DIPLOMA IN MEDICAL IMAGING

FINAL YEAR CASE STUDY

BREAST CANCER

NAME: MARINA CHONG

MATRIC ID: DMI14042309

INTAKE: 02/14

COURSE: DIPLOMA IN MEDICAL IMAGING

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 TABLE OF CONTENTS

CONTENTS PAGE

DECLARATION 3

ACKNOWLEDGEMENT 4

INTRODUCTION OF THE ANATOMY 5

INTRODUCTION OF THE PATHOLOGY 6

CAUSES OF DISEASE 7-8

PATHOPHYSIOLOGY 9

SIGNS AND SYMPTOMS 10

INCIDENCE AND MORTALITY 11

CASE HISTORY & CLINICAL FINDINGS 12-13

IMAGING STUDY & CONSIDERATION 14

IMAGES FROM CASE STUDY 15

RADIOLOGICAL REPORTS & DIAGNOSIS 16-17

DISCUSSION 18

LIMITATION & CONCLUSION 19-20

REFERENCES 21

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DECLARATION

I hereby proclaim that all the contents of this attached paper is my own work and any

material drawn from other sources has been properly acknowledge within the text of the

paper and in the reference list at the end of the paper by using referencing of American

Psychological Association (APA) system.

Marina Chong

( ___________________ )

DMI14042309

7th July 2017

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ACKNOWLEDGEMENT

In the name of Allah, the Most Gracious, Most Merciful. Our gratefulness to God, the
Almighty for His blessing throughout the process of completing this assignment. Here I
would like to thank all individuals who are involved in this assignment and helped me in
various ways in the completion of this assignment. Without such help, I cannot complete this
assignment. The production of this assignment would not be done in time without the
encouragement and support of my family, friends, course mates and especially the lecturers
who have been involved with this assignment.

First among those to whom I was indebted is Mr Abdul Halim Bin Jasni, my lecturer,
who served as the monitor and supervision of the flow of my information. He kept me on
tract by giving gentle reminders on my progression of this assignment.

Also, special thanks to staffs of Hospital Queen Elizabeth II (HQE2) for their help and
support: radiologists, medical officers, radiographers and nurses. My deepest thanks to the
staffs who helped me in the process of getting the patient’s case files, history, reports and
images from the PACS system.

Finally, a very special thanks for my parents for their support. Without them, I would
not be able to come to this level of achievement. There are many words of wisdom and
support that they gave throughout the years that helped me to be who I am today.

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INTRODUCTION OF THE ANATOMY

Figure 1: Anatomy of breast

The breast is the tissue overlying the chest (pectoral) muscles. Women's breasts are made
of specialized tissue that produces milk (glandular tissue) as well as fatty tissue. The amount
of fat determines the size of the breast.

The milk-producing part of the breast is organized into 15 to 20 sections, called lobes. Within
each lobe are smaller structures, called lobules, where milk is produced. The milk travels
through a network of tiny tubes called ducts. The ducts connect and come together into
larger ducts, which eventually exit the skin in the nipple. The dark area of skin surrounding
the nipple is called the areola.

Connective tissue and ligaments provide support to the breast and give it its shape. Nerves
provide sensation to the breast. The breast also contains blood vessels, lymph vessels, and
lymph nodes.

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INTRODUCTION OF THE PATHOLOGY

Breast cancer is a kind of cancer that develops from breast cells.

Breast cancer usually starts off in the inner lining of milk ducts or the lobules that supply
them with milk. A malignant tumor can spread to other parts of the body. A breast cancer
that started off in the lobules is known as lobular carcinoma, while one that developed from
the ducts is called ductal carcinoma.

Figure 2: Anatomy of breast with cancer

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CAUSES OF DISEASE

Figure 3: Damaged DNA in cells

It is not clear what causes breast cancer. Doctors know that breast cancer occurs when
some breast cells begin growing abnormally.

Experts are not definitively sure what causes breast cancer. It is hard to say why one person
develops the disease while another does not. We know that some risk factors can impact on
a woman's likelihood of developing breast cancer. These are:

1) Getting older

The older a woman gets, the higher is her risk of developing breast cancer; age is a risk
factor. Over 80% of all female breast cancers occur among women aged 50+ years (after
the menopause).

