DEPARTMENT OF SURGERY

KULLIYYAH OF MEDICINE
INTERNATIONAL ISLAMIC UNIVERSITY MALAYSIA

CASE WRITE UP II
YEAR 3 BLOCK 4 (2015/2016)

TITLE:
BREAST CANCER

Name : FARIS MOHD NASIR

Matric : 1314597
Number
Supervisor : ASSOC PROF DR AKMAL AZIM
Date/Time of : 15TH JULY 2016
Submission
CASE WRITE UP YEAR 3

History /5

Examination /5

i) Provisional/differential diagnosis /5
ii) Investigation
iii) Final diagnosis with adequate reasons
Discussion /15

TOTAL /30
SUMMARY

Breast cancer is the most frequently diagnosed malignancy worldwide, accounting over a
million cases per year [1] and the second most common cause of cancer death in women [2].
The diagnosis of breast cancer can be confirmed by the triple assessment which includes the
clinical assessments, imaging and biopsy. Once the diagnosis of breast cancer is established,
it is crucial to determine the extent of the disease as this will affect the treatment selection
and prognosis. This case report discusses a case of breast cancer in a 53-year-old Indian lady.

BACKGROUND

Breast cancer is a major world health problem and around 1.6 million new cases are
diagnosed every year. The incidence rates are highest in North America, Australia/New
Zealand and in western and northern Europe. Lowest incidence rates are recorded in Asia and
Sub-Saharan Africa [3]. In the United States, breast cancer accounts for more than 230 000
cases yearly and is responsible for over 40, 000 deaths.

In Malaysia, 1 out of 19 women picked at random will develop breast cancer at some point in
their lifetime. Around 5000 Malaysian women are being diagnosed to have breast cancer
yearly, majority of them aged between 30 and 60 years [4]. A number of lifestyle and genetic
factors may increase the risk of developing breast cancer. Among the established risk factors
include nulliparity, family history, not breast feeding and use of oral contraceptives.

Genetic predisposition also plays a role in the etiology of breast cancer. Around 15% of
breast cancer patients reported to have a positive family history of breast cancer and ovarian
cancer [5]. The most significant genetic predisposition genes identified are the gene BRCA1
and BRCA2. The inherited mutation in BRCA1 or BRCA2 genes may interfere the DNA
cross-link repair and causing the DNA double strands to break [6]. Damages caused by the
carcinogens require a pathway involving BRCA1 and BRCA2 genes to repair [7]. Another
protective pathway involved is the PI3K/AKT pathway. Mutation in this gene will cause the
cancerous cells to lose their ability to stop dividing and to die at the proper time.

This case report is regarding a 53-year-old Indian lady with a left breast carcinoma.

CASE PRESENTATION

A 53-year-old Indian lady, with underlying Diabetes Mellitus, electively admitted to Hospital
Tengku Ampuan Afzan (HTAA) for removal of lump on left breast of 11 months’ duration.
The lump was first discovered by a medical student during the last professional exam in
IIUM and she was then referred to Surgical Out Patient Department (SOPD). The mass was
initially of a 20 cent coin size and increasing in size slowly over the period. It is also
associated with on and off pain. She also claimed to have loss of appetite and she has lost 5kg
over the past 11 months. Otherwise, no discharge and skin changes. It was not preceded by
trauma and no previous history of adenocarcinoma. She also has no metastatic symptoms and
no family history of breast cancer. She is nulliparous. She has never taken any oral
contraceptive pills (OCP) or hormone replacement therapy (HRT).

On examination, she was medium build and not cachexic. She was not pale nor jaundice.
Vital signs were normal. On breast examination, the breasts were symmetrical. No skin
changes. Nipple not retracted. No nipple discharge. There was a palpable mass at the lower
inner quadrant of the left breast, measuring 3 x 3 cm, firm in consistency, regular surface,
well-defined margin, so skin and muscle attached. Axillary lymph nodes were not palpable.

On examination of other systems, no signs of metastasis.

INVESTIGATIONS

Blood investigations were normal. Bilateral breast mammography revealed scalloped

contours of breast pattern with lucent areas of fatty replacement. A lobulated opaque lesion
with part of it has speculated margin seen at the left lower inner quadrant measures about 3 x
3 cm. Ultrasound of the breast revealed an irregular hypodense lesion at the 9H of the left
breast (FIGURE 1). Increase in intralesional vascularity was noted. No dilated duct. FNAC
cytology report shows smears are cellular exhibiting cells in small and large clusters and also
singly. Malignant cells can be seen, compatible with invasive carcinoma.

