Breast Magnetic Resonance Imaging - Assignment Example

1. Discuss the hormonal influences on breast tissue during the normal menstrual cycle. Why is this important when scheduling a breast MRI? Normal menstrual circles often come with a number of hormonal influences to the breast tissues in the process of preparing the body for sexual production. During this time, the body responds by producing hormones that result to changes in the breast tissues (Alrashidi et al., 2011). Most women, before or during their menses may experience swollen, painful or tender breasts. In other instances, the women may feel hard lumps in their breasts due to extra fluids in the breasts (Soderqvist, 2008). All these prepare the ovary and the female uterus for the reproduction process. During the preparation of the ovary and the uterus, progesterone and estrogen hormones are produced which mainly affect the changes in breast tissues (Gompel et al., 2013). These changes on the breast tissues are likely to interfere with MRI scan that are performed on the breast. When the menstrual cycle begin, production of estrogen in the first half of the menses is increased and gets to the peak just before the mid cycle. In the process, the breast milk ducts enlarge (Fuller, 2010). Moreover, the progesterone level in the second half of the cycle gets to the peak at the onset of 21st day and causes the breast lobules (milk glands) to develop (figure 1). The premenstrual swellings of the breast are not well understood, but are largely related to hormonal changes, which are considered normal (Rashidi et al, 2012). Figure 1: shows the slide view of normal breast during normal menstrual cycle (Fuller, 2010). The hormonal influences on the breast are likely to cause a number of problems during breast MRI. Breast MRI is often performed to diagnose the presence of breast tumors. Under certain circumstances, the MRI scan may work better when used in examining a woman’s breast with a small mass, rather than breast with large massive tissues (Ferguson, 2010). During menstrual period, the breast develop a number of tissues, which make it hard for the MRI examination to be effective. Furthermore, during the menstrual period, the hormonal changes results into the breast enlarging and therefore reducing the efficiency of the MRI scan. The contrast – enhanced breast MRI provides a great sensitivity for detecting early breast tissue abnormality, the sensitivity has demonstrated 94% -100%, so, it is used in screening women for breast cancer or even gaining more information regarding the stage of the cancerous disease once the diagnosis has been done. In other instances, the MRI breast is used in determining the patient’s recovery during chemotherapy. The MRI breast is not efficient for detecting the cancer when the woman is experiencing her menstrual period (Dabrosin, 2013). The large mass of tissues on the breast during menstruation may interfere with the validity of the scan performed. Therefore, it is imperative that the contrast – enhanced breast MRI scan on women be done when the woman is not experiencing her menstrual period (Leifer, 2011). This would improve the accuracy of the results and therefore make them useful and valid. Therefore, caution should be taken since breast MRI may produce false positive results, which may negatively affect the health of the patient. 2. Discuss the BRCA 1 and BRCA 2 genes. What are the implication for a patient who has a harmful BRCA gene mutation, and how are such patients managed clinically? BRCA 1 and BRCA 2 genes refer to human genes and their respective proteins. BRCA1 is genes that suppress tumors in the human body; its protein that responsible for the repair of DNA. BRCA 1 and BRCA 2 genes are often manifested in the breast cells and other tissues in which case they repair the damaged DNA or then destroy the associated cells in cases where the DNA cannot be repaired (Budryk, Tacza, & Grzybowska, 2009). The BRCA 1 and BRCA 2 genes engage in repair of any chromosomal damage and play a crucial role in the error-free fixing where DNA double strand breaks have occurred. In a case where BRCA 1 and BRCA 2 genes are damaged by BRCA mutation, the damaged DNA is never repaired properly, and this makes the human vulnerable to breast cancer. In many cases, the terms such as “breast cancer susceptibility proteins” and the “breasts cancer susceptibility genes” have