Table 18.1 Nomenclature of bone tumors
Breast cancer is the most common cancer in women who do not smoke. The screening programme in the UK, with biplanar digital mammography every 3 years in women aged 50-70 and improvements in multimodality treatment, have improved overall survival and rates of cure, while breastconserving surgery has greatly ameliorated the psychosexual impact of the disease.
The term breast cancer refers to invasive carcinoma of the breast, whether ductal or lobular.
Carcinoma of the breast
SYMPTOMS AND SIGNS
Most women with symptomatic rather than screen-detected breast cancer present with a painless increasing mass which may also be associated with nipple discharge, skin tethering, ulceration and, in inflammatory cancers, oedema and erythema. In developing countries, 80% are likely to present with advanced disease and metastases.
EPIDEMIOLOGY & DEMOGRAPHICS
• Nearly exclusively the disease of women, with only 2% of breast cancers in males
• Steady increase in its incidence in the U.S., with 205,000 new patients annually
• Annual mortality of 40,000
• Risk steadily increases with age
• Genetically defined group of women with BRCA-1 or BRCA-2 identified to carry lifetime risk as high as 87%
• Increasing number of small breast cancers found by mammograms
• Patients usually completely free of physical findings
• Palpable tumors possibly as small as 1 cm or even smaller
• Size of the mass and its location measured and documented
• Skin and/or nipple retraction and skin edema / erythema /ulcer / satellite nodule
• Nodal enlargement in axilla and supraclavicular areas
• Advanced disease: clinical signs of pleural effusion and/or hepatomegaly
• Rare instances: clear, serous, or bloody discharge only symptom
• Nipple evaluation
• Precise mechanism of carcinogenesis not understood
• Possibly interaction of ovarian estrogen, nonovarian estrogen, estrogens of exogenous origin with breast tissue of varied carcinogenic susceptibility to develop cancer
• Other known or suspected variables: childbearing, breast-feeding practice, diet, physical activities, body mass, alcoholic intake
• Have identified families with known high risk
• Women with BRCA-1 and BRCA-2 associated with high risk
The following nonmalignant breast lesions can simulate breast cancer on both physical and mammogram examinations:
1. Fibrocystic changes
Mammograms: 35% to 55% of breast cancers detected by screening mammograms only as a spiculated mass, a mass with or without microcalcifications, or a cluster of microcalcifications (Fig. 66)
• Physical examination:
1. Mass detected by patient or medical professional: workup required
2. Negative mammogram: breast cancer not ruled out
3. Sonogram: to demonstrate mass to be cyst, usually eliminating need for further workup
• To establish diagnosis:
1. Positive aspiration cytology on a clinically and mammographically malignant mass-highly accurate but still requires open biopsy confirmation
2. Stereotactic core needle biopsy diagnosis: reliable with invasive carcinoma identified, but negative or equivocal results require careful evaluation
3. Atypical hyperplasia or in situ carcinoma found by core needle biopsy: open surgical biopsy confirmation still required
4. Excisional or incisional biopsy: establishes diagnosis
• NOTE: Do not rely on negative mammogram or negative aspiration cytology to exclude malignancy. Make appropriate referral. Obtain imaging studies such as bone scan, chest x-ray examination, CT scan of abdomen, or CT scan of liver.
Surgery may vary from wide local excision or segmental mastectomy and breast conservation for masses < 4 cm in diameter, to simple mastectomy with or without reconstruction. The choice is dictated by the location and extent of the breast mass in relation to the breast size, and patient preferences. Surgery of the axilla is by sentinel lymph node guided sampling (after dye injection) in the absence of clinical or radiological (usually ultrasound) evidence of lymphadenopathy, or full dissection to level 3 if there are clinically involved nodes in order to gain local control and provide prognostic information to guide adjuvant treatment. The greater the amount of axillary surgery the more the risk of post-operative lymphoedema.
Radiotherapy is given to the conserved breast after wide local excision to reduce local recurrence, and to the chest wall after mastectomy if there are risk factors such as proximity to surgical margins or lymph node metastases, to complete the local control measures. Radiotherapy to the axilla and supraclavicular fossa can be added after sampling but not full dissection of the axilla because the combination raises the risk of severe lymphoedema to 30%. Adjuvant radiotherapy reduces the risk of local recurrence by 27% and improves 10-year survival by 5%.
Recent data suggest that women over 70 years with oestrogen receptor positive cancers up to 2 cm diameter may be offered surgery and tamoxifen alone without radiotherapy, without compromising outcome.
• Early breast cancer: primarily surgical or surgical and radiotherapeutic
• Choice in 65% to 75% of women between modified mastectomy and breast-conserving treatment, which consists of lumpectomy, axillary staging with sentinel node biopsy or axillary dissection, and breast irradiation
ACUTE GENERAL Rx
• May require adjuvant chemotherapy or endocrine therapy
• Evaluation and treatment by medical oncologist
Follow-up required after proper treatment of primary breast cancer includes:
1. Periodic clinical evaluations
2. Annual mammograms
3. Other tests as indicated
4. Patient instruction in monthly breast self-examination technique
• Prognosis after curative therapy: depends on size of tumor, extent of nodal metastasis, and pathologic grade of tumor
1. Patient with 1-cm tumor with no axillary node metastasis: 10 years disease-free survival rate of 90-95%
2. Patient with 3-cm tumor with metastasis in four nodes: 10 years disease-free survival rate of 15-20% if no systemic adjuvant therapy given
3. Outlook for most patients is between these extremes
• Systemic adjuvant therapy: improves prognosis significantly
Figure 66: A, Right mediolateral and, B, spot magnification view from routine screening mammography demonstrates a small, ill-defined mass with minimal spiculation. This was nonpalpable, and biopsy demonstrated infiltrating ductal carcinoma