, family history, BRCA mutations, obesity, smoking, radiation exposure), physical examination (inspection for asymmetry, skin changes, nipple retraction; palpation for lump characteristics, fixity, and lymph node involvement), and staging investigations including ultrasound, mammography, PET scan, and CT scan. Management follows a sequential approach: neoadjuvant chemotherapy (typically taxane-based regimens like docetaxel or AC) to downstage the tumor and assess response, followed by modified radical mastectomy (removing breast tissue, pectoralis fascia, and levels 1-2 axillary lymph nodes), radiotherapy, and adjuvant hormonal therapy (tamoxifen for premenopausal patients, aromatase inhibitors for postmenopausal patients) for hormone receptor-positive disease.
PG CLINICS CARCINOMA BREAST - LABCAdded:
Sir, good evening sir. Sir.
>> Sir, good evening sir.
>> Sir, good evening sir. Sir, good evening sir.
>> How are you?
Good morning sir.
>> Good evening sir. Good evening sir.
Sir Ibra is my student sir at MMC Metas College very good sir very nice 2005 to 2008 sir >> yes sir >> I by then I finished off and left.
>> Yes. Yes.
Um we'll start. Good evening friends. Uh we have uh yet another the PG clinics lined up. Today's an exclusive breast session. Um the candidate is a repeat presenter Dr. Janat who presented a case some time back in the same forum. She's kindly permitted to present by professor Shilpara from Sith GS Medical College and KM Hospital Mumbai. Today we have our own faculty professor, Professor Rajiv Sahiser and we have invited faculty for the evening uh professor Prabakar uh from Chetinard Medical College. Professor Mohammed Ibrahim from SIC Medical College at Dal Valley.
Professor Papita should be joining now.
She's just finished the case. She promised to join now. So without much ado, uh we will start the presentation.
I request the to kindly take over. Uh Dr. Janak, please introduce yourself, your unit chief and your head of the department and start your presentation.
Good luck to you.
>> Thank you sir. Uh good evening everyone.
Uh Dr. Janak from KM hospital junior resident. presenting a case of LABC under the guidance of Dr. Shilpara ma'am.
Uh 55 year old lady resident of Mumbai homemaker uh came with complaint of a lump in the right breast since 4 months ulceration and swelling over the nipple in the right breast since 2 weeks.
Uh patient was apparently asytomatic 4 months back when she noticed a swelling in the right breast. Since then it has pro rapidly progressed to current size of approximately 10 cm not associated with any pain or fever. Uh two months later another swelling appeared in the right axilla about 1 to two cm in size gradually progressive in size.
Uh she developed an ulcer run of the nipple two weeks back just above the swelling. It is also associated with mild pale localized to the region of the ulcer ding character relieved on taking medication.
Uh no issue of nipple discharge. Uh no issue of trauma or radiation exposure.
uh no issue of chest pain, cuff or hemoptis. There was no issue of weight loss or loss of appetite. No issue of pain in abdomen or jaundice. And no issue of lower back pain or pain in the limbs. No issue of headache, vomiting, weakness of any any limbs and seizures.
No issue of any coalities like hypertension, diabetes or asthma. Uh no history of cox or cox contact and no of any previous surgical intervention.
Uh no family history of any breast or ovarian ovarian or prostate or GI malignancy in the first degree relatives or other family members. Uh menstrual and obstetric history. Uh patient attended menarchy at the age of 12 years and menopause at the age of 50 years.
She was married at the age of 16 years had first life first child at at the age of 20 years. Has had four children and one abortion. All breastfed for a minimum of 2 years. uh youngest was a 15 at is at 15 years old now and she did not take any birth control pills and she has had any has normal menstrual cycles throughout.
Uh personally patient is vegetarian uh having normal sleep pattern uh normal bowel and bladder habits no addictions smoking on alcohol and no known allergies.
uh to summarize our case uh it's a 55 year old uh post-menopausal lady which is presented to us with a rapidly progressing lump in the right breast since four months which is at present force and 10 cm in size and swelling in the right axilla since 2 months and ulcer over the swelling for 2 weeks >> uh general examination patient exam >> what you mean by rapidly progressing go to the first slide issue of present illness four months back when she noticed a swelling in the right breast then rapidly progress. What do you say rapidly progressed?
>> So uh in the course of >> what is or otherwise what is the difference between rapid increase and sudden increase?
uh more than 50% increase to >> you is it rapid increase means in months sudden increase means in 2 days or 3 days like that due to some hemorrhage inside the tumor. Okay.
Right. Rapid increase.
Two months later another swinging appeared in the right axilla about 2 cm in size gradually progressive in size.
Right. Go to the next slide.
Ulcer around the nipple two weeks back just above the swelling.
>> Yes sir.
>> Mild pain.
What are the painful swellings of the breast? Uh infosessor mastitis. uh or traumatic fat necrosis or >> Okay.
>> Why you issue of low back pain when the patient is complaining of swelling in the breast?
>> Uh sir uh sir since the patient is an el is an old age 55 years lady postmenopausal and complaining of a lump in the right breast. So we had so to maintain a we were maintaining a suspicion of malignancy and health.
Therefore we asked for the lower back pain sir to rule out metastas.
>> Okay. What are the different types of nipple discharges you can expect? What are the physiological nipple discharge?
What are pathological nipple discharge?
Sir physiological sir while milk is for lactation and uh serious discharge is serious discharges can be seen for duct tactasia greenish color can also be seen in duct tactasia sir and bloody discharge is seen in papilloma sir >> why you is of radiation exposure >> radiation exposure where >> uh to the test what Yes sir.
>> Okay. Go to the next slide.
Why the issue of TB in a case of lump in the breast?
>> So because TB can also cause a infection in the breast a granolomatus mastitis sir. So therefore to rule out we ask for cox.
>> What kind of surgical intervention you elicited?
previous surgical intervention any abdominal surgery or in the any surgeries in the lower limb what surgical intervention you have asked >> uh any so surgeries in the breast per say for example there were if there was any lump in the breast which was excised in the past but the patient does not know what lump it was so to rule out that yes sir >> okay go to next slide why you have elicited particularly the ovarian breast sorry ovarian prostate not any other malignancy when you are eliciting the history of when when you are elating history in the case of c breast or any lump in the breast.
Uh yes sir because all these are all these cancers are usually linked to the group BA mutations BRCA mutations sir.
So to rule out that and since BRCA mutations uh BRC has all these breast can present with breast CAC or prostate or prostate CA. So to rule out that in firstderee relatives and in other family members we asked for this history.
Among these two braa one and braa 2 which one is a autotosomal dominant or autotosomal recessive which one is inheritant as autotosomal dominant or as an autotosal recessive one >> automal dominant sir >> which one braa one or braa 2 both sir >> both two is a familiar braa one is highly penetrated And it is a mtosomal dominant inherited. Okay. Yes.
Next slide.
What is early manarchy? What is late menopas? In Indian setup, >> sir. Uh less than age of 8 to 10 years, sir. It's called early menarchy.
>> Menopas.
>> So 45 to 55 years is considered more than 55 is considered as late menopause.
Why do you bother about the first child at the age of 20 years? Why ask the why the history is of the first child birth?
>> Uh since breast cancers are usually associated with increased risk of exposure to estrogen and since the after pregnancy the estrogen level falls so the patient is exposed to that that level of estrogen since all these years.
Sir from menarchy till first live birth sir. So we had we rule out the s.
>> Why is it the issue of birth control pills that is OCPS?
>> Yes. A patient going to be taking oral control pills are synthetic estrogen progesterones. So that increase the risks.
>> You elicited breasted breastfeeding how many years it is protective period. It's called as protective period. If the mother is feeding her child her baby protective period of breastfeeding to avoid see a breast 6 months 1 year 1 and a half years 2 years >> so 6 months >> two years minimum two years respect it's a protective period okay yes go to the next slide Why you consider issue of vegetarian or non-vegetarian?
In what way it is related to the CA breast or any lumps in the breast?
Uh sir uh p for example patient if uh >> no idea.
>> No no sir patient can uh uh breast hydrated disease can also seen in rare conditions sir. So, so to rule out that >> the patient is taking fat rich diet. Is there any chance is it a risk factor or not a risk factor?
>> Obesity fatrich diet.
>> Yes sir.
>> Uh yes.
>> Okay. Next slide.
So 55 year old postmenopausal lady presented with a rapidly progressing lump in her right breast for 4 months at present 10 cm in size and swelling in the right axilla since 2 months and also over the swelling for two weeks.
>> Two weeks.
>> What would for the ulcer of the swelling?
>> Uh so reason could be because the lump in the breast is pressing on the skin and there is a skin necro the skin necrosis is happening. Therefore the ulcer has formed sir >> in carcinoma of the breast and in saroma of the breast. In which one? Due to necrosis the answer will be present over the breast or in the skin of the breast due to necrosis.
In one condition it will be due to the necrosis and in one condition compression necrosis and in one condition it will produce due to infiltration.
Sir breast CA is because of infiltration sir sarcom will be the large lamb so it will compress sir >> yes pressure neck pro pressure what is probe test have you ever heard of that terminology probe test what is probe test so probe test sir to look at the base of the ulcer we pass a probe and if there is a lump we can feel and if there's no lump and there just superficial skin ulceration is there we won't be feeling any lump beneath the ulcer sir So after eliciting the issue what you are suspecting benign tumor or it's a malignant tumor of the right breast is there any family history? Have you? Yes.
>> Yes. Yes sir. I've asked there's no family history sir.
>> Yes. What you suspecting >> sir? I suspect since the age of the patient is 55 years of postmenopausal and having a lump this big with axillary lymph nodes and ulcer over the skin. I'm suspecting it will be a malignancy. Sir, >> what are points in Java?
>> Yes sir.
>> Jan probe test is to differentiate whether the ulcer is due to the pressure necrosis or infiltration. So in malignancy you will not be able to pass the probe between the mass and the ulcer.
>> Yes sir.
>> Okay. It's continuous. Where is in a benign condition or where there's pressure necrosis >> pressure necrosis >> you can pass between beneath the skin through the above the mass that is probe test.
>> You said birth control pills are they protective are they harmful.
The recent concept is there were the progesterone controlling pills which are they say it is protect more protective.
Did he ask for history of repeated abortions?
>> No sir. Sir he had just one abortion sir it was way back he >> okay okay so please take over somebody Rajie sir was madam >> I have one question he has written ulcer over the swelling I can't understand what is that answer over the swelling you told ulcer swelling in the axial and lump in the breast you telling the answer is over the lump or the swelling in the axilla uh sorry answer the breast lump breast or the breast Ma'am, >> the breast or over the lump?
>> Uh, over the breast ma'am. Skin >> separate from the lump.
>> Yes ma'am. It's on the skin ma'am.
>> No, no, no. What I am asking is whether the ulcer is present over the lump.
>> No ma'am. It's on the skin ma'am. The skin of the breast there is ulcer ma'am.
>> No, no. Is it different? The lump is this different area and the ulcer is in a different area.
>> No sir. on the same ulcer is on the nipple. Any sir, I'll show you the mad asking. Huh? That's what madam is asking because you have written a lump in the right breast and ulcer over the swelling. So I thought there are two separate entities.
>> Uh I I'll show the lump was very big and it got ulcerated like that only. Now >> yes ulcer is on the n ma'am.
>> Ulcer in the >> ulcer over the nipple ma'am. Nipple edition small ulcer over the nipple gum >> seems to be nipple has been eroded not an ulcer you told the swelling but here there is no ulcer over the swelling no >> uh I think if you enlarge it >> enlarge the picture we'll be able to see >> there is a destruction of the nipple aola complex >> there's destruction of the that's what we >> nipple has been destroyed If possible, nipple complex.
>> Yes sir.
>> If possible you please focus on that NAC of the right breast so that we can see clearly the answer over that area.
>> Yes sir sir.
>> The nipple is destroyed but there is smaller in this area.
>> Okay.
See madam for any retraction before this also.
>> No ma'am.
>> Any history of nipple retraction? He asked.
>> No ma'am there was no nipple retraction.
Just the skin started to erode as the patient gives history of >> there is no history of nipple retraction.
>> No.