2) Genetics

Women who have a close relative who has/had breast or ovarian cancer are more likely to
develop breast cancer. If two close family members develop the disease, it does not
necessarily mean they shared the genes that make them more vulnerable, because breast
cancer is a relatively common cancer.

The majority of breast cancers are not hereditary.

Women who carry the BRCA1 and BRCA2 genes have a considerably higher risk of
developing breast and/or ovarian cancer. These genes can be inherited. TP53, another gene,
is also linked to greater breast cancer risk.

3) A history of breast cancer

Women who have had breast cancer, even non-invasive cancer, are more likely to develop
the disease again, compared to women who have no history of the disease.

4) Having had certain types of breast lumps

Women who have had some types of benign (non-cancerous) breast lumps are more likely
to develop cancer later on. Examples include atypical ductal hyperplasia or lobular
carcinoma in situ.

5) Dense breast tissue

Women with denser breast tissue have a greater chance of developing breast cancer.

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6) Estrogen exposure

Women who started having periods earlier or entered menopause later than usual have a
higher risk of developing breast cancer. This is because their bodies have been exposed
to estrogen for longer. Estrogen exposure begins when periods start, and drops dramatically
during the menopause.

7) Obesity

Post-menopausal obese and overweight women may have a higher risk of developing breast
cancer. Experts say that there are higher levels of estrogen in obese menopausal women,
which may be the cause of the higher risk.

8) Height

Taller-than-average women have a slightly greater likelihood of developing breast cancer

than shorter-than-average women. Experts are not sure why.

9) Alcohol consumption

The more alcohol a woman regularly drinks, the higher her risk of developing breast cancer
is. The Mayo Clinic says that if a woman wants to drink, she should not exceed one alcoholic
beverage per day.

10) Radiation exposure

Undergoing X-rays and CT scans may raise a woman's risk of developing breast cancer
slightly. Scientists at the Memorial Sloan-Kettering Cancer Center found that women who
had been treated with radiation to the chest for a childhood cancer have a higher risk of
developing breast cancer.

11) HRT (hormone replacement therapy)

Both forms, combined and estrogen-only HRT therapies may increase a woman's risk of
developing breast cancer slightly. Combined HRT causes a higher risk.

12) Certain jobs

French researchers found that women who worked at night prior to a first pregnancy had a
higher risk of eventually developing breast cancer.

Canadian researchers found that certain jobs, especially those that bring the human body
into contact with possible carcinogens and endocrine disruptors are linked to a higher risk of
developing breast cancer. Examples include bar/gambling, automotive plastics
manufacturing, metal-working, food canning and agriculture. They reported their findings in
the November 2012 issue of Environmental Health.

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PATHOPHYSIOLOGY

Breast cancer is a malignant tumor that starts in the cells of the breast. Like other cancers,
there are several factors that can raise the risk of getting breast cancer. Damage to the DNA
and genetic mutations can lead to breast cancer have been experimentally linked
to estrogen exposure. Some individuals inherit defects in the DNA and genes like the
BRCA1, BRCA2 and P53 among others. Those with a family history of ovarian or breast
cancer thus are at an increased risk of breast cancer.

The immune system normally seeks out cancer cells and cells with damaged DNA and
destroys them. Breast cancer may be a result of failure of such an effective immune defence
and surveillance.

These are several signalling systems of growth factors and other mediators that interact
between stromal cells and epithelial cells. Disrupting these may lead to breast cancer as well.

Breast cancer invades locally and spreads through the regional lymph nodes, bloodstream,
or both. Metastatic breast cancer may affect almost any organ in the body --- most
commonly, lungs, liver, bone, brain and skin.

Most skin metastases occur near the site of breast surgery; scalp metastases are also
common. Metastatic breast cancer frequently appears years or decades after initial
diagnosis and treatment.

