Malignant diagnosis
Malignant diagnosis
In-situ carcinoma
Invasive carcinoma
Paget's disease
In-situ carcinoma
Ductal Carcinoma In Situ (DCIS) represents a group of lesions whose common histological feature is the proliferation of cancer cells within the ducts, without invasion of the surrounding stromal tissue.
DCIS is best regarded as pre- malignant lesion and therefore requires surgical excission.
Lobular Carcinoma In Situ (LCIS) is a solid proliferation of small cells in the breast lobules it is commonly found in multiple areas of the breast (multicentric) and is rarely associated with occult invasive cancers.
LCIS is best regarded as an histological marker of increased risk and not as truly pre- malignant, i.e.both breasts are at risk, and both lobular or ductal invasive carcinoma may occur in patients with LCIS.
DCIS may be impalpable or palpable. LCIS is usually impalpable. Microcalcification detected mammographically may be associated with DCIS but not LCIS.
Management of DCIS requires complete excision of the affected breast tissue:- by wide local excision or mastectomy. Some Breast Units recommend subsequent radiotherapy but the role of radiotherapy in this group is uncertain.
Management of LCIS is controversial, but the usual policy is to recommend close surveillance of both breasts by regular clinical examination and mammography.
Invasive carcinoma
There are about 30,000 new cases of breast cancer diagnosed per year in the UK. The incidence is increasing whereas the mortality is decreasing.
Factors which influence prognosis include size, type, grade of tumour and nodal status. These factors can be combined into prognostic indices (e.g. The Nottingham Prognostic Index).
There is some correlation between histological type and prognosis. For example, tubular carcinomas are well differentiated and have a good prognosis, while ductal carcinomas are more frequently poorly differentiated with a less favourable prognosis.
More important prognostic factors are tumour size and lymph node status and all of these factors need to be taken into consideration when deciding treatment options.
The behaviour of the different sub-types of invasive carcinoma is otherwise very similar, although lobular invasive carcinoma has a particular tendency to metastasise to visceral sites such as the brain and peritoneum.
Paget's disease
Paget's disease of the nipple is an eczematoid change of the nipple due to intraepithelial spread of malignant cells, which is associated with underlying DCIS and/or invasive breast malignancy.
1-2% of patients with breast cancer have Paget's disease of the nipple.
Approximately 50% of patients with Paget's disease will have an underlying mass (of whom 60% will have involved axillary nodes) and 90% of these patients will have an invasive carcinoma.
Paget's disease may be either localised or occupy a large area. It is important to differentiate Paget's disease from eczema affecting the nipple and from direct spread of an adjacent invasive carcinoma.
Investigation of suspected Paget's disease includes mammography to determine the presence of an underlying lesion and incisional biopsy with pathological examination of the tissue removed.
Treatment for Paget's disease :-
mass present:
- mastectomy (or wide local excision),
- axillary node clearance and radiotherapy.
no mass present:
- wide local excision or mastectomy,
- node sampling and radiotherapy.
These patients tend to have a increased rate of local recurrence which may be controlled by radiotherapy, if wide local excision is performed.
Adjuvant treatment depends on nodal and menopausal status.
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