College of Medicine

Department of Medical Education

“…What
Options Do I
Have?”
Tutorial One

REPRODUCTION BLOCK- YEAR 2

Curriculum Development & Research Unit
Problem-Based Learning
STUDENT’S CASE
Case 3, 2022
2011-2022© Student Case Medical Program Case 3-Part 1 “What options do I have ?” 1
 Copyright Statement

This material is protected by copyright laws. For any other purposes other than teaching
and research in the King Saud University, no part may be reproduced or copied in any
form or by any means without prior permission of King Saud University.

© King Saud University, Saudi Arabia (2022).

The Template used in creating the Student’s Case and Facilitator’s Guide (IP) by:
Professor Dr Samy A. Azer
Professor of Medical Education

The Case is authored by:

• Dr Maha Iqbal
• Dr Hala Kfoury
• Professor Samy Azer
• Dr Huda AlKareem

This case and the tutor guide were reviewed in 2017 by the Problem-Based Learning Review Committee,
comprising:
• Professor Samy Azer (Chair)
• Professor Hanan Habib (Member)
• Dr Othman Al Harbi (Member)

KEY WORDS
Anxiety, Axillary lymphadenopathy, Bilateral mastectomy, BRCA-1, BRCA-2, Breast anatomy,
Breast cancer, Breast mass, Breast physiology, Cancer pathology, Cancer spread, Cancer staging,
Chemotherapy, Ductal carcinoma, Family history, Genetics, Management options, Mammography,
MRI scan, Nipple discharge, Oncogenes, Pathogenesis, Prognosis, Risk factors, Supraclavicular
lymphnodes, Surgery, Prophylactic bilateral oophorectomy, Ultrasound examinations.

2011-2022© Student Case Medical Program Case 3-Part 1 “What options do I have ?” 2
Trigger (50 Minutes)

Amal Ahmad, a 36-year-old housewife, comes in to see Dr. Rania Al Khalid in her surgery clinic.
Amal is very concerned because while she was having a shower two days ago, she felt a small
lump in her right breast. She is worried because her older sister has been recently diagnosed with
a breast cancer four months ago. Amal is anxious lest she might have cancer.

Discussion Questions:

• Are there any difficult words you do not understand?

• List the key information about Amal.
• Identify Amal’s presenting problems.
• For each problem, generate a list of possible causes (hypotheses).
• What further information would you like to know from history to refine your hypotheses?

2011-2022© Student Case Medical Program Case 3-Part 1 “What options do I have ?” 3
History (30 Minutes)

History
Amal has been well and healthy. She has felt a mass in her right breast during self-examination.
She had no tenderness while examining her breast and noticed no nipple discharge or changes in
the shape or the color of the areola and nipple. This has triggered her fears particularly after the
death of her sister. She read in a weekly magazine that breast cancer can be familial. She is not
sure whether there is a real mass in her breast. She never had any mammogram or any other
investigations.

Amal has two sons who are five years and three years old respectively. She got married at the age
of 29 years, and she had her first baby when she was 30 years old. Both her children were born
through spontaneous vaginal delivery with no complications. She has breastfed both her children
till the age of 2. Currently, she is taking oral contraceptive pills.

Past medical history

No history of chronic illnesses, hospital admision or surgery.

Allergy and Medication

Nil

Smoking and Alcohol

She occasionally smokes with her friends in parties. She does not drink.

Family history
Amal has three sisters; the eldest was 38 years old (when she died of breast cancer). Her two
younger sisters are aged 35 years and 33 years old. Amal and her sisters all had their first periods
(menarche) when they were approximately 13 years old. Amal’s maternal aunt was diagnosed with
breast cancer when she was 39 years old, and she died because of metastasis a year later. Both
Amal’s parents are alive and healthy.

Social history
Amal is happily married with two sons. She completed a bachelor degree in Arts but preferred to
look after her family rather than work.

Discussion Questions:

§ Are there words that you do not understand?

§ Summarize key information that you have obtained from this progress.
§ Identify patient’s new problems. Provide hypotheses for each problem.
§ What further information would you like to know through clinical examination and
investigations?

