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    Definition

    Breast cancer is a malignant (cancerous) growth that begins in the tissues of the breast. Over the course of a lifetime, one in eight women will be diagnosed with breast cancer.
    Causes, incidence, and risk factors
    There are several different types of breast cancer.
    Ductal carcinoma begins in the cells lining the ducts that bring milk to the nipple and accounts for more than 75% of breast cancers.
    Lobular carcinoma begins in the milk-secreting glands of the breast but is otherwise fairly similar in its behavior to ductal carcinoma. Other varieties of breast cancer can arise from the skin, fat, connective tissues, and other cells present in the breast.
    Some women have what is known as HER2-positive breast cancer. HER2, short for human epidermal growth factor receptor-2, is a gene that helps control cell growth, division, and repair. When cells have too many copies of this gene, cell growth speeds up. Its believed that HER2 plays a key role in turning healthy cells into cancerous ones. Some women with breast cancer have too much HER2, and are therefore considered HER2-positive. Research suggests that women with HER2-positive breast cancer have a more aggressive disease and a higher risk of recurrence than those who have HER2 negative breast cancer.
    Risk factors for breast cancer include:
    Age and Gender -- As with most cancers, age is a significant factor. In fact, 77% of new cases and 84% of breast cancer deaths occur in women aged 50 and older. More than 80% of breast cancer cases occur in women over 50. Less than 1% of breast cancers occur in men. The risk of breast cancer is clearly related to hormonal influences, but how these affect the disease and particularly types of the disease is not yet clear.
    Genetic Factors and Family History of Breast Cancer -- Some families appear to have a genetic tendency for breast cancer. Two variant genes have been found that appear to account for this: BRCA1 and BRCA2. The genes p53 and BARD1 also appear to be important. Researchers have identified several other defective genes that may cause breast cancer, including BRCA3 and Noey2 (which is a disease inherited only from the father's side of the family). These discoveries suggest that breast cancer occurs when the ****s anti-cancer surveillance and control systems, which normally get rid of abnormal cells, fail to work. The ****'s reduced ability to get rid of abnormal cells leads to damage that gradually accumulates. Women carrying mutated BRCA1 and/or BRCA2 genes start with pre-existing dysfunction of this system and have a "head start" in this damaging process. Hormones are important because they encourage cell growth. High levels of hormones during a woman's reproductive years, especially when they are not interrupted by the hormonal changes of pregnancy, appear to increase the chances that genetically damaged cells will grow and cause cancer.
    Early Menstruation and Late Menopause -- Women who get their periods early (before age 12) or went through menopause late (after age 55) are at higher risk. Also, women who have never had children or who had them only after the age of 30 have an increased risk.
    Oral Contraceptives (birth control pills) -- Birth control pills may slightly increase the risk for breast cancer, depending on age, length of use, and other factors. No one knows how long the effects of the pill last after stopping it.
    Hormone Replacement Therapy(HRT) -- Use of HRT has been shown to increase the risk of breast cancer.
    Obesity -- Obesity is controversial as a risk factor. Some studies report obesity as a risk of breast cancer, possibly associated with higher levels of estrogen production in obese women.
    Alcohol Consumption -- Significant alcohol use (more than 1-2 drinks a day) has been associated with an increased risk of breast cancer.
    Chemicals -- Some studies have pointed to exposure to estrogen-like chemicals that are found in pesticides and other industrial products as a possible increased risk of breast cancer.
    DES -- Women who took diethylstilbestrol (DES) to prevent miscarriage may have an increased risk of breast cancer after age 40.
    Radiation -- People exposed to radiation, particularly during childhood, may face an increased risk for breast cancer in *****hood. Especially at risk are those that received chest irradiation for prior cancers.
    Additional Risk Factors -- Some studies show previous breast, uterine, ovarian, or colon cancer, and a strong history of cancer in the family may increase the risk for breast cancer. Such history may indicate genetic factors described above.
    The Gail Model is a simple breast cancer risk assessment tool that is available online and takes into account the most important risk factors. A number of other models are also used.

    Symptoms
    Breast lump or breast mass noted upon breast exam -- usually painless, firm to hard and usually with irregular borders
    Lump or mass in the armpit
    A change in the size or shape of the breast
    Abnormal nipple discharge
    Usually bloody or clear-to-yellow or green fluid
    May look like pus (purulent)
    Change in the color or feel of the skin of the breast, nipple, or areola


    Dimpled, puckered, or scaly

    Retraction, "orange peel" appearance
    Redness
    Accentuated veins on breast surface
    Change in appearance or sensation of the nipple

    Pulled in (retraction), enlargement, or itching
    Breast pain, enlargement, or discomfort on one side only
    Any breast lump, pain, tenderness, or other change in a man
    Symptoms of advanced disease are bone pain, weight loss, swelling of one arm, and skin ulceration
    Signs and tests


