External Beam Radiation Therapy Record

Three-Dimensional Conformal Radiation Therapy (3DCRT)

Clinical Diagnosis: Invasive Ductal Carcinoma, Left Breast

Region Treated LEFT CHEST WAKK

Technique 6 Fields Static Windw/ Multileaf Collimator
Energy 6 MV Photons

The planning target volume (PTV50) was prescribed a dose of 5,000 cGy in 25 fractions at 200
cGy per fraction. The doses to the critical organs were kept below the tolerance level.

Target Volumes and Summary of Doses

Target Target Prescribed Total Max. Total Min. Total Mean Fractions
Definitions dose (cGy) Dose (cGy) Dose (cGy) Dose (cGy)
PTV50 CTV (left 5,000 6,757 824 5,499 25
breast) +
Margin
Remarks With conventional radiation treatment
 Left Supraclavicular Field
Total Dose: 5,000 cGy in 25 fractions at 200 cGy per fraction using 6 MV
photon beam.

 Left Internal Mammary Chain

Total Dose: 5,000 cGy in 25 fractions at 200 cGy per fraction using 6MeV
and 9 MeV electron beams

 Scarboost
Total Dose: 1,000 cGy in 5 fractions at 200 cGy per fraction using 6 MeV
electron beam

Patient tolerated the treatment well.

PATHOLOGY CONSULTATION REPORT

Pathological Diagnosis:
 Breast Mass Left, S/P Excision Biopsy for Invasive Ductal Carcinoma Tumor Size – 1.5cm

MRM:
Positive for residual invasive ductal carcinoma, Notthingham Combined Histologic Grade 2
Tumor size 1cm (total combined size - 2.5 cm)
Ductal Carcinoma In Situ (DCIS), High grade, Solid and Comedo Pattern Tumor Size 1cm
Lymph-vascular and neural invasion not identified
Skin, nipple – areola complex and all margins – clear
Lymph nodes – positive for metastatic invasive ductal carcinoma 7 out of 12 nodes recovered.

Other findings:
 Fibrocystic Disease (lobular hyperplasia and cystic disease)
CT/ MRI SECTION

Clinical Data: Status post left mastectomy for breast carcinoma IIB

Findings:
Digital craniocaudal and mediolateral oblique images of the right breast were obtained.
No prior study submitted for comparison
The right breast is heterogeneously dense, which may obscure small masses. Few punctate
calcifications are seen.
No suspicious discrete masses, grouped calcifications, architectural distortion, skin thickening
or indirect signs of malignancy identified.

Unenlarged and fat laden right axillary lymph nodes are seen.

Impression:
 Dense right breast parenchyma with benign calcifications.
 No suspicious mammographic findings.
 The absence of mammographic abnormality should not preclude further evaluation or
even biopsy, if a clinically suspicious mass is palpable.

Bi-RADS category 2: BENIGN FINDINGS

Recommendation:
 Mammographic follow up per clinical discretion
 Additional ultrasound evaluation may be done to further assess the breast parenchyma
to exclude underlying lesions.
IMMUNOHISTOCHEMICAL STAINING REPORT

Specimen: BREAST, LEFT

Pathologic Diagnosis:
1. ESTROGEN RECEPTOR (ER) Assay: POSITIVE
Proportion Score: 5 (>67%)
Intensity Score: 3
Total Score: 8

2. PROGESTERONE RECEPTOR (PgR) Assay: POSITIVE

Proportion Score: 4 (60%)
Intensity Score: 3
Total Score: 7
3. HER2: NEGATIVE (Score +1)

Altered Score for Estrogen and Progesterone Receptor Evaluation

PROPORTION POSITIVE CELLS % INTENSITY SCORE (IS) INTENSITY
SCORE
0 0 0 NONE
1 <1 1 WEAK
2 1-10 2 INTERMEDIATE
3 11-33 3 STRONG
4 34-66 TOTAL SCORE PS + IS
5 >67 NEGATIVE = 0 TO 2 POSITIVE = 3 TO 8

Reporting Results of HER2 Testing by Immunohistochemistry

Negative (Score 0) No staining observed or incomplete, faint/barely perceptible
membrane staining in <10% of invasive tumor cells
Negative (Score 1+) Incomplete, faint/ barely perceptible membrane staining in >10% of
invasive tumor cells
Equivocal (Score Incomplete and/or weak to moderate circumferential membrane
2+) staining in >10% of invasive tumor cells or complete, intense,
circumferential membrane staining <10% of invasive tumor cells.
Positive (Score 3+) Complete, intense, circumferential membrane staining in >10% of
invasive tumor cells.
1. Examination: ULTRASOUND WHOLE ABDOMEN

Liver (length): right middle hepatic lobe – 12.7cm; left lobe – 7.04 cm
-echopattern is slightly increased
Gallbladder (L x AP): 6.30 x 1.43 cm, non shadowing high level echoes of about 0.75cm,
0.34 cm; 0.29 cm; 0.34 cm
Kidney (L x W x AP) Left 10.3 x 5.85 cm; parenchymal thickness 1.12 cm
Lower pole cortex echogenic noduleof about 0.91 x 0.70 xm (length
x AP)

