Breast cancer (breast cancer)

Breast cancer, or mammary gland cancer, occurs in every tenth woman. Mortality among those affected is about 50%. The main reason for high mortality is the advanced stage of the disease. Thus, patients with stages I and II, when there is a real chance of success of the operation and favorable long-term results, on average in Ukraine make up only 56%.

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Symptoms breast cancer

Signs of breast cancer are quite variable and can be similar to other diseases of the mammary glands. The main signs of this disease include erosive formations on and around the nipple, discharge from the nipple with blood, violation of the boundaries of the mammary gland, and a permanent hardening in the gland. Retraction of the nipple and wrinkling of the skin, swelling of the breast and its deformation can also be signs of the development of a neoplasm. It should be remembered that only a qualified specialist can differentiate the signs and make a diagnosis, so if you have any symptoms that bother you, you should consult a mammologist.

Characteristic clinical signs:

• the tumor is usually one-sided;
• tumor sizes from a few millimeters to 10 cm or more;
• the tumor borders are unclear, the surface is uneven, bumpy, the consistency depends on the histotype;
• characteristic localization - upper-outer quadrant;
• asymmetry of the mammary glands;
• changes in the skin in the form of “platform”, “lemon peel”;
• in Paget's disease - eczema-, psoriasis-like changes in the areola and nipple;
• nipple retraction;
• bloody discharge from the nipple;
• palpation of the axillary, sub- and supraclavicular lymph nodes.

Depending on the form and type of the disease, the oncologist-mammologist differentiates breast cancer and distinguishes the following forms:

• In the nodular form of the disease, palpation may reveal a hard, rounded formation that has no clear boundaries and does not, as a rule, cause pain. Subsequently, skin retraction and wrinkling, formation of lemon peel, low mobility or complete immobility of the neoplasm, changes in the appearance of the nipple, and an increase in the size of the lymph nodes in the armpit area may be observed.
• In the edematous form, the pain syndrome is often not expressed, the lump is characterized by rapid growth, the skin and tissues of the mammary gland swell, turn red, become thicker, and early metastases occur in the axillary lymph nodes.
• The erysipelas-like form is characterized by clearly expressed hyperemia of the skin and the appearance of formations on its surface, resembling tongues of flame in appearance. The tumor is not palpable upon palpation, the redness of the skin can affect the chest area, the body temperature can increase to forty degrees, and rapid metastasis to the lymph nodes occurs.
• In the mastitis-like form, there is a high temperature, an increase in the size of the breast or its individual segments, swelling, hyperemia, a rapid progression of the disease, and the early appearance of metastases.
• Paget's disease (damage to the nipple and areola around it) is characterized by the separation of cells in the tissues and the formation of ulcers on the nipple. As the disease progresses, the nipple is destroyed and an ulcerous formation appears in its place.
• With shell cancer, the breast decreases in size, its mobility is limited, the skin is thickened and uneven, like a shell, and both mammary glands may be affected.
• The latent form may manifest itself as enlarged lymph nodes in the axillary region, while the neoplasm itself, as a rule, cannot be felt.

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Stages

• Stage zero is characterized by the tumor being located in the area of its appearance and not extending beyond its boundaries.
• The first stage is characterized by damage to nearby tissues, the size of the neoplasm usually does not exceed two centimeters, the lymph nodes are not affected.
• At the second stage, the size of the neoplasm can reach five centimeters, the lymph nodes in the axillary region on the side of the damaged organ are affected, at this stage the lymph nodes do not grow together with each other and with the surrounding tissues.
• The third stage is divided into two types - A and B. In type A, the tumor size exceeds five centimeters, the lymph nodes are greatly enlarged and fused with each other or with nearby tissues. In type B, the tumor affects the skin of the mammary glands, chest or lymph nodes, and can be of varying sizes. Hyperemia, wrinkling and reddening of the skin are also noted, the breast or its individual segments become dense and increase in size. Similar symptoms are also noted during the development of mastitis.
• At stage four, the tumor affects the lymph nodes in the armpits and inside the chest and extends beyond the chest. The tumor may also spread to the lymph nodes located above the collarbone, as well as damage to the liver, lungs, brain, etc.

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Forms

There are currently two accepted clinical classifications of breast cancer.

