Breast cancer

Mammary cancer

Breast cancer (BC) in the structure of women's cancer takes 1st place, and the incidence is growing. According to the Russian Cancer Research Center. NN Blokhin annually in Russia revealed about 50,000 cases of breast cancer, accounting for about one-fifth (19.8%) of all tumors in women. 41% of breast cancer cases are diagnosed at later stages (in countries with mammographic screening 85% of women come to the doctor with a curable stage of the disease).

Each year, breast cancer kills more than 20,000 Russians. The highest death rate from breast cancer observed in St. Petersburg, Kaliningrad and Moscow regions. Increase the absolute number of new patients - 11.1%. The disease is rapidly getting younger: it is increasingly found among Russians aged 40. One in eight women during the lifetime risk of breast cancer.

Unfortunately, the real way to prevent breast cancer is not present - multifactor disease origin.
  However, if it is recognized in the period in the pre-clinical tumor size of 1 cm in diameter, when the probability of metastasis is low, it is possible to cure the majority of patients (although 10-15% of patients in this stage are subsequently identified metastases). Therefore, clinicians should focus on identifying tumors 1 cm or less.

Despite the fact that the mammary gland is a visual localization and easily accessible to research it in your cancer stage I-II diagnosed in only 57.6% of patients, and mortality in the first year after diagnosis of 12.6% (data for 1998). Thus, patients with advanced breast cancer is 42.4%. Analysis of the causes of neglect conducted Cancer Institute. PA Herzen, showed that a significant degree of neglect due to the low culture of health of the population: 42% of this population by all means put off a visit to the doctor, claiming employment, family circumstances, unfavorable situation at work, etc., 10.9% patients openly stated that they were afraid to go to the doctor, 6.5% - were engaged in self-treatment, which often leads to a dramatic progression of the disease. However, in 32.5% of neglect entirely on the conscience of general health services, due to their low cancer awareness and lack of suspicion of cancer: in 51.7% of patients after the onset of clinical signs of breast cancer before the diagnosis is from 1 to 6 months.

Mammary gland - an organ of the reproductive system of women. Therefore, among the causes of cancer in the first place are dishormonal violations caused dysfunction of the ovaries, adrenal glands, thyroid gland, the hypothalamus. Mechanisms dishormonal disorders, leading to the development of breast cancer, yet completely understood. However, there is a clear link between the incidence of breast cancer and reproductive harm.

Thus, the indigenous people of Central Asia, Transbaikalia and the Far North, in contrast to Russian living there not using contraception, not abortion, giving birth at a younger age, have more re-birth and long-term breastfeeding. The incidence of breast cancer in these women the lowest in the country. The protective role of lactation against breast cancer is to reduce estrogenic activity in this period, as well as that of milk from the mammary gland are derived chemical carcinogens and mutant cells. According to American authors, a woman who has given birth for the first time in 18 years, has three times less risk of developing breast cancer than a woman who has given birth for the first time in 35 years. Early first pregnancy contributes to a sharp increase in the production of one of the three estrogens - estriol, which is a metabolite of estradiol and estrone and inhibits carcinogen latter. On the other hand, late first birth (after 30-40 years) lead to a sharp increase in estradiol levels, which may contribute to the development of breast cancer. As the number of births decreases in serum prolactin levels, an excess of which can act on the mammary gland as a carcinogen.

Many patients are associated with the appearance in their breast cancer with various mental injuries, that is, with different stress situations in which they found themselves. This is easily understood if we consider that any stress is accompanied by the ejection of blood corticoids, have immunosuppressive properties and inhibition timikolimfaticheskoy systems of the body, or, more simply, immunosuppression.

Up to 25% of women with breast cancer, noted in the history of trauma of this gland. Among blood relatives of female patients with breast cancer occurs 8.5 times more often than in the general population.

Many authors point out that the risk of breast cancer increased by 3.5 times in women with a history of three or more abortions. Yellow body in full bloom during pregnancy. After a miscarriage, it continues to function for a long time, resulting in the body, changes in the hormonal balance, accompanied by a predominance of proliferation.

In development dishormonal disorders play a significant role inflammation in the pelvis and in the first place, and inflammatory diseases of the uterus, which can cause significant structural and functional disorders of the pituitary-ovarian axis.

We know that even with 1-stage breast cancer 5-year survival does not exceed 95%, and 10-year-old - 80%. It follows that the treatment of breast cancer, even in the early stages does not give one hundred percent recovery of patients. This is explained by the fact that in the earliest stages of tumor development, inaccessible to any diagnosis, when the number of cells it is 1000, and the size of the tumor is less than 0.5 mm in diameter, it begins the process of angiogenesis (vascularization), ie the opportunity intravazatsii tumor cells canceremia and as a result in the appearance of micrometastases in various organs. Micrometastases can be realized in the future and cause the premature death of patients.