    Any worrisome breast changes should be confirmed and investigated by a medical professional. After getting as much information as possible about the symptom and any risk factors, the physician performs a physical examination including both breasts, armpits, and the area of the neck and chest. Additional tests and treatment may then be recommended:
    X-ray mammography may help identify the breast mass.
    Ultrasound (sonogram) can show whether the lump is solid or fluid-filled.
    Needle aspiration or needle biopsy of breast lumps can demonstrate if they are fluid-filled and provide material to send to the laboratory for analysis. In the case of very small abnormalities visible only on mammography, special techniques are necessary.
    A surgical biopsy or breast lump removal provides a portion or all of a breast lump for laboratory study.
    If breast cancer is diagnosed, additional testing is performed, including chest X-ray and blood tests. Surgery, radiation, chemotherapy, or a combination of these may then be recommended, not only for treatment, but also to help determine the stage of disease. Staging is important to help guide future treatment and follow-up, and to give some idea of what to expect in the future.
    Stages of Breast Cancer (from the American Joint Committee on Cancer):
    STAGE 0. In Situ ("in place") disease in which the cancerous cells are in their original ******** within normal breast tissue. Known as either DCIS (ductoral carcinoma in situ) or LCIS (lobular carcinoma in situ) depending on the type of cells involved and the ********, this is a pre-cancerous condition, and only a small percentage of DCIS tumors progress to become invasive cancers. There is some controversy within the medical community on how to best treat DCIS.
    STAGE I. Tumor less than 2 cm in diameter with no spread beyond the breast
    STAGE IIA. Tumor 2 to 5 cm in size without spread to axillary (armpit) lymph nodes or tumor less than 2 cm in size with spread to axillary lymph nodes
    STAGE IIB. Tumor greater than 5 cm in size without spread to axillary lymph nodes or tumor 2 to 5 cm in size with spread to axillary lymph nodes
    STAGE IIIA. Tumor smaller than 5 cm in size with spread to axillary lymph nodes which are attached to each other or to other structures, or tumor larger than 5 cm in size with spread to axillary lymph nodes
    STAGE IIIB. The tumor has penetrated outside the breast to the skin of the breast or of the chest wall or has spread to lymph nodes inside the chest wall along the sternum
    STAGE IV. A tumor of any size with spread beyond the region of the breast and chest wall, such as to liver, bone, or lungs
    Many additional factors besides staging can influence the recommended treatment and the likely outcome. These can include the precise cell type and appearance of the cancer, whether the cancer cells respond to hormones, and the presence or absence of genes known to cause breast cancer.

    Treatment
    The choice of initial treatment is ****d on many factors. For stage I, II, or III cancers, the main considerations are to adequately treat the cancer and prevent a recurrence either at the place of the original tumor (local) or elsewhere in the **** (****static). For stage IV cancer, the goal is to improve symptoms and prolong survival. However, in most cases, stage IV breast cancer cannot be cured.
    Surgery may consist only of breast lump removal (lumpectomy ), or partial, total, or radical mastectomy, usually with the removal of one or more lymph nodes from the armpit (axilla). Special procedures to find the most likely lymph nodes to which cancer may have spread (sentinel nodes) are often used.
    Radiation therapy can be directed at the tumor, the breast, the chest wall, or other tissues known or suspected to have remaining cancer cells.
    Chemotherapy is often used to kill cancer cells that may still remain in the breast or that may have already spread to other parts of the ****.
    Biologicals are an entirely new type of anti-cancer drug. Biologicals can be used alone or with chemotherapy. Trastuzumab (Herceptin) is an example of this class of drugs. It affects how cancer cells function and grow. Some 20 - 25% of breast cancers respond to trastuzumab. Trastuzumab is not chemotherapy, but it may be combined with chemotherapy. Recent studies show that adding trastuzumab to chemotherapy or treating with trastuzumab after chemotherapy helps prevent the cancer from coming back and can make people who had HER2-positive breast cancer live longer.
    Hormonal therapy with tamoxifen is used to block the effects of estrogen that may otherwise help breast cancer cells to survive and grow. Most women with breast cancers which express estrogen or progesterone on their surface benefit from treatment with tamoxifen. A new class of medicines called aromatase inhibitors, such as Aromasin, have been shown to be as good or possibly even better than tamoxifen in women with stage IV breast cancer.
    Most women receive a combination of these treatments. For stage 0 breast cancer, mastectomy or lumpectomy plus radiation is the standard treatment. However, there is some controversy on how best to treat DCIS. For stage 1 and 2 disease, lumpectomy (plus radiation) or mastectomy with at least "sentinel node" lymph node removal is standard treatment.
    Chemotherapy with or without trastuzumab, hormone therapy, or both may be recommended following surgery. The presence of breast cancer in the axillary lymph nodes is very useful for staging and the appropriate follow-up treatment.
    Stage III patients are usually treated with surgery followed by chemotherapy with or without hormonal therapy. Radiation therapy may also be considered under special circumstances.
    Stage IV breast cancer may be treated with surgery, radiation, chemotherapy, hormonal therapy, or a combination of these (depending on the situation).
    Support Groups
    The stress of breast cancer can often be helped by joining a support group where members share common experiences and problems.
    Expectations (prognosis)
    The clinical stage of breast cancer is the best indicator for prognosis (probable outcome), in addition to some other factors. Five-year survival rates for individuals with breast cancer who receive appropriate treatment are approximately:
    95% for stage 0
    88% for stage I
    66% for stage II
    36% for stage III
    7% for stage IV
    The axillary (armpit) lymph nodes are the main passageway that breast cancer cells must use to reach the rest of the ****. Their involvement at any time strongly affects the prognosis.
    Chemotherapy and hormone therapy can improve prognosis in all patients and increase the likelihood of cure in patients with stage I, II, and III disease.
    Complications
    Even with aggressive and appropriate treatments, breast cancer often spreads (****stasizes) to other parts of the **** such as the lungs, liver and bones. The recurrence rate is about 5% after total mastectomy and removing armpit lymph nodes when the nodes are found not to have cancer. The recurrence rate is 25% in those with similar treatment when the nodes have cancer.
    Other complications can be the result of surgery, altered drainage of the lymph from the arm, radiation changes and treatment with chemotherapy and tamoxifen. But the results of delaying or avoiding early detection and treatment of breast cancer are far more distressing and often deadly.
    Calling your health care provider
    See your health care provider if you are a man or a woman who notices any of the symptoms which could indicate breast cancer or:
    If you are a woman, 40 years or older, and have not had a mammogram in the last year.
    If you are a woman, 35 years or older, and have a mother or sister with breast cancer, or have already had cancer of the breast, uterus, ovary, or colon.
    If you are a woman, 20 years or older, and do not know how or need help to learn how to perform a breast self-examination.
    Prevention
    Many risk factors cannot be controlled. Some experts in the field of diet and cancer agree that changes in diet and lifestyle may reduce the incidence of cancer generally.
    Efforts have focused on early detection since breast cancer is more easily treated and often curable if it is found early. Breast self-examination (BSE), clinical breast examination (CBE) by a medical professional, and screening mammography are the three tools of early detection. Women who carry the BRCA mutations have several effective options for screening and prevention.
    Most recommend breast self-examinations (BSE) once a month -- the week following your menstrual period if you are age 20 or older.
    Regular clinical breast examinations (CBE) by a health professional are recommended for women between ages 20 and 39, at least every 3 years. After age 40, women should have a CBE by a health professional every year.
    Mammography is the most effective way of detecting breast cancer early. The American Cancer Society recommends mammogram screening every year for all women age 40 and older.
    The National Cancer Institute (NCI) recommends mammogram screening every 1-2 years for women age 40 and older. For those with risk factors, including a close family member with the disease, annual mammograms should begin 10 years earlier than the age at which the relative was diagnosed.
    Questions have been raised about the benefit of screening mammography. Some respected medical organizations such as PDQ, part of the NCI, no longer recommend screening mammography. This is a topic fraught with controversy, and a woman needs to have an informed and balanced discussion with her doctor, along with doing additional reading and researching on her own, to determine if mammography is right for her.
    Two drugs are being studied currently that have been shown to reduce the risk of breast cancer: tamoxifen (Nolvadex ) and raloxifene (Evista ). Both are anti-estrogens in breast tissue.
    Tamoxifen is already widely used to prevent recurrence in women who have been treated for breast cancer. Many other newer hormonal agents, such as aromatase inhibitors and others, are being used after Tamoxifen is stopped, or even in place of Tamoxifen. For some women at very high risk of breast cancer, preventive use of these drugs may be appropriate. This should be discussed with a qualified physician.
    Preventive Mastectomy, which is the surgical removal of one or both breasts, is an option to prevent breast cancer for women who are at very high risk for breast cancer.
    Possible candidates for this procedure are women who have already had one breast removed due to cancer, women with a strong family history of breast cancer and those who have a mutation in genes p53, BRCA1, or have gene BRCA2.

