Teaching Rounds

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Teaching Rounds

• By
• Rajeev Suryavanshi

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NON INVASIVE BREAST CANCER
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Noninvasive Breast Cancer

• DCIS (Ductal Carcinoma insitu)-
• proliferation of epithelial cells confined
  to the mammary ducts.
• LICS ( Lobular Carcinoma insitu)-
• Proliferation of the epithelial cells
  confined to the lobule.
• Without demonstrable evidence of invasion through
  the basement membrane.

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Ductal Carcinoma insitu (DCIS)

• Epidemiology-
• 20 45 of all new screening detected Breast
  neoplasm.
• Incidence 10- 20 / 100,000 woman years.
• Mean age 47 - 63 years.

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Pathology-

• Origin- terminal lobular- ductal unit.
• Stage from atypical ductal hyperplasia to
  invasive ductal carcinoma.
• Classification
• (cellular architecture, nuclear features)
• Comedo
• Solid
• Cribriform
• Micro papillary
• papillary

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Pathology-

• Multifocality- 2 or more foci separated by 5mm in
  the same breast quadrant.
• Multicentricity- a separate focus outside the
  index quadrant.
• Micro invasion- invasion by breast Ca, through
  basement membrane _at_ one or more foci. Invasion
  depth is 1mm or less.
• DCIS T0
• Micro invasion T1mic.

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Pathology-

• Incidence of micro invasion increases with size
  of DCIS Lesion.
• Size of DCIS lesion micro invasion
• lt 25 mm 2
• gt 26 mm 29
• Natural history-
• All forms of DCIS will eventually develop into
  invasive Ca , if left untreated.

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Diagnosis-

• Clinical Presentation-
• Mammographic screening
• Nipple discharge
• Mammographic features-
• Microcalcification in 80 in DCIS, 2
  types.
• Linear branching type high grade , Comedo type
• Fine granular micropapillary, Cribriform.

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Mammographic calcification seen in DCIS.
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Diagnostic biopsy-

• Core biopsy (stereotactic)
• Vacuum assisted biopsy(stereotactic)
• Needle localization biopsy.
• 1977 Sweden published 1st case where stereotaxis
  was used.
• Over these years special tables have been
  designed to use this technique.

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Stereotactic table

• Patient lies prone
• Breast hang through aperture in the table.
• Mammographic paddles below compress the breast ,
  image taken
• 15 degree -15 degree angles.
• Images sent to computer
• Localization accuracy is with in 1 mm.

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Stereotactic table.
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Difference in Digital Film mammogram
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Diagnosis-

• Stereotactic core biopsy 1991
• 14 G needle, tissue length 2-10mm
• 5 cores taken.
• sensitivity 85 96
• Specificity 96 100
• Vacuum assisted biopsy- 1994
• 11 G probe , ? L.A,
• lesion is suctioned coaxial blade advanced.
• lesion withdrawn through probe.
• Needle loc core biopsy-

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Contraindication to stereotactic biopsy-

• Calcification close to chest
• weight gt140 Kgs.
• Small breast
• If unable to lie prone for 30 min.
• Anticoagulation
• Pregnancy.

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Treatment

• Mastectomy Vs Breast Conserving surgery ( BCS)-
• Most Patients suitable for BCS.
• consider tumor size
• - grade
• - margin width
• - mammographic appearance
• - patient preference.

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Van Nuys Prognostic Index

• Silverstein et al , 1995.
• Nuclear grade, size, Comedo histo surgical
  margin.

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Van Nuys Prognostic Index

• score
• 3 4 Local excision alone
• 5 7 Local excision RXT
• 8 9 Total Mastectomy.

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2. Axillary node sampling

• Theoretically no role , as no invasion
• If large tumor, high grade a focus of invasive Ca
  can be missed.
• Kauber Demore et al 2000, Ann Surg Oncol.
• showed SN (Sentinel node )positive in 12
  patient with DCIS.
• Consider in high grade, large tumor.

