Breast+(T3-T4)

__**Family history factors**__: __**Hormonal and reproductive factors**__: __**Environmental factors**__: · Ductal carcinoma in situ (DCIS) is the most common noninvasive diagnosis. · Lobular carcinoma in situ(LCIS) · Infiltrating dutal carcinoma (IDC) is the most common diagnosis originating in the mammary ducts (lactiferous ducts), then breaking through tissue wall and invading adjacent tissues. Roughly 80% of all breast cancers. · Infiltrating lobular carcinoma (ILC) starts in mammary lobe glands before duct and infiltrates adjacent tissues. Roughly 10% of all breast cancers. [5] For stages T3,T4 and inflammatory breast cancer share the same histology as the less advanced breast cancers but will have local and distant nodal involvement as well as demonstrable tumor size being larger. Often having direct extension to ribs, intercostal muscles, skin or lymph nodes will classify as stage T3a/T3bT3c or T4a/T4b. [5] || · Brain · Bone · Lung · Liver · Pleura || Grade one looks like cells are fairly normal with a tubule format of greater than 75 percent. The cell division (mitosis) will be up to seven. Additionally, grade one cancer cells are small and they look fairly uniformed. Cells from breast cancer tumors at this stage are not growing at a rapid rate[7]. Furthermore, grade two is less defined and more a combination of features that doesn’t fit one and three, but instead fall between them[7]. Grade two has moderately-differentiated cells. The tubule format is between 10 to 75 percent. There is some change is the size of the cells and variation[7]. The cell division or mitosis count is between eight and 14[7]. Last but not least, the grade three is the least differentiated and most aggressive of the breast cancer tumors[7]. The features are not normal and are likely to spread and grow quickly. The tubule formation in grade three is less than 10 percent. There is a marked variation in the changing of the cells[7]. There will also be a notable cell division 15 or more in grade three tumors[7]. || Stage is usually expressed as a number on a scale of 0 through IV — with stage 0 describing non-invasive cancers that remain within their original location and stage IV describing invasive cancers that have spread outside the breast to other parts of the body. The system is based on the size of the tumor (T), lymph node involvement (N), and whether the cancer has spread, or metastasized, to other parts of the body (M). breast[8].
 * **Epidemiolgy:** || Breast cancer, worldwide, is the most diagnosed life-threatening cancer in women, and the leading cause of cancer death. Over the last 25 years breast cancer has increased globally. The highest rates of breast cancer are in Westernized countries. Although the breast cancer rates are on the rise, breast cancer mortality has been decreasing (especially in industrialized countries). The lifetime risk for breast cancer in the U.S. is about 12.7% for all women, 13.3% for non-Hispanic whites, and 9.98% for black women. Black women are more likely to have larger, advanced-stage breast tumors (>5cm).[1] ||
 * **Etiology:** || The etiology of breast cancer remains largely unknown. The risk factors can be classified into 3 different groups: family history factors, hormonal and reproductive factors, and environmental factors.[2] 73% of breast cancers are attributed to environmental factors, and over 78% happen in postmenopausal women. Age is the most significant risk factor for breast cancer. Your risk increases with increasing age (plateaus in women aged 50-55 years old). Some of the other risk factors are:[1]
 * One or more relatives with breast or ovarian cancer
 * Breast cancer occurring in an affected relative younger than 50 years old
 * Male relatives with breast cancer
 * BRCA1 and BRCA2 mutations
 * Ataxia-telangiectasia heterozygotes (4 times’ increased risk)
 * Ashkenazi Jewish descent (2 times’ greater risk)
 * Nulliparity
 * First full pregnancy older than 30 years old
 * Menarche younger than 13 years old (2 times’ the risk)
 * Menopause older than 50 years old
 * Not breastfeeding
 * Diethylstilbestrol use (synthetic nonsteroidal estrogen)
 * Alcohol consumption (probably through increasing estrogen levels)
 * Irradiation (particularly in the first decade of life)
 * Exposure to dichlorodiphenyldichloroethylene- DDE (a metabolite of the insecticide DDT)
 * Dietary
 * Physical activity
 * Exposure to chemicals ||
 * **Signs & Symptoms:** || The most common physical sign of cancer of the breast is a mass or lump that tends to be painless or slightly tender. Spontaneous, unilateral serous nipple discharge in a nonlactating breast may indicate cancer. [3] Nipple retraction or tenderness and pain in the nipple may suggest cancer as well. Occasionally, enlargement of an axillary lymph node can be the first sign of detection. [4] Dimpling of the skin or changes or distortion in the contour of the breast can indicate an advanced stage carcinoma. Additionally, fixation of a mass to the pectoral fascia or chest wall, edema, and erythema of the skin and axillary adenopathy can be signs of a cancer of the breast. [3] ||
