Diagnosis

Benign Breast Disease (noncancerous)

The most common findings in breast biopsies are benign (noncancerous). Some of these findings are markers of an increased risk of breast cancer, others are not associated with that risk.

Different forms of benign breast disease:

• Cysts
• Fibroadenoma
• Hamartoma - a noncancerous grown consisting of abnormal cells
• Lymph node
• Benign phylloides tumor - painful solidity of the breast
• Fibrocystic lumps

Cysts

Can be removed by suction (aspirated) with complete disappearance if they are palpable or symptomatic (pain). Occasionally we biopsy cysts if they recur, occur in the wrong age group or have ultrasound features that are concerning.

Fibroadenomas

• One of the most common benign masses
• Sometimes multiple masses and often feel like "slippery marbles"
• Some are easily removeable, others are needle biopsied and watched, and some are simply watched
• Not associated with an increased risk for breast cancer
• Do not turn into cancer

Fibrocystic Lumps and Changes

There are many different findings of fibrocystic changes (ill defined) while some are more significant than others.

Lumpy tender areas when biopsied display variable mixtures of:

• Scarring
• Overgrowth of glandular tissue
• Cysts
• Inflammation
• Hyperplexia - an abnormal multiplication of cells
• Certain varieties if fibrocystic lumps and changes that have overgrowth of lobular and ductal cells.
• Atypical Hyperplasia
• Overgrowing cells are unusual and may even resemble early breast cancer.
  • Although hyperplasia is associated with a slight increase in breast cancer, atypical hyperplasia has significantly more risk especially in women that have immediate family history of breast cancer

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Carcinoma In Situ (CIS)

Background Information about the breast

The Breast is a mound of fatty tissue with mammary units scattered in between. A mammary unit is like a vine with lobules that are like the grapes that secrete milk when a woman is nursing and ducts which are like the ribs in the vine. The ducts carry the milk from the lobule to the nipple. Around these vines is a microscopic basement membrane and in the tissues around these vines are arteries, veins and lymphatic channels.

Cancers form in the ducts in the majority of cases and in the lobules in most of the rest of cases. If cancers are contained within the ducts and lobules they are carcinoma-in-situ (CIS). CIS thus has no access to the circulation and thus it does not spread to the lymph nodes or the rest of the body. Cancer cells need access to these lymphatic channels or blood vessels to spread to the lymph nodes or the rest of the body. Since breast cancer kills mostly by metastasis (Spread to the rest of the body) then CIS is almost always 100% curable.

Two Types of CIS:

Ductal CIS (DCIS)

• Has a higher tendency to turn into invasive cancer if not treated.

Lobular CIS (LCIS)

• Seems to indicate a higher risk of getting cancer that is often not in the same location of the LCIS itself.

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Invasive Cancer

Invasive cancer has invaded through the membrane around the ducts and lobules and has access to lymphatics and blood vessels. Having access to these means it has the potential of spreading to lymphatics and blood vessels and thus it can be a fatal disease that may spread to the rest of the body.

Having said that I want to point out that only a minority of patients with breast cancer die from it and that depends on the stage of the disease and the characteristics of the tumor. Host factors probably play a significant role but they are not well studied or understood. Of the 220,000 women diagnosed with breast cancer 40,000 die from the disease.

Prognostic factors on invasive cancer

1. The stage of the disease at diagnosis: The stage is dictated by the size of the cancer, lymph node involvement and its extent and the presence of distant metastasis at diagnosis. Very few patients have metastasis at diagnosis. Stage I with tumors that are less than 2 centimeters and negative lymph nodes have 90% cure rate while stage IV with metastasis is uniformly fatal.
2. Tumor Grade based on how irregular the tumor cells are, how fast they are dividing and whether they show any degree of order in their division and growth. Grades I, II and III appear to be independent predictors of the aggressiveness of the cancer.
3. Estrogen and progesterone receptors are surface receptors that are excellent predictors of aggressiveness of a cancer and its responsiveness to low toxicity anti estrogen medications. Receptor positive cancers respond well to anti estrogen treatment as if you are depriving them from a key nutrient. Anti estrogen drugs include Tamoxifen that blocks the estrogen receptor in pre and post menopausal women and Aromatase (an enzyme that converts testosterone into estrogen) inhibitors that block estrogen synthesis in post menopausal women.
4. Other receptors such as Her 2 Neu and Ki 67 are also good predictors of cancer behavior. Her 2 Neu positive cancers are very aggressive but antibodies that have been developed to block that receptors have tamed that tumor and has given us a good target for treatment using a medication called Trastuzumab (Herceptin)
5. Genetic profiles have been developed that gives us a genetic imprint that can predict recurrence rates. Oncotype Dx is the most commonly used test in the United States and it gives patients a recurrence score that they can use to make treatment decisions.

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