BREAST CANCER TREATMENTS

11. BREAST CANCER TREATMENTS.

Cancer treatment may be local or systemic:
Local treatments involve only the area of the disease. Surgery and radiation are forms of local treatment.
Systemic treatments affect the entire body. Chemotherapy, hormonal therapy and targeted therapy are the forms of systemic treatments.
Earlier diagnosis might lead to increased cure rates with such local treatment; however, early micro-metastasis is a characteristic feature of the neoplasm or cancer, indicating that a systemic approach such as chemotherapy is required.
Most women receive a combination of treatments. For women with stage 0, 1, 2 or 3 breast cancer, the main goal is to treat the cancer and prevent it from recurring.

The treatment according to the stage of the cancer as follows:

• Stage 0 Cancer in situ: DCIS and LCIS – Lumpectomy plus radiation.
• Sage 1 and 2 – Mastectomy with some sort of lymph nodes removal is standard treatment. Chemotherapy, hormone therapy and biologic therapy may also be recommended following surgery.
• Stage 3: Radical mastectomy possibly followed by chemotherapy, hormone therapy and biologic therapy..
• Stage 4: The goal is to improve symptoms and help them live longer. Treatment may involve surgery, radiation, chemotherapy or combination of such treatment. Chemotherapy provides only palliative rather than curative therapy at present. In most cases, stage 4 breast cancer cannot be cure.

SURGERY
Surgery is usually the first line of attack against breast cancer.
Possible surgical procedures include the following:
Lumpectomy: The surgeon removes only the tumor [the lump] and some of the normal tissue that surround it, but not the whole breast.. Sometimes armpit [underarm] lymph nodes are remove for examination.

Fig. 8: Surgery of breast cancer with segmental

mastectomy or lumpectomy.

Mastectomy :

• Radical mastectomy: Removes the entire breast, the nipple, the skin, the muscle under the breast, and the lymph nodes in the armpit. The radical mastectomy is seldom done anymore, except that the cancer had spread to the nearby structure such as the muscle, the ribs, the lymph nodes beneath the breast or to the skin or for advanced stage 3 breast cancer..

Fig 9: Woman with Radical Mastectomy:

A Pink highlighted area are indicated tissue removal at

mastectomy.

B Axillary [armpit] lymph nodes: level I

C Axillary lymph nodes: level II

D Axillary lymph nodes: level III

E Supraclavicular lymph nodes.

F Internal mammary lymph nodes.

• Modified radical mastectomy: Surgeon removes the entire breast, the nipple, some skin and some of the lymph nodes in the armpit. The muscle under the breast is left in place. It is indicated for stage 1 and 2 breast cancer.

Fig. 10:Woman with modified radical mastectomy:

A Pink highlighted area indicated tissue removed at

mastectomy.

B Axillary lymph nodes: level I

C Axillary lymph nodes: level II

D Axillary lymph nodes: level III.

• Total or simple mastectomy: Removal of the breast tissue only, without removal of the lymph nodes or any muscle tissue beneath the breast.

Fig.: 11 Woman with total [simple] mastectomy

A Pink highlighted area indicates tissue removed at

mastectomy

B Axillary lymph nodes: level I

C Axillary lymph nodes: level II

D Axillary lymph nodes: level III.

• Skin-sparing mastectomy is a technique that preserves as much of the breast skin as possible. The surgeon removes the breast tissue through the small opening that is created. The remaining pouch of skin provides the best save and form to accommodate an implant or a reconstruction using your own tissue. Many women chose this type of mastectomy in order to get the most realistic and pleasing results from immediate breast reconstruction. Most women are eligible for skin-sparing mastectomy. However, there are some exceptions: If the patients have decided will not have immediate breast reconstruction. A skin-sparing mastectomy is not safe if there is the cancer cells are close to the skin or that the cancer may involve the skin, such as in inflammatory breast cancer.

OPERATIONAL PROCEDURES OR STEPS OF MASTECTOMY.

