THE REGISTRATION OF BREAST CANCER The anatomy of the breast, the pathology and treatment of breast cancer, and collecting breast cancer data FIVE FACTS ABOUT BREAST CANCER Incidence: 1 in 9 women in the TCR area develop breast cancer during their lifetime.
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The anatomy of the breast, the pathology and treatment of breast cancer, and collecting breast cancer data
1 in 9women in the TCR area develop breast cancer during their lifetime.
0.5%of breast cancer cases occur in men.
Now improving. Depends on stage at diagnosis.
90% at 5yrsfor localised disease, 77%at 5 yrsif lymph nodes involved.
A disease of the western world. It is much less common in Japan.
Very little is known about the causes of breast cancer. In 5%of cases
there is a genetic abnormality.
Japanese women who move to the USA eventually acquire the same risk of developing breast cancer as US citizens, suggesting environmental causes.
The lobes are separated by septa which are attached to the skin and the chest wall.
THE BREAST – section to reveal the right breast divided by fibrous septa into lobes, with their component ducts and lobules
A cross section through the breast to show the different parts of the ductal
system. DUCTALtumours arise in the ducts, LOBULAR tumours in the
lobules at the end of the breast duct system.
Diagram showing the breast divided into 4 quadrants plus axillary tail and
nipple. Breast tumours are recorded to the part of the breast in which they
arose. The nipple and areola count as a single site, and the area behind this is
known as the central portion of the breast.
The most common site for breast tumour is the upper outer quadrant.
Carcinomas of the breast may be:
Sarcomas of the breast may be:
There is no basement membrane in connective tissue to allow the
identification of an in-situ malignancy.
Common types of breast cancer, all arising in the lobules and ducts:
The most common (up to 85%) -
Arises in the lining of the breast ducts
These 4 types are not distinguished in the ICD classifications.
Tubulo-lobular is not the same thing as mixed tubular and lobular.
Lobular carcinoma arises in the lining of the breast lobules
Other types- Tubular,cribriform, medullary,atypical medullary,
arising in themucinous,spindle cell,infiltrating papillary, argyrophyl,
duct systemsecretory,apocrine, inflammatory carcinoma.
All these tumours may be either INVASIVE, MICROINVASIVEor IN SITU.
(Microinvasive = invasion of no more than 1mm beyond the basement membrane)
In situ ductal carcinoma is often referred to as DCIS.
In situ lobular carcinoma is often referred to as LCIS.
Some tumours may consist of elements of more than one of the categories
listed on the previous slide. There are 3 main categories:
INFILTRATING DUCT AND LOBULAR CARCINOMA
INFILTRATING DUCT MIXED WITH OTHER TYPES OF CARCINOMA
as the single lesion:
INFILTRATING LOBULAR MIXED WITH OTHER TYPES OF CARCINOMA
Some patients may develop more than one tumour in the same breast:
Some patients may develop malignancies in both breasts:
to a number of conditions. We are only concerned with Paget’s
disease of the nipple)
In mammary Paget’s Disease cells from
a ductal tumour spread up the ducts to
the nipple without crossing the basement
membrane. The condition is therefore
not invasive in itself.
The underlying ductal tumour may be
in-situ or invasive, and may not be
palpable (especially if in-situ).
(There are problems for cancer registries in
that clinicians usually record the Paget’s
disease separately as a non-invasive
disease. The ICD classifications record the
nipple disease and the underlying ductal
tumour together as a single entity)
Paget’s disease of the right nipple in a
male patient. Paget’s resembles
eczema. The lump suggesting a
ductal carcinoma can be seen
underneathPAGET’S DISEASE - MAMMARY
Tumours of the connective tissue or lymphatics of the breast may occur, but
they are much less common:
Large, rapidly growing tumours that are usually benign, but the “NOS” category is always regarded as borderline because of its capacity to recur (10%) and the fact that sarcomas develop in 5% of tumours.
Very rarely angiosarcomas, liposarcomas, malignant fibrous histiocytomas and even osteosarcomas(3-4 annually in UK) may occur.
Primary lymphomas of the breast occur, but breast involvement in generalised lymphomas and leukaemias is more common.