From the above it follows that in addition to fighting cancer early diagnosis of malignant tumors of no less importance is the early detection and treatment of precancerous disease.

To inspect the female breasts need to undress from the waist up, and to face the light source, then the doctor evaluates the appearance of glands, paying attention to all the manifestations of asymmetry (contours, color of skin, the nipple position, etc.). Then studied to raise their hands, and the glands examined again in this position. After the inspection is performed palpation of breast first in the position of the patient standing and then lying on her back. Simultaneously palpable axillary, subclavian, and supraclavicular lymph nodes. If you notice any changes in the mammary glands to produce mammography and ultrasound.

Mammography - X-ray of the breast that is without the use of contrast agents, performed in two projections. He is currently the most common method of instrumental studies of breast. Reliability of its rather high. On mammograms experienced radiologist-mammologist can judge hormonal status in women. However, to use this method, there are contraindications: the young age of the patients (under 35 years), pregnancy and lactation. In addition, information is insufficient for the study of mammography dense breasts of young women (for more information see the section "Methods of Diagnostics").

Breast ultrasonography is gaining in popularity. This method is safe, that if necessary, allows multiple repeat studies. It outperforms mammography in the study of dense breasts in young women, and to identify cysts, including a small (2-3 mm in diameter), with no additional intervention makes it possible to judge the state of the epithelium lining of the cyst and the differential diagnosis between cysts and fibroadenoma. Besides ultrasonic method is leading the investigation of the lymph nodes and in the study of mammary glands with diffuse changes (dysplasia).

However, the results of ultrasonic research depends on the level of qualifications of the doctor and the technical parameters of the used ultrasound scanner and ultrasonic sensors.

Upon detection of nodules or suspicious area is needed to puncture followed by cytological examination of the received material.

Surgical treatment of benign tumors - diagnostic sectoral resection of the breast with the obligatory plan or (ii) term histology remote site.

In forming at risk for breast cancer should be considered risk factors.

The most likely risk factors for breast cancer are:

1. Availability dyshormonal hyperplasia of mammary glands;
2. Primary infertility;
3. First child at an older age (26 years and older);
4. Early onset of menstruation;
5. Late onset of menopause;
6. Irregularity and delayed sexual debut (30 years and older), the use of contraceptives (chemical, mechanical, hormonal);
7. Decreased libido, frigidity;
8. Short period of breast-feeding, or lack thereof;
9. The birth of large children;
10. Overweight (70 kg or more);
11. Estrogen saturation body of elderly women with a duration of menopause 10 years or more;
12. Enlargement of the thyroid gland (with a decrease of its function);
13. The high incidence of cancer of the breast and female genital organs of relatives;
14. High incidence of malignant tumors among maternal relatives;
15. Transferred postpartum mastitis, especially treatment of conservative.;
16. Injuries to the breast;
It should be noted that a combination of factors increases the risk of breast cancer.

The pathogenic characteristics of breast cancer based on the size of the primary tumor, its location in the breast, the type and rate of growth of the tumor, its morphology, degree of differentiation, presence of regional and distant metastases.

As the size of the tumor increases its aggressiveness when the tumor size of 3 cm or more sharply increased intensity lymphatic and hematogenous metastasis.

Metastasis of cancer in the axillary lymph nodes most likely to happen when localizing it in the outer quadrants of cancer. Tumors localized in the medial portions of the breast, can metastasize to the parasternal lymph nodes. Tumor, located in the central parts of the breast, can produce metastases in the axillary and in parasterialiye lymph nodes, but as the main ways of blocking lpmfoottoka tumor emboli may be the most unexpected localization of lymph node metastases.

According to the type of tumor growth are two main forms of cancer: nodal and diffuse. The latter in turn is diffuse infiltrative, edematous infiltration, tubular and inflammatory (mastitopodobnaya and rozhepodobnaya).

Diffuse form of cancer worse treatment and have a worse prognosis than nodular.

The growth rate of the tumor, which is determined by the time of doubling its size, characterizes its aggressiveness. It is believed that the doubling time of breast cancer from 2.9 to 440 days. Lethal tumor volume reached in 40 doubling. There are 4 types of tumor growth: rapid - the average doubling time of 19.7 days, fast - the average doubling time of 58.8 days, a moderate - 91.1 days and slow - 206.8 days.