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Classification by stages

• 1 - a small tumor up to 2 cm in diameter is located in the thickness of the affected organ, does not spread to the surrounding tissue and integuments and without histologically verified damage to the regional lymphatic system
• 2a - Tumor diameter not > 5 cm, extending into the tissue, there is adhesion to the skin: wrinkling symptom, without metastases
• 2b - Tumor diameter not > 5 cm, extending into the tissue, there is adhesion to the skin: wrinkling symptom, with damage to single axillary lymph nodes
• 3a - Size > 5 cm in diameter. Fusion, ingrowth and ulceration of the skin. Penetration of the neoplasm into the underlying fascial-muscular layers, but without regional metastases
• 3b - Tumors of any size with multiple axillary or subclavian and subscapular metastases
• 3c - Tumors of any size with metastases to the supraclavicular lymph nodes or identified parasternal metastases
• 4 - Widespread organ involvement with dissemination through the skin or extensive ulceration. The size of the tumor node(s) is any, the nodes are firmly fixed to the chest, with or without metastases to regional lymph nodes. The presence of distant metastases.

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Breast Cancer Classification by TNM

• T1 - Tumor less than 2 cm without involvement of the skin, nipple (except Paget's disease) and fixation to the chest wall
• T2 - Tumor 2-5 cm with limited retraction, skin wrinkling, nipple retraction with subarsolar tumor location, Paget's disease extending beyond the nipple
• TZ - Tumor 5-10 cm or skin lesions in one form or another or fixation to the pectoral muscle
• T4 - Tumor larger than 10 cm or skin lesions of some form that exceed the size of the tumor but are within the affected organ, or fixation of the mammary gland to the chest wall

Regional lymph nodes

• N0 - Regional lymph nodes are not palpable
• N1 - Dense, displaced lymph nodes are palpable
• N2 - Axillary lymph nodes are large, fused, organically mobile

Distant metastases

• M0 - Unilateral supraclavicular or infraclavicular lymph nodes or arm swelling
• M1 - No distant metastases

The presence of distant metastases - skin lesions outside the mammary gland, metastases in the opposite armpit, metastases in the other mammary gland, metastases in other organs

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Classification of breast cancer according to WHO (1981)

1. Preinvasive (intraductal and lobular).
2. Invasive (ductal, lobular, mucous, medullary, tubular, adenoid-cystic, secretory, apocrine, metaplastic).
3. Paget's disease (nipple cancer).

According to histological structure, the following are distinguished:

• Intraductal and intralobular non-infiltrating carcinoma, the so-called carcinoma in situ;
• Infiltrating carcinoma;
• Special histological variants of carcinomas:
  • medullary;
  • papillary;
  • lattice;
  • mucous;
  • squamous cell;
  • Paget's disease.

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Clinical forms of breast cancer

Clinical forms of breast cancer are very diverse. Often confused symptoms of fibroadenoma of the mammary gland, which can imitate a more severe disease. There are nodular (the most common), diffuse forms of malignant neoplasm and Paget's cancer. In the nodular form, the tumor can be spherical, stellate or mixed. The tumor node is of a dense consistency, usually painless, moves only with the tissue of the mammary gland. Often, already in the early stages, a symptom of skin wrinkling, a symptom of a platform or a symptom of retraction is determined above it. Significant local spread of the process is evidenced by skin edema (the "orange peel" symptom), skin ingrowth, ulceration, intradermal disseminates, nipple retraction. Nodular limitedly growing forms of cancer are characterized by a slower course and less intensity of metastasis than diffuse ones.

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Complications and consequences

Metastases begin to develop practically from the moment of the appearance of a malignant tumor. Its cells enter the lumen of blood or lymph vessels and move to other areas, after which they begin to grow and form metastases, which are characterized by rapid or gradual progression. Metastases in breast cancer occur in the armpits, under the collarbones and above the collarbones (lymphogenous metastasis). Hematogenous metastases often form in the bones, lungs, liver, and kidneys. Breast cancer can cause hidden metastases, which can manifest themselves only seven to ten years or more after the primary tumor has been removed.

Metastasis occurs primarily through the lymphatic system.