2011-2022© Student Case Medical Program Case 3-Part 1 “What options do I have ?” 4
Clinical Examination and Investigations (40 Minutes)

Amal looks anxious. Her bodyweight is 95 kg and her height is 171 cm. Her BMI is 32.5. Her vital signs are
summarized in the table below:

Vital signs
Vital signs Amal Normal range
Pulse rate 80 regular 60-100/min
Blood pressure 110/70 100/60-120/80
Temperature 37.1 36.6-37.2 °C
Respiratory rate 18 12-16/min

Breast examination:
The skin overlying both breasts is normal. Nipples and areola look normal with no spontaneous or
induced discharge. On palpation there is no tenderness and no palpable mass. There are no
palpable axillary or supraclavicular lymphnodes

Chest and Abdominal examination:

No tenderness on examination of the ribs. Ascultation of lungs is normal.
No papable abdominal masses

Investigations
Dr. Rania explains to Amal that the clinical examination is normal. However because of her family
history of breast cancer she needs to do a mammogram of her breasts and an ultrasound
examination for the both breasts and ovaries. Dr Rania also recommends Amal to have a genetic
screening test called BRCA1 and BRCA2 to detect gene mutation. She explains to Amal that the
genetic test togather with the mammography, ultrasound examination and the family history will
help in assessing the risk of developing breast cancer.

Two weeks later the results of the investigations become avaliable.

2011-2022© Student Case Medical Program Case 3-Part 1 “What options do I have ?” 5
Radiological images:
Mammogram of left and right breast

Adapted from: Radiographic reporting. [Online] Available at: http://www.xray2000.co.uk/ [Accessed: Feburaray 2011].

Report:

Both breasts are heterogeneously dense which is normal for her body weight. There are no obvious
masses, calcifications, or other abnormalities present. Follow-up in 12 months is recommended.

Ultrasound examination of the breasts and ovaries
No abnormality detected

Genetic test: The exact genetic focus was first studied in Amal’s sister and then Amal was
studied for the identified defect.

BRCA 1 Positive
BRCA 2 Negative

Discussion Questions:
• Are there any terms that you do not understand?
• Summarize the key information that you have obtained from this progress.
• Use the new information for this progress obtained to refine and rank your hypotheses.
• Do you know a Nobel Prize laureate whose work has contributed to the advancement of
our knowledge in physiology and/or pharmacology related to this case? What was exactly
his/her work about? Give a summary.
• Work out with your group your “learning issues”

2011-2022© Student Case Medical Program Case 3-Part 1 “What options do I have ?” 6
Resources
A note to students: You are not required to read all these textbooks and resources to prepare for your learning issues.
You could use one textbook or one resource for each discipline. For example, for this case you will need to use a
resource covering issues related to the case from the following disciplines: Physiology, Anatomy, Histology and
Pathology. Once you have identified your learning resources, research them for your learning issues and the questions
raised in the group discussion. You might choose to use alternative resources other than those listed below:

Textbooks:

Textbooks:

• Moore KL, Dalley AF, Agur AMR. MOORE Clinically Oriented Anatomy. 7th ed.
Philadelphia: Lippincott, Williams & Wilkins; 2015.

• Drake RL, A Vogl W, Mitchell AWM. Gray’s anatomy for students, 3rd ed. Philadelphia:
Elsevier Churchill Livingstone, 2014.

• Guyton AC and Hall JE. Textbook of Medical Physiology. 13th ed. Philadelphia: WB
Saunders &
Co, 2016.

• Gartner LP. Textbook of Histology. 4th ed. Philadelphia: WB Saunders & Co, 2016.

• Kumar P and Clark M. Clinical Medicine. 9th ed. Edinburgh: WB Saunders, 2016.

• Fox SI. Human Physiology, 14th Ed. McGraw Hill, 2015.

Educational websites:
1. Emedicine: Breast Cancer
http://emedicine.medscape.com/article/283561-overview

This educational website provides you with more detail about breast cancer. Be selective about what you
need to know in relation to the basic sciences (i.e. pathology, risk factors, pathogenesis and genetics)
covering breast cancer.

2. BRCA 1 and 2: Genetic testing and Cancer risk

http://www.cancer.gov/cancertopics/factsheet/Risk/BRCA

This website from the United States National Cancer Institute provides you with the information on BRCA 1
and 2 tests performed to assess breast cancer risk.

2011-2022© Student Case Medical Program Case 3-Part 1 “What options do I have ?” 7
3. Breast Cancer Module I: Breast Anatomy, Physiology, and Pathology
http://www.medscape.org/viewarticle/548921

This link helps in Understanding breast anatomy, physiology and pathology and is designed specifically for
medical students and clinicians.