    Anatomy Of The Breast

    The breast consists of a mixture of:



    Fat
    Milk glands - lobules that secrete milk during pregnancy and breastfeeding
    Mammary ducts canals that carry milk from the lobules to the nipple openings
    Fibrous connective tissue
    Nerves
    Blood vessels
    Lymph vessels delicate vessels that collect lymph fluid from tissues and drain it back into the bloodstream
    Small amounts of muscle tissue
    In the nipple to allow it to become erect in response to ***ual stimulation or breastfeeding
    Around the lobules to help squeeze milk into the ducts.

    Key muscles support the breasts rom behind and underneath.







    Breast size and shape is unique to each woman and is determined by heredity and **** size. However, breast tissue changes throughout a womans lifetime depending on hormonal changes.

    Breasts develop at puberty as hormones stimulate the system to form and enlarge lobules and ducts. Full development can occur any time between the ages of 12 and 19.
    A womans monthly menstrual cycle causes breast granularity to change. Swelling and tenderness of both breasts may occur during the second half of the menstrual cycle. Cysts may grow and then shrink.
    During pregnancy, the lobules multiply and begin to produce milk.
    When a baby is born, milk is released into the ducts for breastfeeding (lactation).
    During menopause the number of lobules decreases and those remaining shrink. A larger proportion of the breast is made up of fat so breast density decreases.


    ANATOMY OF THE BREAST AND AXILLA
    THE BREAST
    The Breast Parenchyma: The breast is the specialized human tissue located on the chest between the pectoralis muscle, i.e. the superficial fascia and the subcutaneous tissue, i.e. right beneath the skin.
    The Retromammary Space: The breast rests on a rich vascular and lymphatic network within the pectoralis fascia. This represents the retromammary space which is positioned between the deep pectoralis fascia and the superficial pectoralis fascia.
    The Nipple-Areolar Complex: The Nipple-Areolar complex is the center of the breast. It is the end portion of the largest lactiferous duct.
    The Microscopic Anatomy:
    The microscopic anatomy is best visualized by analyzing the lactiferous complex. The breast is a milk producing organ and its microscopic anatomy is ****d on this function.



