BREAST CANCER

BREAST CANCER

Breast cancer this is the commonest amongest women affecting 1 in 13 and resulting in 25000 new cases and 15000 deaths per year in the  UK . the incidence rises rapidly to 200|100000 women per year by age 45 and continues to rise into old age . one per cent of breast cancers occur in men . the severity of the problem in the UK  has led to a government directive that all women suspected of having breast cancer must offered an outpatient appointment within 2 weeks of referral nulliparous women in developed countries are increased risk of breast cancer whereas women who have their first child young and breast feed are protected . modern low dose oral contraception does not seem to increase the incidence of breast cancer . predisposing factors include oestrogen exposure unopposed by progesterone , hyperoestrogenism family history of premenopausal breast cancer , saturated dietary fats and previous benign a typical hyperplasia two important breast genes (BRCA1-  chromosome11 and BRCA2-  chromosome17)are associated with inherited breast cancer which accounts for about 5% of cases but environmental factors seem more important

pathology of breast cancer :it is very difficult to define the cell of origin of most tumours and WHO  classification divides tumours into those derived from epithelial cells and those derived from connective tissue

EPITHELIAL
  
 NON-INVASIVE
  
  Invasive ductal carcinoma in - situ (DCIS)3-5% 
LOBULAR CARCINMOA-IN-SITU(LCIS)1%
   
 INVASIVE
  
Invasive ductal carcinoma 80-90%,(not otherwise specified NOS
Invasive lobular 1-2%
Mucinous ,medullary ,papillary are rare
Tubular ,sectory ,apocrine 2%
  paget,s disease 2% 

MIXED CONNECTIVE TISSUE
 MISCELLANEOUS unclassified

Non- invasive pathology is increasingly common in screening -detected tumours
Lobular carcinoma -in-situ is uncommon as is ductal carcinoma in situ(DCIS) in isolation
this is much commoner in combination with invasive ductal cancers

 DCIS in premalignant , invasive ductal tumours (NOS)  form the majority of breast cancers although most are undifferentiated and can not easily be classified morphologically , lobular , medullary , mucinous etc are specific differentiated forms of invasive cancer that can sometimes be identified

Their differentiation gives them a better prognosis than the NOS group
 
 paget,s disease indicates an underlying invasive or intraductal carcinoma

phylloids tumours are the commonest group in the mixed connective tissue and epithelial group . their behavior is difficult to predict but a high mitotic rate atypia and infiltration indicate local recurrence after simple excision invasion of the regional axillary lymph nodes has an adverse effect on prognosis with a 5-year survival of less than 20% where more than five lymph glands are involved other markers of poor prognosis are vascular invasion
Tumour multicentricity and poor differentiation

 The content of oestrogen receptor proteins in the primary tumour is useful for indicating the response to endocrine therapy and for prognosis

CLINICAL FEATURES

 Breast cancer may be presented by

firm irregular painless lump or mass , may be fixed to skin or muscle
pain in 10% 
 Axillary or supraclavicular lymph node involvement
 Recent nipple retraction and or bloody discharge 
 Paget,s disease 
 peau d, orange 
  Signs of metastatic disease as loss of weight ascitis jaundice CNS signs 

          
INVESTIGATIONS

Of breast cancer  mammography used for investigating symptomatic patients and for screening in 80-90%accurate but less accurate in young dense breast
   
Breast ultrasound

Demonstrates cystic disease  colour flow duplex mode may distinguish abnormal tumour circulation , often used to guide FNAC  or core biopsy for smaller lesions
 
 Fine needle aspiration cytology (FNAC
 
Simple and quick 95%accurate

trucut or biopsy gun biopsy for lumps larger than 2 cm diameter a tissue core can be obtained under local anaesthesia for histological  examination
 
 Excision biopsy 

 . This is performed where other investigations have failed to define the lump proceeding to a more extensive procedure after frozen section analysis is not recommended 

 Wire - guided biopsy

Impalpable suspicious lesions identified at mammography are localized by insertion of a wire under screening control a core of breast tissue around the wire is then excised surgically a radiography of the specimen is taken to ensure total excision of the abnormality

 Chest x-ray . bone scan  CT, MRI scan
helpful in defining the extent of metastatic disease

Breast cancer risk factors see here

Breast cancer treatment see here

tags:cancer,breast