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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 registration of breast cancer

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
FIVE FACTS ABOUT BREAST CANCER
  • Incidence:

1 in 9women in the TCR area develop breast cancer during their lifetime.

0.5%of breast cancer cases occur in men.

  • Survival:

Now improving. Depends on stage at diagnosis.

90% at 5yrsfor localised disease, 77%at 5 yrsif lymph nodes involved.

  • Most common agegroup:

50-70 yrs

  • Population most at risk:

A disease of the western world. It is much less common in Japan.

  • Predisposing factors:

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 anatomy of the breast
THE ANATOMY OF THE BREAST
  • The breasts are situated on either side of the upper part of the anterior trunk, from the level of the 2nd rib to the 6th rib, and from the sternum to the axillary midline.
  • Each breast has a tail which extends into the axilla.
  • Each breast is made up of 15-20 lobes.

The lobes are separated by septa which are attached to the skin and the chest wall.

  • Each lobe contains a system of branching ducts embedded in connective tissue.
  • Each duct starts in a cluster of terminal ductules called a lobule.
  • The main duct from each lobe opens onto the nipple.
slide4

THE BREAST – section to reveal the right breast divided by fibrous septa into lobes, with their component ducts and lobules

Ducts

Lobules

Ampulla

Nipple

Areola

Fibrous septa

Tubercles

Connective tissue

the breast longitudinal section
THE BREAST – longitudinal section

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.

Lobular carcinoma

Ductal carcinoma

topography information in breast cancer data
Topography information in breast cancer data

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.

the behaviour of breast tumours
THE BEHAVIOUR OF BREAST TUMOURS

Carcinomas of the breast may be:

  • Confined to the linings of the ductal system – IN-SITU
  • Beginning to invade through the basement membrane of the lining of the ductal system, but by no more than 1mm – MICROINVASIVE
  • Invading through the basement membrane into surrounding tissue for a distance of more than 1mm – INVASIVE

Sarcomas of the breast may be:

  • In cases where it is not possible to assess the malignancy of a tumour under the microscope it is termed – BORDERLINE
  • Otherwise it will be termed – INVASIVE

There is no basement membrane in connective tissue to allow the

identification of an in-situ malignancy.

types of breast cancer
TYPES OF BREAST CANCER

Common types of breast cancer, all arising in the lobules and ducts:

The most common (up to 85%) -

  • DUCTALOften called: infiltrating duct carcinomaor

ductal NST

Arises in the lining of the breast ducts

  • LOBULARThere are 4 types: alveolar,solid,tubulo-lobular,pleomorphic

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.

mixed breast carcinomas
MIXED BREAST CARCINOMAS

Some tumours may consist of elements of more than one of the categories

listed on the previous slide. There are 3 main categories:

  • Mixtures of ductaland lobularare recorded as a single lesion:

INFILTRATING DUCT AND LOBULAR CARCINOMA

  • Mixtures of ductalcarcinoma and any other type of carcinomaare also recorded as a single lesion:

INFILTRATING DUCT MIXED WITH OTHER TYPES OF CARCINOMA

  • Mixtures of lobularcarcinoma and any other type of carcinomaare recorded

as the single lesion:

INFILTRATING LOBULAR MIXED WITH OTHER TYPES OF CARCINOMA

multiple breast tumours
MULTIPLE BREAST TUMOURS

Some patients may develop more than one tumour in the same breast:

  • If the morphologies are different,the tumours are registered separately.
  • If they are the same,one registration is made for multifocal disease.

Some patients may develop malignancies in both breasts:

  • In cancer registration the breasts are considered as separate organs. Therefore if a patient has malignant tumours in both breasts 2 separate registrations are made, even if the tumours have the same morphology.
paget s disease mammary
(N.B. Paget was a famous 19th century surgeon who gave his name

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

underneath

PAGET’S DISEASE - MAMMARY
non epithelial breast malignancies
NON-EPITHELIAL BREAST MALIGNANCIES

Tumours of the connective tissue or lymphatics of the breast may occur, but

they are much less common:

  • CYSTOSARCOMA PHYLLO(I)DES

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.

