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A Case of Invasive Ductal Carcinoma in Diagnostic Medical Sonography

Kristen Cherry & Shelley Kraft


DMS 497 Clinical Practicum IV
14 Nov 2014

This paper will present a sonographic study of invasive ductal carcinoma. Clinical
symptoms and presentation, risk factors, labs, and sonographic findings will be discussed. A
detailed account of the diagnosis, and pathology treatment and follow up will be given as well.
Case History
The female outpatient had a mammogram performed on 11/14/2013 due to a palpable
mass in the right breast. The patient had a diagnostic ultrasound of the right breast to evaluate
the suspicious area that was visualized on the mammogram. There were no laboratory values
available for interpretation. The patient had a family history of breast cancer in her paternal
grandmother, which drastically increased her risk for breast cancer.

Sonographic Findings
A palpable mass was located in the right breast at 12 oclock and 4 centimeters away
from the nipple. It demonstrated a wider than tall shape, and appeared to have
microlobulations and irregular borders. It had a hypoechoic echogenicity with a heterogeneous
echotexture. A single, centrally located, feeding vessel was present within the mass. Posterior
shadowing was also visualized, along with an echogenic halo. The mass scored a BIRADS
category 4, meaning it is an abnormality that is suspicious for malignancy.
There was also an abnormal axillary lymph node that was visualized in this case. The
node appeared very round, and had lost the echogenic, fatty hilum. When color Doppler was
utilized, the node appeared to be hypervascular, which is also abnormal.
Diagnosis
Based on the biopsy pathology report, results revealed invasive ductal carcinoma of the
palpable mass, as well as within a right axillary lymph node. Invasive ductal carcinoma, also
known as infiltrating ductal carcinoma or squamous carcinoma, is a cancer of the ductal
epithelium. It usually originates in the terminal duct of the terminal ductal-lobar unit (TDLU).
The TDLU is the smallest functional portion of the breast involving the terminal duct and its
associated lobule containing as least one acinus (tiny milk producing gland). 1
Invasive ductal carcinoma leads to an increase in duct size, which can be traced back to
the site of the mass. These masses can be fairly small, and on ultrasound they usually produce
posterior acoustic shadowing. This comes from the hypercellular stromal tissue present in some
cancers.2 Other common sonographic findings include: irregular, spiculated or angular borders
with indistinct margins, hypoechoic echogenicity, heterogeneous echotexture, taller than wide
shape, and boundary echoes.1 These thick boundary echoes are referred to as an echogenic halo.

They are often a result of hyperechoic spicules that are too small to be seen individually.3 Other
times, this halo consists of fibrous tissue. This is an attempt by the body to protect itself from
the invading mass.4 Color Doppler will demonstrate that vascularity is present within the mass,
but may sometimes be shadowed out along with some of the tissue. This does not mean the mass
is avascular.
Invasive ductal carcinoma (IDC) is the most common type of breast cancer, accounting
for about 85% of all cases.1 Breast cancer in general is second in incidence, only to skin cancer.
According to the literature, breast cancer affects approximately 180,000 women, and 1,500 men
each year, with most of these being IDC in both genders. The risk of breast cancer increases
with age, which is one of the most important risk factors. At age 30 there is only a one in 2,525
chance of a person getting breast cancer. At age 80 that ratio has increased to one in ten. It is
typically uncommon in women under thirty-five, and also in women who have had children
before the age of thirty. This has to do with the amount of estrogen being produced in the body,
which is also a risk factor. Evidence suggests that the longer a woman is exposed to estrogen,
the more likely she is to have breast cancer. 5 In most cases these are women who began
menstruating before age twelve, and those who started menopause after age fifty-five. Another
main risk factor is personal history. A woman who has had cancer in one breast is at an increased
risk for cancer in the opposite breast. Other risk factors include: race (Caucasian women are
more susceptible than African American or Asian women), family history, exposure to radiation
therapy, high alcohol consumption, and obesity.5
Clinically, a patient with invasive ductal carcinoma is likely to have a solitary, palpable
mass. The mass will be in a fixed position and feel hard. It will also be painless. Retraction or
skin dimpling can also occur due to the invasive nature of how the mass grows.