4. Lactation: Medline Plus

http://www.nlm.nih.gov/medlineplus/breastfeeding.html
This link provides further links about different aspects of lactation such as an overview, research and related
issues.

Interesting Articles:

Metcalfe K. et al (2010) Family History of Cancer and Cancer Risks in Women with BRCA1 or BRCA2
Mutations . JNCI J Natl Cancer Inst first published online November 23, 2010 doi:10.1093/jnci/djq443.
Available online: http://jnci.oxfordjournals.org/content/early/2010/11/23/jnci.djq443.long

2011-2022© Student Case Medical Program Case 3-Part 1 “What options do I have ?” 8
 College of Medicine
Department of Medical Education

“…What
Options Do I
Have?”
Tutorial Two

REPRODUCTION BLOCK- YEAR 2

Curriculum Development & Research Unit
Problem-Based Learning
STUDENT’S CASE
Case 3, 2022
2011-2022© Student Case Medical Program Case 3-Part 2 “What options do I have?” 1
 Copyright Statement

This material is protected by copyright laws. For any other purposes other than teaching
and research in the King Saud University, no part may be reproduced or copied in any
form or by any means without prior permission of King Saud University.

© King Saud University, Saudi Arabia (2022).

The Template used in creating the Student’s Case and Facilitator’s Guide (IP) by:
Professor Dr Samy A. Azer
Professor of Medical Education

The Case is authored by:

• Dr Maha Iqbal
• Dr Hala Kfoury
• Professor Samy Azer
• Dr Huda AlKareem

This case and the tutor guide were reviewed in 2017 by the Problem-Based Learning Review Committee,
comprising:
• Professor Samy Azer (Chair)
• Professor Hanan Habib (Member)
• Dr Othman Al Harbi (Member)

KEY WORDS
Anxiety, Axillary lymphadenopathy, Bilateral mastectomy, BRCA-1, BRCA-2, Breast anatomy,
Breast cancer, Breast mass, Breast physiology, Cancer pathology, Cancer spread, Cancer staging,
Chemotherapy, Ductal carcinoma, Family history, Genetics, Management options, Mammography,
MRI scan, Nipple discharge, Oncogenes, Pathogenesis, Prognosis, Risk factors, Supraclavicular
lymphnodes, Surgery, Prophylactic bilateral oophorectomy, Ultrasound examinations.

2011-2022© Student Case Medical Program Case 3-Part 2 “What options do I have?” 2
Tutorial 2:
Discussion of Learning Issues (60 minutes)
Students: You should start by discussing your “learning issues” that you have identified at the end of
tutorial one. You might spend about 60 minutes on this task. A scribe on the whiteboard is needed to help
in this process.

Once you have completed the discussion of your “learning issues”, you might progress to these questions.
Spend about 10 minutes on discussing them in your group. A scribe on the whiteboard will help in this
process.

Discussion Questions:
• On the basis of the information provided, what is your final hypothesis? Justify your views.
• Discuss the role of genetics and other risk factors responsible for the development of breast
cancer.
• What would you do at this stage?

Do you know a Nobel Prize winner whose work has helped in understanding a physiological principle related
to this case? Discuss how his/her work has helped in the advancement of our knowledge in this area.

2011-2022© Student Case Medical Program Case 3-Part 2 “What options do I have?” 3
 Progress (30 minutes)

Two weeks later, Amal and her husband come to see Dr. Rania in her clinic. Dr. Rania prepares
Amal for breaking bad news. She holds the meeting in a quiet meeting room and asks the nurse
not to disturb them during the meeting.

She explains to Amal that the radiological tests and the clinical examination reveal no abnormality.
However, her genetic tests for BRCA 1 and BRCA 2 gene mutation revealed that that BRCA1 gene
mutation is positive. Dr. Rania explains to Amal that BRCA1 positive means an increased risk of
developing breast and /or ovarian cancer at a younger age. This risk is significant with the
presence of a strong family history of breast cancer. Using the information provided by Amal about
her family Dr. Rania draws a diagram to explain how the genetic make-up plays a role in breast
cancer development in the family. The diagram is shown below:

Amal’s Family Tree

Maternal Family Paternal Family

Grandmother Grandfather
Grandmother
Grandfather

Aunt
Aunt + died Father
Mother
of breast Uncle
cancer

Sister
Sister Sister

Female
Amal
Husband
Male

Breast Cancer + Dead

Son Son
5 Years old 3 Years old

2011-2022© Student Case Medical Program Case 3-Part 2 “What options do I have?” 4
Dr. Rania responds to Amal’s questions and discusses three options:

Option 1:
Amal could have an annual MRI examination along with mammography and ovarian studies to
early detect any changes in her breasts and ovaries. She also needs to perform a self-breast
examination on a regular basis.