  • SARCOMA

Very rarely angiosarcomas, liposarcomas, malignant fibrous histiocytomas and even osteosarcomas(3-4 annually in UK) may occur.

  • LYMPHOMA

Primary lymphomas of the breast occur, but breast involvement in generalised lymphomas and leukaemias is more common.

a phylloides tumour of the breast
A PHYLLOIDES TUMOUR OF THE BREAST

Sarcomatous change may occur in some of these tumours leading to an

aggressive malignancy.

the growth and spread of breast cancer
THE GROWTH AND SPREAD OF BREAST CANCER
  • LOCAL GROWTH

The tumour first invades adjacent breast tissue.

  • LOCAL SPREAD

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).

  • REGIONAL LYMPH NODE INVOLVEMENT

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.

  • DISTANT METASTASES

Metastases may occur in bone,lung,brain andskin, and “KRUKENBERG”

tumours may arise in the ovary.

the lymphatic drainage of the breast
The lymphatic drainage of the breast

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.

the treatment of breast cancer 1
Surgery

Lumpectomy

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)
the treatment of breast cancer 2
Chemotherapy

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

Hormone therapy

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)
prognostic factors in breast cancer 1
PROGNOSTIC FACTORS IN BREAST CANCER (1)

The patient’s likely prognosis is defined by:

  • The histological type of the tumour
  • The differentiation of the tumour cells
  • The tumour stage
  • DIFFERENTIATION or GRADE evaluates how different the tumour cells are from the normal cells at that site. The greater the difference the more aggressive the tumour, and the greater the likelihood of tumour spread.
  • STAGE indicates how far the tumour has spread at any particular time.

Cancer registries only record the prognostic factors present at diagnosis.

prognostic factors in breast cancer 2
PROGNOSTIC FACTORS IN BREAST CANCER(2)
  • Professors Elston & Ellis introduced a system for grading breast cancer, based on the work ofBloom & Richardson,which takestubule formation, nuclear pleomorphism&no. of mitosesand adds together the values to form ascore. The scores are then grouped intogrades.
  • This has been shown to be a better predictor of outcome than differentiation alone.

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

prognostic factors in breast cancer 3
PROGNOSTIC FACTORS IN BREAST CANCER(3)

OESTROGEN RECEPTOR (ER) POSITIVITY

Patients with ER+tumours do better than those with ER-tumours.

NOTTINGHAM PROGNOSTIC INDEX (NPI)

This new grading system combines:

TUMOUR SIZE+

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

MODERATE

POOR

This is said to be a better indicator than Bloom & Richardson alone.

prognostic factors for breast cancer 4
PROGNOSTIC FACTORS FOR BREAST CANCER(4)

STAGE

The UICC TNMstaging system for breast cancer is quite complex in order to

identify precisely defined groups of patients in terms of survival and

treatment requirements.

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 registration
CANCER REGISTRATION

Cancer registries exist to monitor:

  • the INCIDENCE of cancer
  • cancer SURVIVAL

within a given population, in a given time period –

  • They are POPULATION BASED registries.

Data are subdivided by the agegroup and sex of the patient.

basic cancer registration for breast cancer
Basic cancer registration for breast cancer

The key data required to make a cancer registration are:

  • The usual place of residence at diagnosis (essential for calculating incidence rates)
  • The site of the tumour
  • The date on which the diagnosis was made (essential for calculating incidence & survival)
  • The patient’s identification details
  • The sex of the patient
  • The age of the patient at diagnosis (essential for evaluating prognosis)
  • The histology of the tumour
  • The grade or differentiation of the tumour (essential for evaluating survival)
  • The tumour stage at the time of diagnosis (essential for evaluating survival)
  • The treatment given to the patient

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
THE DATE OF DIAGNOSIS

The date of diagnosis is defined as:

In order of declining priority:

  • The date of the first histological or cytological confirmation of the malignancy.
  • The date of admission to hospital because of this malignancy.
  • The date of first consultation at an outpatient clinic because of this malignancy, if treated as an outpatient only.
  • Any other date of diagnosis.
  • Date of death (includes malignancies discovered at autopsy).
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