Impression:
Mild Fatty liver
Gall bladder polyps
Left renal angiomyolipoma
Unremarkable ultrasound of pancreas, spleen, right kidney, urinary bladder, normosized
anteverted uterus with proliferative endometrium.
2. Examination: CHEST XRAY
Findings:
 NO abnormal lung opacities are seen
 The cardiac diameter is at the upper limit of normal size
 Trachea is at Midline
 Diaphragm and sulci are unremarkable
 Left breast shadow are well delineated (surgically absent)
Impression:
 Cardiac diameter is at upper limit of normal size
CT/MRI SECTION

Clinical Data: Status post mastectomy for breast carcinoma IIB

Findings:
 Digital craniocaudal and mediolateral oblique images of the right breast were obtained.
 No prior study submitted for comparison
 The right breast is heterogeneously dense, which may obscure small masses. Few
punctate calcifications are seen.
 No suspicious discrete masses, grouped calcifications, architectural distortion, skin
thickening or other indirect signs of malignancy identified.
 Unenlarged and fat laden right axillary lymph nodes are seen.

IMPRESSION:
 Dense right breast parenchyma with benign calcifications
 No suspicious mammographic finding
 The absence of mammographic abnormality should not preclude further evaluation or
even biopsy, if a clinically suspicious mass is palpable

Bi-rads category 2: benign findings

Recommendation:
 Mammographic follow up per clinical discretion
 Additional ultrasound evaluation may be done to further assess the breast parenchyma,
to exclude underlying lesions
Ultrasound of the Whole Abdomen

The liver is normal in size with smooth contour exhibiting mild diffusely increased parenchymal
echogenicity. NO discrete focal lesions are identified. The intra and extrahepatic ducts are not
dilated. The gall bladder is within the normal limits in size. Its wall is not thickened. Multiple
wall adherent medium level echoes are seen ranging in size from 0.31 cm to 0.78 cm. NO
pericholecystic fluid is noted. The visualized proximal common bile duct measures 0.39 cm in
diameter. The pancreas is normal in size with homogeneous parenchyma. The main pancreatic
duct is not dilated. The spleen is not enlarge.

The right kidney measured 10.1 x 3.9 x 3.6 with cortial thickness of 1.1 cm while the left kidney
measures about 9.6 x 4.3 x 4.1 cm with cortical thickness of 1.3 cm. The central echo complexes
in both sides are intact with no evident hydronephrosis. A 1.0 x 0.93 x 0.93 cm circumscribed
echogenic focus is seen in the inferior portion of the left kidney. The cortices are normal in
echogenicity. The urinary bladder is physiologically distended with urine to a volume of 440 ml.
Its wall is not thickened. No intraluminal echoes are seen. Post void residual volume measures
23.1 ml (1% of the prevoid volume).

The uterus is anteverted and measures 5.8 x 4.8 x 4.5 cm with homogenous echopattern. No
discrete focal lesion is seen. The endometrial stripe is echogenic measuring about 1.3 cm in full
thickness. The ovaries are not clearly delineated. No definite mass is identified. No fluid is seen
in the posterior cul de sac.

The rest of the abdomen is obscured by overlying bowel gas.

IMPRESSION
Hepatic steatosis
Consider gallbladder polyps versus cholesteroloses
Consider angiomyolipoma, left kidney. Contrast enhanced CT correlation is suggested.
Unremarkable ultrasound of the pancreas, spleen, right kidney and urinary bladder.
Negative for biliary ectasia
Average sized anteverted uterus with thickened endometrium
Non visualized ovaries
No definite adnexal identified
Please correlate with clinical and laboratory findings.
CT SCAN OF THE CHEST

Status post left sided MRM

Plain CT study of the chest in multiplanar views shows cystic changes in the left breast
There is cutaneous thickening of the breast
There are small nodules in the left axillary area, largest of which measures approximately 7mm.
There is no pleural effusion or thickening
The trachea, carina and right and left mainstem bronchi are intact.
The prevascular space and aortapulmonary window are clear
The mediastinal and hilar lymph nodes are intact
The esophagus and azygoesophageal recess are unremarkable.
The sternum, ribs, thoracic vertebrae and soft tissue chest wall structures are intact.

IMPRESSION:
 Heterogeneous cystic changes in the left breast with cutaneous thickening are
presumably post surgical
 Small left axillary lymphadenopathy measuring 7mm greatest axial diameter
 No pulmonary metastasis
 No mediastinal nor hilar lymphadenopathy
BONE IMAGING

Clinical History:
Patient with breast carcinoma, s/p left mastectomy was referred for bone scintigraphy
to assess for osseous metastasis.

Technique:
Whole body imaging in the anterior/posterior projections, along with bilateral views of
the head and thorax, was odne 2.5 hours after intravenous injections of 1034 MBq of
99mTc MDP.

Findings
The osseous structures are well visualized. The kidneys are sen and appear
unremarkable.
Inflammatory changes are seen in the shoulders , stenoclavicular joints, knees and feet.
Symmetrical and physiologic tracer distribution is observed in the rest of the skeletal
structures.

IMPRESSION:
No Scintigraphic evidence of osseous metastasis

This Nuclear Medicine report is part of the overall assessment of a patient’s condition
and best explained by the attending physician to the patient. Correlation with clinical,
laboratory, and other ancillary parameter may be necessary for a comprehensive
analysis.