>> And why are you asking for normal sleep pattern and normal bowel and bladder habits?
Is it necessary for this patient as a postgraduate? Not you don't need to mention all this for a completion sake.
If you have any value in this question then it's okay otherwise no need to use it just for a completion sake. I think so.
>> Yes. Yes. In thyrotoxosis patient it is valid. Okay.
There's no need. Sir I I think in this case if the patient is having >> uh disturbed sleep because of pain that has some significance >> bony metastasis like that >> isn't it >> in that way >> you told there is no history of pain no sir >> no so that's what I'm saying that it's just to rule out that that that there's no med painful meds >> j what are the risk factors in your patient >> based on Uh >> so based on the s first sir gender sir uh age of the patient uh early menopause sir and uh >> age at menopar menopause is the risk factor you are saying >> early minarchy ma'am minarchy >> minarchy is less than 12 years only early your return it is at the age of 12 early >> no the question is what are the risk factors In this patient >> hello >> in this particular patient what are the risk factors >> sir female gender sir >> yes very good female number one number two age >> age sir >> post menop 55 years yes any other factor any family history >> no family history sir >> what are why did you Ask about the breast biopsy in a patient with a cancer of the so like 5 years back the patient had a biopsy which was a benign condition.
So which condition is likely to have developed the cancer is benign condition.
>> Uh benign sir DCIS can develop into malignancy sir. A typical hyperlasia sir.
>> Which which hyperlasia?
>> Uh a typical uh ductal hyperlasia.
>> Typical ductal hyperlasia. Yeah. Yes.
Now can you stage your patient based only on the history? It's a patient with a car breast. Can you make the staging in your patient only on the history?
>> Uh only for only on the history sir. Uh yes sir. We can say since the lump is large we can on the bas on the basis of just history sir we can say it's t4 n1 uh m0 sir >> which t4 >> uh t4 sir uh for exam we'll have to examine sir but considering the size and uh skin involvement ulceration over the skin sir >> history sir is asking in the history >> only in the history you know >> history alone without seeing the patient with the history alone can you stage the disease >> where you say there is ulceration is there over a big lump so what stage it will be and you are also saying there is a swelling in the axilla also >> yes sir >> so based on that what is the stage in your patient >> ailla uh sir stage three sub three >> but you are saying there is there over the lump s if The ulceration is here then it becomes uh stage four three >> stage three stage >> what is T4B >> uh sir T4B skin involvement sir >> so is that ulceration is not a skin involvement >> yes sir skin involvement >> so it is T4B you know >> T4B yes sir >> okay 10 cm lump can be in T3 also but once the solution is there it becomes a T4 >> T4 is T4 B N1 M0 at least >> at least you can say based only on the history.
>> Only on the history is yes sir.
>> Yeah.
>> Okay.
>> What are the features of skin involvement Janak?
>> What are the features of skin involvement in see breast?
>> Uh skin involvement sir ulceration sir pure orange appearance and satellite nodules sir.
>> Yes. Then ulcer you can include ulcer also.
>> Yes.
>> Okay. S has asked about some risk factors. What are modifiable risk factors? What are non-modifiable risk factors of CA breast?
So non-modifiable risk factors would be age and gender gender of the patient sir.
>> Number one, >> genetic mutations or family history or history. Yes.
>> Then >> uh modifiable history. Modifiable is >> non modifiable that is manarchy and >> early late menopause these are the things nonmodifiable >> non modifiable >> modifiable risk factors >> obesity smoking >> obesity smoking yes sir >> radiation exposure yes sir >> all these things okay yes these are what is absolute risk factors And the relative risk factors >> uh absolute risk factors sir. Uh family history of breast sir.
>> Yes.
>> And genetic >> again. Gender >> gender. Yes. Family history and genetic.
Genetic outs.
>> Family history.
>> Okay. Relative >> uh relative sir uh history of radiation exposure.
>> All other things.
>> Yes. Uh g u early men.
Basically the blood.
>> Okay.
>> Yes. Coming to the general examination.
>> Uh so uh patient was examined.
>> Yes sir.
>> Wait wait wait. Anybody else wants to?
We have to get the opinion. Ibraim was there.
>> There was there was a discussion about benign things and uh he was telling DCIS has a benign. Do you think DCS is a benign one?
Uh >> yeah no sir it's considered as premalignant. Yes sir.
>> Yeah it's not considered it is premalignant that's okay. So it is not benign and when you are presenting the history just present it like a story and don't run like a news reporting. Okay.
>> So that you have to take the examiner along with your history. Here all the examiners are running behind you to follow you.
>> Sorry sir.
>> Got it. Yeah. Go go go ahead. Go ahead.
Yeah. Uh sir condition.
Uh yes sir. If dermal lymphatics are blocked p orange can occur.
>> One thing tell me some one or two conditions in which pine conditions it can occur.
Orange.
>> Pilarious.
>> Master like Okay. Yes. Okay. Go ahead. General examination.
>> Yes. Uh proceeding with general examination. Uh patient was examined in a valid room after informed consent in the presence of a female attendant. Uh patient is conscious oriented to time, place and person average built uh BMF 22. Uh no there was no palar clubbing ether spy generalized infinopathy apart from an auxilary influence of the patient pulse is 80 per minute VP 108 70 Rapid respirator rate of 16 per minute templ.
>> Just a minute just a minute. Why are you rushing through? again that just now again >> we all have to follow >> then you return informed consent. Why you written informed consent after getting a consent for examination that is not a informed consent.
You get a consent for examination.
>> Yes ma'am. We inform the patient that we will be >> that after getting a consent not informed consent >> informed consent usually we give it in a for a procedure >> procedure yes ma'am I'm writing >> not for history or examination >> you didn't mention the EC score eco score >> uh yes I forgot to mention s sorry it not is it >> yes it is important Uh what are the two scores you mentioned?
>> Oh sir, ECOG score and carnovski index scores. We forgot to mention >> is for malignancy.
>> Yes, >> score should be mentioned.
What is the next slide?
>> Yes.
Uh start.
>> Yes. Yes. Yes. Start inspection.
>> Yes. Uh local examination. Uh on inspection the there was asymmetry in the noted. Uh right breast was at a significantly higher level than the left. Uh visible fullness was seen in the right upper quadrant. Uh the skin was shiny having engorgosed veins and a pudo orange appearance was present. An ulcer was seen over the swelling of size 1x1 cm involving the nipple areola complex which was irregular and had averted edges and the floor of pale necrotic tissue and no satellite nodals were seen.
Uh on leaning forward the p the left breast fell more forward.
The NAC was NC was seen on both side but the right NAC was seen around 2 cm higher than the left and retracted. The right nipple was involved in the ulsa.
Uh on raising both arms above the head the right nipple triple appeared retracted and pud orange appear appearance became more prominent.
Palpation left please go to the first slide of the inspection.
So I mentioned asymmetry noted right breast lying at a higher level. You cannot mention like that lying. Okay.
Right breast at a higher level. Okay.
>> Yes sir.
>> It is actually not a breast. It is actually the nipple area which is at a higher level.
Okay. Got it. And also you mentioned about visible fullness in the right upper quadrant. So how many quadrants are there?
>> Four quadrants.
>> So which quadrants it is fullness? That is the medial upper quadrant or lateral outer upper quadrant. Which one you are mentioning?
>> Lateral upper quadrant. So, >> so in the picture I can see the medial upper quadrant is also pull. So how do you how the upper is occupying the whole of the upper quadrant coming down?
>> Yeah. It is almost the >> entire breast itself is enlarged. You can mention like >> entire breast itself.
>> Yeah.
>> Right breast is larger than the left that itself.
>> Yeah. And uh quadrant you have a central quadrant also 12% of the customers are >> yes the entire breast was enlarged sir >> and uh you mentioned about uh engorged veins where do you see the engorged veins where it is seen? It is in the right breast or left breast or the tumor or in the normal skin area where it is seen.
So what the normal skin it's on the photo but >> no no no you explain it's okay where the normal breast tissue sir apart from the lumps >> no on the normal breast tissue means even in the left side also or in the right side >> no sir only on the right side sir >> right side normal breast tissue as well as >> just above the lump there were engaged veins sir >> above okay and ulcer you have mentioned as 1 cm n irregular in shapeverted edges and floor of pale necrotic till next.
Yes sir.
>> No satellite nodules seen. Okay. Go ahead. Next.
>> What are satellite nodules? Tanak.
>> Uh sir, nodes which lumps which are seen apart from the mass in the breast.
>> Why there are satellite nodules?
In which condition it will be?
>> Uh in how it is formed satellite nodules.
Sir, one mass breaks in two mass break separate.
>> Okay then.
>> Okay. And uh on leaning forward you mentioned the left breast fell more forward. So our area of interest is in the right breast. So we have to quantify it as the right. So the right breast is not moving well forward. That is the actual thing.
Got it?
>> Yes sir.
>> And go to the next slide.
And what are the things you will see when raising both arms above the head?
What are the things you will see?
>> Sir, uh we can demonstrate the fixity of the lump with the pectoralis major muscle chest also.
>> Okay. What else you can see extra once you raise the hands?
Sir, >> inframeary crease and axilla.
>> Inframe crease and a sir.
>> Uh and you already mentioned about some swelling in the axilla on the right side, right? So you you can mention about that.
Are you able to see any swelling in the axilla?
>> Sir, we could not see an example.
>> So that you can mention here.
Okay. And what about the inframame crease?
>> No, nothing significant. So >> what is important about the inframameary crease? Why it is significant? Why do you have to see about the intramic >> sir? Thromboplabitis of internal memory vein sir. Mondo's disease breast pain patient can present with breast pain sir.
>> What is disease?
>> Uh thromboplabitis of veins intermary ve we are you want to see the inframeary crease. know how it is related surgical wise inframeary crease most of the time the patient themselves will not be able to see the inframameary region so there may be some swelling there may be some ulcer there may be some rash there may be some fungal infection so those things will be visible only when we raise the arm got it >> uh may I just comment please about the satellite nodules there are two types of satellite nodules, one on the skin and other on the in the within the breast tissue. You'll have to explain both that satellite nodules are smaller nodules which are away from the primary nodule could be within the tumor within the breast or on the skin.
>> Yes sir.
>> Okay, you can go ahead. Yeah, go to the next slide.
>> On palpation sir, uh the left breast appeared within normal limits. uh on right breast there was no local rise of temperature. Uh a swelling of 10 by 10 cm size was palpable in the right breast mainly in the right upper and lower outer quadrant and extending into the inner quadrants. The surface was smooth margins well defined non- tender and firm to hard in consistency. It was fixed to the skin and breast tissue and ulcer was present over it with beauty orange appearance. It was neither fixed to the chest wall nor to the underlying petrolis major muscle.
>> Can you present again slowly?
uh not able to understand your quadrants description itself was confusing.
>> Left breast was within normal limits. Uh right breast no local rise of temperature was seen. Uh swelling of 10 by 10 cm palpable in the right breast mainly in the right upper and lower upper outer quadrant and extending to the inner quadrant. Surface was smooth margins well defined uh non- tender and the swelling was firm to hard in consistency. You can say it is not a swelling, it is a lump. You can say the lump of size this much involving all the four quadrants or all the three quadrants. What are the three quadrants? You are saying whether it has been arising from the outer or upper quadrant and extending into the inner quadrant that that you cannot say no from which quadrant it arises. So you can say all all these quadrants has been involved and you are saying surface is smooth.
Will the surface in CA breast will be smooth?
>> Uh on palpation we could find it >> palpation will it be smooth like a fibroid?
>> Uh no ma'am.
>> And you are saying margins are well defined. Will it be well defined? Are you able to define it clearly from the breast tissue and the lump?
>> Yes ma'am. The consistency we can feel there's a difference in the lump >> different when you say well defined you should be able to delineate the lump from the normal tissue will it be possible in case of malignancy >> no it will be otherred ma'am the >> that is the one point to differentiates benign from malignant in cancer breast no >> and I'm also doubtful whether it is firm to hard in consistency See >> how will you know that it is fixed to the skin?
>> Yes sir.
>> How will you know that the tumor is fixed to the skin? What clinical test you have done?