often appeared to consider the BRCA 1 and BRCA 2 genes to be normal; however, their mutation is regarded as abnormal (Krum, 2007). BRCA1 often combine with the DNA damage sensors, tumor suppressors and signal transducers to form a huge multi- subunit protein complex,BRCA1 associated genome complex. The BRCA1 protein then unites with the RNA polymerase II and then interacts through the C-terminal domain. This protein, therefore, plays an important role in transcription, ubiquitination, and the DNA repair of the double strand breaks (Zwet, 2009). The carriers of the germline mutation in BRCA2 genes have high propensity to breast and ovarian cancer. However, the risk of other cancers is uncertain in mutation. The BRCA2 mutations often incline individuals to a lifetime of peril of breast cancer. This case is almost similar to BRCA1 mutations although it proves further risks of getting ovarian cancer. The role of ensuring genetic stability in a cell is crucial, and therefore makes the functions of the BRCA 1 and BRCA 2 genes to be useful. During mutation or alteration of these genes to an extent that their protein products do not function properly, the process of DNA repair may not effectively occur; as a result, there is a possibility of the resulting cells developing additional genetic alterations, which may lead to cancer (Ellis, 2010). There are also the cases of BRCA 1 and BRCA 2 inherited mutations, which increase risks of ovarian, and breast cancers, and this has equally been associated with the vulnerability to other types of cancer. The BRCA 1 and BRCA 2 gene mutations account for the 15% of ovarian cancer cases. Breast cancers that are related to BRCA1 and BRCA2 mutations are more common in cases of young people than the sporadic breast cancers. Consequently, a person often inherits BRCA 1 and BRCA 2 genes mutation from parents. Any child from parents carrying either of these gene types stands 50 percent chances of inheriting the mutation (Krum, 2007). The impacts of BRCA 1 and BRCA 2 mutations may be visible even in cases where the individual’s second genetic copy is normal. Fig.2 Showing BRCA1 and BRCA2 (Image courtesy of http://urologyinstitute.com/articles/brca-gene-mutation). A BRCA mutation is the type of mutation that occurs in both the BRCA1 and the BRCA2. The harmful mutations in the tumor suppressor genes result into hereditary breast cancer syndrome in the families affected. These types of mutations are not common, and only cases account for approximately 5 percent of the breast cancer in women. Various mutations have been identified in the genes. One such mutation is the high – risk mutation that prevents a vital error-free DNA repair process. The reasons why the BRCA1 and the BRCA2 mutations often lead preferentially to breast and ovarian cancer is still unknown, however, lack of BRCA1 function often leads to the formation of the non-functional x-chromosome inactivation (Burnette, 2012). It is important to noting that the cancer risks that come with any given mutation normally vary depending on the nature of mutation and the location among other individual factors. Women possessing the harmful BRCA1 and the BRCA2 mutations have the high risks of breast cancer almost five times above the normal risks. The BRCA1 mutations have thus been observed to confer higher risks of ovarian and breast cancer as compared to the BRCA2 mutations. The presence of the BRCA1 and the BRCA2 mutation genes that are normally held responsible for the stimulation of the hereditary breasts cancer should be detected early enough to ensure adequate prevention. This means that an individual that has the hereditary BRCA1 and the BRCA2 mutation are largely exposed to cancer of ovarian and the breast cancer (Choi, Lee, & Haffty, 2013). Various options can be used to assist in diagnosis for the presence of ovarian and breast cancer. The tests performed involve screening that helps in identification of the cancer cells. During the tests, breasts imaging is done, and such procedures involve the use of MRI, which has been proved effective in the examination of the breast tissues (Hansen, 2013). The MRI imaging procedures are preferred due to their efficiency in results as well as their fewer side effects to the person. Aside from the MRI, tests are other options such as Computer Tomography (CT) scans, Elastography, Thermography, PET scans, and scintimammography