MALINANT Breast Cancer 5

6. SPECIAL INVESTIGATIONS

 

6.1 MAMMOGRAPHY

 

Mammography is an X-ray examination of the breast.

 

This technique is helpful in diagnosis in cases where the mass is

ill-defined in outline.

 

This  is true mostly in large fatty breasts where tumours  cannot

be easily felt.

 

6.2 THERMOGRAPHY

 

This  techniqe  measures  the amount of  heat  in  masses,  since

tumours  are more vascular they are detected by heat scanners  as

hot spots on a film

 

It  is worth remembering that infections may also be  represented

as hot spots because of the accompanying vascularity.

To day a combination of:

Clinical examination

Ultrasound

And NMR are most depended on.

 

 

6.3 FINE NEEDLE ASPIRATION CYTOLOGY(FNAC)

 

An experienced cytologist can usually give an accurate  diagnosis

on the small amounty of cellular material made available by  fine

needle  aspiration of a breast lesion.  The level of accuracy  is

variable.

 

6.4 EXCISION BIOPSY

 

This method is perhaps the most dependable means of coming to  an

accurate tissue diagnosis.

 

In  all suspicious masses information can be obtained  by  frozen

sections  and surgery planned during the same  anaesthetic  after

obtaining results.

 

6.5 ESTROGEN RECEPTORS

 

Estrogen  sensitive  target tissues (Breast,  uterus  etc.)  have

specific protein receptors for this hormone.

 

   *  Breast  cancer  tissue can also retain ability  to  produce,

      these receptors(receptor positive cases).

   *  These  cases have a better prognosis and are responsive  to

      hormone  manipulation.  The change in hormonal  environment

      is achieved by:

      i)   Oophorectomy

      ii)  Stilbestrol therapy

      iii) Tamoxifen therapy

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MALIGNANT Breast tumour 4

4.7 CLINICAL FEATURES

 

*  Carcinoma  of  the  breast  is relatively slow-growing tumour.

   Average  expectation  of  life  in  a  patient  that  gets  no

   treatment is three years.

*  It  appears as a small (1 cm.) nodule in any quadrant  of  the

   breast.

*  This   slow  growing  nodule  is  painless;  usually  has   no

   accompanying symptoms.

*  On  palpation,  a  lesion  is firm  to  hard,  its  edges  are

   distinct, usually irregular, at an early stage the nodule  may

   show  no evidence of attachment to  surrounding  structuresand

   move freely.

*  This  type of presentation is no problem as  regard  diagnosis

   and occurs in nearly 80% of all breast cancers.

*  The sites of the lesions and examination methods are  depicted

   in Fig. 13.6

 

The  remaining  tumours (20%) the presentation  is  atypical  and

requires distinguishing from other benign lesions of the breast.

 

5. T.N.M. CLASSIFICATION

 

The  details  are  giv  in  Table above  the  purpose  of  this

classification is to be able to accurately record, the extent  of

lesion  (to compare results with other people's cases) and to  be

able to give a reasonably accurate prognosis.

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Malignant Breast tumour 3

4.3 CLINICAL EXAMINATION

History  and physical examination of the breast is, perhaps,  one

of  the  most  important aids to diagnosis in a  case  of  breast

lesion 

    * A  firm  to hard, painless mass in the breast of  a  female

      over the age of twenty is highly suspect of malignancy.

    * There are however,other significant clinical manifestations

      - like indrawing of the nipple.

      - asymmetry of the breast,

      - involvement of the skin leading to

      - fixity  to  the skin and orange peal  appearance  of  the

        skin, later frank infiltration and ulceration.

    * There is on occasions a weeping eczematous condition,of the

      nipple  and areola in cases with underlying  breast  cancer

      which  is  reffered  to as Pagets' disease  of  the  nipple

      already mentioned above.

      High risk factors are history of breast cancer in the patients past or in the family.History of cancer in situ in the patient ia also a high risk factor. 

All these  must be enquired into while taking a history and recorded.

 

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MALIGNANT Breast tumour 2

4.2 PATHOLOGY

The  lesion  is an adenocarcinoma and the cell of origin  is  the

epithelial  lining  of the lactiferous ducts and lobules  of  the

breast. 

In  most cases it originates from the  duct  epithelium. 

The classification used by most pathologists is:

    1.In  Intraduct and Intralobular  Non-infiltrating  carcinoma

      (Carcinoma   in   situ)   DCIS:   Cell   morphology   shows

      hyperchromatic nuclei and mitotic figures with no  invasion

      of basement membrane.

      Those  showing  papillary overgrowth are  called  papillary

      carcinoma.

    2.Infiltrating  Adenocarcinoma constitutes 75% of cases  seen

      in practice.

      There is intense fibrosis (Scirrhus)

      On   microscopic  examination  it  shows  all  degrees   of

      differentiation  from  anaplastic  to  well  differentiated

      tumours.

      The  fibrosis  can  also be of  different  grades  mild  to

      moderate or severe (atrophic scirrhus)

    3.Medullary  carcinoma  a  type  of  carcinoma  with  minimal

      fibrosis  cells arranged in anastomosing large islands  and

      the scanty fibrosis shows lymphocytic infiltration.

      It is a slow growing carcinoma.

    4.Inflammatory  carcinoma usually occurs in younger women  in

      pregnancy  or post-partum period, acute in onset and  there

      is redness and pain.

      Microscopic examination shows undifferentiated tumor cells,

      lymphatics and veins are involved by tumour cells.

    5.Paget's  disease  of  nipple: The  disease  presents  as  a

      weeping eczema of the nipple. 

      The  areola and surrounding skin may be involved. There  is

      always an underlying carcinoma of the breast.

      Microscopically  a biopsy of the involved  eczematoid  area

      will show:

       *  Large vacuolated clear Paget's cells

       *  Round cell infiltration

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MALIGNANT Breast toumor 1

4. CARCINOMA OF THE BREAST

Breast  carcinoma is the second most common carcinoma in  females

in India , the first being carcinoma of the cervix.

    * In the United States , one out of four women will get cancer breast in that country.

    * In  world-wide  figures, the highest  incidence  of  breast cancer is among the Dutch and lowest among Japanese women.

    * There is  a five fold difference in breast cancer in the diferent regions of the world.

 

4.1 ETIOLOGY

The  disease  is  almost  always met  with  in  females, and is extremely rare in males.

    * Breast  cancer is not met with before puberty and  is  very rare before the age of twenty.

    * In  many  instances,  family history of  breast  cancer  is available. It is known that in those who have this history,the female off-springs have two to three times higher  risk

of developing cancer of the breast.

    * It has also been noticed that in the subsequent generations cancer occurs earlier.

    * It  has  been  known for sometime that cancer  in  mice  is transmitted through a factor found in milk (Bittner's  milk virus) of the mothers.

    * Diet rich in saturated fats is suspected cause.  It  is common in Developing countries and in the obese.

    * It  is  common in nulliparous. Less common if  first  child before 20 years.

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