    The Lobules: The lobules, also called the lobular units, are responsible for the production of milk.
    The Ductal System: The milk is collected by distal lactiferous ducts or acini which merge into minor and then major lactiferous ducts. In most instances, these empty into the major duct or sinus which ends in the nipple. The ductal system has a ductal epithelium surrounded by a myo-epithelium. This ductal epithelium is responsible for the propulsion of milk through the ductal system as it has contractile capabilities. This ductal system is sealed and surrounded by an uninterrupted ****ment membrane.
    The Stroma: This interlobular tissue, also referred to as connective tissue, contains capillaries and other specialized cells.
    Cooper's Ligaments: These are dense strands of fascia found throughout the entire breast which end on the skin itself.
    The ****ment Membrane of the Ductal System: It is essential to visualize the ****ment membrane in the microscopic analysis of a malignant breast tumor. This will assist in the assessment as to whether a tumor is "in situ" (has not grown through the ****ment membrane) or "invasive" (has grown through the ****ment membrane).

    The microscopic anatomy of the breast demonstrates why most breast cancers are ductal or lobular in origin.

    Age Dependant Anatomical Changes of the Breast:
    With age, the breast tissue will change. In a young woman, the breast tissue is dense and parenchyma rich. As the woman ages, the fat ******* of the breast tissue will increase. This explains the overall aspect of the breast, as it will begin to droop. The increased fat ******* of the breast in older patients accounts for the higher quality of their mammograms (increased fat ******* equals increased image quality).
    Pathology Dependant Anatomical Changes:
    Peau d'Orange: From the French term, orange skin, this identifies a malignant obstruction of the superficial lymphatic channels.
    Skin Retraction: Skin or Cooper's ligament pulled in by a malignant lesion.
    Nipple Inversion: Inward retraction of the nipple by a malignant ductal lesion.
    Breast Abscess: Fluctuant, purulent collection within the breast parenchyma
    Mondor's Disease: Thrombophlebitis of a superficial vein, usually by a nonmalignant lesion
    Inflammatory Breast Carcinoma: Malignant invasion of the superficial skin lymphatic channels seen in advanced breast cancer.
    Gynecomastia: This is an activation and hypertrophy of the breast tissue in men. It can occur frequently in young men (pubertal hypertrophy) and in older men. It can also be caused by numerous medications and hormones.
    Changes Secondary to Breast Augmentation Surgery
    All surgeons should be familiar with the pathology generated by the placement of breast implants during augmentation mammoplasty. Earlier augmentation mammoplasty techniques placed the implants behind the skin or breast parenchyma. Newer techniques are placing it behind the pectoralis major muscle.
    THE AXILLA
    The anatomy of the axilla or the axillary basin is important to all oncologic surgeons as it represents the principal lymphatic drainage region of the breast. Lymphatic ****stasis from a malignant breast lesion will most often occur in this region. For inner quadrant lesions, it can occur in the internal mammary chain. Lymphatic ****stasis can also be present in the supraclavicular nodes.
    The surgeon should have an extensive knowledge of the anatomy of the axilla and its *******s in order to perform a safe, precise and appropriate axillary dissection.
    The lymph node bearing area has been divided into three axillary regions:
    Level I: Lymph nodes lateral and inferior to the pectoralis minor muscle
    Level II: Lymph nodes under the pectoralis minor muscle
    Level III: Lymph nodes under and deep to the pectoralis minor muscle
    Most axillary dissections include lymph nodes from Level I and II. In order to remove these lymph nodes with minimal morbidity, several structures will have to be identified un*****ocally. They are as follow:
    The lateral border of the Pectoralis Minor and Major muscle
    The Latissimus Dorsi Muscle
    The Axillary Vein
    The Long Thoracic Nerve which innervates the Serratus Anterior Muscle
    The Thoraco-Dorsal Nerve which innervates the Latissimus Dorsi Muscle
    The Intercostal Brachial Nerve which is a sensory nerve for the inferior aspect of the arm and the posterior aspect of the axilla
    The Lateral Pectoral Nerve which innervates portions of the pectoralis muscle


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    Breast cancer is the most common malignancy in women and the second leading cause of cancer death (exceeded by lung cancer in 1985). Breast cancer is three times more common than all gynecologic malignancies put together. The incidence of breast cancer has been increasing steadily from an incidence of 1:20 in 1960 to 1:7 women today.
    The American Cancer Society estimates that 211,000 new cases of invasive breast cancer will be diagnosed this year and 43,300 patients will die from the disease. Breast cancer is truly an epidemic among women and we don't know why.
    Breast cancer is not exclusively a disease of women. For every 100 women with breast cancer, 1 male will develop the disease. The American Cancer society estimates that 1,600 men will develop the disease this year. The evaluation of men with breast masses is similar to that in women, including mammography.
    The incidence of breast cancer is very low in the twenties (age) gradually increases and plateaus at the age of forty-five and increases dramatically after fifty. Fifty percent of breast cancer is diagnosed in women over sixty-five indicating the ongoing necessity of yearly screening throughout a woman's life.
    Breast cancer is considered a heterogenous disease, meaning that it is a different disease in different women, a different disease in different age groups and has different cell populations within the tumor itself. Generally, breast cancer is a much more aggressive disease in younger women. Autopsy studies show that 2% of the population has undiagnosed breast cancer at the time of death. Older women typically have much less aggressive disease than younger women.