What is happened to the patients breast in mastectomy surgery ?
The skin incisions shown in Fig.8 will suffice for all intents and purposes; it can be extended and amplified to meet the special needs of a given case. Ample exposure and through anatomic dissections are essentials. The axilla [armpit] should be dissected first.

This procedure is about radical mastectomy, another types of mastectomy are the modification of the radical mastectomy according to the stage of the breast cancer.

• Step 1: The skin along the entire margin of the incision is freely dissected up from the under lying tissue to an extent.
• Step 2: Expose the pectoral fascia in the line of the upper incision. Lift the skin and fat off the muscle until the furrow is reached; this furrow marks the dividing line of pectoral major muscle.
• Step 3: Dissection of the greater pectoral muscle almost as far as its humoral [upper arm] attachment. The entire mass [pectoral major muscle and mammary gland] is dissected away from the ribs.
• Step 4: Expose the outer edge of the pectoral minor in it’s entirely. The gland and major pectoral muscle now are attached only by connective tissue and armpit fat.
• Step 5: Cleaning out the armpit. Expose the armpit vein. The armpit vein usually is a large single trunk but often is found as two branches. The nerves of the brachial plexus surround the armpit vein. A number of tributary veins enter it from the armpit fat; the largest and most important of these is the scapular vein which accompanies the scapular artery.
• Step 6: Ligate or tie and divide all tributary vessels in this locality: this is to go hand to hand with the removal of all fat, lymph nodes and other elements.
• Step 7: Close the wound. Introduce a rubber or cigarette drain through a stab wound. Hemostasis [control of bleeding] must be perfect. The skin should be closed with interrupted sutures. [cont.]

STAGE OF BREAST CANCER AND DIAGNOSIS

9. STAGE OF BREAST CANCER.

For the breast cancer, there are 5 stages:
Stage 0: There are two kinds of stage 0 breast cancer:
Duct carcinoma in situ [DCIS]: Abnormal cells are in the lining of a milk duct and have not spread outside of the duct.
Lobular [lobe] carcinoma in situ [LCIS] : Abnormal cells are in the living of a lobe, non invasive cancer.

Stage 1: Cancer is 2 cm or smaller and the cancer has not spread outside the breast.

Fig. 5: Diagram showing a stage T1 breast cancer

Stage 2: Cancer is 2 to 5 cm, or has spread to the lymph nodes, or both.

Stage 3: Cancer is larger than 5 cm and it has spread to the lymph nodes and may have
spread to nearby tissue such as muscle, ribs or the skin.

Fig. 6: Diagram showing a stage 3 breast cancer, where the cancer is greater than 5 cm and has spread to the lymph node and nearby tissue.

Stage 4: Cancer has spread to distant parts of the body, or other organs—usually the lung,
liver, bone or brain.

10. DIAGNOSTIC AND TEST OF BREAST CANCER.

Whether you discover a lump or one is found during a routine breast exam or mammogram, the doctor has a few of diagnostic tests to choose for the further examination.
The following technique that diagnose and gather more information about invasive cancer:
Test for diagnosing cancer.
Test for staging of cancer.
Test to gather more information about cancer.

TEST FOR DIAGNOSING CANCER.
Diagnosing invasive cancer usually involved a combination of procedures, including a physical examination and imaging tests:
Physical examination of the breasts
Mammography
Ultrasound bounces sound waves of the breasts
Breast magnetic resonance imaging [MRI].
Biopsy: If the patient has a suspicious mammogram or other imaging test result, the doctor will probably want the patient to have a biopsy. Highly suggestive of malignancy [cancer] from imaging tests- means that are findings that look like and probably are cancer, require biopsy. Known biopsy-proven malignancy- means that any findings on the imaging tests have already proven to be cancer through a biopsy.

Fig.7: Sentinel node biopsy from the left breast

TEST FOR STAGING
Staging is the process used to detect how far invasive cancer may have spread from its original location.
The stage of the cancer is based on 3 kinds of information:
The size of the cancer.
Whether the cancer has spread to any lymph nodes, and if so, how many.
Whether the cancer has spread to other organs of the body.
Test that could be done include:
An x-ray of the chest to check the lungs.
Bone scan.
CT [Computerized tomography] scan, ultrasound, or MRI are used to create images of the abdomen, pelvis, the stomach area, or other areas of the body.

