Breast+(Tis-T2)

__**Family history factors**__: __**Hormonal and reproductive factors**__: __**Environmental factors**__: 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). [] Figure 1, Image to show DCIS [] Figure 2 To show histology of IDC [] Figure 3, To show histology of ILC || Grade one looks like cells are fairly normal with a tubule format of greater than 75 percent[7]. The cell division (mitosis) will be up to seven[7]. 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[7]. The tubule format is between 10 to 75 percent[7]. There is some change is the size of the cells and variation. 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[7]. There is a marked variation in the changing of the cells. There will also be a notable cell division 15 or more in grade three tumors[7]. ||
 * **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 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] ||
 * **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. [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]
 * Ductal carcinoma in situ (DCIS) is the most common noninvasive diagnosis.
 * Lobular carcinoma in situ(LCIS)
 * Infiltrating ductal 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]
 * **Lymph node drainage:** || Once breast cancer has reached a certain point, it becomes invasive and moves beyond tissue lining can quickly move to the blood stream, lymph. Pending on the location of the primary tumor site and stage at diagnosis affect the possible lymph chains that can be involved due to the number of nodal systems within the breast itself. [5]
 * 10% to 40% of T1 and T2 show axillary node involvement. [5]
 * Supraclavicular nodes are occasionally involved. [5]
 * infraclavicular nodes.
 * Internal mammary if more medial. ||
 * **Metastatic spread:** || The main locations of metastasis of breast cancer are to the lung, liver and bones due to the location to major lymph node chains and proximity to major vascular networks. ||
 * **Grading:** || Grading of Breast for T1-T2 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[7]. A grade is a nuclear grade, with mitotic rate and tubule formation to grade breast cancer[7].
 * Staging: || The stage of breast cancer is 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[8]. There our four characteristics of staging. [8] The 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 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. [8]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).[8]

The Stage 0
Stage 0 is used to describe non-invasive breast cancers, such as DCIS (ductal carcinoma in situ. In stage 0, there is no evidence of cancer cells or non-cancerous abnormal cells breaking out of the part of the breast in which they started, or getting through to or invading neighboring normal tissue[8].

Stage I
Stage I describes invasive breast cancer (cancer cells are breaking through to or invading normal surrounding breast tissue) Stage I is divided into subcategories known as IA and IB. Stage IA describes invasive breast cancer in which: Stage IB describes invasive breast cancer in which: Microscopic invasion is possible in stage I breast cancer. In microscopic invasion, the cancer cells have just started to invade the tissue outside the lining of the duct or lobule, but the invading cancer cells can't measure more than 1 mm.
 * the tumor measures up to 2 cm AND
 * the cancer has not spread outside the breast; no lymph nodes are involved
 * there is no tumor in the breast; instead, small groups of cancer cells – larger than 0.2 millimeter but not larger than 2 millimeters – are found in the lymph nodes, OR
 * there is a tumor in the breast that is no larger than 2 centimeters, and there are small groups of cancer cells – larger than 0.2 millimeter but not larger than 2 millimeters – in the lymph nodes.

Stage II
Stage II is divided into subcategories known as IIA and IIB. Stage IIA describes invasive breast cancer in which: Stage IIB describes invasive breast cancer in which: 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]  ||  ||
 * no tumor can be found in the breast, but cancer cells are found in the lymph nodes under the arm (axillary) OR
 * the tumor measures 2 cm or smaller and has spread to the axillary lymph nodes OR
 * the tumor is larger than 2 cm but not larger than 5 cm and has not spread to the axillary lymph nodes
 * the tumor is larger than 2 cm but no larger than 5 cm and has spread to the axillary lymph nodes OR
 * the tumor is larger than 5 cm but has not spread to the axillary lymph nodes[8] ||
 * **Radiation side effects:** || The most common side effect of radiation therapy for breast cancer is fatigue, and skin reaction. Breast cancer side effects that are possible experience is armpit discomfort, chest pain, fatigue, heart problems, lowered white blood cell counts and lung problems[9]. ||
 * **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] The table includes the five most commonly evaluated structures for irradiation of the breast.

Nov. 18,2011. Available at: [|http://emedicine.medscape.com/article/1947145-overview#showall]. . Accessed June 4, 2012. 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. ||
 * **References:** || 1. Swart R, Harris JE, Downey L, et al. Breast Cancer. //Medscape//.

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