Breast tumours

Ductal carcinoma of breast

Lobular carcinoma of breast

Paget's carcinoma of breast

It is one of the most common tumors in general. They form two basic groups:

1. benign tumors;
2. malignant tumors.

Benign breast tumors

 For more information see Benign breast disease.

Malignant breast tumors

They are the most common malignant tumors of women in the Czech Republic, their incidence is still increasing.

Epidemiology

Paget's carcinoma of breast

• Incidence is rising, but mortality is not rising because they are diagnosed at earlier stages;
• peak incidence is around age 57;
• In men, it occurs at a ratio of 1:140.

Etiology

• Age is the most serious risk (incidence rises from 30 years of age, with 85% of tumors above 45 years of age);
• Sporadic carcinomas - dysplastic changes of epithelial cells (carcinoma in situ) occur until cancer develops;
• but also involves the activity of stromal cells, which produce proteolytic enzymes and angiogenic factors-facilitating growth and metastasis;
• hormonal effects - long-term effects of estrogens;
• genetic carcinomas - occurrence in direct relatives (mother, sister, daughter) or accumulation of tumors within syndromes (Li-Fraumeni syndrome - mutation of one p53 allele, Cowden syndrome - rare, associated with hamartomas);
• the gene BRCA 1 and 2 is of greatest importance for the detection of genetic susceptibility;
  • a woman with a BRCA 1 mutation has a lifetime risk of 55-85% for cancer (15-45% for ovarian cancer);
  • common in the Jewish population;
  • male BRCA carriers are in turn at risk for prostate cancer and colorectal cancer;
  • hereditary cancer is often bilateral;
  • BRCA 2 positive carcinoma is usually very poorly differentiated, aggressive.

Risk factors: =

1. length of exposure to estrogens - early menarche, late menopause, nulliparity;
2. other breast disease - cystic adenomas, ductal papillomas (risk of missed carcinoma);
3. effects of ionizing radiation - also mammography;
4. obesity, increased fat intake and lack of exercise;
5. the effect of smoking, chemicals, hormonal contraceptives has not been clearly documented.

Clinical manifestations

Macroscopically visible breast lump, deformity and nipple retraction

• Most commonly, it is a palpable, painless lump in the breast (in 75% it is the first manifestation of the disease);
• Optimally, however, a non-palpable lesion should be found on mammography;
• other symptoms (less common) - breast pain (5%), breast enlargement (1%), skin or nipple retraction (5%), discharge (2%), superficial changes on the nipple (1%);
• enlargement of axillary nodes - regional spread;
• at advanced stage - bone pain, weight loss,...
• paraneoplasia - dermatomyositis, neuromuscular syndrome, acanthosis nigrans, hypercalcemia in bone metastases.

Diagnostics

Clinical examination:

• Careful personal, family and gynecological medical history;
• appearance - symmetry of the breasts, symmetry with breathing, nipple regularity, skin color, vein enlargement may indicate tumor activity;
• palpation - systematically all quadrants, size of resistance, mobility, border, consistency;
• frequency of findings of carcinomas in each quadrant - most often HZK (47%), nipple (22%) and HVK (14%), lower quadrants few;
• palpation of nodes axillary, above the germ.

Imaging methods:

 For more information see Diagnostic imaging methods in senology.

• mammography is dominant - the yield is up to 90%;
  • finding - microcalcifications are usually visible, solid lesion with serrated edges;
  • ultrasound - usually complementary to mammography, has high sensitivity (95%) but limited specificity, preferred in women under 40 years of age;
  • CT, MRI, less so ductography, PET.

Biochemical testing:

• standard - liver tests, urea, creatinine, electrolytes,
• tumor markers - CEA, CA 15-3, TPA;
• of particular importance is the determination of hormone receptors - by immunohistochemistry in tissue sections; the influence of estrogen and progesterone on tumor growth is assumed
• molecular biology - especially determination of HER-2/neu - causes increased proliferative activity (prognostic and predictive significance);
• biopsy - fine needle aspiration (FNA) - more important to differentiate between cystic and solid masses;
• histology is only possible with a self-cutting needle (core biopsy) under anaesthesia (local or general).

