CASE OF THE WEEK – “Case of extensive (DCIS) – ‘Ductal Carcinoma In Situ’ in a 44 years old Sri Lankan woman’ at NMC Royal Hospital Sharjah.

CASE OF THE WEEK – “Case of extensive (DCIS) – ‘Ductal Carcinoma In Situ’ in a 44 years old Sri Lankan woman’ at NMC Royal Hospital Sharjah.

A 44 years old female who presented to our Unit with a 2 months history of bloody nipple discharge after visiting several facilities who misdiagnosed her condition. She has no family history of breast cancer.

On examination of the left breast, there was tenderness and thickening in the upper outer quadrant, there was also bloody nipple discharge from the left breast.

This patient underwent a bilateral high resolution breast ultrasound scan with Doppler and elastography and the conclusion was left breast having a marked duct ectasia associated with vascular intraductal masses and diffuse echogenic foci of calcification. This was also consistent with the mammogram findings of widespread crusted microcalcifications.

The imaging studies were concluded by MRI to both breasts which showed no evidence of skin infiltration, but also evidenced marked duct ectasia of left breast associated with enhancing intraductal masses and wide adjacent area of parenchymal infiltration involving most of the left breast. A suspicious ipsilateral axillary lymph node was also seen. All imaging procedures proved a Bi-RADS of 5 to the left breast and a Bi-RADS 1 to the right breast which was a normal.

A TruCut biopsy was performed and this proved ductal carcinoma in situ (DCIS) of intermediate to high grade and a solid cribriform and papillary architecture with comedonecrosis. No evidence of invasive cancer.

The case was discussed in the Multidisciplinary Conference (MDC) and the decision taken was to do a sentinel lymph node biopsy with skin sparing mastectomy and immediate reconstruction +/- axillary dissection depending on the frozen section result of the sentinel lymph node biopsy. The patient and husband were counseled in full detail for the procedure.

In the morning of the operation, a 99MTC nanocolloid sentinel lymph node scintigraphy was performed in the nuclear lab (Technetium Scan). The patient was shifted to the theater four hours later.

After prepping and draping the skin, a 3cm incision was performed on the anterior axillary line, where the sentinel lymph node was identified by the gamma probe and was excised. No methylene blue was injected. The node was immediately sent for histopathology frozen section. The result was received after a few minutes and it was negative for malignancy. No axillary dissection was performed for this patient.

While waiting for the result of the lymph node, a skin sparing mastectomy with inverted T incision, on a previously designed skin markings and the mastectomy was completed involving the nipple areolar complex and inferior breast skin (7mm skin thickness spared).

After hemostasis, drains were placed over the pectoralis muscle and immediate reconstruction with anatomical a Mentor CPG 322 Cohesive III breast implant of 585ml, wrapped with Prolene mesh and placed prepectorally. The skin flaps were approximated and sutured in the inverted T-shape. The patient was discharged home on the second day postoperative in a good general condition.

It is worth mentioning that all the above procedures were carried out with dedication by a highly specialized Team and the most important thing is that this patient received the best of care all under one roof with all specialties involved, including Radiology, Nuclear Medicine, Oncology, Pathology, Surgery and Reconstruction.