Invasive ductal carcinoma of the breast Introduction Invasive breast cancers have been described as lobular or ductal in origin.

The term lobular was used to describe invasive cancers that were associated with lobular carcinoma in situ, while all other were referred to as ductal. Invasive ductal carcinoma accounts for 65 85% of all invasive breast cancer; it is also known as infiltrating ductal carcinoma (IDC) or carcinoma of no special type (NST). IDC starts in the breast milks ducts and invades surrounding breast tissues. Invasive ductal carcinoma is histologically classified as Adenocarcinoma with productive fibrosis accounts for 80% and presents with axillary lymph node metastases in 60% of cases. Usually presents in the fifth and sixth decades of life as a solitary, firm mass Medullary carcinoma accounts for 4% and is a frequent phenotype of BRCA-1 hereditary breast cancer. The cancer is soft and hemorrhagic. It is bulky and often positioned deep within the breast. Mucinous carcinoma accounts for 2% and typically presents in the elderly population as a bulky tumor. Papillary carcinoma accounts for 2% and generally presents in the seventh decade Tubular carcinoma accounts for 2%.

Risk factors and aetiology Risk factor include a positive family history of breast cancer, early menarche, late menopause, nulli parity or late first pregnancy after age of 30 years, long term use of oral contraceptives, exposure to radiation. Increasing age. Symptoms In 33% of the breast cancers, the woman discovers a lump in the breast as in the case of N.F. other less frequent presenting signs and symptoms of breast cancer include: breast enlargement or asymmetry, nipple changes, retraction or discharge, ulceration or erythema of the skin of the breast, an axillary mass, musculoskeletal discomfort

However, up to 50% of women presenting with breast complaints have no physical signs of breast pathology. Breast pain usually is associated with benign disease.

Diagnosis Testing is required to differentiate benign lesions from cancer since early detection and treatment of breast cancer improves prognosis. If cancer is suspected based on physical examination, biopsy should be done first. A pre-biopsy mammogram or ultrasound may help delineate other areas that should be biopsied and provides a baseline for future reference. Biopsy can be needle or incisional biopsy or, if the tumor is small, excisional biopsy. Chest x-ray, CBC and liver function tests should be done to check for metastatic disease. Bone scanning should be done if patient have tumors > 2 cm, musculoskeletal pain, lymphadenopathy or elevated alkaline phosphatase. Evaluation after cancer diagnosis: part of posistive biopsy should be analyzed for oestrogen and progesterone receptors and HER2 protein. WBCs should be tested for BRCA1 and BRCA2 genes when family history include multiple cases of early onset breast cancer or when ovarian cancer develops in patients with family history of breast or ovarian cancer. TNM classification Primary Tumor (T) Tx T0 Tis T1 T2 T3 T4 primary tumor cannot be assessed No evidence of primary tumor Carcinoma in situ Tumor < 20 mm in greatest dimensions Tumor > 20 mm but < 50 mm in greatest dimension Tumor > 50 mm in greatest dimension Tumor of any size with direct extension to the chest wall and/or the skin

Regional Lymph Node (N) N0

N1 No regional lymph node metastasis Metastasis to movable ipsilateral level I, II axillary lymph node(s) Metastases in ipsilateral level I, II axillary lymph nodes that are clinically fixed or matted or in clinically detected* ipsilateral internal mammary nodes in the absence of clinically evident axillary lymph node metastasis Metastases in ipsilateral infraclavicular (level III axillary) lymph node(s), with or without level I, II axillary node involvement, or in clinically detected * ipsilateral internal mammary lymph node(s) and in the presence of clinically evident level I, II axillary lymph node metastasis; or metastasis in ipsilateral supraclavicular lymph node(s), with or without axillary or internal mammary lymph node involvement

N2 N3

Distant Metastasis (M) M0 M1

No clinical or radiographic evidence of distant metastasis Distant detectable metastases as determined by classic clinical and radiographic means and/or histologically proven > 0.2 mm

Treatment
Invasive carcinoma is treated through one or more of the following: surgery, chemotherapy, hormonal therapy and radiation therapy. Surgery is considered primary treatment for breast cancer, as many patients with early-stage disease are cured with surgery alone. The goals of breast cancer surgery include complete resection of the primary tumor with negative margins to reduce the risk of local recurrences. Surgical treatment of invasive breast cancer may consist of lumpectomy or total mastectomy. In addition to surgery, the use of radiation therapy, chemotherapy, or both may be indicated. The purpose of radiation therapy following breast-conserving surgery is to eradicate local subclinical residual disease while reducing local recurrence rates by approximately 75%. The purpose of radiation therapy following breast-conserving surgery is to eradicate local subclinical residual disease while reducing local recurrence rates by approximately 75%. Radiation delivered to the breast at a dose of 50-55 Gy over 56 weeks. This is often followed by a boost dose specifically directed to the area in the breast where the tumor was removed. Common side effects of radiation therapy include fatigue, breast pain, swelling, and skin desquamation. Late toxicity (lasting 6 mo or longer following treatment) may include persistent breast edema, pain, fibrosis, and skin hyperpigmentation. Rare side effects include rib fractures, pulmonary fibrosis, cardiac disease (left breast treatment), and secondary malignancies such as radiation-induced sarcoma. Adjuvant treatment of breast cancer is designed to treat micrometastatic disease, or breast cancer cells that have escaped the breast and regional lymph nodes but have not yet had an established identifiable metastasis. Combination chemotherapy regimens are standard recommendations in the adjuvant setting. The most commonly used regimens are: doxotaxel, doxorubin and cyclophosphamide. n ER-positive early-stage breast cancer, hormone therapy plays a main role in adjuvant treatment, either alone or in combination with chemotherapy. Hormone treatments function to decrease estrogen's ability to stimulate existing micrometastases or dormant cancer cells. Adjuvant hormone therapy can reduce the relative risk of distant, ipsilateral, and contralateral breast cancer recurrence by up to 50% in tumors with high ER expression Prognosis Long-term prognosis depends on extent of lymph node involvement, number of axillary lymph nodes involved, size of primary tumor, tumor grade, stage, presence of estrogen and progesterone receptors, patient age, and presence of HER2 protein. Nodal status correlates with disease-free and overall survival better than other prognostic factors. For node-negative patients, 10-year disease-free survival rate is > 70%, and overall survival rate is > 80%. For node-positive patients, rates are about 25% and 40%, respectively. Conclusion

N.F was still in the early stage of the carcinoma when she was diagnosed and surgical intervention was chosen. It therefore my opinion that the prognosis of her condition is going to be good. References Allison T. Stopeck et al, Breast Cancer, url= http://emedicine.medscape.com/article/1947145/overview F. Charles Brunicard, Schwartzs Principle of surgery, 8 th Ed.,