>> Sir, we tried to move the lump by holding the lump and in different directions sir. So the lump we could not move it sir. The skin was also moving and we tried moving the skin itself and the lump was also moving with the skin sir. Neither had we tried to pinch the lump, sir, we could not pinch it, sir.
Pinch the skin, sir. We could not pinch the skin.
>> So why do you do this test? Why do you want to examine this part?
>> So uh so we can rule out the involvement of skin, sir.
>> So any infiltration of the skin you mean?
>> Yes sir.
>> Okay. So in the next in that same point itself you have mentioned it is fixed to skin and breast tissue. That means it is fixed to the breast tissue, right? So if it is fixed to the breast tissue then the margins will not be well defined.
You cannot have a well definfined margin. It be regular because in some areas the breast tissue will be fixed.
Some areas it will not be fixed. You can have a well definfined margin only if it is uniformly not fixed at all 360°.
Okay. That's what madam is mentioning you. Okay.
>> Yes. I'll make the change. Yes sir.
>> Dr. Jan.
>> Yes sir. You're saying swelling. What is what is the what is a mass? What is the lump? And what is a swelling?
>> This is not a swelling.
>> Sorry.
>> A small size, a small size growth is a lump. A larger size growth is a mass.
>> Swelling is something because of edema or collection of fluid or something. You can't label this as a swelling.
>> Yes, >> you get me. Yeah.
>> Sorry sir. So you have to use a proper adjective whether it is a swelling, whether it's a lump or whether it is a mass. So a 10 into 10 cm is almost like a mass or at least you can call it a lump and not as >> lump. Yes sir. Good. Yes sir.
>> Janak is neither fixed to the chest wall. The tumor is not fixed to the chest wall.
What clinical test you have done?
What are the components of chest wall?
First of all, >> sir, chest wall includes ribs, intercostal muscles and seratus anterior muscles, sir.
>> Only to these two. What is the other one?
Ribs.
>> Uh ribs intercostal muscles and seratus anterior sir.
>> Okay. So, how do you know whether it is fixed to the chest wall or not? What clinical test you have done? Sir uh we'll ask the patient to keep hands on the hips and uh move the lump in different tight moving the lumps in different directions. Uh if it's if we can move the pump it is not fixed.
>> So why do you want to keep the hands on the hip?
>> Sir pectoralis muscle is fixed sir.
>> No are we testing pectoral fixity or chest wall fixity? Sir was asking about chest wall fixity now. How do you fix major is not chest wall fixity?
>> So what you're describing is you are examining whether the swelling is fixed to the pectoralis major. S is asking how we will examine whether the tumor is fixed to the chest wall.
So now it is almost involving all the quadrants. So you have to what are the muscles you will check and how you will check?
>> How will you check seratus anterior? How will you check latis mas dorsy >> s ser will ask the patient to push a wall stand facing the wall and push it and try to move the lumps up.
>> How will you push the wall? That is important. How will you push the wall with flexed elbow or extended elbow?
>> Uh fully uh extended elbow.
>> So in which quadrant you will see the serus anterior muscle? That's sir. Uh upper outer quadrant something.
>> Upper outer quadrant. Are you sure?
>> Lower lower outer part.
>> Yeah, it's lower outer.
>> Lower out.
>> Now what about the ribs and intercostal muscles? How we will check?
>> Ribs and intercostal. We'll ask the patient to uh we'll try moving the lump in different directions.
>> Mhm.
>> Uh if it is fixed to the chest wall, it will not be mobile. Sir, >> it is not like that. It is not mobile.
You should not. You should tell it as there will be restricted mobility. There is a word. Okay. There will be restricted mobility which shows there is infiltration of the chest wall. Now, how do you check whether it is infiltrating the pectoralis major? Tell all the points correctly.
>> Pectoris measure sir. We'll ask the patient to fix the pectoralis measure by like keeping the hands on the hips and then try moving the lump in different directions.
>> Before that do you want to check anything before touching the lump? You want to check anything? How will you know whether the pectoralis major is contracting or not?
The patient may place the hands just like that without contracting the hip.
Contracting the pectoralis major. How will you confirm the pectoralis major muscle is contracted or not?
>> Will you check any prominence of the borders of the axilla?
>> So anterior border of the axill.
>> Yeah, it is not borderillary fillary axillary f.
>> So you check the antaxillary fold it becomes prominent that means the rectalis major is contracting >> contract.
>> So then you check further. So how will you see the mobility? You you told you are going to move it in all axis or circular movement. Oblique moment or up and horizontal and vertical moment. How you are going to check it?
>> What is the direction of the pectoralis major muscle fibers?
>> So medial medial to lateral s inferome medial to superior lateral.
>> Yes. Excellent. So it's an oblique. So how you will check? So in what axis you will check horizontal and vertical or in any other direction?
uh perpendicular to the axis.
>> Yeah, it is along the fibers and perpendicular to the fibers. So, it's an oblique oblique axis. Okay. Not like the vertical and horizontal.
>> Yes, sir.
>> Okay.
>> Yeah. Dr. Janak, I just like to clear the one point. First, you ask the patient to lean forward. If the lump does not fall forward, that means either it attached to the pectus major or to right. Then you do that exercise for chest pix major.
Right? If it is mo moving around moving around and then getting the certain movement on contraction. If it is not moving at all in spite of anything then it is the chest wall rather than pec m p m p m p m p m p m p m p m p m p m pure >> test.
So it is leaning forwards is the first then is mobility. If it moves then it could be the pector test for it. If it doesn't move at all then it is chest chest wall.
You get it? Yeah.
>> That's good. I think to to say it is a T4A lesion in the spine position. If you move the lump and the lump is not movable except in the lower outer quadrant it is T4.
In the lower outer quadrant you have to check for the serus antior where the lump may be mobile.
>> Yes sir.
>> So that is to say the T4. So you need not to ask the patient to bend the forwards and all. Yeah. And keeping the hands up. So nothing is done there in the supine position which you are examining. You move the lump. If the lump is not mobile, it is a T4A leion >> T4 >> except in the outer lower quadrant >> where you have to check for the serus inter mobile and you have to check for the serus interior. Okay.
Yeah. Carry on. Carry on. Proceed. Go to the next. Yeah.
>> When do you say T4B leion?
>> Uh sir T4B when the skin involvement is there sir?
>> In which form? Skin involvement?
>> Uh ulceration sir. Uh pure orange and edema of the skin sir. Skin that >> leg there are only three things in the T4B reason.
If there's ulceration is there, >> there's a satellite nodule is there and there's a orange interference. Okay.
Other things like fixity of the local fixity, retraction of the nipple, inversion of the nipple they are not the part of the >> notion.
Okay. So only three things in T4.
>> Can you include the dimpling of the skin as the skin involvement? Chanak.
>> No sir. No sir. We cannot include sir.
Skin involvement sir it is because of the involvement of ligaments of cooper sir which are >> what is the function of the ligaments of cooper >> say they provide support and structure to the breast s >> what is the concept of retraction of the nipple involvement of the nipple involvement of the uh thermal sorry ligaments of poop are ligaments of >> what opens into the nipple. What opens into the nipple?
>> So, lactiferous duct sucks are opening in a single nipple.
>> How many lactiferous ducts are opening in a single nipple >> in a breast?
>> 10 to 12, sir.
>> Yes. 14 to 15 or 18 like that. Okay. So, involvement of that Lacrosse will produce retraction of the deep everything you have. Yes, go ahead.
Uh sir, an an ulcer of size 1x1 cm present over the swelling involving the nipple aerial complex was seen. It was non- tender and had irregular margins.
Floor was covered with necrotic tissue and hadverted edges. Base was formed by the underlying nump. There was no nipple discharge on expression.
You have to mention uh go back. Yes sir.
>> So we were discussing a lot about the ulcer. You have to mention whether the ulcer is separate or it is ulcer is along the tumor. It is fixed to the tumor. That's the most important thing.
We all waiting for that one day you mention that how is it are you able to move the ulcer over the swelling or it is moving along with the swelling.
>> It moves along with the swelling sir.
>> So that means the answer is fixed to the >> skin. Yes sir. No no no no to the lump.
So that means you are mentioning that the lump has eroded the skin.
>> Yes sir.
>> Or infiltrated the skin.
>> Lump has eroded and infiltrate both s.
>> No both are different. Eeroded is different. Infiltrated is different.
What do you think?
>> Oh it looks more like eroding the skin sir.
>> So like eroding means pressure necrosis.
>> Pressure necrosis >> not infiltrating.
>> Uh so the surrounding skin is involved.
Therefore, we have seen the ped. Yes, sir.
>> Look, if the it's a malignant clump is going to involve the skin and finally erode the skin.
>> Sorry, sir.
>> If you think it's a malignant lump, then it's going to involve the skin and erode it.
>> Yes sir.
>> So, it's an ulcerate. The tumor has involve the skin and the skin has been ulcerated. So, why you think that it is different?
It is a tumor which is ulcerated.
>> Yes sir. Tumor is ulcerated and so it is not a separate ulcer. It is the tumor itself which has started ulcerating.
So normally in ulcerated malignant tumors of the breast where where do you see the ulceration commonly in the nipple complex region or in other areas where do you see mostly the other part of the lump where the lump is there sir just above the lump s >> so all this what is the hisystologology actual hisystologology Normally what is the commonest hisy hisystologology of all these breast lumps malignant breast lumps it's a ductal carcinoma or llar carcinoma >> ductal ductal so the history or the pathogenesis is like that the tumor grows in one of the lactiferous ducts it travels through the lactiferous ducts reaches the nipple complex and there it grows and ulcerates so most of the time you will see the ulcer even though the tumor started in some other quadrant.
You will see the ulcer typically in the near the nipple complex complex.
>> So it is part of the tumor only. It's not a separate ulcer.
Okay. Yeah.
So you mentioned about there was no nipple discharge on expression. How do you do this thing this maneuver or this test? How will you elicit? Uh >> sir, we squeeze the nipple from the base sir.
So what will happen if two fingers base means which which position 12:00 or 6:00 where do you squeeze the nipple? It will be painful. If you squeeze the nipple it will be painful.
>> Yes sir.
>> Will you excuse the nipple or you will excuse the tumor?
>> Uh nipples.
So imagine in a patient where there are no mass and the patient is telling there is a nipple discharge. How will you elicit this nipple discharge? How will you elicit? There's a history of nipple discharge but during examination there is no nipple discharge. So how will you elicit? Check whether there is any nipple discharge or not. How do you do?
>> Uh sir like I said we squeeze the nipple area complex if there's any discharge we can see.
>> Now how the discharge comes from where the discharge is coming? uh from the duct or from >> so to the duct from where the it is coming to the duct from where it is coming to the duct >> beyond the duct what is there >> the lobules are there >> lobules yes sir >> so the lobules are present in a radial radial manner so you have to not skew or pinch or anything you have to just stroke your fingers in a radial direction from the periphery towards the nipple so in which quadrant for which lobular unit the thing is expressed that particular lob is involved.
Got it? So you should not pinch or squeeze the nipple at the base. So that will just compress the ducks alone. It will not cause any discharge.
>> Okay. Got it. Okay. Go ahead. Yeah.
>> What is the commonest cause of bloody discharge per nipple?
>> Sir, ductal interactal papilloma.
>> So what does that mean? Intraductal papilloma means what what is the meaning of that? Where is the papilloma >> sir? Uh inside the duct s arises from the epithelium lining the duct s there in one of the ducts.
>> One of the ducks.
>> So that is the pathogenesis of a IDC or intraduct.
>> Yeah. Next.
>> So a lymph node examination. Uh there were two groups of lymph nodes palpable.
uh one lymph node of size 2x2 cm uh hard non- tender mobile in the central group was palpated palpated and another lymph node of size 1.5x2 cm hard and non- tender mobile and in the anterior group was palpated no supra clavicular infra lymph nodes were seen and palpated and no lymphopathy in the contrateral axilla >> so how do you know that swelling is node first of all the patient presented with the axillary swelling only can it be some other thing other and axillary axillary node. You mentioned about axillary lymph node examination. How do you know it is lymph node?
So it is actually examination of the axill not axillary node examination.
