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REGUB Path - Malignant Breast Disease (ii) (Prognostic factors (invasive…
REGUB Path - Malignant Breast Disease (ii)
LCIS
abnormal cells fill lobules
usually incidental find as not a/w mass or microcalcifications
can be bilat + multifocal
a/w increased risk of lobular or ductal carc developing in same or contralat breast
management: tamoxifen + close followup
more common in young women
dyscohesive
loosened intercellular connections - early histologic sign of malignancy
cells lack E-cadherin (one of the most important molecules in cell-cell adhesion in epithelial tissues)
Invasive carc of no special type
80% - most common type of breast cancer
mass detected by physical exam or mammography
advanced tumours may result in skin dimpling/nipple retraction
macroscopically: hard, irregular border
microscopically
adenocarc
fibrous desmoplastic (growth of fibrous or connective tissue)
stroma (scirrhous carc - hard slow growing malignancy a/w preponderance od fibrous tissue)
may be a/w DCIS
Invasive carc of special types
invasive lobular
15%
morphologically distinct
occurs in younger women (pre-menopausal)
can be bilat (20%)
can be multi-centric within the same breast
cell invade cells in cords, single file pattern - "Indian filling"
loss of E-Cadherin
Most are ER+ve, Her2-ve
invasive mucinous (colloid)
3%
abundant extracellular pools of mucin
good prognosis
elderly women
invasive medullary
3%
circumscribed edge
large malignant cells
surrounding lymphocytic response
slightly better prognosis than non-special invasive carc
triple -ve
3% a/w BRCA1
invasive tubular
2%
well-differentiated, prominent tubules/ducts
good prognosis
ER+, Her2-ve
invasive papillary: 2%
Breast carc spread
local - surrounding breast tissue, chest wall + skin - 'peau d'orange'
lymphatic - axillary, int mammary (carc in inner quadrants), ipsilat supraclav node
vasc - bone, lung, liver, brain
transcoelomic - pleura cavities
recurrences may be local, regional (LN) or distant (systemic)
TNM
T
size + involvement of skin +/or chest wall (fixed or not)
<2cm, 2-5cm, >5cm
N (regional LN status, prognosis a/w no. involved)
M (distant mets)
Histologic grade: Scarff Bloom Richardson
standardised - reduces inter-observer variation
3 features assessed + scored 1-3
% of tubule formation
mitotic count
nuclear pleomorphism
min score = 3, max = 9
Grade 1: scores 3-5
Grade 2: scores 6-7
Grade 3: scores 8-9
Prognostic factors
invasive or in situ
stage - size, nodes, fixation, mets
inflamm
grade
histologic subtype
excision adequacy
lymphovasc invasion
prolif rate
angiogenesis
ploidy status (DNA content - no. of chromo)
gene expression profiling
Factors predicting response to tx
expression of hormone Rs
80% ER + PR +ve
ER +VE response to anti-oestrogenic drugs (tamoxifen)
nuclear staining
Her2 (aka neu or c-erb B2)
related to EGFR
+ve in 20-30%
more aggressive, poorer response to systemic tx
response to trastuzumab/herceptin (monoclonal ab)
triple -ve: poor prognosis
Prognosis
overall crude mortality: 40% @ 5yrs, 60% @ 10yrs, continues rising
recurrence/mets unpredictable
10yr survival 70% of LN -ve, 30% if LN +ve
more aggressive in younger women
distant mets: median survival = 12-18 months
Carc of male breast
rare
usual older age
10% a/w BRCA2
usually invasive @ time of dx
behaves as invasive ductal carc of female breast