Carcinoma of the Breast: Clinical Presentation, Diagnosis, and Treatment

by Richard Mitchell, MD, PhD

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    00:01 The clinical presentation.

    00:03 Most breast tumors occur in the upper outer quadrant.

    00:06 The superior lateral quadrant, that's actually where you have the most breast tissue.

    00:11 The inner lower quadrant.

    00:14 So, the medial inferior quadrant has the least amount of breast cancers.

    00:19 What you'll see is a palpable mass, usually firm.

    00:23 Although it doesn't have to be.

    00:25 And you may then see associated changes in the overlying skin with dimpling, erythema, induration the nipple retraction and/or discharge tends to indicate that you have a larger ductular involvement.

    00:40 And especially in lobular carcinoma, the contralateral breast can be affected even though you may not have detected anything.

    00:47 So, a diagnosis of lobular carcinoma really mandates that you look very carefully at the other breast.

    00:55 This is just an example of some of the gross and then the microscopic manifestations.

    00:59 Paget's disease typically involves the more distal ducts and into the nipple, and we see kind of an erythematous mass like lesion involving the nipple.

    01:12 When you look at the histology, there are tumor cells percolating through all the way up into the skin.

    01:20 Inflammatory carcinoma, it's not so much inflammatory is that we have invasion of the lymphatics by tumor, and it gives that the skin a very indurated appearance because of the subcutaneous lymphatic filling with tumor and that the peau d'orange appearance.

    01:38 This is the Phyllodes tumor, they can, as I've already said, be quite dramatic.

    01:43 And this particular one, although it looks incredibly large, is benign. The epithelium is totally normal.

    01:53 It's actually kind of an afterthought, and we have this stromal proliferation.

    01:57 But this was not a malignant version, so, size does not necessarily equate to malignant potential.

    02:06 Making the diagnosis.

    02:08 It's a combination of imaging and pathology.

    02:12 A breast exam is clearly also indicated before you progress to any of the other things.

    02:17 A discrete mass with irregular borders that is firmly fixed to the chest wall or to the overlying skin, typically indicates that we have a malignancy.

    02:29 We can do a variety of other imaging, including ultrasonography, and Magnetic Resonance Imaging.

    02:35 The final gold standard, however, is going to be a biopsy, and it can be an excisional biopsy, it can be a core biopsy, it depends on the practice within the particular oncologic service.

    02:49 It's really important, that when we do a biopsy, or an excision that we also look at tumor biomarkers.

    02:57 And it's not just because we're curious, but because that will impact and instruck exactly how we're going to treat the patient.

    03:05 So, we will want to look for the presence of hormone receptors.

    03:09 We want to see if there's estrogen or progesterone receptors.

    03:11 And if there are, then we can give antagonists that will in many cases will provide very good medical therapy for the tumors.

    03:20 If the tumor’s overexpressing the epidermal growth factor receptor, there's very intense immunohistochemical staining for HER2/neu, then these tumors are going to respond to monoclonal antibodies that block that receptor.

    03:32 So, we will always on breast cancers look for estrogen and progesterone receptor and HER2/neu overexpression.

    03:39 Other tumor markers in the blood can be helpful for following disease, such as carcinoembryonic antigen and some of the other cancer antigens, although they are somewhat nonspecific, and are useful only in following response to therapy.

    03:57 So, if you know that your tumor has a high level of CEA that you can detect in the bloodstream, you may be able to do follow on CEAs after therapy and make sure the tumor is not recurring.

    04:09 Or if it is, then you can go looking for where it may be re established.

    04:15 The Treatment. Depends on what we have.

    04:18 If it's carcinoma in situ, surgery is usually completely curative.

    04:22 We may do radiation therapy, and certainly would do endocrine therapy if it's estrogen or progesterone receptor positive.

    04:31 For early stage invasive cancer.

    04:33 So for infiltrative ductal, infiltrative lobular carcinoma, we clearly have to excise that with wide margins.

    04:41 We will probably also do lymph node dissections.

    04:44 We'll do radiotherapy to the original site of the tumor, as well as to the draining nodal tissue.

    04:51 And we may do neoadjuvant or adjuvant therapy with either endocrine blockers.

    04:58 So, if it's estrogen and progesterone receptor positive, or HER2 monoclonal antibodies.

    05:05 Chemotherapy may also be indicated. Although in most of the cases endocrine or HER2 therapies are more than sufficient.

    05:14 For locally advanced invasive carcinoma.

    05:16 So large tumors infiltrating into the chest wall, or infiltrating into the overlying skin.

    05:22 We have to do surgery. We will do adjuvant therapy for sure that may involve immunotherapy, radiotherapy, chemotherapy, hormonal therapy.

    05:33 And then for metastatic cancer.

    05:35 In many cases, we will still do a primary excision, but then we're going to follow that up with any of a variety of ways to treat this.

    05:43 Metastatic cancer has the worst overall prognosis.

    05:46 But we are getting better at treating that.

    05:49 And again, for all comers in cancer of the breast, only 1 in 39 will die of her breast cancer.

    05:57 With that, a rather long talk about a very important topic that occurs quite frequently in women as well as occasionally in men, breast cancer.

    About the Lecture

    The lecture Carcinoma of the Breast: Clinical Presentation, Diagnosis, and Treatment by Richard Mitchell, MD, PhD is from the course Breast Pathology.

    Included Quiz Questions

    1. Upper outer quadrant
    2. Upper inner quadrant
    3. Lower outer quadrant
    4. Lower inner quadrant
    5. Evenly distributed
    1. Skin changes on the nipple and areola
    2. Nipple discharge without skin changes
    3. Hardened breast tissue
    4. Localized breast pain without skin involvement
    5. Localized breast irritation without skin lesions
    1. HER2
    2. CEA
    3. CA 15-3
    4. CA 27-29
    5. CA 19-9

    Author of lecture Carcinoma of the Breast: Clinical Presentation, Diagnosis, and Treatment

     Richard Mitchell, MD, PhD

    Richard Mitchell, MD, PhD

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