So in the axillary node examination you have mentioned two groups of lymph nodes are palpable. What does that mean? Two groups you mean to say multiple nodes are stuck to each other one area and in another area. Two areas. What is that meaning? Or it is just two nodes palpable or two group of >> two s two nodes in different areas palpate palpate.
>> So you cannot mention as two groups of lymph nodes. So two nodes are palpable.
So then you tell which are the groups you are able to palpate. So what are the groups you are able to palpate?
>> Uh so central group and the anterior group sir >> anterior group. Anterior group you will palpate along what what >> along the uh lateral border of pectoralis major s.
>> Okay. And what about the central group where you will palpate >> in the axilla sir? In the upper super >> a only in which boundary or which wall of the axilla you will palpate? You need a rigid structure to palpate any structure right?
>> Yes sir.
>> Yeah. Against which rigid structure you're going to palpate the central group.
>> Uh so on the first trip sir >> in the medial chest wall >> medial chest walls.
>> Chest wall. Okay.
and one lymph node 2 into 2 cm size. So this is which one central group or anterior group which one is >> central group that the larger lymph.
>> So that you have to mention. So it is hard non- tender mobile whether it is regular or irregular we could just palpate a lump >> you're not able to mention about the surface is it so you are not able to appreciate the surface. Yes sir it was just a lump sub.
>> Okay. So >> here you should not mention lump. Okay.
If you mention lump it is in the breast not in the sorry just >> use the correct terminology. Okay. So another node you are able to palpate in the that is in the anterior group that is again non- tender.
>> Yes sir.
>> Okay. No supra or infra lymphodopathy and no lymph then contraateral axilla.
Don't put the CL axel and all. It is contra atal. Mention proper things.
Okay.
>> Yes. I'll mention the proper wording sir.
>> So how do you how will you examine the supraclavicular lymph nodes?
>> Uh supraclavicular I will stand behind the patient and palpate in the supraclavicular region. Sir >> where which area? Supraclavicular clavicle extends from medial sternum to up to the acchromian where you will examine in the lateral part of the clavicle. Sir, >> lateral part of clavicle. Are you sure?
Supraclavicular.
>> Oh, sorry sir. S medial medial part of clavicle. Sir, >> medial part of clavicle between what?
What structures? So you can see any muscle or any other structure to know here only we have to palpate.
>> Uh labon.
>> What muscle we'll be using as the guidance there?
Stern mastoid it has two heads. What are the two heads?
>> Uh so sternal and clavicular heads.
>> Yeah. Between the two heads and uh how should be the neck during this examination?
>> Uh next patient facing forward sir.
>> Okay. Any other maneuver? How will you relax the sternome muscle?
>> Uh ask the patient to face the same side with palpating sir. No, you how will you relax both the muscles at the same time?
>> Both the muscles are facing.
>> So that is called neck flexion. Press the chin.
>> Flexion. Yeah. The flexion of the neck.
Okay.
Flexing the neck.
>> Flexing the neck. Yes.
>> Flexing the neck. Okay. And how will you examine the infra for? You mentioned infra lympodinopathy.
>> Yes sir. Sir infraul will palpate from the front of in the front of the patient sir uh to the lateral part of below the lateral end of clavicle sir.
>> No we cannot palpate and examine infra lymph nodes at all. It is deep to the muscle. You cannot examine clinically.
Okay. So this infra lymphopathy is a image finding only not clinical finding.
Unless you have a very big node eroding the muscle then only you'll be able to see. And this examination should be done in sitting posture. question lying down >> sitting position sir.
>> Okay. If the if you have any doubt there appears to be some fullness but you are not sure there is a supraal lymph node or not. Can you do any manure to make it more prominent the nodes to become more prominent?
Are you able to understand?
>> Uh yes sir. So we'll ask the patient to take a deep breath.
>> Yes exactly. So what happens when you take a deep breath?
The chest wall becomes the alarm becomes more prominent sir.
>> Yeah. How how deep breath what happens? The intrathoracic pressure what happens to the intrathoracic pressure?
>> So it rises sir >> it rises. So it will push all the structures outward. So the nodes will become more prominent. So that's how we have to see when there is a doubt in the supraclavicular lymph nodes. Of all the lymph nodes which is more important in the clinical examination axillary supra clavicular or neck nodes which is more important axillary lymph nodes are more important sir >> axillary lymph node is the first first.
>> Okay. Okay. Uh next you can go I will ask one question.
>> Yes sir.
>> When swelling is present in a but there is no tumor at all in the breast. How will you clinically differentiate between whether that swelling in the axilla is due to hypertrophy of the tail of spense or it is due to the axillary lymph node? Are you able to understand my question?
>> Yes sir.
>> Yes. Tell me.
So clinically we'll ask the patient for history of fever and on palpation sir if the if there is if it's a lymph node on palpation it will be tender sir if it is due to fever lymphopathy >> okay >> so for axillary tail of spenser it will be just a lump in the axilla sir it will not be painful >> why should the lymph nodes always tender you have mentioned about the lymph nodes here all are Not non- tender only. No.
Is tenderness a point to differentiate the both?
>> Sir, if the if there is fever, systemic fever, then there can be inflam inflamed lymph nodes are painful.
>> No, no, no. The answer is if you pull the nipple area complex, then if it is due to the hypertrophy of the act of spins, it will come down otherwise it will not come up. If there is a node, it will not come. Okay. In that way, you can differentiate between these two swellings. Whether it is a node or it is a tail of spins. Answer.
>> Okay. Right. Go ahead.
>> Then how do you differentiate between a central group of lymph node and the epical group of lymph node?
How you will do the clinical examination for that?
central and the epical >> sir a group of lymph nodes will present high up in the axilla sir >> so what manure you have to do >> uh what special manure you have to carry out >> uh we'll ask the patient to uh we'll rest the patient's arm on our arm we'll support the patient's arm and you have to do in every case you have to support the patient's arm then only you can palpate the exil Yes.
>> But what extra maneuver has to be done to palpate the epical group of the lymph node and that has to be done by you?
Where will be your other hand?
>> One hand will be supporting the patient's arm and the other arm will be palpate.
>> No, you have to push down the shoulder with your hand. other hand >> the the supporting the supporting arm only is the palp palpating arm also both okay so in this uh if you are examining the right axilla you have to use your left hand both to support the arm as well as to palpate but for the deeper palpation you have to use your right arm and push the shoulder down so that you'll be able to palpate it further >> yes contact sir >> yeah there's a good good picture of it in the Clinical examination by Das you can see it. So examination of Axilla you may be asked to demonstrate also there.
Okay >> are you there?
>> No sir lost India.
>> Yes sir. He's not seen. Yeah, he's not see >> Can I What happened?
The clinical point you mentioned to differentiate between axillary node and a spins is very excellent sir.
>> Thank you. You're you're a surgical oncologist. I am a small.
>> Really great sir. Really great sir.
>> Hello sir.
What happened to sir?
I'm calling.
It's not connected. He's not connected.
Ibrahim sir is from which place sir he is my student sir at medical college now he's practicing atal valley sir so I'm basically from Chennai sir did my undergraduation from Stanley and postgraduation from MMC sir underagar sir and I did surgical oncology from RCC regional cancer center. Now I'm practicing in valley >> attached to institution sir.
>> Uh I am attached to ESA hospital here sir.
And also I practice in Shifa hospital which is 150 hospitalifa.
>> Yes sir.
>> Thank you sir.
>> Yes it means you have DNB pages sir.
>> Yes sir. Yes sir. DNB page. Yes sir.
some problem with the connectivity.
>> Yeah. Yes sir.
>> Yes sir.
Yes sir.
>> I think there is a power failure or something. Uh yes sir. Allow him couple of minutes sir. He's moving to another place where they have power backup. He's in the college hostel only.
>> Yes sir.
Ibrahim sir when are you arriving for the sports meet?
>> I saw your name in the list.
>> Yes sir sir I have registered for it sir. Actually it is a steps challenge no sir for six days I something like that.
>> We are arranging a stay locally. You're welcome to stay with us or it is in the N block of the Ramchandra. We are planning for the accommodation.
>> So what what's what are the days of the events? 14 >> 13 and 14 sir. 13 and 14.
>> Okay sir. Okay sir.
>> 13 morning we are starting by 8:00. 8 by say lunch time of Sunday it should be over sir.
>> Okay sir. Okay sir.
>> By Monday or Tuesday we'll get the final minutebym minute program sir.
>> Okay sir. Okay sir. Sports sir can sir.
>> This is a national sports even for the sir. Sorry sir.
I'm running the events for ASA Chennai.
I'm running this sport event sir.
I'm in charge of organizing teams running everywhere.
Running everywhere.
Those who cannot attend at Chennai can do running or walking in their own place and give us the proof.
>> Oh taken as award >> through the straa I have registered for that.
>> Same thing. Same thing. So those who cannot come to Chennai, they can do their running or walking in their home place and then upload the certification process.
Sir Professor actually breast examination has lot of clinical examination sir but but students have to learn all the techniques. Yes. Yes. Yes. Yes.
Examination. So many techniques are there.
palpation some books gives five or seven methods lying pos so that the breast doesn't fall forward and the ideal thing they say is in a semi-recommend position you have to palpate so many things >> yeah he's back sir >> yes >> janak is back >> good luck sir >> yes >> yes go ahead janak Yes sir. Uh extremely sorry professors for the >> Okay. No problem.
>> Uh we proceed to systemic examination.
Uh >> yeah you can proceed with systemic examination.
>> Yes. Thanks. Uh so per abdo parabo soft on tender. Uh no organomeal seen on digital rectile examination. No fissures visual sinus openings. No suggestive of blood or molina. Peraginal examination was normal. Uh spine examination was normal. There was no tenderness and chest bilateral air entry was seen. No added sounds. And uh Case examination S1 S2 was present.
>> Did you do the D here in this patient?
>> Yes sir.
>> Okay. I think uh sir other professors is D allowed in examination s PG examination?
>> Yes sir. Yes, postgraduates have to do sir.
>> Okay sir. Okay sir.
>> Normal and you should put PV as the first.
Which do you do first?
>> Sir PV PV PV sir per first >> sir per abdomen. What are you look for in per abdomen?
>> Per abdomen we look for sir organomegali. Sir there is if there's any organal present or >> tenderness over the right hyperact liver specifically sir >> what sir is asking is in this patient where do you expect the organome to be >> sir in the right hypocond region liver sir >> so heptogali >> hepattoomegali sir >> any patient asitis >> asitis and abdomen distension >> any nodules aroundus Okay. All this thing will clinically how will you clinically differentiate between peronial deposits and rectal carcinoma by doing this Dr. In both cases you will feel mass per rectum isn't it? How you differentiate between rectal carcinoma and petonial depos.
>> Huh? Yes. By >> yeah sir.
>> On Dr. sir the rectal mass will be felt with the finger sir. We can feel it and uh it can bleed also sir. palpated flight the mucosa will be involved there will be mucosa will be involved but in ponial deposits it won't be involved isn't it yes >> so basically you can move the mucosa if it is deposit and you cannot move the mucosa if it is a rectal tumor that's >> what are tumors >> sir metastatic tumors to the ovary sir >> it's a solid tumor or it's a cystic tumor.
>> Bilateral or unilateral >> bilateral bilateral bilateral.
>> So, so when the question is asked cruenber's tumor that time we have to qualify it as bilateral solid tumors. So that that's of the ovary. So that should be the answer cruenber. Okay.
Instead of spine examination you can put skeletal examination. So not only the spine you examine you examine the any long bones of the long bones.
>> Yes sir. Feel >> where will you examine the spine paraspinal spaces or over the spinal process?
>> S just the spinal spinus process sir the paraspinal spinal spines.
>> Sorry sir.
>> Why not the spine? Why not go over the spines? Why lateral to the spines?
>> Uh sir if the s the venus flexes is in around the lateral end of the just lateral to the paras spines of the vertebra sir. So if there's if there is any metastasis which is deposited over there we can palpate and over the over it sir.
>> So you mean you mean to say you can palpate the spinal metastasis?