 * **Diagnostic Procedures:** || The diagnostic workup for carcinoma of the breast begins with a general history including menstrual status, parity, and family history of cancer; in addition, to a physical examination. Special tests that may be done include needle aspiration or a biopsy to determine the histopathologic diagnosis, and/or an evaluation for horomone receptors. A biopsy can be performed through one of several techniques including a fine-needle biopsy, core-needle biopsy, incisional or excisional biopsy. Before a biopsy is done, a chest x-ray, mammogram, ultrasound, or magnetic resonance imaging (MRI) should be performed. Laboratory studies including a complete blood cell count, blood chemistry and urinalysis should be done. Optional tests such as growth factor, DNA index and oncogene assays may be performed. Bone scans are highly recommended and if results are positive, a computed tomography (CT) scan of the liver and spleen should be done. A postitron emission tomography (PET) is being utilized more frequently for detection of regional lymph nodes or distant metastases. If neurologic symptoms suggest cerebral metastases, a CT or MRI should be obtained. [5] ||
 * **Histology:** || Breast cancer can have many different histology’s’ depending on the tissue of origin or location but most of breast cancer tumors originate in the epithelia cells that compose the lining layers of organs. Others can originate in connective tissues (fat, cartilages, muscle) or tissues have secretory properties (production of mucous or milk). [5] The breast consists of glandular epithelia tissue arranged into lobes connected by lobules in ducts with a network of lymph chains and blood vessels. [5] Breast cancers can be divided into four main location categories, ductal carcinoma in situ (DCIS), lobular carcinoma in situ (LCIS), infiltrating ductal carcinoma (IDC) and infiltrating lobular carcinoma (ILC).
 * **Lymph node drainage:** || The most common lymph nodes involved with breast cancer are the axillary chain due to smaller chains draining into it. The supraclavicular, infraclavicular and internal mammary nodal chains are also seen to have involvement but are more dependent on primary location. ||
 * **Metastatic spread:** || Metastatic spread of advanced breast cancer through lymph nodes and blood circulation can include the following sites. If there the supraclavicular node is involved the chance of metastatic spread is increased to the following structures.
 * **Grading:** || Grading of Breast for T3-T4 involvement is determined through a biopsy sample and then is placed under a microscope to determine the grade then only can determine the stage of the tumor. A grade is a nuclear grade, with mitotic rate and tubule formation to grade breast cancer[7].
 * **Staging:** || The stage of the breast cancer that is whether it is limited to one area in the breast, or it has spread to healthy tissues inside the breast or to other parts of the body. There our four characteristics of staging. Staging is dependent on the size of the cancer, whether the cancer is invasive or non-invasive, whether the cancer is in the lymph nodes, and whether the cancer has spread to other parts of the body beyond the breast[8].

Stage III
Stage III is divided into subcategories known as IIIA, IIIB, and IIIC. Stage IIIA describes invasive breast cancer in which either[8]: Stage IIIB describes invasive breast cancer in which: Inflammatory breast cancer is considered at least stage IIIB. Typical features of inflammatory breast cancer include: Stage IIIC describes invasive breast cancer in which:
 * no tumor is found, but cancer is found in axillary lymph nodes, which are clumped together or sticking to other structures, or cancer may have spread to lymph nodes near the breastbone OR
 * the cancer is any size and has spread to axillary lymph nodes, which are clumped together or sticking to other structures
 * the cancer may be any size and has spread to the chest wall and/or skin of the breast AND
 * may have spread to axillary lymph nodes, which are clumped together or sticking to other structures, or cancer may have spread to lymph nodes near the breastbone
 * reddening of a large portion of the breast skin
 * the breast feels warm and may be swollen
 * cancer cells have spread to the lymph nodes and may be found in the skin
 * there may be no sign of cancer in the breast or, if there is a tumor, it may be any size and may have spread to the chest wall and/or the skin of the breast AND
 * the cancer has spread to lymph nodes above or below the collarbone AND
 * the cancer may have spread to axillary lymph nodes or to lymph nodes near the breastbone

Stage IV
