Breast cancer is relatively common and politically visible. For these reasons. a screening programme was established and there have been more problems with objectivity than lower profile malignacies but at the same time a greater understanding by the public and indeed doctors due to relatively plentiful research funding. As a histologically, molecularly, and epidemiologically heterogeneous disease matters are sometimes quite complex however.
- ductal carcinoma-in-situ
- invasive ductal carcinoma
- lobular carcinoma-in-situ
- invasive lobular carcinoma
- patients are rarely younger than 35 years
- 1% occur in males
- Family history may sometimes indicate a strong trait suggesting one of the small number of recognised mutations.
- Family history - 1st degree relatives
- This risk factor could have either or both genetic and infective (oncovirus) relevance
- Contralateral breast carcinoma
- Atypical hyperplasia on previous biopsy
- Early menarche
- Painless lump in the breast
- Nipple retraction
- Nipple discharge
- Skin dimpling
- Peau d'orange
- Breast asymmetry
- Paget's disease of the nipple
- Symptoms of metastasis
- bone pain
Signs suggestive of carcinoma:
- Hard irregular mass
- Fixed to skin or deeply
- fixed → infiltration of skin, no mobility, skin cannot be moved over lump
- tethering → infiltration along ligaments of Astley Cooper, some mobility, skin dimples at extremes of movement
- Paget's disease
- Peau d'orange
- Axillary nodes (are they mobile, fixed, matted?)
- Supraclavicular nodes
- Signs of metastasis
- bone tenderness
- pathological fractures
- Pleural effusion
- personality change
'Triple assessment' of the breast lesion
- clinical examination
- imaging (mammography/USS/MRI)
- Bone scan
- USS of liver for secondaries
- CT scan of brain
- giving peau d'orange appearance
- axillary common (40-50% at presentation)
- lung / bone (most frequent)
- pleura leading to effusion
- infiltrating lobular carcinoma spreads to more unusual sites due to single cell spread
Staging and Grading
TNM System (AJCC 2002)
Greatest dimension of tumour:
This breaks down into the following stages:
|Stage 3C||Any T||N3||M0|
|Stage 4||Any T||Any N||M1|
- See also Breast cancer grading
Grading of breast cancer is usually based on the modified Bloom-Richardson grading system, which is used, along with other parameters, to calculate the Nottingham prognostic index.
Oestrogen (abbreviated ER) and progesterone receptor (PR or PgR) status is not strictly part of grading. This is commonly assessed using the Quick score (also known eponymously as the Allred score). An alternative method of scoring oestrogen receptor status is the H scoring.
It has implications for treatment in that hormone positive tumours are amenable to oestrogen antagonism, e.g. tamoxifen (see Treatment below) or aromatase inhibitors.
Her2 receptor expression is usually assessed using immunohistochemistry with recourse to in situ hybridisation in equivocal cases (or vice versa). Breast cancers which are Her2 positive can be treated with Trastuzumab (trade name Herceptin®).
When all 3 of the above markers are negative, the tumour is often referred to as a triple negative tumours and it tends to carry a poorer prognosis.
The prognostic relevance of mammary tumor virus sequencies in human breast cancer is presently unknown
The 10 IntClust groups appear to offer the most accurate prognostic data.
|Stage 0||Stage I||Stage II||Stage III||Stage IV|
|T0N0M0||T1N0M0||T1-2N1 M0 / T3N0M0||T1-4N2-3||M1|
- Most women, especially those with oestrogen receptor positive tumours (as determined by quick score according to the NHSBSP guidelines), are given tamoxifen for 5 years
- Trastuzumab has a role in HER2 positive breast cancer and NICE has recently recommended its use in early as well as advanced disease.
- NICE Guidelines on breast cancer
- NICE Guidelines on familial breast cancer
- SIGN guidelines on breast cancer
- ↑ Taneja P, Frazier DP, Kendig RD, Maglic D, Sugiyama T, Kai F, Taneja NK, Inoue K. MMTV mouse models and the diagnostic values of MMTV-like sequences in human breast cancer. Expert review of molecular diagnostics. 2009 Jul; 9(5):423-40.(Link to article – subscription may be required.)
- ↑ Curtis C, Shah SP, Chin S et al. The genomic and transcriptomic architecture of 2,000 breast tumours reveals novel subgroups. Nature 2012 doi:10.1038/nature10983
- ↑ Trastuzumab for the adjuvant treatment of early-stage HER2-positive breast cancer