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Updated: Nov 14 2021

Malignant Breast Tumors

  • Introduction
    • Epidemiology
      • breast cancer is the most common cancer and second most common cause of death in adult women
    • Risk factors
      • BRCA1 and BRCA2 mutations
        • associated with multiple / early onset breast and ovarian cancer
        • other genetic relationships
          • RAS oncogene gain of function
          • overexpression of estrogen/progesterone receptors
          • overexpression of erb-B2 (HER-2, an EGF receptor)
          • Li-Fraumeni associated TP53 loss
      • increasing age
      • smoking
      • breast cancer in first degree relatives or mother with breast cancer
      • history of contralateral breast cancer
      • history of endometrial cancer
        • also an estrogen induced cancer
      • increased exposure to estrogen
        • obesity
        • nulliparity
        • early menarche (<11 y.o.)
        • late menopause (>50 y.o.)
        • late first pregnancy (>30 y.o.)
      • atypical ductal hyperplasia
  • Classification
    • Ductal carcinoma in situ (DCIS)
      • arises from progression of ductal hyperplasia
      • non-palpable mass
        • seen most often on mammography due to microcalcifications
      • histology shows filled ductal lumen without basement membrane penetration
      • subtypes
        • comedocarcinoma
          • ductal carcinoma with caseous necrosis at the mass center
    • Paget's disease
      • extension of DCIS into lactiferous ducts and skin of nipple
        • eczematous patches on nipple
      • histology shows Paget cells
        • large cells in epidermis with clear halo
        • also seen on vulva
    • Invasive/infiltrating ductal carcinoma
      • worst and most invasive
      • most common type
      • firm, fibrous, "rock-hard" mass
      • histology shows small, glandular, duct-like cells with stellate morphology
      • subtypes
        • tubular carcinoma
          • histology
            • well-differentiated tubules that lack myoepithelial cells
        • mucinous carcinoma
          • histology
            • carcinoma with abundant extracellular mucin
    • Lobular carcinoma in situ (LCIS)
      • non-palpable mass
      • often bilateral
      • histology shows distended lobules with neoplastic cells without BM penetration
    • Invasive lobular
      • often multiple and bilateral
      • histology shows orderly row of cells
    • Medullary
      • associated with BRCA1 and ER/PR negativity
      • histology shows fleshy, cellular, lymphatic infiltrate
    • Inflammatory
      • poor prognosis (50% survival at 5 years)
      • histology shows dermal lymphatic invasion by tumor
      • peau d'orange seen on exam
        • see below
  • Presentation
    • Symptoms
      • often asymptomatic
      • breast lump
        • most commonly in upper-outer quadrant
      • nipple discharge
    • Physical exam
      • firm immobile, painless lump
      • some skin changes
        • redness, ulcerations, edema, and nodularity
      • axillary lymphadenopathy
        • in more advanced cases
      • breast skin edema with dimpling (peau d' orange)
        • represents obstruction of the lymphatics by cancer
  • Evaluation
    • Fine needle aspiration
      • can identify whether mass is solid or cystic
      • can also retrieve sample for cancer diagnosis
    • Estrogen/Progesterone receptor assays
      • most often positive in post-menopausal cancers
        • low estrogen state after menopause results in upregulation of receptors
      • positivity confers better prognosis with more effective therapeutics
    • Sentinel lymph node biopsy
      • if negative high likelihood no other nodes in group are involved
      • if positive there is 1/3 chance other nodes in group are involved
  • Treatment
    • Surgery
      • breast conservation resection
        • resection of tumor with margins
        • sentinel node biopsy
        • radiation
      • modified radical mastectomy
        • resection of nipple, entire breast, pectoralis minor, and level I-II axillary nodes
        • level III axillary nodes removed if involved
        • complications
          • long thoracic nerve damage
            • results in winged scapula
          • lymphedema
  • Prognosis, Prevention, and Complications
    • Prognosis
      • lymph node involvement is the single most important prognostic factor
      • TNM staging
        • extranodal metastases has more significance than lymph node metastasis
    • Prevention
      • mammography
        • effective screening tool except in young woman
          • dense breast tissue in young woman interferes with specificity and sensitivity
          • most effective in postmenopausal patients because of less glandular breast
        • identifies microcalcifications or moderate sized masses
        • all woman > 40 should have mammograms
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