    Inflammatory breast cancer is a unique and uncommon type of breast cancer. It is unique in that inflammatory breast cancer does not produce a distinct mass or lump that can be felt within the breast. The lack of a lump or mass also makes inflammatory breast cancer difficult to detect by mammograms. Inflammatory breast cancer cells infiltrate the skin and lymph vessels of the breast. When the lymph vessels become blocked by the breast cancer cells the breast typically becomes red, swollen, and warm. The skin changes associated with inflammatory can cause the breast skin to look like the skin of an orange a finding called peau d'orange. The appearance of the breast is similar to other inflammatory conditions such as cellulitis or mastitis. Other possible associate symptoms include enlarged lymph nodes under the arm or above the collar bone on the affected side.

    Inflammatory breast cancer is diagnosed ****d upon the results of a biopsy and the clinical judgment of the treating physician. Typically, inflammatory breast cancer grows rapidly and requires aggressive treatment. There are two aspects to treating all breast cancer, local treatment and systemic or total **** treatment. Because inflammatory breast cancer is aggressive, most oncologists recommend both systemic and local treatment. The typical sequence of treatment is to start with chemotherapy, systemic treatment, followed by surgery and radiation therapy, which are the local treatments, often followed by additional chemotherapy and possibly hormone treatments. With aggressive treatment using this multimodality approach, the 5 year survival for inflammatory breast cancer has improved significantly from an average survival of 18 months to an approximately 50% survival rate at 5 years.

    How many cases of IBC are diagnosed each year?
    The numbers vary, but approximately 1% to 2% of newly diagnosed invasive breast cancers (that have spread beyond the breast) in the United States are described as inflammatory breast cancers.

    What are the symptoms of IBC?
    Symptoms may include:

    One breast larger than the other
    Red or pink skin
    Swelling
    Rash (entire breast or small patches)
    Orange-like ****ure (peau d orange)
    Skin hot to the touch
    Pain and/or itchiness
    Ridges or thickened areas of breast
    Nipple discharge
    Nipples that appear inverted or flattened
    Swollen lymph nodes under the armpit
    Swollen lymph nodes of the neck (sometimes)


    What should people do if they have IBC symptoms?
    If one or more symptoms continue for more than a week, look for information and talk to a physician with experience with this particular type of breast cancer.

    The resources below may help guide you to physicians and centers with this expertise.

    How old are typical IBC patients at diagnosis?
    The median age range is between 45 and 55 years old, but there may be patients either younger or older. The symptoms must guide the diagnosis, and age should not be used to exclude it.

    How well do diagnostic tests work in identifying IBC?
    IBC typically cannot be identified through:
    Mammogram Because IBC usually does not occur in the form of a lump (the cancer is spread throughout breast tissue), it is difficult to detect with a mammogram. The most characteristic mammography findings consist of swelling of the skin.
    Ultrasound This test confirms the swelling (edema) of the skin and can better identify breast nodules (if present). It also is the most appropriate test for the evaluation of lymph nodes.
    Magnetic Resonance Imaging (MRI) This is probably the most sensitive test because it includes a functional de******ion of the abnormal findings. It should be included among the diagnostic tests once the pathological diagnosis is confirmed. It is extremely useful in evaluating the clinical response to chemotherapy.
    Core biopsy Typically, fine-needle aspiration or a core biopsy (removal of tissue with a needle) is performed to obtain a pathological diagnosis of invasive disease, but these diagnostic procedures are not appropriate for IBC because of the peculiar growth pattern in the breast lymphatic system.

    What diagnostic tests identify IBC?
    Surgical biopsy Most of the time a skin biopsy or a surgical biopsy is necessary. These procedures are able to collect larger samples that include the skin and underlying tissue with higher chances to identify the cancer cells.
    PET Scan In the near future, this could be one of the most important diagnostic/staging tests for IBC, though it still is under study. We have found that with the PET scan we can see more disease.

    We can see lymph nodes far from the breast, which tells us we have a ****static cancer already at the time of diagnosis. If we limit staging to mammogram, CT (computed tomography computerized X-rays) and bone scans we may miss different components of this inflammatory spreading, which may have significant consequences in the way we treat the cancer and the way we process patients.

    What is the survival rate for IBC?
    The five-year median survival rate for inflammatory breast cancer is approximately 40%. The main reasons for such a disappointing outcome are multiple and include: a delay in diagnosis, the lack of expertise in treating IBC because it is so rare and the relative resistance the disease has to standard chemotherapeutic agents.

    With regard to the first critical issue, it is important to keep in mind that IBC is a fast-growing cancer (it can spread within weeks), and it is often mistaken for something other than breast cancer, such as a rash or infection.

    What are common mistakes in treating IBC?
    A surgeon might want to remove the breast too early, which would increase the chance of local recurrence (return of the disease).

    A radiation oncologist with experience in treating IBC also is important. IBC might require a different schedule than most breast cancers. You might need two treatments a day, instead of one, because this is a highly aggressive tumor. Patients also need a specific chemotherapy dose.

    A particular challenge with treating IBC is that it is difficult to measure response since a nodule or mass is usually not present.

    If patients have had incorrect treatment, it may be hard to go back and improve the prognosis (outcome).