Hormone receptors such as estrogen and progesterone that presents in some breast
cancers, are nuclear hormone receptors that promote DNA replication and cell division when
the appropriate hormones bind to them. Thus, drugs that block these receptors may be
useful in treating tumors with the receptors. About two thirds of postmenopausal patients
have an estrogen – receptor (ER+) tumor. Incidence of ER+ tumors is lower among
premenopausal patients.

Another cellular receptor is human epidermal growth factor receptor 2 (HER2; also called
HER2/neu or ErbB2); its presence correlates with a poorer prognosis at any given stage of
cancer.

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SIGNS AND SYMPTOMS

 Lump in a breast
 Pain in the armpits or breast that does not seem to be related to the woman's
menstrual period
 Pitting or redness of the skin of the breast; like the skin of an orange
 Rash around (or on) one of the nipples,
 Swelling (lump) in one of the armpits.
 An area of thickened tissue in a breast
 One of the nipples has a discharge; sometimes it may contain blood
 The nipple changes in appearance; it may become sunken or inverted
 The size or the shape of the breast changes
 The nipple-skin or breast-skin may have started to peel, scale or flake.

Figure 4: Signs of breast cancer

Figure 5: Signs and symptoms of breast cancer

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INCIDENCE AND MORTALITY

Figure 6: statistic of breast cancer in Malaysia

Breast cancer is the most common cancer occurred in women and it can be diagnosed in
women in any age. Although breast cancer is associated with age factor, where the older
women can develop breast cancer easier than those of the younger age. For women in their
30’s, 1 in 280 women will be diagnosed with breast cancer. But the risk factor increases for
women in 50’s where 1 in 40 women will be diagnosed with breast cancer.

Breast cancer is the most common type of cancer among Malaysian women. Other than
hospital based results, there are no documented population – based survival rates of
Malaysian women for breast cancers. This population – based retrosprective cohort study
was therefore conducted. Data were obtained from Health Informatics Centre, Ministry of
Health Malaysia.

Mortality trends tended to be more favourable for women aged under 50 compared to those
who were 50 years or older.

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 CASE HISTORY

Patient is an 81 years old female referred from Klinik Kesihatan Putatan to the Breast and
Endocrine Clinic on 28th of February. Patient has no known allergic and is a well fit lady. She
also has no known family history of cancer.

She was presented with large lump on the left breast with no nipple discharge and
increasing in size over the course of eight months.

Upon investigation, she was diagnosed with left breast carcinoma with axillary lymph node
involvement.

CLINICAL HISTORY:

 Mamoography done on 14/03/2017

 Ultrasound done on 14/03/2017
 CT TAP done on 16/03/2017

CLINICAL FINDINGS

PHYSICAL EXAMINATIONS

VITAL SIGNS

BP: 140/90 PR: 82 T: 37.0 SPO2: 99

Normal range: 120- Normal range: 80 - Normal range: 36.8 - Normal range: 90-
140/80 90 37.0 100

LAB TESTS

Urea: 2.6 Creat: Sodium: Potassium: Chloride: CEA: Calcium Albumi Inorganic
mmol/L 36.3 142 3.8 mmol/L 50 3.6 : 2.23 n: 20 phosphorus
mmol/ mmol/L mmol/L ug/L mmol/L g/L – 1.15
L mmol/L

Normal Normal Normal Normal Normal Normal Normal Normal Normal

range: 1.2 range: range: range: 3.5 range:96 range: range: range: range: 1 –
–3 50 – 135 – – 5 mmol/L – 106 < 3.0 2.10 – 35 – 40 1.5 mmol/L
mmol/L 100 145 mmol/L ug/L 2.50 g/L
mmol/ mmol/L mmol/L
L

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Imaging modalities suggested:

 Mammography – a specialized radiographic technique which creates an image of the

breast on an x – ray film.
 Ultrasound – exposing part of the breast to high – frequency sound waves to produce
pictures of the inside of the breast.
 CT Scan – a scan that enhances the part of breast using contrast agents.

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 IMAGING STUDIES AND CONSIDERATIONS

Modality Advantages Strength Disadvantages Positioning

Able to improve
Provide real time the cancer High radiation
CT Scan Supine
scanning, quick. diagnose and dose
treatment
Patient may feel
Better image and
Small dose of slightly
Mammography more detail on soft Supine
radiation uncomfortable due
tissue.
to compression.