Stage IV describes invasive breast cancer that has spread beyond the breast and nearby lymph nodes to other organs of the body, such as the lungs, distant lymph nodes, skin, bones, liver, or brain. You may hear the words “advanced” and “metastatic” used to describe stage IV breast cancer. Cancer may be stage IV at first diagnosis or it can be a recurrence of a previous breast cancer that has spread to other parts of the body. || Tangent field are used to treat the entire breast tissue to 45 to 55 Gy depending on stage and type, while sparing the lung, heart, and other normal tissues. [5] A supraclavicular field can be added and matched to the tangents to treat nodes extending in to the shoulder and neck areas. [5] After initial whole breast treatments, a boost can be treated to the surgical cavity alone usualy with electrons to 10 to 15 Gy. [5]  ||  || 2. Ezzia MC. Etiology of breast cancer. //Ezine Articles.// 2012. Available at: []. Accessed June 4, 2012. 3. Lenhard RE, Osteen R, Gansler T. //The American Cancer Society’s Clinical Oncology//. Williston, VT: Blackwell Publishing, Inc; 2001. 4. Washington CM, Leaver D. //Principles and Practice of Radiation Therapy//. St. Louis, MO: Mosby; 2010. 5. Chao KS, Perez CA, Brady LW. //Radiation Oncology: Management Decisions//. Philadelphia, PA: Lippincott Williams & Wilkins; 2002. 6. Emami B, Lyman J, Brown A, et al. Tolerance of normal tissue to therapeutic irradiation. //Int J Radiat Oncol Biol Phys.// 1991 7. Frost, M. Grades of Breast Cancer Tumors. Ehow. 2012. Available at: []. Accessed: June 6, 2012. 8. Stages of Breast Cancer. March 2012. Available at: [|http://www.breastcancer.org/symptoms/diagnosis/staging.jsp#tnm]. Accessed: June 6, 2012. 9. Managing Other Sides Effect. March 2012. Available at: []. Accessed: June 6, 2012. ||
 * **Radiation side effects:** || The most common side effect of radiation therapy for breast cancer is fatigue, and skin reaction[9]. Breast cancer side effects that are possible experience is armpit discomfort, chest pain, fatigue, heart problems, lowered white blood cell counts and lung problems. ||
 * **Prognosis:** || The prognosis of a breast cancer diagnosis is specific to the patient due to the many factors that play a roll.
 * 1) Nodal status which can only be evaluated from biopsy significantly affects staging and prognosis. The more nodes the poorer the prognosis.
 * 2) Tumor size also affects staging and prognosis. If caught early the prognosis is much better than later on when larger tumors can also increase nymph node involvement.
 * 3) The cellular type or histology of tumor is another prognostic factor. 70 to 80 percent of breast cancers are infiltrating ductal. 5 to 10 percent are infiltrating lobular and rarer types of infiltrating breast cancer are mucinous, colloid, tubular and papillary. These infiltrating types all have a fairly good prognosis when caught early. Inflammatory breast cancer has the worst prognosis.
 * 4) Hormonal evaluations can play a huge roll in predicting the prognosis in patients. Patients with estrogen/progesterone receptor positive tissue samples can be more responsive to hormone therapies and may have a better treatment response than patients without.
 * 5) Some lab studies can indicate prognosis and help in the decision making process as to what type of treatment would be best for specific patients. [4] ||
 * **Treatments:** || Radiation treatment of breast cancer is highly dependent on the stage of the disease which is based on nodal involvement and extent of primary tumor. Other factors come in to play such as chemo treatment, mastectomy, and genetic testing which can now determine if a patient may respond to some types of treatment. The basic premise has been to include the entire involved breast along with involved lymph nodes in treatment fields while avoiding critical structures to the best ability. This is fine for patients that are eligible for this type of treatment however, in recent years patients diagnosed with early stage breast cancer may be eligible for accelerated partial breast irradiation. This type of treatment irradiates a smaller volume in a much shorter time frame. This is only available for early stage centrally lying tumors. Some patients have radical surgery before treatment leaving very little breast tissue behind but also requiring radiation treatments. Some of these patients have reconstruction before and or after treatment which can further complicate treatment planning and outcomes. Every patient is unique and requires significant planning to achieve the best outcome. [5] Included are some different treatment plans and fields.
 * **TD 5/5:** || TD 5/5 is a statistical guideline to consider which states that there has been a five percent probability of complication in five years. These values are based on a 200cGy 5 fraction a week treatment schedule.[6]
 * **References:** || 1. Swart R, Harris JE, Downey L, et al. Breast Cancer. //Medscape//. Nov. 18, 2011. Available at: [|http://emedicine.medscape.com/article/1947145-overview#showall]. Accessed June 4, 2012.

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Metastatic spread of advanced breast cancer through lymph nodes and blood circulation can include the following sites. If there the supraclavicular node is involved the chance of metastatic spread is increased to the following structures.  · Brain  · Bone  · Lung  · Liver  · Pleura