Infiltrating Ductal Carcinoma
This is the most common breast malignancy accounting for 80% of breast cancers. Most are unilateral and start as atypical ductal hyperplasia which may progress to ductal carcinoma in situ (DCIS) which then may break through the basement membrane and progress to invasive ductal carcinoma. Over time the tumor will become a stony hard mass as it increases in size and undergoes a fibrotic response.
Infiltrating Lobular Carcinoma
This is the second most common breast malignancy accounting for 10% of breast cancers. Most are unilateral and start as lobular carcinoma in situ (LCIS) which then may break through the basement membrane and progress to invasive lobular carcinoma. The prognosis is better with lobular than with ductal carcinoma.
Inflammatory Breast Cancer
This is an uncommon breast malignancy. Usually, there is no single lump or tumor. It is charac-terized by rapid growth with early metastasis. As the lymphatics get blocked, the breast becomes erythematous, swollen and warm to examination. The edematous skin of the breast appears pitted, like the skin of an orange, giving the classic peau d’orange appearance.
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USMLE Step 2 l Gynecology
Paget Disease of the Breast/Nipple
This is an uncommon breast malignancy with a generally better prognosis than infiltrating ductal carcinoma. The lesion is pruritic and appears red and scaly often located in the nipple spreading to the areola. The skin appearance can mimic dermatosis like eczema or psoriasis. The nipple may become inverted and discharge may occur. It is almost always associated with DCIS or infiltrating ductal carcinoma.
Breast Cancer Risk Factors
BRCA 1 or 2 gene mutation RR 15
Ductal or Lobular CIS RR 15
Atypical hyperplasia RR 4
Breast irradiation age < 20 RR 3
Positive family history RR 3
Sentinel Node Biopsy
A sentinel node (SLN) is the first lymph node(s) to which cancer cells are likely to spread from the primary tumor. Cancer cells may appear in the sentinel node before spreading to other lymph nodes. A dye is injected near the tumor to allow flow to the SLN. A biopsy of the dye-stained node is performed to help determine the extent or stage of cancer. Because SLN biopsy involves the removal of fewer lymph nodes than standard lymph node removal procedures, the potential for side effects is lower.
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Node-Positive Early Breast Cancer
A healthy 55-year-old woman had a lumpectomy (negative margins) and axillary node dissection for a 2.5-cm tumor in the upper outer quadrant of the left breast, with three positive lymph nodes. The tumor was positive for both estrogen and progesterone receptors. She comes to the gynecologist’s office wanting an opinion about further therapy.
Management. Breast-conserving therapy with a wide excision (lumpectomy), axillary dissec-tion (or sentinel node biopsy), and radiation therapy is considered the preferred treatment for most patients with stage I or II breast cancer.
In patients at moderate or high risk of developing systemic metastasis, it is preferable to give adjuvant therapy, beginning with chemotherapy followed with radiation therapy. This patient has a high risk of recurrence because of the presence of lymph node metastasis, and it would be inappropriate to withhold further therapy.
Another high risk factor that this patient has is that the tumor is larger than 1 cm. Recommended adjuvant treatment for patients with node-positive breast cancer is explained in the table below.
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Chapter 13 l The Female Breast
A large number of prospective randomized trials, as well as recent overviews and meta-analysis of adjuvant systemic therapy, have determined that both chemotherapy and tamoxifen therapy reduce the odds of recurrence in breast cancer patients. A few randomized clinical trials and the overview of meta-analysis of randomized clinical trials have suggested that the combination of chemotherapy and tamoxifen is superior to chemotherapy alone or tamoxifen alone in post-menopausal patients with node-positive breast cancer. Women with estrogen receptor-negative breast cancer appear to have no improvement in recurrence or survival from tamoxifen use.
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It has been established that combination chemotherapy is superior to single-agent therapy, and that 4 to 6 cycles of combination therapy are as effective as >6 cycles of treatment.
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