Breast cancer

How many types of breast cancer are there?

It is usually classified in infiltrating ductal and in infiltrating lobular, depending on whether it originates from the cells of the epithelium of the lobules or from those of the ducts. Infiltrating because it extends beyond the epithelium, also affecting nearby and sometimes distant structures (metastases to lymph nodes and other organs). In the infiltrating ductal carcinoma group there is a subgroup of tumors which is called infiltrating ductal carcinoma not otherwise specified (NAS), extremely aggressive and malignant, and which unfortunately accounts for 50% of breast cancers. Infiltrating lobular carcinoma, on the other hand, is divided into five varieties: classic, solid, tubulo-alveolar and mixed. The solid and tubuloalveolar forms have a better prognosis than the other three.
There is also Paget's carcinoma, a variant in its own right, in which the tumor cells originate from the epithelial cells of the nipple, which appears red, retracted and sometimes bleeding. This tumor is often associated with infiltrating ductal carcinoma, most frequently of the NAS type.
The inflammatory carcinoma it is characterized instead by a rapidly growing thickening, often painful, with the overlying skin that appears hot, red and swollen. It metastasizes very quickly and early, especially to the lymphatic system.
Finally, we find the juvenile carcinoma, which is very rare and has a fairly favorable prognosis.

Breast Cancer Symptoms and Signs

For further information: Breast cancer symptoms

The symptomatology depends on the type of tumor, its diameter, its spread, and the age of the patient. In the initial forms, we will have an early symptomatology, characterized by the presence of a single mass, generally less than 5 centimeters in diameter, but with however, an extremely variable volume, with a hard, fibrous, almost wooden consistency (like wood) with poorly definable margins, mobile or not very mobile on the underlying superficial and deep planes.It may also not be dissociable from the surrounding tissues and is initially not painful. Moderate erosions or swelling or serous or blood secretions from the nipple, puckering of the overlying skin, increase in volume of the axillary lymph nodes on the same side of the diseased breast, which are still mobile, however, may coexist. Late signs, typical of an already advanced tumor, instead they are due to the presence of a mass of considerable volume, greater than 5 centimeters, fixed, not mobile, with respect to the planes the underlying (pectoral muscle and chest wall), with associated edema (swelling) of the breast, which is also red, painful, with swelling adhering to the skin (orange peel skin) and its infiltration or ulceration, sometimes skin nodules ( secondary tumors that have detached from the main mass), axillary lymph nodes enlarged and fixed in the underlying planes, nipple retraction, sometimes arm edema on the same side of the tumor.
The cancer can spread to nearby organs, such as the lung, or through the lymphatics, to the lymph nodes in the armpit, through the blood, to the bones, liver and brain.

Diagnosis

See also: CA 15-3: tumor antigen 15-3

It is very important to question the patient (anamnesis), to know the existence of a possible risk factor, especially for a breast cancer in the family. Subsequently, the doctor will move on to the "inspection, to see any asymmetries of shape or volume of one breast with respect to the other, and to palpation, which must be done with the patient lying with his arms behind his head: he will evaluate the consistency, volume, tenderness and mobility of the nodule with respect to the underlying planes. We will then move on to the instrumental diagnosis: the mammography to both breasts (bilateral) it is essential to plan any diagnostic procedure and also therapy. It can highlight a tumor before the mass becomes palpable (preclinical phase) and recognizes about 70% of lesions smaller than 1 centimeter thanks to the stereotaxic technique, that is the three-dimensional configuration of the suspected area. The main advantage of mammography is that of be the most reliable exam to see small diameter lesions. The disadvantages, on the other hand, concern its reduced specificity in a breast of young women or in the detection of a very peripheral tumor.cytological examination by fine needle aspiration: with a fine needle, under the guidance of the ultrasound, material is aspirated from the lesion, which will then be analyzed under a microscope to see what type of cells form it (whether malignant or benign). The cytological examination can also be performed on discharge from the nipple, or on any questionable swelling. In the event that this assessment has not been carried out, or in any case it has not resolved the doubt about the diagnosis, one will be carried out biopsy, i.e. a small surgery to remove a small piece of tumor lesion, which will be further analyzed under a microscope to see how much surrounding tissue has been invaded (histological examination).
L"ultrasound it is especially indicated for differentiating fluid-filled cysts from solid lesions, as a diagnostic study in dubious palpable lesions in association with mammography, and as a guide for fine needle aspiration. It has low sensitivity for minor lesions of a centimeter, but it is preferable as a control tool in young women under 30, who have dense breasts that can be better explored with this technique.