    How is IBC currently treated?
    We typically treat IBC with chemotherapy before surgery, and we also are using drugs like Herceptin (trastuzumab) or TykerbTM






    Early onset of menses and late menopause: Onset of the menstrual cycle prior to the age of 12 and menopause after 50 causes increased risk of developing breast cancer.
    Diets high in saturated fat: The types of fat are important. Monounsaturated fats such as canola oil and olive oil do not appear to increase the risk of developing breast cancer like polyunsaturated fats; corn oil and ****.
    Family history of breast cancer: Patients with a positive family history of breast cancer are at increased risk for developing the disease. However, 85% of women with breast cancer have a negative family history!
    Family history only includes immediate relatives, mother, sisters and daughters. If a family member was post-menopausal (fifty or older) when she was diagnosed with breast cancer, the lifetime risk is only increased 5%. If the family member was premenopausal, the lifetime risk is 18.6%. If the family member was premenopausal and had bilateral breast cancer, the lifetime risk is 50%.
    Genetic testing of the BRCA1 and BRCA2 genes is increasingly being integrated into clinical care for appropriately counseled ****** who meet established criteria for this testing. The American Society of Clinical Oncologists (ASCO) and the National Comprehensive Cancer Network (NCCN) are among the professional healthcare organizations who have published criteria for genetic counseling/testing and cancer risk management. Increased and earlier surveillance, chemoprevention (tamoxifen, oral contraceptives) and surgical interventions (mastectomy, oophorectomy - removal of the ovaries and fallopian tubes) are among the current early detection and risk-reducing strategies discussed with women undergoing BRCA testing. In contrast to breast cancer, there is no reliable early detection for ovarian cancer, which is often fatal due to late stage at diagnosis. Therefore, oophorectomy is generally recommended between ages 35-40 or upon completion of childbearing for women at high risk for ovarian cancer. Despite initial concerns about insurance coverage discrimination, many insurers, including major indemnity plans (BC/BS, Aetna, Kaiser, etc.) recognize the healthcare benefits of this BRCA testing and cover test and genetic counsultation fees when demmed medically necessary. To date, more than 10,000 women and men have had BRCA testing. Similar to other medical tests, BRCA test results are often used to substantiate the need for the early detection and risk-reducing options available for individuals at high-risk for breast and ovarian cancers.
    Late or no pregnancies: Pregnancies prior to the age of twenty-six are somewhat protective. Nuns have a higher incidence of breast cancer.
    Moderate alcohol intake: Greater than two alcoholic beverages per day.
    Estrogen replacement therapy: Most studies indicate that taking estrogen longer than ten years may lead to a slight increase in risk for developing breast cancer. However, these studies indicate that the positive benefits of taking estrogen as far as reducing the risk for osteoporosis, heart disease and now more recently Alzheimer's and colon cancer, far outweigh the slight increase in risk that may be associated with estrogen replacement therapy.
    Caution should be exercised in those women with a significantly positive family history of breast cancer or atypical intraductal hyperplasia. Women with breast cancer are not currently give estrogen replacement. There are no scientific studies currently justifying this practice. However, until those studies are available, by convention, women are taken off estrogen.
    History of prior breast cancer: Patients with a prior history of breast cancer are at increased risk for developing breast cancer in the other breast. This risk is 1% per year or a lifetime risk of 10%. The reason for close clinical follow-up after the diagnosis of breast cancer is not only to detect recurrence of the disease, but also to detect breast cancer in the opposite breast.
    Female: The mere fact that being female increases the risk of developing breast cancer. However, for every 100 women with breast cancer, 1 male will develop the disease.
    Therapeutic irradiation to chest wall i.e., for Hodgkins Disease (cancer of lymph nodes): Patients who have had therapeutic irradiation to the chest are at increased risk for developing breast cancer approximately 10 years later and consideration should be given to earlier screening in this population.
    Moderate obesity: The relationship of breast cancer to obesity is more complex but associated with an increased risk.





    BREAST CANCER TYPES:
    Ductal Carcinoma in-situ: Generally divided into comedo (blackhead, the cut surface of the tumor demonstrates extrusion of dead and necrotic tumor cells similar to a blackhead) and non-comedo types. DCIS is early breast cancer confined to the inside of the ductal system. The distinction between comedo and non-comedo types is important as comedocarcinoma in-situ generally behaves more aggressively and may show areas of microinvasion (small areas of invasion through the ductal wall into surrounding tissue).
    The surgical management is the same as for other types of breast cancer except axillary node sampling is not done, as only 1% of these lesions will have axillary ****stasis. We recommend, however, that irradiation be given if treated with conservative breast surgery to reduce the recurrence rate from 21% without irradiation, to 5%-10% with irradiation. This is a controversial area of the treatment of breast cancer.
    Infiltrating Ductal: The most common type of breast cancer representing 78% of all malignancies. These lesions can be stellate (star like in appearance on mammography) in appearance or well circumscribed (rounded). The stellate lesions generally have a poorer prognosis.
    Medullary Carcinoma: Comprise 15% of breast cancers. These lesions are generally well circumscribed and may be difficult to distinguish from fibroadenoma by mammography or sonography. Medullary carcinoma is estrogen and progesterone receptor (prognostic indicator) negative 90% of the time. Medullary carcinoma usually has a better prognosis than ordinary breast cancer.
    Infiltrating Lobular: Representing 15% of breast cancer these lesions generally present in the upper outer quadrant of the breast as a subtle thickening and are difficult to diagnose by mammography. Infiltrating lobular can be bilateral (involve both breasts). Microscopically, these tumors exhibit a linear array of cells (Indian filing) and grow around the ducts and lobules (targeting).
    Tubular Carcinoma: Orderly or well differentiated carcinoma of the breast. These lesions make up about 2% of breast cancer. They have a favorable prognosis with nearly a 95% 10-year survival.
    Mucinous Carcinoma: Represents 1%-2% of carcinoma of the breast and has a favorable prognosis. These lesions are usually well circumscribed (rounded).
    Inflammatory Breast Cancer: A particularly aggressive type of breast cancer the presentation is usually noted in changes in the skin of the breast including redness (erythema), thickening of the skin and prominence of the hair follicles resembling an orange peel (peau d' orange). The diagnosis is made by a skin biopsy, which reveals tumor in the lymphatic and vascular channels 50% of the time.

