Abnormal cells may:

  1. If you become cancerous,
  2. Invade the surrounding tissue.

With screening, medical examinations for early detection and subsequent treatment, most people with breast cancer can lead a normal life.

 

Anatomy from mama

Adipose tissue
The female breast is composed primarily of a collection of fat cells, called adipose tissue. This tissue extends from the clavicle to the axilla, to the center of the rib cage.

Wolves, lobes and ducts
A female breast is composed of 12 – 20 sections called wolves.
Each of these lobes consists of many smaller lobes where there are glands that produce milk.
Both lobes and lobes have milk ducts, ie tubes that carry milk to the nipple.
These structures, lobes and lobules of the breast are usually the parts where the cancer begins to form.

The lymphatic system
Inside the adipose tissue is a network of ligaments, a fibrous connective tissue with:

  1. Nervous,
  2. Lymphatic vessels,
  3. Lymph nodes,
  4. Blood vessels.

The lymphatic system is a part of the immune system, is composed of a network of lymphatic vessels and lymph nodes located throughout the body.
A part of the fluid that is in the interstitial tissues (between the cells) enters the lymphatic system.
Inside the lymphatic vessels, the flow of fluid goes from the periphery to the heart.
This liquid is composed mainly of :

  1. Fat,
  2. Large proteins,
  3. Debris of inflammation,
  4. Cell waste,
  5. Bacteria and viruses,
  6. Normal and tumor cells.

 

Classification of breast cancer

Breast carcinoma is divided into two types:

  • Ductal carcinoma arising from ducts (more frequent),
  • arcinoma lobular derived from glandular component (more stealthy, usually multi – center, can be bilateral, often more aggressive than ductal).

 

Causes of breast cancer

The exact causes of breast cancer are not known.
What we do know is that breast cancer is caused by:

  1. Changes in the DNA of a cell,
  2. Factors that worsen cell damage as a lifestyle.

 

Genetic risk factors

  • Age , the risk of breast cancer increases after 50 years of age.
  • Breast cancer is diagnosed more often in Caucasian women ,
  • Family history The risk is highest for people with breast or ovarian cancer in the family, especially first-degree relatives (eg, mother-daughter).
  • Clinical history : If other breast cancers have already been diagnosed, there is a greater likelihood of developing cancer in the future.
    In addition, the risk increases if breast cancer cells originated from lobular carcinoma in situ (LCIS) or ductal carcinoma in situ (DCIS).
  • Menstrual history : Premature menarche (menstruation before 12 years of age), late menopause (after 55), having the first child at a later age (after 30 years) or being nulliparous (not getting pregnant) may also increase the risk.
  • Mutations in certain genes such as BRCA1 and BRCA2 are risk factors.
  • Dense breast tissue : Having less fat in the breast tissue can increase the risk of cancer and the lumps are harder to detect. Young women have less fat tissue than older women.
  • Obesity and overweight : excess fat can alter the production of hormones thus increasing the risk of breast cancer.
  • Estrogen-based treatments : Excessive use of estrogen increases the risk of developing breast cancer.

Deodorants do not cause breast cancer.

 

Breast cancer growth

Breast cancer can spread in three ways:

1. Abnormal cells multiply causing tumor growth.
2. Hormones and chemicals in the body can accelerate the growth of some tumors.
3. Through the lymph nodes and blood vessels it can spread to other parts of the body.

If the tumor is diagnosed in the neighboring sentinel lymph node of the breast, it means that the cancer has spread.
If there are cancerous cells in the nearest lymph nodes, the doctor examines the more distant lymph nodes to check for the presence or absence of tumor cells.
Histological examination of the lymph nodes may help to detect the progression of the disease.

 

Altered
Cells Healthy cells are the “bricks  of building all the tissues and organs of the body.
When the cellular DNA is altered, it is possible that the mutant cells reproduce rapidly in an uncontrolled way.
Aggressive cell growth can form a mass of tissue that does not work as it should, so it creates a tumor.
Damaged cells can form breast cancer and can spread to other parts of the body.

Acceleration of cancer growth

The growth and spread of breast cancer can be difficult to control because it is stimulated by certain substances that are normally found in the body, such as:

  1. Estrogen,
  2. Progesterone,
  3. Epidermal growth factor.

Cells have receptors on the outside of the cell membrane.
We need to think of a receiver as a mouth.
When it is opened, the cancer cells can feed and grow.
When it is closed or blocked, the same cells stop growing or die.

 

Breast cancer in men

All people are born with breasts (male or female), but in men they do not develop after puberty.
Although men do not develop breasts, a man’s breast cells can develop cancer.
Male breast cancer is rare.
One percent of all breast cancer cases affect men.
Breast cancer in men is generally identified as a   hard nodule under the nipple and areola.
Men have a higher mortality than women, mainly because there is less awareness and men are less likely to assume that a lump may be breast cancer.
This may cause a delay in treatment.

