Breast cancer

What Is Breast Cancer: How Many Types Of Breast Cancer Are There? Symptoms and surgical treatment

It is usually classified into infiltrating ductal and infiltrating lobular , depending on whether it originates from the epithelial cells of the lobules or from those of the ducts. Infiltrating because it extends beyond the epithelium, also affecting nearby and sometimes even distant structures ( metastasis to lymph nodes and other organs). In the group of infiltrating ductal carcinoma there is a subgroup of tumors which is called infiltrating ductal carcinoma not otherwise specified(NAS), extremely aggressive and malignant, and which unfortunately represents 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.

How Many Types Of Breast Cancer Are There?

Then there is Paget’s carcinoma , a variant in its own right, in which the tumor cells originate from the epithelial cells of the nipple, which appears reddened, retracted and sometimes bleeding. This tumor is often associated with an infiltrating ductal carcinoma, most frequently of the NOS type. Inflammatory
cancerinstead, it is characterized by a rapidly growing, often painful thickening, with the overlying skin appearing warm, red, and swollen. It metastasizes very quickly and early, especially to the lymphatic system .
Finally, we find juvenile carcinoma , which is very rare and has a fairly favorable prognosis.


Breast Cancer Symptoms And Signs

Symptoms depend on the type of tumor, its diameter, its spread, and the age of the patient. In the initial forms, we will have early symptoms, characterized by the presence of a single mass, generally less than 5 centimeters in diameter, but with an extremely variable volume, with a hard, fibrous, almost wooden consistency (like wood) with ill-defined margins , mobile or not very mobile on the underlying superficial and deep floors. It may also not be dissociable from surrounding tissue and is initially painless. There may be slight erosions or swellings or serous or bloody secretions from the nipple, rippling of the overlying skin, enlarged lymph nodesaxillaries on the same side as the diseased breast, which are however still mobile. Late signs, typical of an already advanced tumor, are instead due to the presence of a mass of considerable volume, greater than 5 centimeters, fixed, non-mobile, with respect to the underlying planes (pectoral muscle and chest wall), with associated edema (swelling). of the breast , which is also red, sore, 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), enlarged axillary lymph nodes and fixed to underlying planes, nipple retraction, sometimes arm edema on same side as tumor.
The tumor can spread to nearby organs, such as the lungs, or lymphatically, to the lymph nodes in the armpit , through the blood, to the bones , liver and brain .



See also: CA 15-3: tumor antigen 15-3

It is very important to question the patient ( anamnesis ) to find out the existence of a possible risk factor, especially for breast cancer in the family. Subsequently the doctor will proceed to the inspection , to see any asymmetries in shape or volume of one breast with respect to the other, and to the palpation , which must be done with the patient lying down with the arms behind the head: he will evaluate consistency, volume, tenderness and mobility of the nodule relative to the underlying planes. We will then move on to instrumental diagnosis: mammographyto both breasts (bilateral) is indispensable for planning any diagnostic and even therapy procedure. 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, i.e. the three-dimensional configuration of the suspicious area. The main advantage of mammography is that it is the most reliable test for seeing small diameter lesions. The disadvantages instead concern its reduced specificity in a breast of young women or in the identification of a very peripheral tumor. Once the lesion has been identified with the mammography, we will move on to the next procedure, i.e. the cytological examination by needle aspiration: with a thin needle, under the guidance of 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). Cytological examination can also be performed on discharge from the nipple, or on any doubtful swelling. In the event that this verification has not been performed, or in any case has not resolved the doubt about the diagnosis, a biopsy will be performed , i.e. a small surgery to remove a small piece of tumor lesion, which will be further analyzed under the microscope to see how much surrounding tissue has been invaded ( histological examination ).
Ultrasound is indicated above all to differentiate thecysts , filled with fluid, with solid lesions, as a diagnostic study in equivocal palpable lesions in association with mammography, and as a guide for performing fine needle aspiration. It has a low sensitivity for lesions smaller than one centimetre, but it is preferable as a control tool in young women under 30, who have dense breasts that can be explored better with this technique.

Finally, there is an exam called ductogalactography , which consists in injecting a colored radioactive substance into the mammary ducts with a needle. If there is a mass, X-rays will show a defect filling the same ducts with dye. It does not differentiate between benign and malignant lesions, but is indicated in the case of serous or bloody discharge from the nipple or in the suspicion of a ductal tumor.



Breast Self-Examination

Breast self-examination is very important , which women should do every month from the age of 20, preferably in the week in which they have just finished their period ( breasts are less swollen), lying down and with one arm behind their head. The contralateral hand must start from the nipple and, with first light and then deeper circular palpation movements, go and probe the whole breast, up to the chest, and also the axillary lymph nodes. Even the gynecologist or the family doctor can evaluate the patient’s breasts, if requested by the same.
From 20 to 40 years, in addition to self-examination, the woman should undergo a breast examination at least once every three years, especially if she assumes thebirth control pills ; here a more in-depth visit and an ultrasound will be carried out.


The first mammogram should be performed at age 40, and every 12 months thereafter. In patients at risk due to familiarity or other, it should instead start at 30, and then always once a year. If a nonmalignant palpable lump is present, the mammogram should be repeated after 6 months.

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


Surgical Therapy

For many years total mastectomy (removal of the entire breast) was the treatment 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 a piece of the breast → partial mastectomy ).

Furthermore, radiotherapy is also used today after surgery: it reduces the number of local recurrences 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, though, although most women with DCIS are candidates for conservative surgery, total mastectomy is still the treatment of choice for small tumor lesions that spread throughout the breast.

Finally, the efficacy of hormonal treatments with a drug called tamoxifen was seen in reducing the risk of local recurrence and of 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 the tumor is a disease that spreads from the site where it originates to the 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 removing an entire breast, arises instead from the concept according to which breast cancer is a disease which, 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 associating radiotherapy or chemotherapy with conservative surgery .
Since the 1970s, numerous studies have demonstrated 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 followed by radiotherapy is recommended, unless the patient prefers otherwise 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, given that conservative treatment implies the willingness to undergo daily radiotherapy sessions for 5-6 weeks and to accept the risk of local recurrence of the order by 10%, which is higher than that of patients undergoing total mastectomy.

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