Sir you can't palpate the metastasis the the on palpation there will if there is involvement there will be pain sir you can palpate the metast is not called pain it is tenderness >> pain and tenderness >> paraspin tenderness which part of the bone vertebral bone is involved first in c breast metastasis >> trans process is there spinus process is there among all these particular >> just behind the body sir the >> what is that called >> ped pediculture pediculture >> yes pedicle that's why you have to pulpate the paraspinal tendus okay you have to look for the paraspinal tendus >> is the bone metastasis osteoscerotic or osteoporotic s osteolytic s bone it's eroding the bone sir always >> uh not always it's a majority of breast cancers are osteolytic sir >> the majority or osteolytic but it can be also osteosclerotic >> which cancer causes osteosclerotic metastasis uh >> you mentioned that cancer in the family history also here >> prostates >> yeah very good Yes, >> you examine the chest in carcinoma breast. Both plural eusion and consolidation can occur in the lung.
How will you clinically differentiate between consolidation and plural eusion?
Uh sir uh sir uh we'll oscultate sir sorry sorry sir will oscultate the patient sir >> and uh there will be decreased bread sounds on both conditions but uh sir the the uh >> the vocal fitus >> vocal fits yes sir vocal fitus it will be increased in >> consolidation >> consolidation yes sir decreased in plural eusion yes sir >> and how about the percussion Any difference in percussion?
>> D in both s.
>> What specific dullness in plural efficient?
>> Plural efficient s.
So it will be dull sir.
>> Yeah it's dull. What what specific adjective we have to use there?
>> Any stones you know s has already given the answer.
Stony dullness.
>> It's called stony illness. So what so you know what is meant by stony dullness?
>> In in stony dullness if you percuss your finger will be paining like when you hit a stone which will be paining your finger will be paining right?
>> Yes sir.
>> Similarly when you are doing percussing and if your finger is paining that is called stony dness. If you really perused a stony dullness you will never forget in your life.
perus percuss plural eusion and see how your stony illness really feels.
>> Yes. Yeah.
>> What will be the typical uh findings in lungs? That is what is what are the appearances of secondary deposits in the lung?
>> One ball like structure. What is that ball?
>> Cannon ball. They will appear as a mult round metastatic limposites will be seen as round hypolucent.
>> What is the concept behind that cannonball appearance? Why it is not present in the liver secondaries?
>> Can you ever get cannonball deposits in liver? No. But in you can get why >> sir? Because the lung tissue is it allows expansion. Sir lung tissue is soft. allow expansion. Liver is firm so it won't allow expansion.
>> Very good. Very super. Lung is an elastic tissue in all directions.
>> It will grow in a same >> all directions.
>> Yeah. In all directions it will spread.
That's why it's a cannonball. Okay.
>> Canon. Yes. Next.
Uh to summarize our case uh 55 year old lady postmenopausal lady with rapid progressing right breast lump of size 10 cm associated with ulcer and pure orange appearance with ipsilateral axial lymph nodes and no clinical evidence of distant metastasis is probably a malignancy a case of malignant right breast lumps.
What are the points in favor of your diagnosis of malignancy of the breast?
Tell me from the history number one by one sir.
>> Points in favor are uh sir age of the patient uh a post-menopausal status of the patient and s right breast lump which is rapidly growing uh large lump involving all quadrants of the breast uh with fixity to the skin and lymph node involvement in the axilla.
All these point supports or it could it favors the malignancy.
>> Good. So it's an early breast carcinoma or it's a locally advanced breast carcinoma or it's a metastatic breast carcinoma. In which group you will put this one?
>> Sir to place it in a large locally advanced breast caroma sir because there are no metastatic deposits seen sir. Clinically there are no metically no metastical.
Yes.
>> So what are the points to tell it is locally advanced sir?
>> Uh this size of the lump is around 10 cm sir. Uh it is involving the skin sir.
And uh there are axillary lymph nodes on the same side. Sir >> most important about the skin of the breast.
>> Sir involvement of the skin sir. Py orange appearance.
>> Yeah py orange.
is the most important thing. Okay. And what what will be the things in early breast cancer? How can you tell if it is early breast cancer?
>> Sir, uh it will just be a lump with uh lump in the right lump in the breast with uh without any uh skin involvement or chest wall involvement sir. And without any ithering nodes also.
So if there is any nodal involvement it automatically becomes local advanced or early breast cancer can still have nodes.
>> Uh can still have nodes sir?
>> Yeah the node should be mobile >> mobile node sir >> not fixed to each other.
Okay can you can still have a early breast cancer. Okay. So how will you proceed? Sir, I would like to first do a radiological investigation by record USG and mamography to quantify the size of the lump and to look at the uh intern architecture of the lump and see any if there are any other satellite noodles are present and I will try to take a biopsy of the patient of the lump the true cut biopsy of >> mamogram from where which breast you want to do mamogram or ultrasound which breast >> sir I would do both breast sir Why do you need to do for both breast? So >> uh because uh sir there could be some small meta small uh mass which which is not clinically appreciable uh to us or patient is not complain saying but there could be s mass to rule out the mass we need to do a radological sonography or mamography both.
>> Okay. Any other thing also to know the normal architecture of the The breast bats should be known. So then only you can compare the tumor tissue with the normal. In this case it is almost the entire breast is involved.
>> So you cannot have a normal breast tissue at all in this right breast. So you have to compare with the normal breast.
>> Okay.
>> Yeah. What is sonomography?
>> Uh is the same USG of the breast called sonamography.
>> Yes. of the high resolution high resolution resolution ultrasound web.
Can you tell what is the clinical pathological type of breast cancer in your case?
Clinical pathological type >> clinical sang type clinical pathological type >> have you heard the name of medillary carcinoma skus carcinoma atrophic scarus carcinoma inflammatory arcoma phases disease.
>> Yes sir.
>> So where do you fit your patient >> that is a clinical pathological classification?
So where do you put your patient >> sir? We can't say for sure we don't we don't have the bi biopsy of the patient.
We don't know the hisystologology of the tumor.
>> No clinical pathological notes on the clinical findings. I'm not pathological in a clinical pathological.
>> You have all the classical features.
>> Sorry, sir. Sorry.
>> All the classical features of clinical pathological. You can make it.
>> Sorry.
>> Most cars.
It is most likely to be a medularary car. Medoaroma usually occurs in the fifth and sixth decade. They usually present with the big breast and the big lump is there.
Skirus is slightly elderly atrophy 70 80 years phases involve the nipple.
What is inflatic arson of the breast?
>> What do you understand by that >> sir? Uh involvement of the dermal lymphatics more than onethird of the breast sir.
>> So there may no lump may be assessed aroma but more than one of the breast of breast.
>> Okay. Janak is there any two different equipments for doing ultra sonogram of the breast and uh to take son mamogram probe?
Yes. Uh please different equipment.
>> So only the probe is different sir. High resolution probe.
>> High resolution probe.
taking sonogam.
Yes sir.
>> In which age group you will prefer sona mamogram? In which age group you will prefer X-ray mamogram?
>> Uh will prefer son mamogram means sir patients which are less than 40 years of age and those who have dense breasts.
Young people young population. Yes. And people who are more than 40 will go for mamography. Sir >> why >> sir? because uh mamog uh so no u sir we don't want to in give radiation to the patient sir also USG is better for dense breast s better penetration sir high resolution sonomography >> what are mamographic findings in x-ray mamogram >> so we can uh it tells us about the size of the breast in which quadrant it is present and it can also Yes sir.
>> What s is asking is what are the findings you will see in a malignancy in mamogram micro mamogram mass effect architectural distortions micro calcifications >> micro the features you look for in the microcifications. Okay sir, we look for micro calcifications and the lung infiltrating >> micro micro small micro >> microc.
So in the sonop diagnosis or findings you will see the lesion is taller than wider or the leion is wider than more wider than taller. So what does that mean? Which is more malignant? Uh sir the when the probe is placed on the breast sir the lesion which appears taller than wider is more likely to be malignant because it appears it is infiltrating in the breast s and the one which appears wider.
>> Why the malignant swells malignant swellings are taller than wider and why the ben swellings are broader than taller.
So malignant swellings they infiltrate s they will spread inside while on the other hand benign swellings are they won't infiltrate any tissue and they'll just spread along the normal architect normal tissue subcutaneous space increased vascularity >> increased vascularity in malignancy gives you taller viter Okay. Ben swings transverse.
Okay.
So, mamogram over then can you see the mamogram? Can you see axillary nodes in the mamogram? Will you be able to see >> uh in medial oblique? We can see some axillary nodes can be seen if they are involved and if there is classification the lymph nodes. Yeah. Can you see pectoral muscle infiltration in the mamogram? Is it possible?
>> Can be seen.
>> It will be seen. Okay. So, you have seen a mamogram. No. How to read a mamogram?
>> Yes sir.
>> Okay. Next.
>> You have done a mamogram or son mamogram. So, next what is the what is the what you going to do? How will you manage? So I will take a biopsy of the lump to stage the fortop needle biopsy or fine needle biopsy.
>> Uh core needle baptis since the lump is very large you'll take a core but I will do it under USD guidance to avoid the necrotic areas.
>> Okay the patient has an ulcer also here. So you want to go to through the ulcer or you want to take a biopsy from the ulcer or you want only a tissue biopsy taken through some other part where you want to place the needle other than the ulcer sir the we'll go by a US guidance we'll see under the probe where the lump is and then take a biopsy >> so the US guidance is for taking the biopsy what I'm asking is where you will place the needle for that you don't need a So you're going to place the needle by seeing. So the lump is 10 into 10 cm.
Where you going to place the needle?
>> Biopsy. Where will you place incision?
Small strap like incision. You have to put isn't it? Where will you put? Where will circumola region or over the summit of the swing lump or by the side of the lump? Where will you place it? That is east coast sir.
>> Oh on the lump sir on the lump sir.
>> Yeah in the 10 into 10 cm lump where you will place first cm or 10th cm or in the between fifth and sixth centimeter where you will place because this is the most important thing. Yeah.
uh around the NAC s because it's a there is uh so the nipple is involved and suspecting it to be arising from the ductal region ductal so we'll take around the NAC so >> yeah it is perarola per yes sir >> and don't take so close to the ulcer or through the ulcer it is not needed >> it'll be more painful after the procedure because you are going to do only on a local so you take it near the summit >> close to the nipple complex. The most important thing is it should be included in the incision when you're doing the surgery later.
So you should never put it in a virgin area away from the ulcer or in the normal appearing breast skin or normal appearing breast tissue. How many course you will take?
>> Four to six course. Four to six course will take >> to the to the pathology department you have to send in which solution you will send water normal saline or any other thing >> uh sir for hystopathological studies we'll send it in formaline and for I >> what is the percentage of the formal 10% >> yeah 10% yeah very good formaline and formal Formalihide is a gas s formal formaline is 10% formalihide sir like dissolved in water sir >> both are same yeah formaline and formalide 10% okay you have to send in that when will you send today morning 8:00 your your chief is doing your chief has done the surgery today evening 4:00 you can send to the Yes sir. Good.
>> Yes sir.
>> When will you send to the pathology department the specimen core biopsy?
Immediately we have to send to the pathology department within half an hour in 10% formally. Why?
Particularly to see what receptors >> receptors. So receptors we can send it in NS also. So normal saline for receptors >> no even for IHC also you have to send a formalized sample only there is no no cell nos or water sampling okay only this thing is 10% formal deihide and you have to put the specimen immediately in the formal dihide and there should not be any delay >> and then as I told and you have to send the specimen immediately to the pathology department >> patient is taking anti plate tracks, blood thinners by the past two years and the patient has come to you for coronary biopsy. What precaution you will take?
uh first firstly we'll ask the patient to uh to uh stop taking the anti-coagulants and uh correct the coagulation abnorm like INR correction if it is needed and we'll try to if you take the biopsy we'll try to give compression to prevent formation of hematoma and further infection sir >> you have to ask the patient to stop prior to the coronal biopsy >> that's when you are taking that cornal You have to be very careful about your left hand fingers. Why?
Because you may injure when you are when you are shooting.
>> When you are shooting, you have to shoot in a 90° or 45° or parall to the chest wall.
>> Uh sir, around 45° chest wall.
Why not in a 45 90°?
