Breast – Malignant, Males, Children

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Breast-malignant, males, children

Breast cancer-general

Author: Nat Pernick, M.D, PathologyOutlines.com, Inc.

Reviewer: Daniel Visscher, M.D., University of Michigan Hospitals, February 2009 (see Reviewers page)

Revised: 10 September 2009

Last major update: September 2009

Epidemiology

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● Most common invasive malignancy in US women after skin cancer

● Estimated 190K new cases of invasive carcinoma in US women in 2009, 2K in men (American Cancer Society)

● Estimated 62K new cases of in situ carcinoma in US women in 2009

● Occurs in 1 of 8 to 9 women in US (1 of 232 at age 30-39 years, 1 of 29 at age 70-79)

● Similar incidence in other Western countries, but much lower incidence in Japan (Cancer Research UK)

● Sharp decrease in incidence in US women 50-69 years old may reflect reduced use of hormone replacement therapy (Breast Cancer Res 2007;9:R28)

Clinical

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● 50% occur in upper outer quadrant, 17% central (subareolar), 5-15% other quadrants, 13% involve more than one quadrant (3% diffuse)

● Tumors in outer quadrant are more likely to have axillary nodes than those in inner quadrant

● Common symptoms are breast lumps and nipple abnormalities, sometimes discomfort

● Tumors presenting between mammographic screenings (interval tumors) are more aggressive

Synchronous

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● Second tumor discovered within 2 months of initial primary tumor

● Molecular studies can determine if synchronous tumors are two primaries or one primary with metastases (Mod Path 2008;21:1200)

Clinical examination

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● For breast, palpation is less sensitive/specific than mammography; mammographic abnormality is often presenting sign

● For axillary nodes, 40% of clinically negative nodes have tumor and 15% of clinically positive nodes lack tumor

Mammography

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● Can detect tumors as small as 1-2 mm via microcalcifications

● Microcalcifications are present in 50% of carcinomas vs. 20% of benign breast disease

● Suspicious mammographic features are opacity with irregular, spiculated margins +/- calcifications

● Also clusters of fine calcifications and asymmetry

● Only 20% of “suspicious” microcalcifications are actually malignant

● Up to 30% of tumors are not detectable by mammography due to poor resolution from surrounding fibrous breast (generally younger women)

MRI

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● Detects increased tumor vascularity and increased tumor uptake of contrast agents

● Usually no gross findings so must examine entire specimen (Hum Path 2007;38:1754)

Ultrasound

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● Increasing use, can distinguish solid versus cystic lesions (latter are generally benign)

Needle biopsy

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● Radiologist marks microcalcifications with needle, surgeon removes area around needle, specimen is Xrayed to verify specimen includes microcalcifications of interest

● Pathologist should verify presence of microcalcifications (note: calcium oxalate crystals are easily missed by pathologists – must look for birefringence under polarized light)

Case reports

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● Recurrence in myocutaneous flaps (Archives 2004;128:1157)

● Massive thyroid tumoral emboli (Archives 2004;128:804)

Treatment and prognosis

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● Five year relative survival overall has improved from 63% in early 1960s to 89% in 2009 (US National Cancer Institute)

● Five year survival rate is 98% for localized breast cancer, dropping to 27% if distant metastases

● Death rate is 27 per 100,000 women (40,000 deaths per year in US), slowly falling since 1990 in North America, Western Europe and Australia

● #2 cause of US cancer deaths in women after lung cancer

● Main treatment is surgical excision (usually lumpectomy or modified radical mastectomy, sampling lumpectomy cavity margins may reduce need for re-excision, AJSP 2005;29:1625)

● Radiation therapy if positive margins or to control locally recurrent disease (44% recur without radiation if close/non-involved margins for DCIS versus 94% recurrence if margins are extensively positive, Mod Path 2004;17:81)

● Anti-estrogen drugs (tamoxifen and others to reduce risk of recurrence in same or opposite breast, particularly for ER+ tumors)

● Combination chemotherapy (for metastatic disease, to reduce the risk of contralateral breast carcinoma)

● Preoperative (neoadjuvant) chemotherapy shrinks large tumors to allow surgery or more conservative surgery

Clinical images

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Mass and retracted nipple

Microscopic description

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● Invasive if stromal invasion present

● Most tumors are adenocarcinomas arising from terminal duct lobular unit

● In situ carcinoma is present to variable extent (“extensive” if >25% of tumor volume seen inside and outside of invasive tumor field)

Additional references

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● Wikipedia, eMedicine

End of Breast – Malignant, Males, Children > Breast cancer-general

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