Carcinoma of the breast

Carcinoma of the breast is very common in Caucasians, but is less common in Africans. Carcinoma of the African male breast is however not the rarity that it is in Europe. Carcinoma of the breast can occur at any age after 20 years, but is most common between 50 and 70, particularly in non-parous women and in women who started childbearing late; it is also common in the sisters of patients with the disease, and to a lesser extent in their daughters.

Most carcinomas arise from glandular tissue. There are several types: (1) Schirrous carcinomas (75%) contain much connective tissue, and form hard lesions which cut like an unripe pear to produce a greyish cut surface which becomes concave. (2) Medullary (anaplastic) carcinomas (15%) contain less fibrous tissue and are softer. (3) Duct carcinomas (6%) are the least invasive, and present as a watery or blood-stained discharge from the nipple. Clinically, you cannot distinguish them from duct papillomas. (4) ''Inflammatory carcinoma' or ''mastitis carcinomatosa' (uncommon) is the most malignant type, and usually develops during pregnancy.

Breast carcinomas form no capsule; they invade locally through the lymphatics, and spread widely through the bloodstream. A patient's prognosis is related to: (1) the stage at which treatment starts, (2) the number of nodes in her axilla that contain microscopic deposits, and (3), less significantly, the treatment she has. The stage at which the diagnosis is made is critical. Unfortunately, methods of self-examination, which are so effective in educated communities, are seldom applicable in poorly educated ones, in whom carcinoma commonly presents late. There is however one measure you can take[md]persuade your staff to examine their patient's breasts on every convenient opportunity.

Carcinoma of the breast may present as a painless lump in the breast (80%), as enlargement of a breast, as ulceration, or as a discharge from the nipple, which is usually but not always blood-stained.

Treatment is mainly surgical and is controversial[md]the radical and conservative schools do not agree, but the conservatives are gaining ground. As in any other part of the body, surgery can only cure carcinoma of the breast, if it is local and has not spread elsewhere. If radiotherapy is available (unusual in much of the developing world), it is the preferred treatment for axillary nodes. No known drug is curative, although the regimes below do give short remissions. Many patients present late with foul, stinking ulcers. A mastectomy at this stage, if it is possible (the growth may be fixed to the deep structures and make it impossible) relieves a patient's suffering, and makes her last months more bearable, but only if you can remove the tumour with a margin of normal skin all round it and still close the wound.

CARCINOMA OF THE BREAST Here we assume that a patient has a lump in her breast, which you think is probably malignant by the criteria in the previous section.

STAGING and PROGNOSIS. Here is the Manchester system of staging. The prognosis of scirrhous and medullary carcinoma is the same. Duct carcinoma has the best prognosis, even after the excision of an entire duct system, and mastitis carcinomatosa the worst.

Stage One The growth is confined to her breast, and is not adherent to her pectoral muscles or to her chest wall. There are no enlarged nodes in her axilla. Adherence to the skin, or ulceration through it, does not affect staging, if it is smaller than the tumour. 68% of all patients survive 5 years, and 54% 10 years.

Stage Two As for stage One, but there are now mobile nodes in her axilla. 60% of patients survive 5 years and 40% 10 years.

Stage Three There is skin involvement which is larger than the tumour, but it is still limited to her breast. If any axillary nodes are palpable, they are still mobile. Or the tumour is fixed to her pectoral muscle, but not to her chest wall. Or it is fixed to both. 15% of patients survive 5 years and 4% 10 years.

Stage Four She has distant metastases, either lymphatic, or blood-borne. These include infiltration of the skin beyond her breast, fixed nodes in her axilla, palpable nodes in her supraclavicular fossae, involvement of her other breast; or deposits in her bones, liver, or lungs (unusual). 4% of patients survive 5 years and 4% 10 years.

On microscopic examination the axillary nodes are involved in 10% of patients in Stage One, although they may not be obvious for 20 years. Sadly, most patients in the developing world present in stages Three and Four.

In Stages One and Two, a patient's prognosis depends on the stage of the disease, and where the primary tumour is in her breast. Tumours in the lateral half of the breast have a better prognosis.

If the tumour is in the lateral half of her breast, and her axillary nodes are not involved, there is a 90% chance that she can be cured surgically. If they are involved, she has only a 50% chance of surviving 5 years. There is a 20% chance that it will recur locally.

If it is in the medial half of her breast (less common), her prognosis is worse, because it is more likely to spread to her internal mammary nodes.

THE MANAGEMENT [s7]OF CARCINOMA OF THE BREAST STAGE ONE. Do a ''lumpectomy' (21.5). Excise 2 cm of normal breast round the lump, and send tissue for histology. No further treatment is needed, whether or not the report confirms carcinoma.

STAGE TWO. Management depends on whether or not histology is available without undue delay.

If histology is available, first do a biopsy, and then proceed with one of the following operations as soon as the result is available. You have three choices. You can do: (1) A ''lumpectomy' (see below) plus dissection of the axilla preserving pectoralis major. (2) A simple mastectomy plus dissection of the axilla preserving pectoralis major. (3) A ''conservative radical mastectomy' (Patey's operation). (4) Lumpectomy or simple mastectomy combined with radiotherapy to the axilla, if it is available. This is the best because it is least mutilating. If radiotherapy is not available, Patey's operation is recommended.

CAUTION ! For Stage Two, a ''lumpectomy', or simple mastectomy without removing the axillary nodes, is not considered adequate; but it may be all you can do if you are unskilled. We have only described Patey's operation, but operation (2) above is almost the same. See Section 21.5

If histology is not available, or is only available after undue delay, proceed with one of the above definitive operations immediately.

STAGES THREE AND FOUR. Surgery is only palliative, and may not be indicated if the metastases are worse than the primary. Aim to: (1) Prevent the tumour ulcerating through the skin. (2) Remove the primary in toto with, if possible, a margin of 2 cm of surrounding breast. Excise as much breast tissue as is necessary to do this. Usually, only a simple mastectomy is required, but you may need to remove part of her pectoralis major muscle. Leave the nodes in her axilla. The only indication for removing them is when they might ulcerate (unusual). This is only possible when they are mobile. Local removal will make life more bearable. Consider combining it with hormone therapy, which is cheaper and much easier than chemotherapy.

MASTITIS CARCINOMATOSA may develop if a patient is pregnant. Try to distinguish it from an inflammatory mass by needle aspiration, and from Burkitt's lymphoma (in endemic areas) by needle cytology (32-3). Do the appropriate operation for the stage of the lesion. Anything you can do will probably only be palliative. Neither abortion nor subsequent pregnancies alter the prognosis.

HORMONAL AND CYTOTOXIC TREATMENT [s7]FOR BREAST CANCER BILATERAL OOPHORECTOMY may help a premenopausal patient with metastases, especially in bone. It produces remission rates (usually partial) of 20% to 40% in premenopausal patients for up to 7 years, but is unpopular in some commuinities in the developing world. Length of life is not improved.

OESTROGENS. Ethinyl oestradiol in a dose of 1 mg/day is useful for postmenopausal patients, and produces some symptomatic improvement in most patients, especially if they have pain from bony metastases. Or, give her stilboestrol 10 to 20 mg daily in divided doses.

A PROGESTAGEN such as medroxyprogesterone acetate is a possible alternative, if she is postmenopausal.

TAMOXIFEN is a non-steroid oestrogen antagonist which competes with oestrogen for receptor sites on the tumour cells, and has few side effects. Give 10 mg twice daily initially, and continue it indefinitely. Only some tumours are oestrogen- receptor-positive, and only a sophisticated laboratory can identify those that are. Tamoxifen causes partial remissions in postmenopausal patients. The remission rate 0 to 5 years after the menopause is 14%, 5 to 10 years after 30%, and [mt]10 years after 37%. Tamoxifen has been expensive, but is now (1988) much cheaper from secondary sources.

CYTOTOXIC DRUGS produce remissions of 5 to 12 months in 50% of cases, especially in premenopausal patients with soft tissue lesions rather than bony metastases, but often with considerable toxicity. Single-dose regimes are not very effective. If drugs are short, carcinoma of the breast has a low priority; keep them for Burkitt's lymphoma and nephrobastoma. If you decide to use them, here are two possible regimes[md]

Use the ''CMF' regime. Give her cyclophosphamide 100 mg/m['2] by mouth daily for 14 days. Give her methotrexate 30 mg/m['2] intravenously on days 1 and 8. Give her 5-fluorouracil 500 mg/m['2] intravenously on days 1 and 8. Repeat the course 28 days after starting for up to a year if she responds. Stop if there is no response.

Alternatively, give her doxorubicin (''Adriamycin') 60 mg/m['2] every 3 weeks or 20 mg/m['2] weekly to a cumulative maximum dose of 600 mg/m['2]. This simple regime is effective in a high proportion of cases, but will make her lose her hair.

Fig 21-6 ''SHELLING OUT' AND ''LUMPECTOMY' for the removal of a fibroadenoma. A, B, and C, you may be able to shell out a fibroadenoma through a small incision with minimal disturbance to the surrounding tissue. D, E, and F, you may have to expose the lesion, and remove it with a small part of the surrounding breast (lumpectomy). After Rob C and Smith R, ''Operative Surgery' Vol. 1 (2nd edn), (Butterworth) with the kind permission of Hugh Dudley.