Dodge Kegel - Breast Cancer An Illustrated Case Study

“Breast Cancer:
An Illustrated Case Study”

DALEELA G. DODGE, M.D. AND JENNIFER L. KEGEL, M.D.
Judy Connolly (not her real name) had her first screen-
ing mammogram at the age of 46, and a spiculated
density was discovered in her medial left breast (Fig. 1).
Ms. Connolly then acknowledged she was able to
appreciate a palpable prominence in her medial breast
and a “lump” in her left axilla. An ultrasound (Fig. 2)
disclosed a highly suspicious mass that measured 15 ×
14 × 15 mm in the breast, and a left axillary mass that
measured 35 × 29 × 14 mm. Her primary care physician Figure 2: Ultrasound of the left breast reveals a solid mass at the
9 o’clock position of the left breast and an enlarged lymph node in the
referred Ms. Connolly to a surgeon who specialized left axilla.
in breast surgery. In the office, the surgeon performed
ultrasound-guided core biopsies of the tumor and the
axillary mass. Pathologic examination of both lesions the enlarged lymph node in the axilla; it also showed
revealed a Grade III infiltrating ductal carcinoma, which no satellite lesions and a normal right breast (Figs. 3-5).
was estrogen and progesterone receptor negative, and Based on Ms. Connolly’s aggressive and advanced breast
HER-2/neu positive. Ms. Connolly had a normal chest cancer, the surgeon felt she should be considered for
x-ray and bone scan, but a PET scan revealed tumor neoadjuvant chemotherapy. Ideally, the patient would
isolated to the breast and axilla. An MRI confirmed receive immediate systemic therapy, followed by an
the presence of the malignancy in the left breast and assessment of response to this therapy. If the patient then
chose breast conservation, this plan would improve her
chances and the ultimate cosmetic result.
Ms. Connolly was referred to a medical oncologist

and a radiotherapist, and her case was discussed at the
bi-monthly Breast Cancer Tumor Board. A course to
include neo-adjuvant chemotherapy followed by surgery
and postoperative radiation therapy was chosen. The
oncologist treated Ms. Connolly with Adriamycin and
Cytoxan followed by Taxol and Herceptin. She had a
dramatic clinical response with resolution of all palpable
disease. She was counseled by the surgeon and given the
options of breast conserving lumpectomy or mastectomy.
She chose mastectomy and, six months after her original
presentation, underwent a mastectomy with sentinel
lymph node biopsy. The pathology examination found
no residual carcinoma in either the breast or lymph
nodes. The patient plans to undergo breast reconstruc-
Figure 1: Screening film mammography in the mediolateral oblique
(MLO) and craniocaudad (CC) projection reveals the palpable mass
tion after completing her radiation therapy. She has
in the lower inner quadrant of the left breast. The enlarged lymph tolerated her treatments with minimal side effects and
node in the left axilla is partially imaged on the MLO view. no complications.
52 The Journal of Lancaster General Hospital • Fall 2006 • Vol. 1 – No. 2
JLGH-V1_2-Fall_2006.indd 52 8/23/06 4:21:30 PM

breast cancer
Figure 3: MRI in the axial plane shows the malignancy as an

enhancing lesion in the medial aspect of the left breast. (This is a 3D Figure 4: MRI in the sagittal plane shows the enhanced malignancy
Gradient Echo Subtracted MRI. The final image was obtained and a clip (black spot at tip of arrow) that was placed during the
by post-processing of contrast enhanced sequences, which results in previous ultrasound-guided core biopsy. (This is a Water Excitation
better delineation of abnormally enhanced lesions.) MRI, which uses a contrast enhanced sequence that shows optimal
detail of the internal architecture of the breast, and reveals how a
lesion affects the surrounding tissues.)
Figure 5: MRI in the axial plane reveals the enlarged lymph node in
the left axilla. (This is an Inversion Recovery MRI, which uses a
particular sequencing technique to detect adenopathy.)
The Journal of Lancaster General Hospital • Fall 2006 • Vol. 1 – No. 2 53
JLGH-V1_2-Fall_2006.indd 53 8/23/06 4:21:32 PM

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“Breast Cancer:

An Illustrated Case Study”

Ms. Connolly was referred to a medical oncologist

52 The Journal of Lancaster General Hospital • Fall 2006 • Vol. 1 – No. 2

JLGH-V1_2-Fall_2006.indd 52 8/23/06 4:21:30 PM

Figure 3: MRI in the axial plane shows the malignancy as an

The Journal of Lancaster General Hospital • Fall 2006 • Vol. 1 – No. 2 53

JLGH-V1_2-Fall_2006.indd 53 8/23/06 4:21:32 PM

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