Infiltrating ductal carcinoma in men

In most men who develop breast cancer, it is an infiltrating ductal carcinoma (IDC), which means that the cancer cells inside the ducts go beyond the duct wall.
The diagnosis of Paget’s disease of the nipple is very rare in man.

 

Staging: Stages of Breast Cancer

Breast cancer can be divided into four stages, which are distinguished based on:

  1. Size of tumor (lump),
  2. It has spread to the lymph nodes or elsewhere in the body.

Stage 1 – The tumor is smaller than 2 cm and has not spread to the lymph nodes in the axilla.

Stage 2 is divided into two phases:

  • Stage 2A – The nodule is less than 2 cm and has spread to the lymph nodes in the armpit or is larger than 2 cm (but less than 5 cm) and the lymph nodes are unaffected or the tumor is not in the breast, but it is in the lymph nodes in the armpit.
  • Stage 2B – The lump is less than 5 cm and has spread to the lymph nodes in the armpit or is larger than 5 cm but has not spread to the lymph nodes.

Stage – 3 is divided into three phases:

  • Stage 3A – The lump is greater than 5cm and the cancer is in the lymph nodes of the axilla or the lump is larger than 5cm and has spread to the surrounding tissues.
  • Stage 3B – Cancer has spread to the tissues near the breast and can be attacked the surrounding skin or muscle. There are only cancer cells in the lymph nodes in the armpit.
  • Stage 3C – Cancer has spread to the lymph nodes under the axilla that are thickened, under the sternum, near the neck or below the collarbone.

Stage 4 – Cancer has spread to other parts of the body such as the lungs, bone, liver. This is called metastatic cancer in the breast.

 

What is metastatic breast cancer?

Metastatic breast cancer is classified as stage 4
breast cancer . Cancer has spread to other parts of the body.
Usually metastases occur:

  1. In the lungs ,
  2. In the liver ,
  3. In the bones ,
  4. In the brain.

 

How does cancer spread or metastasize?

Propagation can occur through one or more of the following:

  1. Cancer cells invade surrounding healthy tissues and replicate much more.
  2. Cancer cells enter the circulatory or lymphatic system . They then travel through the walls of the lymphatic vessels or blood vessels.
  3. Migration through the circulation . Cancer cells are transported through the lymphatic system and the bloodstream to other parts of the body.
  4. Cancer cells in the capillaries . The cancer cells are in the capillaries and migrate to the surrounding tissues.
  5. Cancer cells form small tumors in another organ (called micro metastases).

 

Symptoms of breast cancer

Signs and symptoms of breast cancer  include:

  • A breast nodule or a thickening that feels different from the surrounding tissue;
  • Pain in the breasts and breast swollen locally, but not always;
  • Blood or liquid secretions from the nipple  of a breast (usually when it occurs in both breasts the cause is hormonal);
  • Change in size or shape of breast;
  • Skin changes on the chest, such as an orange peel;
  • Retraction of the nipple;
  • Decrease or peeling of the skin of the breast or nipple;
  • Redness of the skin of the breast.

 

Diagnosis of breast cancer

Breast self-examination that every woman should do once a month throughout her life is very important.
It is done 4-5 days after the end of the cycle, the woman has to palpate her breasts and look for:

  1. Any nodule,
  2. A retraction of the skin,
  3. Nipple color changes,
  4. Secretions.

Clinical examination is important to evaluate the patient, but the most useful examination is mammography .
The first time can be done after 40 years (not before because the results are reliable in the “clear” breasts, that is, with fat) or earlier if the woman:

  1. It has heredity,
  2. If there are clinical signs.

Imaging tests

The clinical tests and tests used to diagnose and monitor breast cancer patients are:

  • Mammography is a radiological examination and is the standard examination for breast control and for the diagnosis of the tumor. If there is any opacity in the image it is necessary to do other researches.
    Today, most cancers are diagnosed through mammography.
  • The ultrasound . With ultrasound it is possible to see the lymph nodes of the breasts, armpits, neck and chest. Ultrasonography  shows if a lump in the breast and lymph nodes contain solid or liquid material: if the contents are liquid, it is a cyst.
    This test can not see microcalcifications.
    Color Doppler ultrasonography allows visualization of nodule vascularization.
  • Magnetic resonance imaging (MRI) that identifies the lumen very well and allows one to understand whether it is benign or malignant. The resonance also allows to identify the blood vessels that reach the tumor and allow it to grow.
    It is made in women with hereditary breast cancer and in women diagnosed with breast cancer at a young age. It is a thorough examination that studies both breasts, in lobular tumors is very useful. It is always performed in women who undergo preoperative chemotherapy.
  • CT scan to see if cancer has spread.
  • Positron emission tomography ( PET) The doctor injects a radioactive drug to check if the tumor has spread to the lymph nodes or if there are distant metastases; This test is used for tumor staging.

Biopsy
Breast biopsy consists of fine needle aspiration to remove abnormal cells. A mammary biopsy guided by stereotaxy ( mammography ) or by ultrasonography is done.