Screening:

• early diagnosis is the basis for successful treatment;
• mammography screening for women 45 and older (once every two years).

Histopathology

• Carcinoma most commonly arises from the terminal ductal lobular unit (TDLU);
• It is usually preceded by a non-invasive form - carcinoma in situ.

Carcinoma in situ

• Lobular carcinoma in situ' - from mammary lobule cells, proliferation of cells in lobules that dilate;
  • not detectable mammographically (unlike the previous one);
  • often arises multicentrically, even in the contralateral breast;
  • more common in premenopausal women.
• Ductal carcinoma in situ' - proliferation of ductal epithelium without crossing the basement membrane, may form microcalcifications (detectable mammographically), may progress to invasive ductal carcinoma;
  • a special form is Paget's carcinoma of the nipple - when tumor cells from the ducts invade the nipple, more often in postmenopausal women.

Invasive forms of carcinoma

• There are different forms, infiltrating is divided into 2 forms - lobular and ductal.

Lobular

• about 10%, often in the HZK (upper outer quadrant);
• often metastasizes to serous membranes, meninges, ovaries, retroperitoneally.

Ductal

• the most common (75%), often tubular, accompanied by reactive fibrosis - the tumor has a form where it is hard as a stone;
• metastasizes to bone, liver and lungs;

Inflammatory (erysipeloid) carcinoma

• rare (1-3%), the most aggressive form;
• infiltration of the entire breast, diffuse erythema, skin induction (typical orange peel appearance);
• 50-70% of tumors have nodal metastases at the time of diagnosis.

Treatment

The final treatment is the result of a joint decision by a multidisciplinary team.

Surgical treatment

• Since 1882, radical mastectomy with exenteration of the axilla (pectoral muscles, nerves, ...) has been performed;
• Nowadays, modified radical mastectomy is more commonly performed - the breast is separated from the pectoralis fascia, the nodes are removed from the superficial stages, the nodes below the m. pectoralis minor are usually not removed;
• another variant - sentinel node;
• salvage procedures - quadrantectomy, tumorectomy;
  • necessary to complement radiotherapy, reconstructive surgery is performed;
• also as a modality of hormonal treatment - ovarectomy;
• 

  Neoadjuvant chemotherapy for breast Ca (mammography before and after)
  for BRCA, surgery can also be used as prophylaxis.

Radiotherapy

• Carcinoma has limited radiosensitivity;
• it is indicated after salvage surgery, the result is then identical to ablation;
• it is therefore given adjuvantly;
• brachyradiotherapy - application of iridium wires;
• palliative treatment - for bone metastases.

Chemotherapy

• Breast cancer is relatively sensitive to a range of cytostatics, and combinations are mainly used;
• the basic combination is CFM - cyclophosphamide, methotrexate, 5-FU, or combination with anthracyclines;
• monotherapy - in older women with limited marrow reserve;
• adjuvantly - before menopause always when lymph nodes are involved, not given for carcinoma in situ or for tumors under 1 cm;
• neoadjuvant - for large tumors;
• palliation - the main treatment method for disseminated disease, can significantly prolong survival.

Hormone Therapy

• Adjuvant, neoadjuvant and palliative treatment;
• in premenopausal - castration - surgical or pharmacological.
• SERM - Tamoxifen
• Aromatase inhibitors - reduction of female sex hormone synthesis

Biological treatments

• Membrane receptor inhibition - Ig against HER-2/neu receptors - Herceptin.

Links

Related articles

• Breast
• Hereditary cancer syndromes
• Benign breast disease
• Tabar classification of breast cancer
• Breast Cancer Classification BI-RADS
• Diagnostic Imaging in Senology
• Infiltrating Mammary Carcinoma (slide)

Source

• ws:Nádory prsu
• image source: https://www.wikiskripta.eu/w/Soubor:Neoadjuvantn%C3%ADCHT.png