Regional lymph nodes are:

Axillary (on the affected side) and interpectoral (Rotger's lymph nodes); located along the axillary vein and its tributaries and are divided into the following levels:

• Level 1 (lower axillary) - lymph nodes located lateral to the lateral border of the pectoralis minor muscle;
• Level 2 (middle axillary) - lymph nodes located between the medial and lateral edges of the pectoralis minor muscle, and interpectoral (Rotger's lymph nodes);
• Level 3 (apical axillary) - lymph nodes located medial to the medial border of the pectoralis minor muscle, including the subclavian and apical.

Internal mammary lymph nodes (ipsilateral to the affected site) are located in the endothoracic fascia in the intercostal spaces along the sternal border. Any other lymph nodes involved by metastases, including supraclavicular, cervical, or contralateral internal mammary lymph nodes, are referred to as distant metastases - Ml.

By the time of diagnosis, regional metastases are detected in 50% of patients.

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Diagnostics breast cancer

Breast cancer is diagnosed according to established standards worldwide:

• Inspection, palpation;
• Biopsy is a study of gland cells, biopsy can be partial or total (in case of resection of the pathological sector). It is performed using a thin needle;
• Ultrasound – ultrasound scanning of the gland and armpits;
• Mammography is the main part of diagnostics for determining fibroids, cysts, fibroadenomas, tumor localization. This X-ray examination is absolutely painless and very informative;
• Immunohistochemical analysis – determination of receptors to estrogens, progesterone, i.e. resistance of the neoplasm to hormonal therapy. The material for the study is tumor tissue taken by biopsy;
• Analysis of tumor markers.

A visit to a mammologist or gynecologist should be mandatory even if self-examination does not reveal alarming symptoms that characterize a malignant neoplasm. Such a preventive examination should be done at least once a year, and a woman over 50 years old should do it once every six months. The consultation should be scheduled for the period between the 5th and 12th day of the menstrual cycle, starting the count from the first day. The examination is carried out visually and by palpation. The symmetry of the glands, the presence of possible changes in the skin, nipples, and the armpits, where the lymph nodes are located, are also subject to examination.

X-ray of the glands - mammography. The period between the 5th and 12th day of the cycle is also selected, as a rule, mammography is prescribed on the day of the examination by a doctor. Mammography is mandatory for women over 40 years old.

Ductography, or contrast mammography, is also often prescribed. This is how the gland's ducts are examined for hidden pathologies that may be asymptomatic. If breast cancer is lurking in the ducts, the X-ray shows it as an area not filled with contrast.

Ultrasound scanning helps to specify the condition and structure of the examined seal. Cysts, adenomas, benign seals, similar in symptoms to malignant neoplasms, can be differentiated in this way. If the diagnosis is still not specified using the above methods, a biopsy is prescribed.

A biopsy can either confirm the diagnosis or exclude it. A biopsy involves taking material using a thin needle, the tissue is then subject to microscopic examination. There are cases when taking material using a needle is impossible, then the tissue is obtained using an incision or as a result of excision (resection) of the pathological area of the gland.

If a malignant tumor of the glandular tissue of the mammary gland is diagnosed, a set of additional examinations may be prescribed. Depending on the diagnosis of the stage of development of the oncological process, an ultrasound examination of the abdominal organs, pelvic organs, MRI or CT, and examination of the skeletal system are prescribed.

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Treatment breast cancer

The main therapeutic interventions are divided into local-regional (surgical intervention, radiation therapy) and systemic (chemotherapy, hormone therapy).

Treatment of breast cancer includes a comprehensive approach and involves surgical intervention, chemotherapy and radiation therapy, and hormonal treatment. The choice of method depends on many circumstances, in particular, the structure of the tumor, the rate of its development, the presence of metastases, the patient's age, the functioning of the ovaries, etc. The treatment regimen is prescribed only by an experienced specialist after a full examination. In the early stages, a malignant neoplasm can be completely cured. The following methods are used in treatment:

