“Uncontrolled cell growth in the breast”

Risk Factors
  • Female
  • Early age menarche
  • Late menopause
  • Oestrogen medications
  • Lack of childbearing and breast feeding.
Aetiology
  • Genetics (linked to a mutation in BRCA-1, TP53, BRCA-2, ERBB-2)
  • Environmental factors (e.g. exposure to ionising radiation via CT or MRI scans)
Pathophysiology
  • Two main types of breast cancer:
    • Ductal carcinoma in-situ (DCIS) (90%)
    • Lobular carcinoma in-situ (LCIS) (10%).
  • Breasts are made up of three parts – glandular tissue, stroma and lymphatic vessels.
    • Glandular tissue contains hormonal receptors e.g. oestrogen (ER), progesterone (PR), which stimulate the alveolar cells to divide
    • Each menstruation cycle causes a division of cells following by apoptosis
    • Every time cells divide, the risk of genetic mutations increase and thus increase the chance of tumour growth
    • If a mutation occurs, the affected cell (usually epithelial) will undergo uncontrollable division to form the tumour in the BM of the alveoli.
  • DCIS: tumour grows from wall to lumen. Can cross the BM to form an invasive ductal carcinoma.
    • Can lead to Paget’s Disease of the Nipple.
  • LCIS: clusters of tumour cells in the lobule, do not invade the ducts.
  • Some of the tumours also have hormonal receptors: ER+&HER2- (most common), HER2+/ER+/-, ER-/HER2+
Clinical Presentation
  • Local disease:
    • Breast mass – hard, painful, swelling
    • Nipple changes – itching, redness, crusting, discharge – Paget’s disease
    • Swelling under armpit – spread to axillary lymph nodes
    • Breast immobile/fixed – infiltration if cancer cells spread to pectoral muscles
    • Dimpling of skins – involvement of skin
    • Non-specific symptoms – weight loss, loss of appetite, fatigue
  • Metastatic:
    • Shortness of Breath – lung metastases, pleural effusion
    • Headaches/change of vision
    • Seizures – brain metastases
    • Abdominal pain – liver metastases
    • Bone pain/weakness/numbness – spinal cord compression
Investigations
  • Triple assessment: clinical examination, radiology, histology/cytology:
    • Mammogram, ultrasound of breasts (with/without MRI for younger patients)
    • Core biopsy of breast lesion/distant metastatic site
    • CT chest, abdomen, pelvis & bone scan for staging (if lymph nodes are present)
Management
  • Surgery:
    • Removal of the tumour by wide local excision (WLE) or mastectomy +/- axillary node sampling
  • Radiotherapy:
    • Recommended for all patients after WLE.
    • Axillary radiotherapy used if lymph node +ve.
  • Chemotherapy:
    • Considered if high-grade, HER2+, triply negative, node +ve, large tumour (e.g. epirubicin and CMF (cyclophosphamide, methotrexate, 5-FU).
  • Endocrine agents:
    • To decrease oestrogen activity, used in ER+ or PR+ (e.g. tamoxifen).
    • Aromatase inhibitors (e.g. anastrozole) only used if post-menopausal
Complications
  • Inflammation leading to fibrosis, Invasion of nearby tissue (e.g. muscles, skin), entrance and blockage of lymphatic vessels (→ Peau D’orange appearance), tumour spreading via blood and lymph to other tissues

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