Sarcomatous change may occur in some of these tumours leading to an
The tumour first invades adjacent breast tissue.
If neglected the tumour will invade the chest wall, and may eventually involve
the pleura. The overlying skin may become involved either by invasion of the
lymphatics or direct spread (peau d’orange).
The likelihood of regional lymph node involvement increases with the size of
the tumour. Approx 33% have axillarylymph node involvement at diagnosis.
The parasternal nodes may be involved in tumours of the medial breast.
Metastases may occur in bone,lung,brain andskin, and “KRUKENBERG”
tumours may arise in the ovary.
The axillary lymph nodes are on the left, and the internal thoracic chain on the right.
The axillary lymph nodes are divided into levels 1, 2 & 3. The lowest nodes nearest the breast are level 1, and the apical nodes are in level 3.
The internal thoracic nodes are also known as the internal mammary chain or the parasternal nodes.
Where possible the tumour plus a margin of healthy tissue is removed. Mastectomy
If the tumour is aggressive or extensive the whole breast is removed.
Axillary sampling or dissection
In all cases the lymph nodes are sampled carefully to assess whether the tumour is still confined to the breast. If the nodes are involved by tumour, they are removed.
External beam radiotherapy (teletherapy)
The breast is irradiated after lumpectomy, along with the regional lymph nodes in high risk cases.
High risk mastectomy patients also have post operative radiotherapy.
If the breast has not been removed radioactive sources may be implanted (brachytherapy) e.g. Iridium192 wire.The treatment of breast cancer (1)
Various cytotoxic drugs may be given to increase the survival of patients treated with surgery and/or radiotherapy.
These are usually given following a strict protocol which prescribes a group of drugs given in combination.
e.g. Protocol CMF which uses
Cyclophosphamide, Methotrexate & 5FU
Protocol ECF uses Epirubicin, Cisplatinum & 5FU
Altering the patient’s hormone balance may provide an environment which inhibits the growth of the tumour.
Tamoxifen (an anti-oestrogen) is given to most patients aged >50 with oestrogen receptor positive (ER+) tumours.
Goserelin and Leuprorelin prevent the ovaries producing oestrogen.
In pre-menopausal patients a similar effect may be achieved by creating an artificial menopause by removing or irradiating the ovaries.The treatment of breast cancer (2)
The patient’s likely prognosis is defined by:
Cancer registries only record the prognostic factors present at diagnosis.
Tubule formation: +Nuclear pleomorphism:+Mitotic rate: -
Not to be confused with the TNM staging system!
Give site specific grade for breast cancer
Good tubule formation = Moderate variation in size & high mitotic rate =
good prognosis shape of nuclei = poorer prognosis poor prognosis
OESTROGEN RECEPTOR (ER) POSITIVITY
Patients with ER+tumours do better than those with ER-tumours.
NOTTINGHAM PROGNOSTIC INDEX (NPI)
This new grading system combines:
REGIONAL LYMPH NODE INVOLVEMENT+
BLOOM & RICHARDSON GRADE
This value is divided by 0.2and the resulting numerical value is put into one
of 3 groups: GOOD
This is said to be a better indicator than Bloom & Richardson alone.
The UICC TNMstaging system for breast cancer is quite complex in order to
identify precisely defined groups of patients in terms of survival and
The T values are: 1mic,1a,1b,1c,2, 3, 4a, 4b, 4c, 4d(N.B. Only the invasive element of a tumour used in the “T” classification)
The N values are: 0, 1a, 1bi, 1bii, 1biii, 1biv, 2, 3(Pathological “N” only)
The Mvalues are: 0,1
These are grouped into the following STAGES: 0, 1, 2a, 2b, 3a, 3b, 4
Cancer registries exist to monitor:
within a given population, in a given time period –
Data are subdivided by the agegroup and sex of the patient.
The key data required to make a cancer registration are:
Notes: -A usable registration cannot be made at all without items 1-3 above.
-If a patient’s diagnosis is revised after a period of time, the revised diagnosis is recorded, but the original date of diagnosis is retained.
The date of diagnosis is defined as:
In order of declining priority: