The two basic types of breast cancer are ductal and lobular. The breast is composed of ducts which run throughout the breast like tiny roads and through which we nurse our children; and lobules which form the fatty, shapely volume of the breast.
Cancer can be invasive, in which the cell wall has been broken and the cancer inside the cell has the capacity to spread; or it can be noninvasive or “in situ” which means the cell wall is intact and the cancer in the cell does not have the capacity to spread.
In both cases the cancer may not have spread, but in “invasive” or “infiltrating” cancer, the possibility of spread exists. Non-invasive cancer can evolve into invasive cancer over time. For this reason, noninvasive cancer is generally treated similarly to invasive cancer with regards to surgery and radiation. Chemotherapy is never given for noninvasive cancer.
Paget’s disease of the breast in noninvasive cancer of the nipple. It generally presents as a subtle but persistent area of dry, scaly skin or eczema of the nipple and areola. Patients and physicians frequently misdiagnose it as a rash, allergy or skin issue and treat it with topical cremes.
With time, the nipple areolar complex will get crusty and bleed. Any persistent dry, itchy or painful nipple should be biopsied to rule out Paget’s disease.
Anyone diagnosed with Paget’s disease should undergo mammogram and MRI to confirm there is no associated deeper (often invasive) malignant tumor within the breast which is discovered in 30 percent of cases.
Treatment of Paget’s disease depends upon any associated tumors, but generally involves removal of the nipple with radiation therapy of the remaining breast (plastics can fashion a new nipple with excellent cosmetic result), or total mastectomy in which the nipple areola complex and breast is completely removed with or without reconstruction.
The prognosis depends upon associated tumors but is generally excellent.
DCIS is noninvasive cancer of the ducts. It is generally diagnosed mammographically by suspicious calcifications or mass, prompting a radiologically directed needle biopsy. Occasionally, it is a palpable lump. Work up includes ultrasound and MRI. Once DCIS is confirmed by pathology, removal of the entire area with clear margins (a rim of normal breast tissue around the cancer to confirm no cancer tentacles are left behind) and an axillary lymph node biopsy are generally recommended. Radiation therapy is indicated in all but those women with tiny tumors and wide margins, to minimize the risk of the cancer returning. Chemotherapy is not required in noninvasive cancer, but an antihormone pill may be indicated to protect both the affected and opposite breasts. Extensive DCIS which cannot be removed completely without acceptable breast distortion, may require total mastectomy with or without reconstruction. In this case, radiation is not required.
LCIS is confusing to patients and non-breast specialists alike. Although it has the name “carcinoma” in the term, it is not considered to be a cancer. Rather it is considered to be a marker” indicating a higher risk in those patients having it to develop breast cancer in either breast. If discovered by needle or core biopsy, an open larger biopsy is performed to confirm that no cancer is associated with it. Needle biopsy is a sample biopsy; if any atypical or suspicious cells are identified such as LCIS, a larger area of tissue around the needle biopsy site is indicated to make sure nothing more serious lies adjacent to the abnormality. Treatment generally involves close surveillance including breast exam, mammogram and MRI. If a patient has multiple other risk factors for breast cancer in addition to LCIS, the likelihood that she develop the disease may be high enough to warrant more aggressive preventative treatment including bilateral prophylactic mastectomies. This is a highly personal decision that requires serious discussion with a breast specialist. Removal of the affected breast is not adequate as LCIS predicts a higher risk of getting breast cancer in either breast.
Invasive or infiltrating ductal carcinoma is the most common type of breast cancer in women, representing about 80 percent of all breast cancers. It is found 50 percent of the time by a palpable lump – either by the patient herself or by her physician. The remaining cancers are identified by imaging studies including mammogram and ultrasound. Prognosis is excellent if found early and treated promptly. Most commonly treatment involves lumpectomy in which the cancer is removed with a rim of normal tissue (margin) and an axillary lymph node biopsy (to determine whether it has not spread to the armpit nodes) followed by radiation and chemotherapy and/ or an anti-hormone pill. Radiation is recommended in all patients who undergo breast preserving surgery to minimize recurrence of the cancer in the breast. Thirty percent of women treated with lumpectomy with clear margins who do not receive radiation will recur within 10 years. Chemotherapy is given to those patient whose tumors have a high likelihood of spreading outside of the breast even after surgery, since chemotherapy consists of drugs that are given by mouth or vein and go throughout the body to kill any cancer cells that may have gotten away. Anti-hormone pills target hormone sensitive tumor cells and dramatically reduce the risk of those cancers returning in the breast or body. Antihormone pills do not decrease the risk of cancers that are hormone negative from recurring or spreading.