>> Uh sir, because we can pun can create new thorax. Punch the thorax.
into the lungs under the lungs. Yes.
>> To avoid that you have to >> shoot in a parall to the chest wall.
Yes. 45.
>> So now you have sent the hisystologology. So what are the things you expect from the pathology department?
>> Uh sir pathtopath they will tell me about the location of the tumor from where it is arising. uh it's between the ductal cells tell about the location uh from the cells regarding the cells and it will tell they will tell me about the uh estrochemistry markers imtochemistry markers sit markers whether it's ER positive PR positive or positive and then accordingly I can start with the treatment of >> no no you should be complete not just half hazard here and there so histopathology so first thing is the hisytologology of the tumor whether it is tumor or not >> tumor >> benign or malignant?
>> Malignant.
>> Then what type of tumor? What histologology? Whether it is ductile or labular?
>> Labul.
>> Okay. And then what type of tumor? What grade of the tumor? So grade one, grade two, grade three. So there is some criteria. What is that criteria?
>> What is that? On what basis that grading is done? And what is the name of that grading?
On three basis you have to grade. What are they?
uh >> tubular formation and >> mitosis.
>> Mitosis >> and nuclear atpr okayism. Okay.
>> Nuclearprphism and what is the name of that criteria?
>> Bloom riches grade.
>> Okay. So grade grade of the tumor. Then what else you can you'll be seeing next is the iminohistochemistry. So what are the things in iminoistochemistry?
>> What are things?
>> So receptor status of the uh what receptors >> uh estrogen progesterone and her new sir.
>> Yeah it is estrogen receptor progesterone receptor and herpton receptor >> and any other index you will see >> so proliferative ki67 proliferative index. Yeah.
Why it's called Kaki sir? K one one one place in Germany that is called KL in that place it is discovered that protein proliferative index that's why it's called KI index >> K67 okay >> okay good what is expansion of new >> uh percept >> is a drug name that is also a trade name Not a real drug name. Yeah.
What is >> human epidermal growth factor?
>> Human epidermal growth factor is suppressed.
>> So there is one, two and three of the breast. We have to see for the two receptor number two. Okay. So in this patient it has come as infiltrating ductal carcinoma nois. What is mean by no? Uh no specific >> notation specified. Okay. Yes sir.
>> And uh the grade is grade two. Okay. And here that is estrogen receptor positive progesterone receptor positive hair to negative and ka 67 10 percentage. So what what you going to do next?
>> Jennak in in this janak in this uh tro biopsy you have to see for two more things. One is vascular invasion and differentiation of the tumor. If it is poorly differentiated tumor, if it's early in breast also, you cannot do a breast conservative. Only in well differentiated tumors, >> you can go in for a breast. So differentation of the tumor is important. Add that also to the cut biopsy.
>> Yes sir.
>> When will you say proliferative index that is more or higher?
>> Or sorry low or higher.
When it is below 10% it is low. When it is >> high okay then answer the question of >> so what what what you're going to plan it is ERP or positive and negative K67 10 percentage infiltrating ductal car nois grade two tumor. U sir firstly we'll give for we'll go for new adjuant chemotherapy.
>> No investigation is over or any other investigation is still pending. You have done only biopsy and mamogram.
>> Uh sir first we'll like to rule out other other sides of metastasis. We'll try to go for a pet.
>> So in the management of in the management of any cancer two investigations has to be done. One is confirmation of diagnosis.
>> Confirmation.
>> Next is metastatic workup. So never forget that. Okay.
>> Pet CTS. So what you are going to do here?
>> Uh so we'll uh take the patient for a PET scan.
>> Pet scan is not available in in my place scan is not available. So what what is the other alternative?
>> Uh sir we can go go for CT scan mult CT CT scan >> CT scan of >> uh sir CT scan spine uh s CT abdomen pelvis and uh s TT brain sir.
>> What about the local local area? Yeah chest. So first city chest. So what are things you you will see in the city chest? What are things you can see in the city chest?
>> Uh so we can see the uh the the lump in the breast and which if it in if it is infiltrating the chest wall we can see that and the ailary nodes we can see and if it is involving in the lung parang also we can see it can be seen.
>> So in this you have mentioned it is almost involving all the quadrants. So you have examined the supraclavicular nodes, you examined the axillary nodes.
What other nodes you can see extra in CT chest?
>> Uh internal memory notes.
>> Yeah, that you can see that has to be seen in city chest. Okay. What are the other lung features you want to see in the city chest?
>> Because you have not examined the lung by any investigation. No. So what are the things you you you can see in this patient? Uh sir look for involvement of lungs or consolidation or eusion or any metastasis to the lungs.
>> Okay. What about the any other bone will be seen in this spinal metastasis can also be seen?
>> Oh yes spinal >> spinal metastasis. Okay. In the abdomen what all the things we'll see >> sir. Abdomen uh we'll look for the liver sir. Liver we look for any liver metastasis in the liver leg segments. uh a site is in the abdomen s and uh any metastasis in the cruenber tumors or lumps in the par.
>> What is what is sister Joseph nodule in the abdomen?
>> Uh sir tca stomach sir.
>> Yes. What is that nod? Where it will be present? Mr. uh the supra clavicular >> you telling about abdomen.
Okay.
Lymph nodes.
>> Jak, you have done the liver function test in this patient and you find that the alkaline phosphotase is raised.
>> Yes sir.
>> What is your interpretation?
Uh sir if the alkaline phosphotase is raised and we not finding any uh clinical evidence of liver so bone metastasis in this it could be the the ALP could suggest that there is any uh bone involvement or bony metastasis is there but to confirm it from if it is uh if the ALP is raised from the liver and not from the bone we'll do others other LFT stressor like we'll check for Billy Rubin SGPT SG sir.
>> Okay. If the calcium is raised what you suspect >> also sir it can also mean there's bone osteolyis of osteolytic lesions are there and uh >> so when >> if is raised and calcium is also raised so then it suggests in the setting in such a setting sir it can suggest there's bony metastasis.
>> Yes. And if the ALP and the belubin is raised then you suspect the probably liver pathologist.
>> Okay.
In alkaline posit two types are there one is heat label and heat another one is heat stable isn't it? In which condition? Body metastasis or in liver metastasis. In which one which one will be increased?
Any idea?
>> Sorry.
>> No idea. Okay.
Yes, I stud.
>> Okay.
So, your diagnosis is a T4B N1 M0.
>> Why do you say it's a T4B?
>> Sir, uh skin involvement or beauty orange appearance in the past.
>> What is T4 C?
>> Uh T4C is involvement of the chest wall and skin. Sir, >> what is T4 D? Uh sir T4D is inflammatory breast carcinoma uh pud orange appearance is there more than onethird of the breast skin sir >> skin how will you confirm inflammatory carcinoma when there is no tumor in the breast para you are diagnosing a case of inflammatory carcinoma and you have to confirm how will you confirm uh sir on histo biopsy sir there's involvement of dermal lymphatics is seen muscles.
>> What biopsy you will take? From where the biopsy, there is no lump. Now, from where you will take the biopsy, >> you will take a true cut or core needle biopsy or what type of biopsy you're going to take?
>> Oh, core needles are take from the skins.
>> Core needle from the skin. That's really highly difficult.
So, what is the easiest biopsy of the skin?
Core needle is for from the core of an organ. So skin is in the surface. What is the easiest biopsy to take from surface?
>> Excision biopsy.
>> Excision. Entire skin has to be excised or what?
>> What you will excise?
So when you excise part of the structure what it is called?
>> Incisional biopsy.
>> Yeah, it's incision. It's a skin biopsy.
So you have to take a skin biopsy from the where the edema is too much and then you have to suture suture it. Okay. So skin biopsy is the easiest method to identify for inflammatory arcoma. It will have dermal lymphatics infiltration which is not clinically palpable but it will be seen pathologically >> and you have the skin biopsy needles also the roundedruct structure is there. Skin biopsy needles where you can just punch take a small punch of the skin.
>> You have biopsy >> tin biopsy where you have to just make a circular hole and take a tissue.
>> So the should be within 6 months in a case of inflammatory aroma not more than that and it it is having good prognosis or very bad prognosis. Inflammatory caroma >> uh bad prognosis >> in which group of people it is very common postmenopausal premenopausal pregnant lactational mothers >> postmenopausals >> postmenopausal >> already given the answer pregnancy and lactating.
>> Lactating methods. Okay. Lactrosis, huh?
Lactating methods.
Okay. You have done a porn needle biopsy, you have done ultrasog and sir has told some clinical scenario and what next you are going to do?
Uh sir as per the imunoistrochemistry reports uh obtained from the pathologist we'll start the patient on new aduent chemo accordingly and then we >> metastatic workup you have to do you will do >> so metastatic workup we'll do pets cancer we prefer PET scan if that is not available we'll go for CT scans >> for bony metastasis why can't you take x-rays >> we can take x-rays also sir Then what is the advantage of doing this PET scan?
X-ray is very cheap. You can take X-ray.
Then why are you doing for 10,000 or 20,000?
This PET scan.
>> U pet scan. Uh sir, we cannot give entire body X-ray. Sir can give that much radiation to location.
Oh, radiation 6 months it will take of the bones to see the X-rays to see the osteolytic lesions it will take 6 months time for the demineralization.
Okay, that is why we are taking more than 30% of >> immediately you can see >> yes sir more than more than 30% of the bone should be involved or destroyed generally which can be visible in the x-rays >> increase >> so until that you cannot wait so that's why CT once the patient has got some bony pain or thing X-ray you take if you're not satisfied still the bony pain is persisting you can go in for a CT scan bony metastasis and visceral metastasis among these two metastasis which metastasis is having worst prognosis visceral or bony >> uh visceral visceral metastasis >> very good so which type of tumors will produce more of visceral metastasis infiltrating ductal or infiltrating lola >> uh infiltrating uh doctor sir >> it's infiltrating globular so infiltrating globular are more prone for visceral metastasis like uh brain metastasis liver metastasis liver metastasis >> peronial metastasis and it's also more prone for bilaterality also >> always infiltrating loar or moreis okay So in the PET scan you mentioned about PET scan what is the contrast used >> sir 18 FDG sir fluoxylucon.
>> So how do you give that drug?
>> Uh ask them sir oral sir.
>> Oral or IV?
>> IV sir.
>> Yeah usually they give IV contrast oral they give water plain water as oral contrast. Okay.
So what is that uh how will you how will they mention about the uptake?
Have you seen a PET scan report? They'll mention something called SUV. What >> SUV indexes?
>> Yeah. What is mean by UV?
>> Uptake of the contrast in the >> Yeah. What is less? What is U? What is V?
>> Uh no.
>> It is standard uptake value. Okay.
Standard uptake value. If it is more means the tumor is more aggressive and it is more representative. So when you are doing some other malignancy there are tumors in many places like metastasis in one place SUV is 2.5 in another place SUV is 10.5 here you would like to take the biopsy >> in technicium 99 M scan bony scan how they will report the secondary deposit places >> uh sir techn they will show it increased uptake in the Not >> some spots. What spots?
>> Uh hot spots.
>> Hot spots. Very good. Hot spots. Okay.
Yes.
>> So in SUV value from where you will take the biopsy? Higher value or lower value?
>> Uh higher value sir.
>> Higher value is ideal place to take the biopsy. Okay.
>> So now in this patient it is non metastatic. Okay. PET scan or CT scan have done non metastatic but it is locally involving the Skin >> involving the skin and py orange is there and axillary nodes are there. No parernal nodes or intel memory nodes are there.
So what is the management now? Any other investigations you have to take?
Uh sir we've done u we've done uh sono mamography sir we've done mamography we checked out for metastasis also by doing pet scan and uh apart from this >> any blood investigations you want to do >> s routine blood investigation sir >> okay what are the investigations you you want to do in this patient >> routine C sir TBC to look at the baseline hemoglo baseline uh >> okay >> counts of the patients >> okay >> prior to starting chemotherapy >> okay >> and so LFT is to rule out to check for liver metastasis RFT and electrolytes everything else >> okay >> is there any tumor markers for breast cancer >> sorry so there is the tumor marker for breast cancer CA153 but it should not need not be done. Okay, we see patients are doing CA153 for diagnosis or monitoring. Okay, CA153 is a tumor marker which is elev which can be elevated in breast cancer but it should not be done for diagnosis or followup.