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3. Radiation therapy-

• Efficacy of RXT shown in Br.conserving surgery.
• NSABP B-17 (National surgical adjuvant breast
  bowel project)

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4. Hormonal therapy

• NSABP , B-24 Trial, shows significant reduction
  in ipsilateral and Contralateral breast Ca rate.

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Hormonal therapy

• Tamoxifen 20mg , daily is used.
• Side effects-
• Vasomotor
• DVT
• PE
• Endometrial Ca
• ? Stroke rate
• cataract

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Surveillance

• After BCS Radiotherapy 4-6months later a new
  base line Mammogram.
• Follow-up-
• 6monthly clinical exam
• yearly mammogram X 5 years.
• yearly exam and mammogram thereafter.

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Lobular Carcinoma insitu(LCIS)

• Unusual pathological entity termed
• bystander.
• Uncommon
• 0 - 4 incidence.
• Premenopausal group
• Age 40years approx.
• No physical , No radiological manifestation.

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Pathology- LCIS

• Intraepithelial proliferation of terminal lobular
  ductal unit.
• Low histological grade
• ER
• Multifocal Multicentric.
• 50- 90 Contralateral involvement.

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Natural history-

• Not a pre-invasive condition.
• Marker for increased risk of Breast Ca
  development.
• Risk 6 -12 times higher than normal popu.
• Diagnosis
• Incidental finding when breast biopsy performed
  for any reason.

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Treatment options

• No need for - Contralateral breast biopsy.
• - reexcision to get ve
  margin.
• 1. Close Clinical follow-up
• 6monthly clinical exam
• Yearly mammogram.
• Breast MRI under evaluation
• (high sensitivity, low specificity)

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Treatment Options

• 2. Chemoprevention-
• Tamoxifen.
• NSABP, trial P-1 showed 49 reduction in
  group with Tamoxifen.
• 3. Surgery
• Bilateral prophylactic mastectomy (skin
  sparing) with reconstruction.
• if severe anxiety to observation or chemo.

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Pancreatic Endocrine Tumors

• INSULINOMA

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Pancreatic Endocrine tumors

• Neoplasms arise from APUD cells.
• Extremely rare.
• Clinical manifestations depend on hormone
  produced.
• Incidence 1 - 5 cases / million.
• INSULINOMA are the commonest in this group.

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Classificaton of PET
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Insulinoma

• Tumor of Beta Cells of Pancreas.
• Autonomously secrete insulin in excess.
• Whipples Triad-
• Hypoglycemia with fasting or exercise, glucose
  of 2.5 mmol/l, symptoms relief with oral or IV
  glucose.

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Clinical Features

• A.Hypoglycemia induced symptoms-
• Hunger
• Irritability
• Weakness
• Headache
• Blurry vision
• Incoherence
• Seizure, coma.

• B.Catacolamine release
• Palpitations
• Diaphoresis
• Tremors.

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Differential Diagnosis

• Reactive hypoglycemia
• Functional hypoglycemia
• Chronic Adrenal Cortical insufficiency
• Intake of insulin or oral hypoglycemic.

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Investigations-

• Monitored 72 hours fasting
• Insulin/ Glucose Ratio
• lt 0.3 normal
• gt 0.4 overnight fasting in Insulinoma.

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Preoperative localization

• CT Scan initial study in patients with proven
  biochemical changes.
• MRI Scan used if unable to localize by CT
• Selective Angiography was used more frequently
  in past. Had high sensitivity 75 -80, tumor is
  highly vascular.

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Medical therapy

• Diazoxide 150 -800mg / day , controls
  hypoglycemia in 60 -70 patients. this inhibits
  release of insulin.
• Stomatostatin effective in lt 30.
• Propranolol
• Verapamil
• Chlorpromazine.
• Occasionally patient need infusion of glucose.

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Surgical Therapy

• Goal preoperative localization and excision of
  tumor.
• 90 are benign insulinomas
• Surgical resection , enucleation is curative.
• If malignant needs formal resection.

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Enucleation of Insulinoma
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Enucleated Insulinoma
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Team at work
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Questions