Invasive lobular cancer is less common than invasive ductal cancer but is generally treated the same, once identified by biopsy of a palpable lump or mammographic abnormality. Stage for stage the prognosis is the same but invasive lobular cancer does have some unique qualities which must be considered in the workup, surgical treatment and post-surgical follow up. Invasive lobular cancer tends to grow in sheets rather than lumps and may be difficult to discover either on physical exam or imaging studies. Once identified, the tumor may be underestimated preoperatively and reoperation to obtain clear margins is often required. Invasive lobular carcinoma has a higher risk of presenting in the opposite breast than invasive ductal cancer (as high as 50 percent in some studies) and preoperative MRI is required before surgery and as surveillance after surgery. Removing both breasts (bilateral mastectomies) should be considered and discussed in every case of invasive lobular cancer; personalized treatment is than tailored to the individual. Post-surgical treatment depends upon the final pathology and may include radiation (in all breast preserving procedures), chemotherapy and/or antihormone therapy.
Triple negative cancer refers to invasive cancers of either ductal or lobular origin which express no estrogen, progesterone receptors, or have the her 2 neu gene. This has been found to be such an aggressive tumor, that chemotherapy is recommended in all cases to optimize cure. Antihormone medications are not useful in this type of cancer. This cancer is still curable, however. Research is ongoing to determine the optimal chemotherapeutic regimen to achieve the best survival rates.
Tubular carcinoma is a type of invasive ductal carcinoma which represents 2 percent of breast cancers and has a very favorable prognosis.
Cystadenocarcinoma of the breast is a rare cancer (occurring in less than 1 percent of breast cancers) and is generally nonaggressive. It rarely involves lymph nodes and is more likely to be hormone negative than the more common breast cancers, but does not have the aggressive features of hormone negative invasive ductal or lobular cancers. Treatment generally includes lumpectomy and lymph node biopsy followed by radiation and antihormone therapy (if indicated). Mastectomy is necessary only if there are multiple tumors in the breast or partial mastectomy cannot remove all the tumor or is cosmetically unfavorable. Prognosis is excellent.
Inflammatory breast cancer is an aggressive form of breast cancer that either grows very rapidly or has been neglected (that is, very large due to slow long term growth). The hallmarks of the disease is the reddened, thickened skin of the breast for which it is commonly mistaken for an infection and treated with antibiotics to which it does not respond. A lump may or may not be palpable, but biopsy of the skin demonstrates cancer in the dermal (skin) lymphatics which is diagnostic. A combination of chemotherapy, surgery (mastectomy and lymph node dissection) and radiation therapy results in many cures in a disease once considerable uniformly fatal.
Angiosarcoma of the breast is a rare, extremely aggressive malignancy which starts in the cells that line the blood vessels of the breast and presents as a bruise or ill-defined purplish mass. Only about .04 percent of breast cancers are angiosarcoma and are generally associated with prior radiation to the breast. Some angiosarcomas develop without a history of radiation. Treatment is similar to that given to the other types of breast cancer except that lymph node involvement is rare so lymph node biopsy is generally not indicated. Prognosis is poor. Please note: this is a rare tumor and must be watched for in all women, particularly in women who have had prior breast radiation but is absolutely not a contraindication to radiation therapy for breast cancer. Radiation has proven to be a safe, life and breast preserving, treatment in breast cancer and allows for cure without sacrificing a women’s breast in many cases. The value of radiation cannot be overstated despite the remote possibility of angiosarcoma.
Multiple cancers from other parts of the body can spread to the breast including lymphoma (cancer originating in the lymph nodes), and melanoma. Pathology can determine the source of the tumors and appropriate treatment prescribed. The vast majority of breast tumors, however actually come from the breast itself.