Okay, >> what is a tumor of carcinoma of the pancreas?
>> CA 199. What is that? CA >> uh carcinogenic antigen sir. Carson antigen.
>> Carinogenic antigen.
>> Uh car is carbohydrate antigen.
>> Carbohydrate.
>> Normally normally antigens are what?
Carbohydrate protein or fat. Normally antigens are >> uh protein sir.
>> Usually proteins but it's a carbohydrate.
>> Carbohydrate. Yeah, that is CA. So, Sarah asked about pancreatic cancer.
What other tumor marker can be there?
There's two. One is CA9. What is the other one?
>> Ca also embriionic.
>> Carson embriionic.
>> Okay.
>> So, how many internal memory nodes are there? Janak.
>> Yes, sir.
How many internal memory nodes, internal thoracic nodes are there in a human body?
>> I will give three options. 15 25 Three pairs.
Uh >> no idea. Three pairs. Okay. This side three that side that's all only three PS.
>> Can you clinically examine uh internal memory node enlargement?
>> U clinically enlarged significantly enlarged we cannot examine s.
>> So how if it is significantly enlarged how can you detect? If it is enlarged well how can you detect clinically?
>> Uh the parernal uh just lateral to the sternum sorry the interostic space.
>> Yeah. What you will see?
>> You will see any swelling or what?
>> It is parnal dness.
>> Parnal dullness will be there.
>> Okay. Asymmetrically one side it will be more.
>> So in which spaces? In which interal spaces we'll see.
>> Third, fourth and fifth.
>> 3 4 5. Okay. 3 4 5 that is the area where the breast is situated. So parasernally when you percuss you can feel an enlarge enlargement dness will be there. So now you have got all the investigations done blood workout is correct.
>> What is roer node?
>> Uh sir in inter interpectoral node sir between the pectoralis major and pectoralis minor sir.
>> This level one two three >> uh level two sir.
>> Yeah it's level two level two. So what is this grading called as level one 2 3 level of the lymph nodes name?
>> It goes by the name of the birch. B E R G >> level one, level two, level three goes by the name of the birch.
>> Yes.
>> Can you tell me the boundaries of the level one, two and three? Uh sir uh level one is lateral to the lateral and below the uh pectoralis minor. Two is above and below the pectoralis minor and three is medial and above.
>> Two is behind the pectoralis minor.
>> So actually the adjectives you are using is not correct. It is not surgical adjectives. Above below it should be superior, inferior, medial, lateral, anterior, posterior. this only these six adjectives there is no above. So even in the ulcer also you mentioned it is above that's why there was a confusion above the tumor. Above the tumor means it is situated over the tumor in the summit of the tumor or above the skin in the tumor. So you should only use proper surgical adjectives not not your own regular adjectives. Okay.
>> Yes sir.
>> Petrol is minor muscle where it is inserted genoid process.
process where it is humorous, scapula or clavicle.
>> Scapula scap.
>> Very good. Very good.
>> Okay. Right. What you are going to do?
All the investigation reporter Professor Ibrahim has told.
So what you are going to do?
So I will start the patient on new adune chemotherapy to downsize the lump and also do also continue with the metastatic workup till the and give chemotherapy and then take the patient for surgery. Sir, >> what are the advantages of giving new joint chemotherapy in this particular patient of 10 into 10 cm lump? Uh sir particularly this patient sir we can downsize the tumor sir. So we may not be since the lump is large and we can downsize it and downside it and uh also sir it it prevents the excision of the entire breast we can preserve try preserving the mastic breast also.
>> It is not downsizing okay it is called downstaging down >> downstaging. Okay so what is the stage now?
Uh sir now it's three stage 3 B sir.
>> So with giving a neoenone chemotherapy you can give you can make the downstaging. This is one advantage. Any other advantage is there?
>> Sir if there are any metastasis which have micrometastis that has already occurred.
>> Yes. Sterilization of micro microme.
>> Next any other thing? So you are giving a particular regimen of chemotherapy.
The tumor is responding. So what does that mean?
>> You can know isn't it?
>> Sorry sir.
>> Surgery you cannot assess. So before surgery what is the advantage of giving that drugs chemotherapic drugs before surgery? Two things you are told. The next one is >> uh >> efficacy that is >> response.
>> We can assess whether the tumor is responding to that particular drug or not. Okay.
>> So if it is responding you can use the same drug postoperatively also as adjuant drug.
>> Aduent drug.
>> What is the criteria whether it is responding or not?
>> So there is some criteria. I know what are the criterias called as to assess the response >> resist >> resist resist criteria >> resist criteria >> so do you know what what is that resist criteria how do you assess how do you know whether the tumor is responding or not how will you assess it >> uh sir we'll look for the size of the tumor sir >> yes size of the tumor then >> and and size tumors and >> number of tumors, appearance of new tumors, appearance of new lesions. Okay.
So, resist is E C. What is meant by R C S? Resist. What is the expansion?
So, it is response evaluation criteria in solid tumors. So, this is the criteria we use. So we can classify into four groups based on the response.
So what are the four groups?
>> Uh sorry.
>> Okay. Complete response. Complete disappearance of the tumor. Partial response.
>> Okay. Next is stable disease. There is no growth. No growth. There is a stable.
Okay. Next is progressive disease. Not responding. So of this which is good >> complete response is better sir. Yeah, complete response is better and in breast even a partial response is good because we know where the tumor was.
>> Where the tumor >> if it is stable disease or progressive disease that means it is an aggressive disease. Aggressive >> you have to change the chemotherapy >> chemotherapy.
>> So in this patient what chemotherapy regimen you will give normally patient is having erpr positive okay her two negative to zero. So what is the chemotherapy you're going to give here?
Uh so we'll start the patient with taxines first plyaxel or dositexel.
>> Okay. Do you when you're when you are going to start on such type of drugs what investigation has to be done in the patient?
>> Uh sir prior we should do a cardiac evaluation. So 2D yeah echo cardiogram has to be done. Why? Why? Because >> uh heart abnormal cardiotoxic sir.
>> Yes. Some of the chemotherapy drugs are cardiotoxic. So you need to have a baseline cardiac evaluation.
>> Cardiac evaluation.
>> So what is the drug you will give in this patient?
>> Uh since the patient is elderly and we'll start with dositel.
>> Okay.
>> And uh I also start her on give sir four cycles of dositexl and then >> single drug regimen or multi-rug regimen.
>> Uh multi-drug regimen sir.
>> So what is what is the other drugs you are going to give? rosy taxel along with it >> uh adramcin and cyclophosphomide.
>> Okay. You are going to plan for a t tax adram cycloposphomide. Okay. So how long you will give?
>> Uh so we will give four cycles of t tax and four cycles of AC sir adin cycloposine. No, you're going >> after how many of chemotherapy you will assess whether it is responding to the chemotherapy or not? Whether the tumor size has come down or not after how many cycles you will investigate?
>> Uh four >> four >> sir uh sir if the p if sir it depends on the receptor status of the tumor sir. So in this patient ERP are positive. So how often you will test? How will you test?
How will you assess?
>> Sir, we'll look for the size of the reduction in the size of the prime lump.
Uh if there are any new lump when you will see how often you will see you want to see the patient daily or weekly how we will see when you will see the patient >> or after two two cycles of chemotherapy.
uh three three months.
>> So normally you see the patient clinically after every cycle.
>> Okay. Investigation wise it is after third or fourth cycle.
>> Third cycle fourth cycle >> to assess response. So what will be the investigation you will do in this patient?
what imaging you will do. If you have done PET scan previously, then you have to repeat PET scan again.
Okay. Then only they will be able to compare and tell how much percentage it has come down.
So what are the complications? You will see complications due to the chemotherapy.
>> Uh sirin atriomy and cycloposite. So what are the toxicities?
>> Uh sir uh tagins cause neutropenia sir.
>> Okay. So there will be increased risk of infection. Uh and other chemotherapy do they cause neutropenia?
>> What is the commonest side effect of atriumin and what is the commonest side effect of docupism?
Uh so cardiotoxicity sir >> cardiotoxic both drugs are same or different and do rubic >> which is more cardiotoxic doc or >> uh do >> so do is more cardiotoxic both are same only okay both are same means both are same drugs only >> same drugs >> okay so cyclopasmide is more nephrotoxic atrium is more cardiotoxic.
>> Cardiotoxic.
>> Okay. Taxins are more neurotoxic.
>> Neurotoxic.
>> So these things has to be kept in mind.
Okay. So you have given this thing and tumor has shrunk so to 50% no new lesions. Axillary node have become mobile. So what is your plan now?
>> Uh sir we'll complete the cycles of the chemotherapy.
>> How many cycles you want to complete?
>> Uh the entire cycle sir. Sir how much?
Whichever remaining four cycles of t tax and four cycles of adramin cyclophosphomide >> and then we'll take the patient for upfront surgery sir.
>> This is not upfront surgery. Up front >> sorry uh we'll take the after uh after chemotherapy we'll take the patient.
>> So what what surgery you want to do?
>> Uh sir we like to go for uh since the tumor is downstage to 50% the size is decreased. Uh we'll go for MRM s modified radical mastctomy sir. Okay. So what what is the type of modified radical mastctomy surgery? What is this surgery you are going to do?
>> There are three types in your medical college. Which type is being followed?
>> Uh pis scan ain class. Among these three clause or >> what is meant by that? What is mean by that? Arin class.
>> Sir electrical incision. What are the structures that you are going to remove in archin class modified radical mastctomy?
1 2 3 4.
>> Uh sir, the breast tissue.
>> Okay.
>> Uh and uh the auxiliary lymph nodes >> petrol fasia will you remove or not?
>> Yes, I will remove the fasia also.
>> What is the color of the petrol fasia?
>> White sir.
>> Okay. Then in the auary nodes which group of a node you are going to remove?
Uh uh level one and level two sir.
>> Level two. Are you going to cut the petrolis minor? Are you are you going to retract the petrolis minor?
>> So we'll retract it sir.
>> Class you have to retract and you have to remove the level one and two nodes.
>> Level two.
>> Why not level three nodes are removed?
>> What will be the complication if you remove that level three nodes?
Lympadema.
>> Lympadema.
of the >> upper >> very common that's why usually what are the complications >> of MRM >> u complications of MRM >> injury to the long thoracic nerve of >> long thoracic nerve bells if you injure that now what will happen uh long sorry the weakness winging of scapula sir Winging of scapla will be there. What are the boundaries of axillary dection? Superiorly, inferiorly, medially and laterally uh superiorly sir, we'll go up to the pectoralis minor muscle sir.
>> Pectoralis minor muscle axillary dection. I'm asking one vein is there >> inferior border of the axillary vein.
>> Okay. Then below angular.
>> Angular vein sir. Below laterally sir medally to the latisimus dorsa sir and laterally to the later the end of humorus ligament >> ligament. What is ligament? What are the attachments of that ligament?
>> What is the other name of that ligament?
Costtoclavicular.
>> Costtoclavical. Okay. The clavical and the first strip lateral pedal.
Okay. These are the boundaries of the axillary dection.
How many nerves you will come across when you are doing a dissection? Five nerves you you will come across. What are those five nerves?
>> Uh intercosttorical nerve. Uh >> very good. Very good.
Number three.
Yes sir.
>> Which anterior? What are the other two nerves?
>> Uh what are the other two nerves?
>> Two nerves.
>> Fourth one is medial pectoral nerve and third one is >> lateral pectoral nerves. If you the medial pectoral nerve or the lateral pectoral nerve what will happen >> postoperatively?
>> So there will be weakness in the pctoris minor muscles.
>> Fibrosis of the petrol major and fibrosis of the pctoris minor muscle will be there and patient will have chest page posttop. So so you have to be very careful. Okay.
So during the axillary dissection medial and lateral pectoral nerve which is medial which is lateral which now emerges in the lateral border of the pectoralis minor muscle which nerve emerges from the medial edge of the petrolis minor muscle otherwise >> medial pectoral nerve is near the pectoralis minor muscle sir And what about the >> on the major muscle sir?