Staging was done by using mammogram and chest x-ray. The axillary lymph node is
enlarged but no evidence of distant metastasis. Overall clinical features, imaging
characteristics and histopathological findings are suggestive of breast carcinoma stage T2 N1
M0 (Stage IIB).

Figure 1Ultrasound of the left breast revealed an irregular hypodense lesion

Figure 2 This mammogram shows simple lobulated mass lesion in the breast with a
well-defined border

Figure 3 The chest x-ray shows no involvement of the lungs.

 Figure 4 In situ and invasive lobular carcinoma. Malignant cells are marked with arrow in
the diagram.

DIFFERENTIAL DIAGNOSIS

 Fibroadenoma
 Inflammatory breast carcinoma
 Fat necrosis
 Breast abscess

MANAGEMENT

In view of her disease, she had undergone left wide local excision and axillary clearance. A
lump from the left breast measuring 3 x 3 cm was removed from the lower inner quadrant.
Multiple enlarged axillary lymph node was present and removed.

DISCUSSION

Breast cancer is not a new disease. It has been documented since ancient Egypt and
mastectomy was performed ever since Roman times. The diagnosis of breast cancer can be
made by triple assessment which include clinical findings, imaging and biopsy findings. One
may start to suspect to have breast cancer when they discover an abnormal lump or other
abnormal changes such as dimpling of the skin, change in size or shape of the breast, nipple
retraction of skin discoloration. Imaging may include mammogram, breast ultrasound and
breast MRI. If breast cancer is suspected, a sample from the lump should be obtained for
histopathological examination thus to confirm diagnosis.

Once the diagnosis is established, the disease should be staged to assess the extent of the
disease [8]. If there is evidence of axillary involvement, this is a strong indication of micro
metastasis and CT chest and abdomen and bone scan should be done to look for metastatic
disease in distant organ. The prognostic status of patient can be determined by using the
TNM system [9]. The TNM system is used to stage patients into 4 categories which correlate
with 5-year survival rate which are 84% for stage I, 72% for stage II, 47% for stage III and
18% for stage IIIC. Other prognostic value includes the histological lymphovascular invasion
and also hormone receptor status.

Figure 5 Staging system for breast cancer using TNM classification [8]

The treatment of breast cancer must be tailored specific to each individual. Early stage
localized breast cancer which are stage I and II can be treated similarly. The two surgical
options available are mastectomy and breast conservative therapy (BCT). BCT consists of
breast conservation surgery which removes the tumour with a margin of surrounding breast
tissue which may also be referred as wide local excision, followed by radiotherapy to
minimize local recurrence. Selection criteria for breast conservation surgery are single lesion
clinically and mammographically, tumour less than 3 cm, no extensive in situ component,
tumours more than 2 cm away from nipple/areola, lesion of lower histopathological grade and
no extensive nodal involvement [10]. On the other hand, mastectomy is now a standard for all
invasive breast cancer. Breast reconstruction is also an option for patient who undergo
mastectomy which can restore the natural breast shape, re-establish symmetry and creating
nipple-areolar complex [8].

Adjuvant therapy is the administration of systemic anti-cancer treatment that is given before
or after surgery. The goal is to eliminate or prevent the growth of any cancer cells that may
have escaped the breast and that might grow in distant organs. Adjuvant therapy is important
as it may decrease the chance or recurrence thus improves the survival chance. There are
three types of adjuvant systemic therapy which are endocrine, anti-HER2 and chemotherapy.
Patients receive different and even multiple types of therapy based on their tumour
characteristics.

To conclude, breast cancer is one of the leading cause of death in women. Awareness of
breast cancer should be inculcated among the society so that the disease can be detected at
early stage. With the availability of excellent investigation modalities to diagnose and to treat
breast cancer, the overall mortality rate can be reduced.

REFERENCES

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journal for clinicians, 66(1), 7-30.
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Global cancer statistics, 2012. CA: a cancer journal for clinicians,65(2), 87-108.
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stimulates FANCD2 monoubiquitination, H2AX phosphorylation, and BRCA1
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carcinogenesis". Mutat. Res. 664 (1–2): 77–83.
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