TESTS TO GATHER MORE INFORMATION ABOUT CANCER.
Grade: A pathologist examines the cancer cells under the microscope and determines how abnormal they appear and behave when compared with healthy breast cells. There are 3 grades of invasive cancer: low or grade 1, moderate or grade 2, and high or grade 3. Low grade- slow growing, less likely to spread. Grade 3, high grade- tend to grow quickly, more likely to spread.
Surgical margin: A pathologist examines the cancer cells and the outer edge of the tissues. The tissue around the very edge of what was removed is called the margin of the resection.
Hormone receptor assay: This tissue test determines whether or not the breast cancer has receptors for the hormones estrogen and progesterone. A positive result means that estrogen or progesterone [or both] has the ability to fuel the cancer cells’ growth. If the cancer is hormone-receptor-positive, the doctor likely will recommend hormonal therapies that block the effects of estrogen or lower estrogen levels in the body. [cont.]

BREAST LUMPS AND BREAST CANCER

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3.BREAST LUMPS and BREAST CANCER [cont]

The first symptom of breast cancer for many women is a lump in their breast. But many women have breast lumps and 9 of 10 [ 90 %] are benign [not dangerous to health]. That means they are not cancers. Most benign breast lumps are
• Cysts-sacs of fluid in the breast tissue, which are quite common.
• Fibro-adenoma a collection of fibrous glandular tissue [these are common n younger women]
• Areas of breast cell changes, causing lumpiness particularly in women over 35.
• Infection or abscess of the breast.

4. DEFINITION OF BREAST CANCER.

Cancer is a disease characterized by a shift in the control mechanisms that govern cell survival, proliferation and differentiation.
Breast cancer is an uncontrolled growth of breast cells. In other words the breast cancer is a group of abnormal breast cells that have abnormal growth. Such cells proliferate excessively and from a local tumors that can compress or invade adjacent normal structures and to migrate to distant site in the body, called metastasis.

5. SITUATION AND STATISTICS

The breast cancer is the most common type of cancer in women, about one per cent of breast cancers occur in men. Breast cancer incidence in women in United States is 1 in 8 [about 13 %]. In 2009, an estimated 192 370 new cases of invasive breast cancer were expected to be diagnosed in women, along with 62 280 new cases of non-invasive [in situ] breast cancer.
According to the World Health Organization [WHO] statistics in 2005, the number of registered deaths by cause and sex in USA were:
Number [N] of female deaths were 41 116 or rates of 27.3 per 100 000 of female, while number of men deaths were 375 or 0.3 per 100 000 of male population.
The breast cancer was the second leading cause of death of malignant neoplasm in women in USA, the first cause of death was cancer of trachea, bronchus and lung, number female death were 69 105 or 45.9 per 100 000 of female, number of male death were 90 187 or rate of 61.8 per 100 000 of male.


6. THE CAUSE OF BREAST CANCER.

Many women who develop breast cancer have no risk factor other than sex and age. Gender is the biggest risk because breast cancer occurs mostly in women.
Age is another critical factor. Breast cancer may occur at any age, though the risk increases with age.
Breast cancer is always caused by a genetic abnormality. However, only 5-10 % of cancers are due to an abnormality inherited from the mother or father. About 90 % of breast cancers are due to genetic abnormalities that happen as a result of the aging process and the “wear and tear” of life in general.
The p53 gene has been shown to be mutated in up to 50 % of all human solid tumors including liver, breast, colon, lung, cervix, bladder, prostate and skin. Mutation in the gene place the cells at high risk.

7. THE TYPE OF BREAST CANCER

The different type of breast cancer, including:
Duct carcinoma in situ [DCIS] non invasive cancer.

Fig.2: Diagram showing duct cancer in situ [DCIS] and invasive duct cancer [IDC].

Source: http://www.cancerhelp.org.uk/type/brea....

Invasive duct carcinoma [IDC].