>> Medial pal now comes from the lateral edge and lateral pal now comes from the emerges from the medial edge of the palis minor muscle. Then why it is called med in a different way?
Because it is arising from the different parts. That's called medial and lateral.
Okay.
Yes.
What do you mean by adequate lympadenectomy?
>> When will you call a surgeon has done adequate lympadtomy?
>> Sir, uh sir complete level one and level two lymph nodes are removed, dissection is done.
>> I will tell all the surgeons will tell I have done level one and level two. Who will tell that lympadenectomy is adequate? It is the surgeon or the pathologist? Pathologist will service.
>> So how will the pathologist know? How will we know whether it is adequate or not? How will they tell? How will they quantify?
>> The number of the number of lymph nodes examined.
>> Yes.
>> So minimum how many number of lymph nodes it should be there in the sample in the axillary nodes?
>> 14 14 >> 14 to 15 sir >> adequately.
So in the hystopathological report what are the things you will see in this patient post near joint chemotherapy patient what are the things you will see uh sir then we'll try to aim we'll uh we'll send the entire mass for hystopathology and the rected mask and sir on the report yes sir sir we report we'll check for uh the free margins sir margins if the margins of the tumor are free I will try to to aim as close as possible to azero dissection sir.
>> No surgery has been already done. So what are the things you will see in the histopological report? One is margin.
Next what?
Next >> hisytological type whether it is a duct carcinoma or it is a lolly histoological type ductal carcinoma type like that. Number three, grading grading of the tumor.
>> Grading of the tumor.
>> Number four, lymphoascular >> vascular invasion.
>> Number five, how many lymph nodes are there involved? Isn't it like that? You have to tell. Then any other thing?
>> Uh HRP status. What is HR?
Sorry, ERP status. Your >> hormone receptor status.
Yes.
>> So there is something called PTNM staging. So pathological TNM staging.
For that we'll use the T size of the tumor. So you have to see the T size.
>> So if the tumor size is 10 into 8 cm residual tumor. So what is the tumor size? Now which size you will take 10 cm or 8 cm?
So a post will take consider >> the maximum the largest one. So if it is 2 cross 5 cm it is 5 cm. So the largest dimension has to be taken.
Okay. So lympovascular invasion PNI that is perinural invasion. In the lymph nodes you will see number of lymph nodes. The number of lymph nodes positive. Any ECS extra capsular spread is there or not. whether the fat has any deposits isolated cells are there >> and most importantly the margin status >> margin >> okay and another thing it is a post neo joint chemotherapy so they can say how much there is necrosis because of the chemotherapy so the percentage also they can tell so now surgery is done uh you have what are the complications you expect after MRM or modified radical mast the complications sir we can uh sir damage to the nerves >> no no what is the commonest complication whenever there is a complication you always tell the commonest complication what commonest complication you see in your hospital after MRM >> in post-operative what in first and second postoperative days uh >> numbness over the upper arm Seroma collection serum flap necrosis flap necrosis whenever they ask for complication you tell re immediate complications late complications okay immediate complications you can mention about zero >> flap necrosis or >> flap necrosis hematoma >> hemat complications there you can mention about other this neuropathies okay decreased sensitivity all those Yes. I guess any idea?
>> Yes, sir.
>> Lymphia. Have you ever heard of that terminology after MRM?
>> Lymphoria.
>> No.
>> What is mean by lymphia? Lymphoria. What does that mean?
>> Diarrhea. Like that. Lymporia.
Yes. Sorry.
>> Lymph will come through some sinus in the axillary region. It will be there for 3 months.
2 months to 3 months. How will you treat lymphia?
>> No idea. Go and study. Lymphia is very rare complication. Okay. Yes.
>> Definitely stress. very late complication of MRF. The patient has come to you with a huge upper limb >> uh lympadema.
>> Yes.
>> What are the things you will do at the time of the operation that there is less chance of the lympadema there?
uh sir we'll try to try not to remove all the lymph nodes we try to limit to level one and level two lymph nodes try we try to preserve the level three lymph nodes >> so as not to prevent so as to prevent the lympidma >> you get the auxilary vein when you're doing the dissection >> so what is the aary vein to do when you're doing the aary dissection To prevent the lympadeema >> lympadema >> no no what you will do >> you are not supposed to go >> beyond the lymph aillary >> vebove above the above >> we don't go >> above aary ve >> okay do you know any technique which is done sometimes to reduce the lympadema at operation Huh?
Sometimes you can do the anastmosis between the lymph lipatic and the >> blood vessel.
>> Blood vessels.
>> So that is also >> yeah you can do that and then you should avoid the radiation because it's a combined thing is there there's much chance of having the lipid. Yes sir.
What are the ways to prevent the seroma formation? Seroma is the commonest complication of the complication. Yeah.
>> So what are the various ways by which you can reduce the seroma formation?
>> Uh and we can reduce by placing drains in the drains while operating s. Mhm.
>> And giving adequate compression over the pressing side. Okay. What else?
And uh you should ideally tie all the blood vessels there because the leak from there is there and that can cause the serum formation. Then you can glue that area. You can put a glue over the pector major muscle and that can also so that the flap is not free. It is it is just sticking to the >> sticking to the muscle.
massage.
So these are the various ways which can you do the reduction of the synoma formation.
>> What is quilting? Q U I L T I N G quilting >> you can fix the skin to the >> skin to the pectoralis measure is we take a bite s quilting bes like a mattress. Yes.
So Dr. Ibrahim has told the patient is positive for that is PR positive patient. So when will you start hormone therapy >> sir?
Post surgery sir >> surgery over new and chemotherapy over surgery over now what you are going to do hormone for hormone status >> uh since uh since our patient is postmenopausal sir uh we'll start her on >> or which one later we'll start >> why not tmoxifen >> sir uh since tamoxifen increases risk of ovarian and ovarian carcinoma uterine Garos that is >> so in which patient in which patient you will start temoxipan >> uh so premenopausal sir >> so they don't have ovary and uterus will they not cause cancer there >> yes sir >> what is tmoxifen what type of drug is tamoxifen what type of drug is electros tamoxifen is estrogen receptor modifier selective estrogen receptor modulator and T electrosol is a aromatase in individ.
>> So what is the source of estrogen in postpanopasel ladies?
>> Sir testosterone sir from there it's aromatase estrogen sir >> aromatase which causes androgen conversion aromatase inhibitor.
>> Yes sir.
>> So we have to cut the source of estrogen from where it is coming.
>> Yes sir.
>> In postmenopausal it is not from the but it is from the fat and other androgens.
Androgen stress sir.
>> How long you will give letter >> and what is the dose? So I will give uh 20 mg sir 10 to 20 mg bds or od sir od for 5 to 10 years sir mg are you sure >> 10 mg let dose >> not sir tam oxifen sir >> we are discussing about let postmenopausal 55 years >> what is the dose of letter 2.5 millig >> 2.5 >> how many how many days a week you will give how many days you will you once a day, twice a day, once a week, twice a week >> for one year or 3 years or 5 years >> is 2.5 mg once a day daily for 5 years.
So what is the complication of let? What is the commonest complication of letters?
Osteoporosis.
>> So what what you will do if the patient to prevent >> uh we'll give bisphosphonates to the patient oralendonate or something.
>> So what what what is the investigation to find out which patients are at high risk of developing osteopenia or osteoporosis?
>> Uh sir bone cancer.
>> Yeah. What is it called? Uh, DEXA dexa.
>> Dexa. What is DEXA?
>> Uh, diffusion emission X-ray absorptometry.
>> Yeah. Dual dual X absorption.
>> They will give a Z score which will tell you whether it is having normal osteopenia or osteoporosis.
>> Osteop.
>> So who will treat osteopenia and osteoporosis? You have to treat.
>> Yes.
>> How you will treat you? How what is the treatment?
uh s for osteopenia we'll give s calcium supplementation for osteoporosis we'll give s bis phosphinates zolindonator zonic acid how do you give >> oral oral >> oral zonic acid is IV drug okayronate is oral drug you have to give monthly ones okay so what is the complication of bisphosphonates It can cause elevation of renal function. So urine so urin has to be checked. So if ura creatinine is also elevated is there any treatment for osteopenia osteoporosis?
>> Any other drugs can be given?
Injection denosum.
Yeah. Rank liant by >> Yeah. So that can be given. So these are all the treatments positive which you will prefer >> her septin sir if positive will prefer >> actually her septin is a trade name you cannot tell >> injection trisuma.
So what is the dose?
>> If the brain metastasis is there, will you give that drug to control brain metastasis?
If not, which you will prefer?
>> Any idea?
>> Usually it will not cross. Which one?
Um >> sorry other drugs you have to prep. Okay.
Right.
How long you will give truma in a patient?
>> Uh adjuant during aduent.
>> So three weekly for one year.
>> Yes. prior to adjint and then post surgery we'll give as maintenance receptive therapy >> s 3 weekly s for one year >> how long how long one year so so it is not pre prior to surgery 1 year the total duration is one year >> total dation is one year sir >> total duration pre and post is one year okay and you can give monthly or 3 weekly weekly is because you can combine it with the chemotherapy also >> chemotherapy yes sir and what is The dose dose of uh trtoma >> uh eight do >> loading dose is 8 mg per kilogram and maintenance dose is 6 mg per kilogram.
What is the complication of trtoma?
What?
>> I'll read about it. So read about.
>> Yeah, it is cardiotoxic.
>> Cardiotoxic. So you should not combine with other cardiotoxic chemotherapy like Adria.
>> Adri >> I think he has done well sir.
>> Yes sir. Super.
Yes sir.
This is your patient. You plan the full treatment for this after you have done the MDT.
Plan the full treatment.
>> How will you?
>> Yeah. Sequentially, how will you plan the treatment?
>> Uh se sir, I will uh start the patient first on new adent chemotherapy.
>> Okay.
>> Then uh take the patient for surgery.
>> Okay. Okay.
>> And post surgery uh uh since uh go for radiotherapy.
>> Okay.
>> And uh also start around hormonal therapy sir. If the ERP positive is there sir estrogen positive.
>> What about what the adjuant treatment?
>> Will you do the aduent treatment or not?
>> Aduan chemo.
>> Yes sir. uh if uh if the receptor state is her new positive we'll give go for aduent chemo as well.
So since the lump size is large we'll prefer to complete the advanced breast cancer.
>> Yes sir.
>> Okay. So you will complete the >> four to six cycles.
>> Yes sir.
>> Or till the response is there.
>> Yes sir.
>> Then you will go for the surgery.
>> Surgery.
>> Then you will go for the adjuant treatment. Whatever the cycles are left over you will complete that.
>> Yes sir. Then you will give the patient the radiotherapy >> and finally you will keep the patient on the hormonal treatment.
>> Why the hormonal treatment is the last treatment?
>> Sir to prevent recurrence and to prevent other carcin other types of car from developing.
>> Can we give the chemotherapy and the hormone treatment together?
Uh Chemotherapy causes the if you look at the cell cycle demoxifen sends the cells into the zero >> zero G0.
>> Yeah.
>> So once they go in Z then chemotherapy will not be active >> not.
>> So that is why the chemotherapy has to be first finished and then you start the patient on the hormonal.
So that's the overall concept there.
>> So the idea here is you should not combine a cytostatic drug with a cytotoxic drug.
>> Cytotoxic >> is a cytostatic drug >> and chemotherapy is a cytotoxic cytotoxic drugs can act only if the cells are dividing.
>> Dividing. If the cells goes to the yes phase or the resting phase chemotherapy will not act. So that's the idea. Okay.
>> Yes.
>> Okay.
>> Can we call?
>> Yes.
>> Sir, >> maybe we need to ask Janak if he has any questions to ask. Um >> okay I think uh one single case have taken this long time is evident of the amount of quality of discussion we had.
Uh thank you very much and um uh thank you all the faculty especially Ibrahim sir and uh Praaka sir for staying so long kana sir and sah sir it's been always with us I could see ragman sir also staying here for so long and um next week we'll be on oral cancer uh the student is from coin so we look forward to have a discussion on that >> thank you very much with the permission of the faculty I call the session Then applause.
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