among other options (Ellis, 2010). Many studies have proved that clinical management of patients suffering from the hereditary breasts and ovarian cancers can be quite challenging. This is attributed to the fact that, the cancers after reaching the final stages do not respond to any treatment (Burnette, 2012). This is the reason as to why medical professionals recommend early detection of the cells to help in easy management of the disease. Clinical management of cancer patients mainly done to ensure protection of the patient from further spread and development of the cancer cells. Late detection of the cancer cells is often regarded as a risk since during this stage so little, or nothing can be done (Gibbon & Joseph, 2014). The available options for the patients may be chemotherapy to help destroy the cancerous cells. Apart from chemotherapy, there are other interventions, which may be productive in the treatment of cancer; these include the use of prophylactic medication and surgery in the cancer management (Choi, Lee, & Haffty, 2013). The prophylactic surgery comes with a number of risks, most of which are complex and involves the adoption of the most current technology. 3. MRI can be used to assess breast implant integrity. Discuss intracapsular and extracapsular rupture and their MRI appearances? MRI has been adopted among the key methods in the detection of breast implant failures and revealed largely any appearance of implant ruptures or normal silicone gel implants (Munhoz, 2009). Researchers recommend MRI imaging since it is more accurate as compared to other options such as mammography and ultrasound when determining the breasts implant integrity (Brenner, 2008). MRI has been the preferred means of diagnosing since its specific and non-invasive in diagnosing intra and extracapsular rupture. MRI has a high spatial resolution and offers a proper contrast between the soft tissues and the implants. Therefore, MRI is the best and most-efficient means through which the breast implant integrity can be determined. It also has a high sensitivity to specific implant rupture due to the sequences that can suppress the signal from the silicone (Dhumeaux & Sautet, 2008). It also offers a perfect differentiation between the extracapsular and intracapsular rupture and further assess the extent through which silicone leakage has occurred in the breast parenchyma and the granuloma formation. Figure ( ): Image of a normal breast implant as visualized by an axial silicone suppression MRI sequence. An intracapsular rupture often occurs when the implant shell ruptures but the fibrous capsule remains intact. MRI tests offer the best solution towards viewing the intracapsular rupture (Lee, 2009). Silicon does not extravasate freely and therefore making the detection may not be easy. Extracapsular rupture, on the other hand, may lead to changes in the implant contour and are detectable upon mammography or clinical examination. The presence of an extracapsular rapture may be an implication of intracapsular rupture as well (Collis & Sharpe, 2009). Figure ( ): MRI breast image for extracapsualr rupture . The above MRI for a woman having bilateral breast silicone implant. The right implant has an extracapsualr rupture and exhibits a typical linguine sign on the posterior margin. (Image courtesy of http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3259319/figure/Fig8/) The image above represents a woman having an extra capsular rupture occurring on the single lumen silicone implant. The a and b sagittal silicone exited sequences reveal the existence of free silicone gel on the implant (White arrows). In illustration c, the excited axial silicone sequence reveals the silicone gel in the internal mammary chain. Nearly half of the ruptures among women with augmented breasts take place within 12 years. The intracapsular implant is described as a rupture of implant shell that has silicone leakage and does not have a macroscopic extension beyond the fibrous capsules (Kreymerman, 2009). Occurrence of multiple curvilinear low signal intensity in the high signal intensity silicon gel are greatly dependable on MRI criterion. Normally, the linguine sign is invisible in the case of uncollapsed rupture; MRI reveals free silicone on the exterior of the implant shell despite still having attachment to the fibrous capsule. Focal silicone invagination occurring between the