Finally, there is an exam called duttogalactography, which consists in "injecting with a needle a colored radioactive substance into the mammary ducts. If there is a mass, on X-rays you will see a defect in filling the ducts with the dye. It does not differentiate me between benign and malignant lesions, but it is indicated in the case of serous or blood secretions from the nipple or in the suspicion of a ductal tumor.

Screening

Breast self-examination

Breast self-examination is very important, which the woman should carry out from the age of 20 every month, preferably in the week in which she has just finished menstruation (the breasts are less swollen), stretched out and with one arm behind her head. the contralateral hand must start from the nipple and, with circular movements of first light and then deeper palpation, go to probe the whole breast, up to the chest, and also the axillary lymph nodes. The gynecologist or family doctor can also evaluate the breast of the patient, if requested by the same.
From the age of 20 to 40, in addition to self-examination, the woman should undergo a breast examination at least once every three years, especially if she takes the contraceptive pill; here she will be given a more in-depth examination and an ultrasound.

Mammography

For further information: Mammography

The first mammogram must be performed at the age of 40, and from there every 12 months. In patients at risk for familiarity or other, it should instead start at 30, and then always once a year. If there is a palpable non-malignant nodule, mammography should be repeated after 6 months.

If the lump is suspected of being malignant, but is less than 2 centimeters, one should be made after 2 months to see if it has grown or not; if it is suspicious and greater than 2 centimeters, a fine needle aspiration should be done immediately. After the age of 55, mammography can be performed every two years instead of once a year, since the age most at risk for developing it is from 40 to 50-55 years and instead, after menopause, the breasts undergo a certain degree of atrophy.

Surgical therapy

For further information: Mastectomy

For many years, total mastectomy (removal of the entire breast) represented the therapy of DCIS (ductal carcinoma in situ); however, while reducing the number of local recurrences (with mastectomy they were 1-2%, today, without total mastectomy, they are 15-20%), it does not confer any improvement in survival compared to conservative surgery (removal of only one piece breast → partial mastectomy).

Furthermore, radiotherapy is now also used after surgery: it reduces the number of local relapses in patients who have not undergone total mastectomy and is currently considered a standard treatment for the majority of patients with DCIS.

All in all, however, although most women with DCIS are candidates for conservative surgery, total mastectomy is still the treatment of choice for small tumor lesions spread throughout the breast.

Finally, the effectiveness of hormone treatments with a drug called tamoxifen in reducing the risk of local recurrence and contralateral breast cancer. It is an anti-estrogen compound, meaning it prevents estrogen from making cancer cells proliferate.
Radical mastectomy dates back to 1894, and represents the practical application of a theory according to which cancer is a disease that spreads from the site where it originates to nearby (regional) lymph nodes following the lymphatic vessels (which lead to them) in an orderly manner. .
The development of more conservative surgical techniques, and therefore which avoid the removal of an "entire breast, stems from the concept according to which breast cancer is a disease that, from its onset, affects the whole body (systemic involvement), for the frequent presence, from the beginning, of its microscopic metastases in bone marrow, liver and lungs. It follows that, according to this theory, radical surgery does not improve survival, which instead can be improved by combining radiotherapy or chemotherapy with conservative surgery.
Since the 1970s, numerous studies have shown that there are no differences, in terms of prognosis, between conservative treatment and more radical and disfiguring surgery. For patients with tumors in the early stages, conservative surgery is recommended followed by radiotherapy, unless a different preference of the patient or in the presence of contraindications. In any case, the choice of the type of surgical treatment must take into account the preferences of the woman, since conservative treatment implies the willingness to undergo sessions for 5-6 weeks daily radiotherapy and to accept the risk of local recurrence of the order of 10%, which is higher than that of patients undergoing total mastectomy.