• Lumpectomy. The tumor is removed along with adjacent unaffected tissues, while the mammary gland is partially preserved. This procedure is performed exclusively at stage zero of malignant neoplasms and is combined with radiation therapy methods in young women.
• Sectoral resection of the affected organ involves partial removal of the mammary gland and complete removal of the lymph nodes in the armpit area, is performed at the zero and first stages of the disease, and is combined with radiation therapy sessions.
• During a mastectomy, the mammary gland and some lymph nodes are removed while preserving the pectoral muscle. During an extended mastectomy, the lymph nodes in the subclavian and axillary region are removed along with the gland. During an extended radical mastectomy with the mammary gland and lymph nodes, the ribs, sternum, and pectoral muscle are partially removed. This procedure is performed in cases where the tumor grows into the surrounding tissue.
• Chemotherapy for breast cancer helps eliminate abnormal cells that may have spread to other areas. This treatment is usually given two weeks to two months after surgery for three to six months.
• Hormonal therapy is necessary to stop the influence of sex hormones (mainly estrogens) on malignant cells, which contributes to their development. For these purposes, women are prescribed tamoxifen, and in some cases, the ovaries are removed.
• Radiation therapy has a local effect and lymphatic drainage pathways. Before surgery, a radiation therapy session is prescribed to reduce the size of the tumor and eliminate its most aggressive cells. In the postoperative period, radiation therapy helps eliminate tumor cells that may remain both in the affected area and outside it. Side effects of radiation therapy are fraught with skin burns, pneumonia, and rib fractures.

Breast cancer treatment by stages

The choice of treatment method depends mainly on the stage of the disease.

In stages I and IIa, surgical treatment is indicated without the use of additional therapeutic methods.

Scope of surgical treatment:

• Radical mastectomy according to Holstel-Mayer.
• Extended radical mastectomy.
• The Poeti operation is a radical mastectomy with preservation of the pectoralis major muscle.
• Mastectomy with removal of axillary lymph nodes.
• Mastectomy.
• Radical resection of the mammary gland in combination with parasternal lymphadenectomy (endoscopic version).

For malignant neoplasms at stages III, IIIa and IIIb, combined treatment is indicated - radical mastectomy with preoperative radiation or chemotherapy.

During radiation therapy, the mammary gland and areas of regional metastasis are irradiated.

When conducting chemotherapy, it is recommended to use the following regimens:

• CMF (Cyclophosphamide, Methotrexate, 5-Fluorouracil);
• AC (Doxorubipin, Cyclophosphamide);
• RAS (5-Fluorouracil, Doxorubipin, Cyclophosphamide);
• ICE (Ifosfamide, Carboplatin, Etoposide);
• Paclitaxel.

For malignant neoplasms at stage IIIb, complex treatment is used: preoperative radiation therapy, radical mastectomy and hormonal therapy.

The principle of hormonal action is to slow down the development of tumor cells or cause their regression by acting on hormonal receptors. Hormonal therapy can be carried out using the following methods:

• surgical removal of the source of hormones (oophorectomy, adrenalectomy, hypophysectomy) or suppression of organ function through radiation exposure;
• administration of hormones to suppress the function of the endocrine gland (estrogens, androgens, corticosteroids);
• introduction of antagonists of hormones that compete at the cellular level (antiestrogens - tamoxifen; bromocriptine).

At stage IV, especially in the presence of multiple distant metastases, treatment includes hormone and chemotherapy.

In recent years, breast cancer treatment worldwide has become increasingly focused on organ-preserving surgeries.

It is considered proven that patients with stage T1-2, N0-1 disease are suitable for organ-preserving treatment.

The volume of the operation should correspond to the ablastic techniques, i.e. sufficient to remove the entire tumor with adjacent tissues. Practice regarding regional lymph nodes remains controversial. Adjuvant polychemotherapy performed in the postoperative period increases the chances of a relapse-free course.

Prevention

In the complex of preventive measures aimed at early detection of breast cancer, self-examination plays a major role. It is advisable for a woman to palpate her mammary glands once a month in the first phase of the menstrual cycle. During the examination, it is necessary to pay attention to the presence of formations in the thickness of the gland and to identify painful areas of it.

Of the instrumental methods for preventive examination of the mammary glands, X-ray mammography and sonomammography are used. Mammography should be performed on the 5th to 12th day from the beginning of the menstrual cycle. The study is indicated for women over 40 years old - regularly once every 2 years, after 50 years - annually.

Sonomammography should be performed:

• when examining the mammary glands of women under 30 years of age;
• when radiologically dense formations of the mammary glands are detected and a malignant neoplasm is suspected;
• as indicated in children and adolescents, pregnant and lactating women.

Breast cancer is one of the most dangerous female diseases today, the peculiarity of this pathology is the possibility of preventing this disease and stopping it if diagnosed early. That is why it is necessary to regularly perform self-palpation of the glands, and even more appropriate are scheduled preventive examinations by a specialist.

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