fibrous capsule and the inner shell are common, this result into the “keyhole” signs and the teardrop sign (Brenner, 2008) Conventional breast imaging procedures especially MRI and ultrasound still presents important information about the implants. The intracapsular rupture is often frequent but is never easy to detect clinically by the use of mammography due to the radio capacity of the implant. MRI techniques, therefore offer the best solution towards assessment of implant integrity. References Alrashidi, N., Ahearn, T., Jagpal, B., Redpath, T., & Gilbert, F. (2011). Apparent diffusion coefficient of normal breast tissue during the menstrual cycle at 3 Tesla. Breast Cancer Research, 13(Suppl 1), P5. Brenner, R. (2008). Magnetic Resonance Imaging and Explantation Investigation of Long-Term Silicone Gel Implant Integrity. Breast Diseases: A Year Book Quarterly, 19(2), 139-140. Brenner, R. (2008). Magnetic Resonance Imaging and Explantation Investigation of Long-Term Silicone Gel Implant Integrity. Breast Diseases: A Year Book Quarterly, 19(2), 139-140. Budryk, M., Tacza, K., & Grzybowska, E. (2009). Spectrum of Cancers Diagnosed in the Families Carrying Germline Mutation in BRCA 1/2 Genes. Polish Journal of Surgery, 81(10), 453-456. Burnette, J. B. (2012). Cancer time bomb: how the BRCA gene stole my tits and eggs. Charleston, S.C.: CreateSpace]. Choi, D. H., Lee, M. H., & Haffty, B. G. (2013). Double Heterozygotes for Non-Caucasian Families with Mutations in BRCA-1 and BRCA-2 Genes. The Breast Journal, 12(3), 216-220. Collis, N., & Sharpe, D. T. (2009). Silicone Gel???Filled Breast Implant Integrity: A Retrospective Review of 478 Consecutively Explanted Implants. Plastic & Reconstructive Surgery, 105(6), 1979-1985. Dabrosin, C. (2013). Variability of Vascular Endothelial Growth Factor in Normal Human Breast Tissue in Vivo during the Menstrual Cycle. Journal of Clinical Endocrinology & Metabolism, 88(>6), 2695-2698. Dhumeaux, M., & Sautet, J. (2008). Rupture du ligament croiseÌ cranial chez le chien. S.l.: [s.n.]. Ellis, C. N. (2010). Inherited Cancer Syndromes (2nd ed.). Dordrecht: Springer. Ferguson, J. E., Schor, A. M., Howell, A., & Ferguson, M. W. (2010). Changes in the extracellular matrix of the normal human breast during the menstrual cycle. Cell & Tissue Research, 268(1), 167-177. Fuller, J. R. (2010). Surgical technology: principles and practice (5th ed.). St. Louis, Mo.: Saunders Elsevier. Gibbon, S., & Joseph, G. (2014). Breast Cancer Gene Research and Medical Practices Transnational Perspectives in the Time of BRCA. Hoboken: Taylor and Francis. Gompel, A., Truc, J. B., Leygue, E., Audouin, J., Hugol, D., Plu-Bureau, G., et al. (2013). Epidermal growth factor receptor and c-erbB-2 expression in normal breast tissue during the menstrual cycle. Breast Cancer Research and Treatment, 38(2), 227-235. Hansen, N. M. (2013). Management of the patient at high risk for breast cancer. New York: Springer. Kreymerman, P., Patrick, R. J., Rim, A., Djohan, R., & Crowe, J. P. (2009). Guidelines for Using Breast Magnetic Resonance Imaging to Evaluate Implant Integrity. Annals of Plastic Surgery, 62(4), 355-357. Krum, S. A. (2007). The role of BRCA 1 in gene regulation and DNA damage its functional interaction with RNA polymerase II and H2AX. London: Mc Graw. Lee, F. (2009). Axillary silicone lymphadenopathy presenting with a lump and altered sensation in the breast: a case report. London: Mc Graw. Leifer, G. (2011). Introduction to maternity & pediatric nursing (6th ed.). St. Louis, Mo.: Elsevier/Saunders. Middleton, M. S., & McNamara, M. P. (2009). Breast implant imaging. Philadelphia: Lippincott Williams & Wilkins. Munhoz, A. M. (2009). Guidelines for Using Breast Magnetic Resonance Imaging to Evaluate Implant Integrity. Annals of Plastic Surgery, 63(5), 583. Rashidi, N. A., Waiter, G., Redpath, T., & Gilbert, F. J. (2012). Assessment of the apparent diffusion coefficient (ADC) of normal breast tissue during the menstrual cycle at 3T using image segmentation. European Journal of Radiology, 81, S1-S3. Soderqvist, G. (2008). 17 -Hydroxysteroid Dehydrogenase Type 1 in Normal Breast Tissue during the Menstrual Cycle and Hormonal Contraception. Journal of Clinical Endocrinology & metabolism , 83(4), 1190-1193. Zwet, M. (2009). The NBS1 and BRCA2 gene products: important players in the cellular response to DNA double-strand breaks. S.l.: s.n.]. Read More