Fig. 3: Normal breast with invasive duct cancer [IDC]

A Duct

B Lobules [Lobes]

C Dilated section of ducts to hold milk

D Nipple

E Fat

F Pectoral major muscle

G Chest wall.

Enlargement:

A Normal cells; B Invasive duct cancer[IDC] cells breaking through the basement membrane; C Basement membrane.

Source: http://www.breastcancer.org/images/invasiv....

Lobes cancer in situ [LCIS] non invasive cancer.

Invasive lobes carcinoma [ILC].

Fig.4: Normal breast with invasive lobes carcinoma [ILC]

A Ducts; B Lobes; C Dilated section of duct to hold milk; D Nipple; E Fat; F Chestwall/rib cage.

Enlargement:

A Normal cells; B Invasive lobes cancer [ILC] cells breaking through the basement membrane; C Basement membrane.

Source: Ibid.

Inflammatory breast cancer.
Metastasis breast cancer.
Male breast cancer.
Recurrent breast cancer.


8. SIGNS AND SYMPTOMS OF BREAST CANCER.

Initially, beast cancer may not cause any symptoms. Often, an abnormal area turns up on a screening mammogram [x-ray of the breast], which leads to further testing.
According to the American Cancer Society, any of the following unusual changes in the breast can be a symptom of breast cancer:
· Swelling of all or part of the breast.
· Skin irritation or dimpling.
· Breast pain.
· Nipple pain or the nipple turning inward.
· Redness, scaliness, or thickening of the nipple or breast skin.
· A nipple discharge other than breast milk.
· A lump in the underarm area. [cont.]

BREAST CANCER

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BREAST CANCER

1. INTRODUCTION.

This writing is intended to supply the patients, patient’s family, students and practitioner with a working knowledge of common and rare or noted information of health and life are based on the experiences, statistics,value,reference books and website publications.
Noted means specially marked or noticed: well known and highly regarded: Famous [Webster’s dictionary].
The first topic of this writing in this blogspot is BREAST CANCER.
The content consists of:

1. INTRODUCTION.
2. NORMAL ANATOMY AND PHYSIOLOGY OF BREAST.
3. BREAST LUMPS IN GENERAL.
4. DEFINITION OF BREAST CANCER [BC].
5. SITUATION AND STATISTICS .
6. THE CAUSE
7. THE TYPE .
8. THE SIGNS AND SYMPTOMS.
9. THE STAGE .
10. DIAGNOSTIC AND TESTS.
11. TREATMENTS.
12. RECONSTRUCTION OF BREAST.
13. AFTER TREATMENT
14. PROGNOSIS [OUTLOOK]
15. PREVENTION.

2. NORMAL ANATOMY AND PHYSIOLOGY OF THE BREAST.

ANATOMIC CONSIDERATIONS: A thorough knowledge of the anatomy of the breast is essential to forestall errors in operative procedures. The breasts consist of lobes, ducts, stroma [connective tissue], fat and skin. The essential anatomy of the breasts and nearby structures are with muscles, lymph nodes, nerves, arteries, veins, ribs and skin.

Figure 1: [A] Essential Anatomy: 1, Deltoid muscle; 2, cephalic vein; 3, coracoid process; 4, axillary artery; 5, axillary vein; 6, clavicle; 7, subclavicle muscle; 8, pectoral minor muscle; 9, pectoral major muscle; 10, thoraco-dorsal nerve; 12, branches of brachial plexus; 13, short thoracic vessels.

[B] Lymphatic distribution: 1, Deep cervical nodes; 2, apical nodes; 3, sub-scapular nodes; 4, pectoral nodes; 5, lateral axillary nodes; 6, intra-clavicular nodes.

PHYSIOLOGY OF THE BREAST FOR LACTATION.
Many hormones are necessary for full mammary gland development. In all species ovarian hormone estrogen are primary responsible for proliferation of the mammary ducts and progesterone for the development of the lobules [lobes] and alveoli. Oxytocin causes contraction of the myo-epithelial cells lining the duct walls, with consequent ejection of milk through the nipple. Suckling not only evokes reflex oxytocin release and milk ejection, it also maintains and augments the secretion. [continued]