On International histological classification (WHO, 1981), epithelial tumors of the breast are divided into:

A. Benign
B. Malignant
Among them:

1. Non-invasive:

a) intraductal carcinoma;
b) lobular carcinoma.

2. Invasive:

a) invasive ductal carcinoma;
b) invasive ductal carcinoma with a predominance of intraductal component;
c) invasive lobular carcinoma;
d) mucosa;
e) medullary;
e) papillary;
g) tubular;
h) adenoid cystic;
s) secreted (youth);
A) apocrine;
l) carcinoma with metaplasia (squamous type, spindle cell type, mixed type);
m) Other.

3. Paget's disease of the nipple of the breast.

Most often (80%) found invasive ductal carcinoma.

On cell membranes have specific cytoplasmic proteins, hormone receptors, which combines with the hormones may affect the rate of tumor cell division. Determining the level of hormone receptors (estrogen, progestins, androgens) can solve the need for and feasibility of hormone therapy, and to some extent predict the course of the disease: lack gormonoretseptorov worse prognosis.

Metastasis

Metastasis of breast cancer carried out in three directions: intraorganic, lymphogenous and hematogenous. Intraorganic metastasis occurs through the dissemination of tumor cells and interstitial passages milk cracks. Lnmfogennoe - by lymphatic to regional and distant lymph nodes, as described above. Hematogenous metastasis of breast cancer can occur in any organ: lungs, bones, brain, ovaries, etc. Liver metastases may be hematogenous, and lymphatic.

The prevalence of breast cancer is characterized by stage classification.

Patriotic classification stage was proposed in 1985, and is as follows:

I stage. Tumor up to 2 cm in diameter without sprouting into the surrounding fatty tissue and skin. Metastases to regional lymph nodes are not available;
IIa stage. Tumor from 2 to 5 cm in diameter, not germinate surrounding tissue or a tumor of the same size or smaller, germinating fat and welded with the skin (wrinkles symptom, "the site"). Regional metastases absent;
IIb stage. Swelling of the same or a lesser degree of local spread with single (no more than 2) axillary lymph node displaceable and / or parasternal metastases on the affected side;
Stage IIIA. Tumor more than 5 cm in diameter, do not grow into the surrounding tissue or tumor of any size to be infiltrating fascial-muscular layers or skin (a symptom of "umbilikatsii", "lemon peel" - limited swelling, possible ulceration of the skin, nipple retraction). Metastases to regional lymph nodes are not available;
Stage IIIb. Swelling of the same or a lesser degree of local spread with single (no more than 2) limited displaceable or multiple metastases in the axillary, subscapular, subclavian, parasternal nodes on the affected side, a tumor of the same or lesser extent of metastases in supraclavicular lymph nodes on the affected side. Metastases in supraclavicular area can be combined with other metastases;
Stage IVa. Locally advanced tumor dissemination but with the presence of the skin (satellites) or extensive ulceration, or fixed to the chest, or the total swelling of the breast, rozhepodobnye, mastitopodobnye, armored. Regional metastases are not defined;
IVb stage. Swelling of the same degree of local spread to any variants regional metastasis or tumor less local spread with single, multiple or partially displaceable displaceable supraclavicular and / or regional metastases nesmeschaemymi. Any degree of local tumor spread with clinically defined distant metastases, including lymph node contralateral.
Throughout the world, has spread international classification of tumors in TNM, where:

Symbol T denotes the primary tumor

Tx - insufficient data to assess the primary tumor.
Then - the primary tumor is not detected.
Tis - preinvasive carcinoma or carcinoma in situ: intraductal, lobular, or Paget's disease of the nipple without the presence of the tumor site.
Note: Paget's disease, in which the palpable tumor site, is classified by its size.
T1 - tumor 2 cm in greatest dimension.
T1a - the tumor from 0.1 cm to 0.5 cm in greatest dimension.
T1b - Tumor 0.5 cm to 1 cm in greatest dimension.
T1s - a tumor of 1 cm to 2 cm in greatest dimension.
T2 - tumor from 2 cm to 5 cm in greatest dimension.
TK - tumor more than 5 cm in greatest dimension.
T4 - Tumor of any size with direct invasion into the chest wall or skin.
Note: Chest wall includes ribs, intercostal muscles, serratus anterior muscle but not pectoral muscle.
T4a - germination of the chest wall.
T4b - edema (including "lemon peel") or ulceration of the skin of the breast or satellite in skin cancer.
T4s - attributes listed in paragraphs 4a and 4b.
T4d - an inflammatory form of cancer.
The symbol N denotes the regional lymph nodes