Able to detect the

blood vessels and Requires longer
Ultrasound No radiation Supine
lymph nodes scanning time
easier

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IMAGES FROM CASE STUDY

Figure 7: Mammography (Rt CC and MLO)

Figure 8: Ultrasound of the left breast

Figure 9: CT Scan (CT TAP)

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RADIOLOGICAL REPORTS (CT SCAN)

INDICATION:

81, lady, Para 7, NKMI, presented with left breast lump for 8 months with axillary swelling.
Trucut biopsy done: invasive carcinoma. On examination, hard mass 7 x 7 cm on left breast.
Planned for left mastectomy and axillary clearance. For staging.

FINDINGS:

There is alarge lobulated enhancing mass seen at rhe left breast measuring 4.8 x 6.1 x 6.1
cm (AP x W x CC).

No clear fat plane between the mass and underlying pectoralis muscle.

Multiple enlarged and matted left axillary lymph nodes with the largest measuring 2.1 cm in
short axis.

No obvious lesion on right breast. No significant enlarged right axillary lymph node.

There is a large heterogenously enhancing lesion measuring 5.1 x 7.1 x 5.9 cm (AP x W x
CC) seen arising from superior segment of right lower lobe.

No other suspicious lung nodule. Pleural - based nodule seen at the left anterior thorax
adjacent to lingular segment of left upper lobe measuring 0.8 x 1.4 cm (AP x W).

Minimal emphysematous changes at bilateral upper lobes noted. Patchy fibrotic changes
seen at right middle lobe and lingular segment of left upper lobe.

No pleural effusion or pneumothorax.

Several lymph nodes noted at precarinal region with the largest measuring 1.0 cm in short
axis.

Trachea and both bronchi are patent.

Heart size is normal. No pericardial effusion.

Calcified nodule noted at right thyroid lobe.

Hypodense nodule seen at left thyroid lobe.

Multiple cystic lesions noted within both kidneys with the largest seen at right mid - pole
measuring 2.5 x 3.2 cm (AP x W).

Small cystic lesion noted at splenic hilum measuing 3mm in keeping with splenic cyst.

Liver is homogenous with regular outline. No focallesions. Intrahepatic and extrahepatic

ducts are not dilated.

Portal vein and IVC are well opacified.

Gallbladder, pancreas and both adrenals are normal.

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No abnormal bowel dilatation.

Urinary bladder is well distended with no gross abnormality.

Uterus appears atrophic.

No obvious adrenal mass.

No significant abdominal or pelvic lymph nodes.

No ascites.

Atherosclerotic calcification of thoracic and abdominal aorta noted.

There are some ill - defined cortical irregularities seen at the right inferior pubic ramus which
my represent degenerative changes or focused metastasis.

No other suspicious bony lesion.

IMPRESSION:

Known case of left breast carcinoma (HPE proven),current CT shows:

1. Large left breast tumour with features suspicious of infiltration to the underlying pectoralis
muscle.

2. Left axillary lymph node metastasis.

3. Right lower lobe lung metastasis.

4. Small left anterior thorax pleural metastasis.

5. Right inferior pubic ramus cortical irregularities may represent degenerative change or
focal metastasis. Bone scan or further CT scan is suggested.

6. Bilateral renal cysts.

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DISCUSSION

In this case, the first imaging modality is the mammography in which the patient came to the
department via appointment with the complaint of large lump on the left side of the breast.
The physician requested the mammography examination because many breast lesions can
be detected through mammography before they become symptomatic or metastasize.
Mammography can detect lesions as small as 2.0 mm; it may take 2 to 4 years for these
lesions to be palpable on breast self – examination or clinical breast examination. However,
it was unable to be done due to the size of the lump is too big to be compressed. So the
physician proceeded with an ultrasound.

The second imaging modality is the ultrasound where the physician scans the affected
breast since it was unable to be compressed in mammography procedure. Ultrasound uses
high frequency sound waves to produce pictures of the inside of the tissue cells. The
physician was able to detect some inflitration on the left axillary lymph node and the lump
was too large and calcified to be scanned. To further investigate the lump, the physician
requested for a CT TAP (Thorax, Abdomen and Pelvis) to evaluate the size of the lump and
to see whether it has metastasize.