Option 2:
Amal could undergo a bilateral removal of the breast tissue (bilateral mastectomy) and her ovaries
(bilateral oophorectomy) with the aim to reduce the risk of developing breast and ovarian cancer.

Option 3:
Amal could have chemical therapy for prevention of cancer and meticulous surveillance for early
detection of breast and ovarian cancer.

Dr. Rania advises Amal to think about the different options and discuss them with her husband and
family. Dr. Rania arranges to see her in 4 days with her choice. Over the next a few weeks Amal is
seen by a psychologist for counseling. Her husband and her family are very supportive towards
Amal in this process.

Discussion Questions:

• Discuss the diagram outlined by Dr. Rania to explain to Amal her risk factors for cancer
development.
• Discuss the advantages and disadvantages of each option provided to Amal.
• What are the sources of stress that Amal might face at this stage?

2011-2022© Student Case Medical Program Case 3-Part 2 “What options do I have?” 5
Progress (20 minutes)

Amal discusses the options with her husband and her family and she finally chose to undergo
bilateral mastectomy and bilateral oopherectomy. The operation went well and Dr Rania arranged
samples for histopathology examination.

No pathological abnormality was detected in her left breast and ovaries.

Her right breast shows the presence of intraductal carcinoma. A normal section is shown for
comparison

Amal’s right breast section:

Adapted from: Ductal Carcinoma in Situ eAtlas of pathology [Online] Available at:
http://radiology.uchc.edu/eAtlas/Breast/188.htm : [Accessed: February 2011].

Report:
A section from a mass in the right breast shows the presence of intraductal carcinoma.

Normal Breast Tissue:

Adapted from: Pathpedia breast [Online] Available at:

http://www.pathpedia.com/Education/eAtlas/Histology/Breast/Images.aspx?ImageName=Normal-
breast-histology-(4-BT04H%20-2): [Accessed: February 2011].

2011-2022© Student Case Medical Program Case 3-Part 2 “What options do I have?” 6
Discussion Questions
• Discuss the psychological impact of these results on Amal?
• On long-term basis what is your plan for Amal?

2011-2022© Student Case Medical Program Case 3-Part 2 “What options do I have?” 7
Case Closure (10 minutes)

After her discharge from hospital, Amal receives a number of counseling sessions and has been supported
by her husband, friends and family. Gradually she becomes able to overcome her fears and move on with
life. She regularly reviews her treating doctor every six months for follow-up. There is no evidence from
clinical examination and investigations of recurrence of the disease.

Tutor’s note:
In the last 10 minutes of the tutorial, you might encourage your group to discuss how they could work better
as a group. What are the things they need to change and what things they need to improve? This
discussion is very useful and will help the group to function better as they work on the next PBL case.

Challenging and Revision Questions

Tutors: Students could think about these questions on their own as they review the case. They
might discuss their answers with their friends.

• Discuss the anatomy and physiology of the female breast

• Discuss th ehormones responsible for breast development and lactation in females
• Discuss the risk factors in development of breast cancer
• Explain the role of genetics including BRCA 1 and BRCA 2 gene mutation in breast cancer
development.
• Discuss the pathology and pathogenesis of breast cancer.
• Discuss the pharmacology of drugs used in management of breast cancer

Learning Objectives:

On completion of this PBL package the students should be able to

• Understand the anatomy and physiology of the female breast
• Discuss the pathology and pathogenesis of the breast cancer
• Understand the risk factorsin the development of breast cancer.
• Explain the genetic basis in the role of mutation of BRCA1 and BRCA 2 genes in the
development of breast cancer at an earlier age.
• Understand the screening guidelines in breast cancer awareness and prevention.
• Discuss management options and design a management plan for a patient with high-risk of
developing breast cancer

2011-2022© Student Case Medical Program Case 3-Part 2 “What options do I have?” 8