TUTORIAL REPRODUCTIVE SYSTEM TUTOR GUIDE

CASE # 13 BREAST CANCER (CA MAMMAE)

Date : 20,22, Mei 2009

CASE : MRS. CARINA MAMIRI

FRESHMEN YEAR PROGRAM

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Page 1 You are a medical student in charge at the outpatient clinic of Hasan Sadikin Hospital. Mrs. Carina Mamiri , a 38-year-old woman, came due to a lump on her right breast that first noticed about 8 months ago. She feels discomfort and the lump is getting larger. She has one children age 1 year. has never get hormonal therapy. Further history taking revealed that her grandmother died because of ovarian cancer. Physical examination : BP 130/80 mmHg ; RR : 20 time/minute ; HR : 86 bpm ; Temp : 37.0 C Head/ Ear /Nose/ throat : no abnormalities Neck : No lymph node enlargement at supraclavicle region Thorax : Right mammae : A dimple on the skin over a lump. The lump is round, hard, measuring 2.5 cm in diameter, and it is fixed to breast tissue surrounding the lump. Left mammae : No abnormalities Right axilla : No lymph node enlargement palpable Left axilla : No lymph node enlargement palpable Heart and lung : No abnormalities Other physical examination : no specific abnormalities . 1. 2. 3. 4. What are Mrs. Carinas problems ? List your hypotheses and explain the rationale for each one ! What more information do you need from this patient ? What further examination are needed at this stage ? tell us your reasons !

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Tutors guide :
The students may list the problems as follows :

A lump on her right breast since 8 months ago The lump is growing bigger Having children above 35 years age

The students are supposed to discuss topics about : Review anatomy and histology of the breast, vascular and lymph drainage Differences between benign and malignant breast tumor The etiology and predisposing factors of breast cancer (The cellular, genetic, biochemical & bio molecular bases of breast cancer) The pathomechanism and pathology of breast cancer The epidemiologic and clinical manifestation The students should ask about the informations of : Mammography USG mammae Core Needle biopsy (CNB) Laboratory (Pathology anatomy)

The student elicit that she might have breast cancer / Mammary carcinoma on the following bases : A lump on the right breast which clinically appear malignant (dimple formation, causing pain ?) Early stage of disease ( confined to one mammae with no lymph node enlargement on the axilla ) Possibility to have further examination such as : 1. Mammography 2. USG mammae 3. Core Needle Biopsy (CNB) 4. Tumor markers The patient should be informed about possibility that she has breast cancer and that she is advised to see an oncologist surgeon

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Guiding questions for tutor : 1. 2. 3. 4. 5. 6. 7. 8. 9. What are the clinical characteristics of a benign mass on the breast ? How would it be like if its a malignant mass ? How can we find out a malignancy of the breast lump ? Is mammography still needed at this stage ? What do you know about CNB ? what is the role of CNB in breast cancer ? What are the tumor markers that can be used to detect malignancy of the breast? How is the pattern of spread/ metastases for mammary carcinoma ? What are other risk factors involving in breast cancer? What is your plan for this patient ? (informed consent, consult to oncologist surgeon )

Risk factors for breast cancer are associated with an increased risk of developing breast cancer, including increasing age, family history, exposure t female reproductive hormones (both endogenous and exogenous), dietary factors, benign breast disease, and environmental factors. The majority of these factors convey a small to moderate increase in risk for any individual woman. Age plays a major role in breast cancer risk, in women under 30, breast cancer is extremely uncommon, the incidence of breast cancer in women aged 35 to 39 was 59 per 100,000; however, in women 55 to 59, the incidence was 296 per 100,000. Earlier age at menarche is associated with an increased risk of breast cancer; there appear to be a 20% decrease in breast cancer risk for each year that menarche is delayed. The major techniques used to diagnose palpable breast masses are fine needle aspiration (FNA), core-cutting needle biopsy, and excisional biopsy The advantages of FNA are : rapid, painless, inexpensive, no incision before selection of local therapy, and the disadvantages are : will not distinguish in situ from invasive cancer, no histologic detail, false-negative results and insufficient specimens occur, requires experienced cytopathologists. Staging refers to the grouping of patients according to the extent of their disease. It is useful in : 1. determining the choice of treatment for individual patients, 2. estimating their prognosis, and 3. comparing the results of different treatment programs. Staging can be based on either clinical or pathologic findings. Currently, staging of cancer is determined by the American Joint Committee on Cancer (AJCC). The AJCC system is a clinical and pathologic staging system and is based on the TNM system, in which T refers to tumor, N to Nodes, and M to Metastasis. Clinical staging includes physical examination, with careful inspection and palpation of the skin, mammary gland, and lymph nodes (axillary, supraclavicular, and cervical), imaging, and pathologic examination of the breast or other tissues to establish the diagnosis of breast carcinoma. The breast lymphatics drain by way of three major routes : axillary, transpectoral, and internal mammary. All distant visceral sites are potential sites of metastasis. The four major sites of involvement are bone, lung, brain, and liver, but this widely metastasizing disease has been found in many other sites. Page | 5

Page 2 Mammography : A mass with high echogenicity (radio opaque) located in the upper quadrant of breast, sizing approximately 2 cm in diameter. The surface of mass is irregular with a tongue-like formation. Sligt microcalcification is identifiable within the mass. Conclusion : Malignant breast tumor USG : The mammary papils are rotated lateraly. An echogenic mass with irregular border is noticed, sizing 2.3 cm in diameter. Conclusion : Malignant breast tumor

1. Does this information support your hypothesis ? 2. What is the stage of breast cancer in this patient ? 3. What is your further planning for this patient ?

The students may suggest : 1. The clinical stage 2. Possibility that a modified radical mastectomy should be carried out 3. Examine the tissue for estrogen receptor , progesterone receptor and Cerb B2, p53

Grandmother died because of ovarian cancer

Tutors guiding questions : 1. How do you assess the clinical stage of breast cancer ? 2. What are the diagnostic procedure appropriate for this stage? 3. What are the managements of this woman ?

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Page 3 This patient underwent radical mastectomy for her right breast. Histopathological examination, macroscopically showed a tumor mass, sized 2 x 2 x 1 cm, white grayish hard mass with invasion to the surrounding tissue. There were no invasion into the surface skin and fascia of the muscle. Ten lymph node were found from level I, II and III. Microscopic features showed the tumor consist of hyperplastic polygonal cell, which was grow in a mixture of well formed glands and more solid nests. The nuclei were large, polimorphic and hyperchromatic. Mitotic activity were presented. The tumor cells invaded the stromal. There were infiltration of the tumor cells within 1 lymph node. Histopathological conclusion : Invasive ductal carcinoma mammae in the right breast, grade 1, with metastasis to 1 lymph node. Immunohistochemical examination : ER + , PR + , C erb B-2 , P53 1. What us the stage of breast cancer in this patient ? 2. What are the management planning for this patient ?

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Epilogue Mrs. Carina Mamiri has finished her full treatment program, but regular follow up should be done until the following 5 years to detect early recurrence.

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