The third imaging modality used is the CT scan. CT examination was requested to evaluate
the size of the lump and to see whether any other parts are involved. Upon investigation and
evaluation of physician, there is a large size breast tumor measuring at 4.8x6.1x6.1cm. CT
examination is done as a preparation for the mastectomy procedure.

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LIMITATION AND CONCLUSION

Mammography is the best breast cancer screening test that we have at this time. However
there are still limitations. A false – negative mammogram looks normal even though breast
cancer is present. A false – positive mammogram looks abnormal but there is no cancer in
the breast. It is important to know that even though mammograms can show breast cancers
that are too small to be felt, treating a small tumor does not always mean it can be cured. A
fast – growing or aggressive cancer might have already spread.

Women with dense breasts have more false – negative results. Breasts often become less
dense as women age, so false negatives are more common in younger women. False –
positive are more common in women who are younger, have dense breasts, have had
breast biopsies, have breast cancer in the family, or are taking estrogen. About half of the
women getting annual mammograms over a 10 – year period will have a false – positive
finding. The odds of a false – positive are highest for the first mammogram.

CT images of internal organs, bones, soft tissue and blood vessels provide greater detail
than traditional x-rays, particularly of soft tissues and blood vessels. Soft-tissue details in
areas such as the brain, internal pelvic organs, and joints (such as knees and shoulders) can
often be better evaluated with magnetic resonance imaging (MRI). In pregnant women, while
CT can be performed safely, other imaging exams not involving radiation, such as
ultrasound or MRI, are preferred but only if they are likely to be as good as CT in diagnosing
your condition.

A person who is very large may not fit into the opening of a conventional CT scanner or may
be over the weight limit—usually 450 pounds—for the moving table.

Ultrasound imaging uses sound waves to produce pictures of the inside of the body. It is
used to help diagnose the causes of pain, swelling and infection in the body’s internal
organs and to examine a baby in pregnant women and the brain and hips in
infants.Ultrasound waves are disrupted by air or gas; therefore ultrasound is not an ideal
imaging technique for air-filled bowel or organs obscured by the bowel. In most cases,
barium exams, CT scanning, and MRI are the methods of choice in such a setting.

Large patients are more difficult to image by ultrasound because greater amounts of tissue
attenuate (weaken) the sound waves as they pass deeper into the body and need to be
returned to the transducer for analysis.

Ultrasound has difficulty penetrating bone and, therefore, can only see the outer surface of
bony structures and not what lies within (except in infants who have more cartilage in their
skeletons than older children or adults). For visualizing internal structure of bones or certain
joints, other imaging modalities such as MRI are typically used.

There are a few limitations encountered during the study. The first one being that the
patient’s condition, where her breast lump was too large to be compressed, and
compression may cause the lump to explode. There is also problem in retrieving the
patient’s medical records since the patient has been discharged during that time The
ultrasound report was not able to be traced because the department does not keep another
copy of the report. Images from the case study was difficult to be traced because the
radiologist has kept it in PACS system. It was retrieved with the help of the radiographer.

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Breast cancer is the most common type of cancer occurred in women. There are many
factors that contribute to the formation of cancer. The most common is family heredity.

Based on this case study, the gold standard diagnostic modality that has the ability to
diagnose breast cancer is CT TAP because the lump in the breast is fully enhanced by the
contrast media used.

Standard treatment for breast cancer is radiotherapy and mastectomy that is finalized by the
physician. The use of both procedures is to remove the part of breast that has been infected
by the cancerous cells. Mastectomy is preferred because the lump is too big to be treated
using radiotherapy. However, patient may feel slightly uncomfortable due to surgery that has
to be done in order to remove the cancerous parts and may have after surgery complications
considering the age of patient is fairly high.

As the result of this case study, patient underwent mastectomy to remove the affected breast
on 22nd March 2017. The procedure was successful and patient survived. After under
surveillance, the patient was discharged on 25th March 2017.

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