Among the latest innovations in the diagnosis of breast cancer is  the mammotomy(breast biopsy variant).
This is a surgical biopsy made with a computerized machine that can locate the cancer and remove only the suspicious tissue.
The removed breast tissue is analyzed in the laboratory.

Other tests that may be done:

  • Galactography : the contrast medium is injected into the dilated ducts. It is performed when the woman has nipple discharge. Usually the cause is a papilloma growing in a duct: a benign lesion that causes blood secretion in women who have had a pregnancy and who have breast-fed. The galotography allows highlighting the papilloma. The doctor recommends the removal of this lesion because sometimes, after 40 years of age, it can progress to a malignant tumor.

  • Cytological examination : it is performed in case of secretion of the nipple and it is also essential to study the nodules through fine needle aspiration. If possible, it is best to do a histological examination with the tissue taken during the mammotomy.
    This test is performed under local anesthesia .
    A needle with a size of 12-14 gauge (about 2.5 mm diameter) is inserted into the lesion identified on the radiograph, this examination is guided by computer. Through a suction system (vacuum-assisted aspiration biopsy) it is possible to obtain a tissue cylinder to perform a histological examination.
  • Surgical biopsy : it is done only in cases where the other tests were not conclusive (aspiration puncture, biopsy)
  • Nipple biopsy : In addition to ultrasonography and mammography, which are sometimes negative, a suspected Paget tumor is performed a nipple biopsy.

Metastases – Found mainly in the bones, lungs and liver, then in the brain; for this reason, to determine the stage of cancer, it is always performed also:

  • A chest X-ray,
  • A bone scintigraphy,
  • Ultrasonography of the liver.

HER2 hyper-expression with immunohistochemistry
The amount of protein produced by the HER2 gene in the cell membrane must be assessed.
All epithelial cells have this protein, but in minimal amounts (a minimal positivity is a normal situation), so you need to check:

  1. The intensity of the immunohistochemical staining,
  2. If the staining is present on the entire cell membrane or only on one part.

In diagnosis, the positivity of the HER2 gene must be distinguished by 4 degrees based on staining.

Score Coloring
0 No coloring
1+ The cell membrane is not completely colored. There is no overexpression  of the  gene.
2+ The color of the membrane is complete, but it is weak. It is necessary to deepen directly evaluating the gene and not only the protein produced by the hyper-expressed gene
3+ It is the positive reaction. The coloration involves the entire membrane and is very intense.

 

There are some poorly differentiated carcinomas that look like sarcomas; these carcinomas are high grade and usually do not have:

  1. The estrogen and progesterone receptors,
  2. Overexpression of the HER2 gene.

To know if a triple negative carcinoma is a sarcoma, one must look for cytokeratin (a protein found in epithelial cells), if present it means that the tumor is a carcinoma.

Sentinel lymph node examination with ultrasound guided biopsy.
Sentinel lymph node biopsy is the most common way to see if axillary lymph nodes are affected by cancer.
Research has shown that this method is very useful for assessing the condition of the first lymph node of the lymphatic chain.
If the first lymph node in the chain is negative, probably all the others are also negative.
Sentinel lymph node biopsy can correctly diagnose lymph node condition in 97% of women with cancer.
It is possible not to diagnose a positive (false negative) lymph node, which occurs in approximately 7% of cases.

Prevention of breast cancer

Years Exam
20-30 Self exam
30-40 Annual visit and periodically an ultrasound
40 First mammogram
40-45 If the first mammogram is negative, wait 2-3 years
45-75 Annual or semi-annual screening depending on the case
> 75 Continue periodic checks

You should never underestimate a woman with mastitis because underneath it there may be a tumor, so the doctor may prescribe:

  1. A mammogram,
  2. An ultrasound,
  3. The needle aspiration by fine needle.

 

Follow up / Clinical controls

After surgery for an invasive or infiltrating carcinoma in the breast, the program can predict the following tests:

  • physical examination every 4/6 months for 5 years and thereafter every year.
  • After a nodulectomy  or breast surgery, you can schedule a breast mammogram in question 6 months after the end of radiotherapy and then a mammogram annually on both breasts.
  • After a mastectomy it  is necessary to perform a mammogram every year.
    For patients at high risk for the development of another breast tumor by family history or a positive genetic test for mutations in the BRCA1 or BRCA2 genes, the physician may recommend a magnetic resonance imaging of the breast in addition to the annual mammogram.
  • According to the American College of Obstetricians and Gynecologists, women taking tamoxifen should be monitored regularly because this medication may increase the risk of cancer of the uterus. Any unusual symptoms, such as abnormal bleeding , should be reported to the doctor immediately.
    Women of childbearing age do not have an increased risk of endometrial cancer, so they do not need further testing.

 

 

Prognosis of the patient with breast cancer according to the lymph nodes

The prognosis of breast cancer depends on many factors, including the presence of cancer cells in the lymph nodes.

  1. If the first lymph node is negative it means with high probability that the nearby lymph nodes do not contain the cancer.
  2. If the first lymph node is positive it means that the lymph nodes close to the chain may be affected by the disease.

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