There are many different lab values that can be evaluated for breast cancer. Before
diagnosis, BRCA is a lab test that that can be drawn to assess a patients risk of potentially
developing breast cancer. This is associated with the inheritance of abnormalities in the BRCA 1
or BRCA 2. After cancer has been diagnosed, there are very important lab values that should be
evaluated. They can aid in determining the treatment and prognosis for each patient that is
specific to the type and stage of cancer they have. In patients with a diagnosis of invasive ductal
carcinoma, hormone receptor testing is highly recommended to determine whether or not the
cancer will respond to hormone therapy. The cancer may or may not have estrogen or
progesterone receptors. It can be determined once the biopsy is performed if the mass is
estrogen and/or progesterone positive. When the cancer is positive for these receptors, it will
grow when exposed to specific hormones. Most breast cancers that are positive to the receptors
have a greater prognosis than those that do not have these receptors present.6
Another test that is performed is the HER2/NEU test. This test evaluates a gene that
produces cancer cells. HER2 stands for human epidermal growth factor receptor 2. This gene
makes HER2 proteins that help manage how breast cells grow, divide, and repair themselves. In
one fourth of breast cancer patients, the gene is not functioning properly. This test can also
discover whether or not the gene is functioning normally, or if too much of the protein is being
produced. This results in an abnormal amount of copies of the gene, which creates abnormalities
in the breast cells. Prognosis and characteristic of the mass can be determined along with the
appropriate treatment that is comparable to the aggressive nature of the cancer.6
Conclusion
This case of invasive ductal carcinoma compares to the literature review findings in many
significant ways. The sonographic findings of microlobulations, irregular borders, hypoechoic

echogenicity, heterogeneous echotexture, vascularity, posterior shadowing, and an echogenic


halo were all consistent with the literature sources that were reviewed. The shape was the only
aspect that did not correspond with the literature. In this particular case, the mass was wider
than tall rather than taller than wide, which is usually one of the marker for malignancy. This
patient presented with a single, palpable, painless right breast mass, which is consistent with the
clinical findings of invasive ductal carcinoma according to the literature. Where this case starts
to differ from the literature is in incidence. The patient in this case is a twenty-six year old
African American female. According to the literature, invasive ductal carcinoma, and breast
cancer as a whole, is more common in Caucasian women than African American or Asian
women. It is also more common in women over the age of 50, and very rare in those under the
age of 30, especially if the patient has children, which the patient in this case does. The patient
also does not have a history of breast cancer herself. The only risk factor this patient has, other
than being a woman, is a family history of breast cancer in her paternal grandmother, which is
consistent with the reviewed literature.
There are several important things for the sonographer to consider once the pathology is
identified. The tail of Spence should always be thoroughly evaluated after locating a suspicious
breast mass to check for abnormal lymph nodes. These axillary nodes are where the cancer will
spread to first. The sonographer should carefully scan the rest of the affected breast quadrant to
check for any multifocal areas, as well as the remaining quadrants to evaluate for multicentric
masses. The sonographer should also never assume that a mass does not have blood flow. If the
mass shadows heavily, then the flow will be shadowed out along with the tissue, not allowing for
it to be seen on color or spectral Doppler. This does not mean that flow is absent.

Appropriate treatment for invasive ductal carcinoma can consist of local or full body
therapy. Local therapy is aimed at destroying cancer cells in a specific location. This includes
surgery and radiation therapy. There are several different types of surgery that patients can have.
A radical mastectomy is the removal of the entire breast, along with surrounding lymph nodes,
muscles, fatty tissue, and skin. A partial mastectomy is when only a part of the affected breast is
removed. A lumpectomy is a procedure in which only the mass itself and a small amount of
surrounding tissue are removed. Partial mastectomies and lumpectomies are two treatments that
are considered breast sparing surgeries, and will usually be followed up with radiation. Full
body, or systemic, therapy, is aimed at destroying or controlling cancer that has spread
throughout the body. It can also be used to shrink a mass before local therapy is performed, or to
prevent new cancer cell growth. In most cases of breast cancer when surgery is performed, there
will also be an axillary lymph node dissection. This is when lymph nodes are removed from
under the arm and carefully evaluated to determine if the cancer has spread into the lymphatic
system.5 This will help the treating physician to know if any further planning will need to be
made other than follow up exams.
References
1. Hagen-Ansert S. Textbook of Diagnostic Ultrasonography. Philadelphia, PA: Mosby Inc.:
2001.
2. Sanders R. Clinical Sonography A Practical Guide. Philadelphia, PA: Lippincott
Williams & Wilkins: 1998.
3. Rumack CM, Wilson SR, Charboneau JW, Levine D. Diagnostic Ultrasound.
Philadelphia, PA: Mosby, Inc.: 2011.
4. Fox T. Mammography for the Breast Sonographer [Webinar]. Plano, TX: Society of
Diagnostic Medical Sonography: 2011-2013.

5. Krag K, Turkington C. The Encyclopedia of Breast Cancer. New York, NY: Facts on File,
Inc.: 2005.
6. Agency for Healthcare Research and Quality, National Cancer Institute, Lab Tests Online,

and BreastCancer.org. Lab Tests. National Breast Cancer Foundation, Inc.


http://www.nationalbreastcancerfoundation.org/breast-cancer-lab-tests. Last updated
2012. Accessed October 18, 2014.