Introduction
Patient file
| Age |
51 |
| Family status |
2 children |
| Personal history |
None |
| Family history |
None |
| Genetic tests |
not performed as no family history |
| HRT |
no; contraceptive coil |
| Date of last mammography |
2003 |
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Clinical history
This patient recently underwent X-ray examination of the breasts on account of a yellowish discharge from one nipple. In conclusion, it was concluded that there was a small aspecific nodular lesion, fine-needle biopsy of which yielded no cells. Curiously, MRI was then suggested, possibly followed by galactography.
MRI suggested the existence of an atypical nodule with a long-axis dimension of 5mm with no further details and thus no formal grounds for suspicion. Doctor X who carried out this examination then recommended surgical biopsy if the cytological analysis was inconclusive, otherwise a further check at 6 months if the core biopsy was negative.
Doctor Crevecoeur was asked to give a second opinion.
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Clinical examination
The breasts are supple and symmetrical, with no clearly evident suspect lumps. However pressure on the left breast provokes an obvious yellow serous discharge, mainly from a single duct, and easily reproducible.
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Case of Isabelle B
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Mammography
Localization: Upper inner quadrant Image acquisition mode: AOP (automatic mode)
No tegumental modifications. The breast is largely involuted with some scattered fibro-glandular residues. There is some class II fibro-dystrophic calcification of the left upper outer region that appears benign. In the inner part of the breast, somewhat above the level of the nipple, there is a small, poorly-defined, radiologically suspect zone of atypical hyperdensity. The long-axis dimension of this lesion is 5mm. The lactiferous ducts also give the impression of a thickening extending from the nipple towards the inner zone and in particular towards a small area of atypical hyperdensity.
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Bilateral ultrasonography
On the right side no lesions are seen. On the left side the examination reveals no suspect focal lesions. It does however indicate thickening of the lactiferous duct with echogenic material of irregular outline that runs towards the central and upper inner regions with a small nodular structure that is not entirely echo-transparent and that could correspond to a papillomatous.
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Smear
A smear of the discharge was examined. It revealed no atypical or dysplastic cells.
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Galactography
In view of the relatively frank discharge present, galactography was immediately performed.
After easy identification of the orifice a catheter was inserted and contrast medium was injected. This gave rise to no particular problems.
Galactography showed a lactiferous duct of regular size, branching into perfectly normal 2nd and 3rd-order ducts. At one point however opacification of the duct was not obtained, and this absence of opacification terminates at the small zone of hyperdensity already identified. No other abnormalities.
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Stereotactic microbiopsy
Context
- The possibility of an immediate microbiopsy was proposed, and accepted by the patient.
- The cranio caudal position was choosen as supero inferior approach was preferable. Moreover the patient was calm and the risk of syncope seemed low as she had already undergone galactography with no problems.
- No special problems were encountered during the examination procedure nor after the biopsy. There was no hematoma.
- The vertical approach was chosen as the lesion was much more clearly visible after galactography on the cranio caudal than lateral. On the lateral view it was partially masked by the contrast medium.
- 5 microbiopsy samples were obtained in the zone of atypical hyperdensity that appeared to open onto the duct. The samples were obtained with no particular problem apart from a small hematoma. The biopsy confirmed the existence of a papillocarcinoma.
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Conclusion
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The mammography examination directed research towards ductal pathology, already suggested by the existence of a quite significant discharge. Galactography confirmed the presence of a lactiferous duct that was relatively normal apart from the presence in the internal and upper medial regions of a small zone of hyperdensity connected to the duct and which appeared radiologically suspect. Anatomo-pathological analysis of the core samples obtained confirmed the diagnosis of papillocarcinoma.
The patient had the suspicious area removed after positioning of a hook-wire under stereotactic guidance.
Confirmation of the pre-operative diagnosis, that is stage II ductal adenocarcinoma colonizing an intra-ductal papilloma. In view of the lesion score of 8/12 the patient will also receive adjuvant radiotherapy.
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Notes
Clinical benefits of the microbiopsy
The stereotactic examination was performed for diagnostic purposes, because before the consultation there was still no precise diagnosis. If surgery had been performed immediately on suspicion of a papilloma a second operation could have been necessary as insufficient tissue might have been removed. Moreover, the pre-operative diagnosis of papillocarcinoma directed attention towards a sentinel lymph node; this was justified since, if microinvasion of this node had been detected, axillary surgery could have been performed immediately, avoiding a further procedure.
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Practical benefits
The biopsy procedure lasted about 10 minutes. This is confirmed by the times recorded on the different films: the first stereotactic image was obtained at 09.17 and the last post-biopsy view at 09.23. It should be noted that the whole procedure was performed quickly since the first X-ray was performed at 08.52 and the last stereotactic view at 09.23. Half-an-hour was thus sufficient to perform mammography, bilateral ultrasonography and stereotactic biopsy.
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Benefits for the patient
The combined digital mammography-diagnosis-
stereotaxy system made
it possible to obtain, in a single consultation,
a precise diagnosis for this
patient that was entirely confirmed by surgery. It was not necessary to have two different systems available nor to make different appointments for the galactographic and stereotactic examinations. Time between examinations was reduced to a minimum, and the patient also benefited from optimal conditions of comfort during the procedure, thereby reducing stress. Finally the extremely precise diagnostic examinations enabled treatment to be initiated more quickly.
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