    (lapatinib) in a subset of IBC patients who have the HER-2 gene. One of our challenges is to improve our current treatments. We are focused on finding ways to eliminate microscopic disease to prolong survival. What are the Stages of Breast Cancer
    No Matter Your Stage, You Have Many Options for Treatment
    There are many different varieties of breast cancer. Some are fast-growing and unpredictable. Some are slow and steady. Some are stimulated by the estrogen in your ****; some result from a wildly out-of-control oncogene (a cancer gene). You and your doctors will plan your treatment ****d on the special characteristics of your breast cancer. To help you understand the traits of your cancer, and your treatment options, here's information from the National Cancer Institute.

    Overview: When Cancer Is Found
    The most common type of breast cancer is ductal carcinoma. It begins in the lining of the ducts. Another type, called lobular carcinoma, arises in the lobules. When cancer is found, the pathologist can tell what kind of cancer it is (whether it began in a duct or a lobule) and whether it is invasive (has invaded nearby tissues in the breast).

    Special lab tests of the tissue help the doctor learn more about the cancer. For example, hormone receptor tests (estrogen and progesterone receptor tests) can help determine whether hormones help the cancer to grow. If test results show that hormones do affect the cancer's growth (a positive test result), the cancer is likely to respond to hormonal therapy. This therapy deprives the cancer cells of estrogen.

    Other tests are sometimes done to help the doctor predict whether the cancer is likely to progress. For example, the doctor may order x-rays and lab tests. Sometimes a sample of breast tissue is checked for a gene (the human epidermal growth factor receptor-2 or HER-2 gene) that is associated with a higher risk that the breast cancer will come back. The doctor may also order special exams of the bones, liver, or lungs because breast cancer may spread to these areas.

    A woman's treatment options depend on a number of factors. These factors include her age and menopausal status; her general health; the size and ******** of the tumor and the stage of the cancer; the results of lab tests; and the size of her breast. Certain features of the tumor cells (such as whether they depend on hormones to grow) are also considered.

    In most cases, the most important factor is the stage of the disease. The stage is ****d on the size of the tumor and whether the cancer has spread. The following are brief de******ions of the stages of breast cancer and the treatments most often used for each stage. (Other treatments may sometimes be appropriate.)

    Stage 0
    Stage 0 is sometimes called noninvasive carcinoma or carcinoma in situ. Lobular carcinoma in situ (LCIS) refers to abnormal cells in the lining of a lobule. These abnormal cells seldom become invasive cancer. However, their presence is a sign that a woman has an increased risk of developing breast cancer. This risk of cancer is increased for both breasts. Some women with LCIS may take a drug called tamoxifen, which can reduce the risk of developing breast cancer. Others may take part in studies of other promising new preventive treatments. Some women may choose not to have treatment, but to return to the doctor regularly for checkups. And, occasionally, women with LCIS may decide to have surgery to remove both breasts to try to prevent cancer from developing. (In most cases, removal of underarm lymph nodes is not necessary.)

    Ductal carcinoma in situ (DCIS) refers to abnormal cells in the lining of a duct. DCIS is also called intraductal carcinoma. The abnormal cells have not spread beyond the duct to invade the surrounding breast tissue. However, women with DCIS are at an increased risk of getting invasive breast cancer. Some women with DCIS have breast-sparing surgery followed by radiation therapy. Or they may choose to have a mastectomy, with or without breast reconstruction (plastic surgery) to rebuild the breast. Underarm lymph nodes are not usually removed. Also, women with DCIS may want to talk with their doctor about tamoxifen to reduce the risk of developing invasive breast cancer.

    Stage I and II
    Stage I and stage II are early stages of breast cancer in which the cancer has spread beyond the lobe or duct and invaded nearby tissue. Stage I means that the tumor is no more than about an inch across and cancer cells have not spread beyond the breast. Stage II means one of the following: the tumor in the breast is less than 1 inch across and the cancer has spread to the lymph nodes under the arm; or the tumor is between 1 and 2 inches (with or without spread to the lymph nodes under the arm); or the tumor is larger than 2 inches but has not spread to the lymph nodes under the arm.Women with early stage breast cancer may have breast-sparing surgery followed by radiation therapy to the breast, or they may have a mastectomy, with or without breast reconstruction to rebuild the breast. These approaches are equally effective in treating early stage breast cancer. (Sometimes radiation therapy is also given after mastectomy.)

    The choice of breast-sparing surgery or mastectomy depends mostly on the size and ******** of the tumor, the size of the woman's breast, certain features of the cancer, and how the woman feels about preserving her breast. With either approach, lymph nodes under the arm usually are removed.

    Many women with stage I and most with stage II breast cancer have chemotherapy and/or hormonal therapy after primary treatment with surgery or surgery and radiation therapy. This added treatment is called adjuvant therapy. If the systemic therapy is given to shrink the tumor before surgery, this is called neoadjuvant therapy. Systemic treatment is given to try to destroy any remaining cancer cells and prevent the cancer from recurring, or coming back, in the breast or elsewhere.

    Stage III Stage III is also called locally advanced cancer. In this stage, the tumor in the breast is large (more than 2 inches across) and the cancer has spread to the underarm lymph nodes; or the cancer is extensive in the underarm lymph nodes; or the cancer has spread to lymph nodes near the breastbone or to other tissues near the breast.

    Inflammatory breast cancer is a type of locally advanced breast cancer. In this type of cancer the breast looks red and swollen (or inflamed) because cancer cells block the lymph vessels in the skin of the breast.

    Patients with stage III breast cancer usually have both local treatment to remove or destroy the cancer in the breast and systemic treatment to stop the disease from spreading. The local treatment may be surgery and/or radiation therapy to the breast and underarm. The systemic treatment may be chemotherapy, hormonal therapy, or both. Systemic therapy may be given before local therapy to shrink the tumor or afterward to prevent the disease from recurring in the breast or elsewhere.

    Stage IV
    Stage IV is ****static cancer. The cancer has spread beyond the breast and underarm lymph nodes to other parts of the ****.

    Women who have stage IV breast cancer receive chemotherapy and/or hormonal therapy to destroy cancer cells and control the disease. They may have surgery or radiation therapy to control the cancer in the breast. Radiation may also be useful to control tumors in other parts of the ****.

    Recurrent Cancer
    Recurrent cancer means the disease has come back in spite of the initial treatment. Even when a tumor in the breast seems to have been completely removed or destroyed, the disease sometimes returns because undetected cancer cells remained somewhere in the **** after treatment.

    Most recurrences appear within the first 2 or 3 years after treatment, but breast cancer can recur many years later.

    Cancer that returns only in the area of the surgery is called a local recurrence. If the disease returns in another part of the ****, the distant recurrence is called ****static breast cancer. The patient may have one type of treatment or a combination of treatments for recurrent cancer.



    PROGNOSTIC INDICATORS:
    Tumor size: As the size of the tumor increases the risk of axillary and systemic ****stasis increases.
    Histologic Grade: the appearance of the tumor cells under the microscope and graded from 1) well differentiated, 2) Moderately differentiated and 3) poorly differentiated. The survival diminishes with increasing histologic grade.
    Estrogen and Progesterone Receptors: Protein plugs on the surface of the tumor cells to which estrogen and progesterone bind. This complex moves inside the cell causing cellular division. The presence of estrogen and progesterone receptors is a good prognostic indicator. Tumors displaying these receptors will respond to hormonal manipulation, i.e., Tamoxifen.
    Axillary Nodes: The most important prognostic indicator. Patients with negative axillary nodes (microscopically) have improved disease free and long-term survival.
    DNA Flow Cytometry: Test that determines the genetic material within the cell. Tumors with a normal amount of DNA (diploid) have a better disease free and long-term survival than those with an abnormal amount of DNA (aneuploid). This study also determines the percentage of cells in active division. Tumors with active cellular division of <10% have a better prognosis.
    Her-2/neu: Protein product secreted by the tumor indicating a decreased disease free and long term survival.




    BREAST CANCER STAGING:
    Tumor Size or Characteristics:
    TX = Primary tumor cannot be assessed
    TIS = Carcinoma in-situ
    T0 = No evidence of primary tumor
    TIS = Paget's Disease without a tumor, Carcinoma in-situ
    T1 = Tumor less than 2 cm. in greatest dimension
    T2 = Tumor larger than 2 cm. in size but less than 5cm.
    T3 = Tumor larger than 5 cm. in size
    T4 = Tumor of any size extending to the chest wall or skin
    Lymph Nodes:
    N0 = no ****stasis to axillary nodes
    N1 = ****stasis to moveable axillary nodes
    N2 = ****stasis to fixed or matted axillary nodes
    N3 = ****stasis to supraclavicular, infraclavicular or internal mammary nodes
    ****stasis:
    M0 = no distant ****stasis
    M1 = distant ****stasis
    Stages of Breast Cancer
    Stage
    Tumor (T)


    Nodes (N)


    ****stasis (M)
    Stage 0
    TIS


    N/A


    M0
    Stage I
    T1


    N0


    M0
    Stage II
    T0


    N1


    M0


    T1


    N1


    M0


    T2


    N0, N1


    M0
    Stage IIIA
    T0


    N2


    M0


    T1


    N2


    M0


    T2


    N2


    M0


    T3


    N0, N1, N2


    M0
    Stage IIIB
    Any T


    N3


    M0


    T4


    Any N


    M0
    Stage IV
    Any T


    Any N


    M1

    Five Year Survival Rate by Stage Stage Survival Rate Stage 0 100% Stage I 98% Stage II 88% Stage IIIA 56% Stage IIIB 49% Stage IV 16%

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