Topic: Ca Breast, Ca Lung
Question: A 50-year-old nulliparous female presents with a hard lesion of the right breast that she had noticed 2 weeks ago. Clinical examination reveals puckering of the overlying skin and retraction of the nipple along with a 3 cm hard mass in the upper outer quadrant of the right breast. 3 hard masses are palpable in the right axilla. On questioning the patient reveals a weight loss of 7kg in the last 2 months. Mammogram reveals a 3.4 cm mass with irregular spiculated margins and increased density compared to the surrounding breast tissue. (a) What is your diagnosis. Justify it (b) What is the gross and histology of this lesion (c) List the major prognostic and predictive markers
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(a) The clinical presentation and imaging findings are highly suspicious for breast cancer. The hard mass with overlying skin changes like puckering and nipple retraction indicate infiltration of the mass into the skin. This is concerning for an invasive locally advanced breast cancer. The enlarged, hard axillary lymph nodes suggest lymph node metastatic disease. Unexplained weight loss can occur in malignancy due to cachexia. On imaging, the spiculated irregular mass with increased density is typical for a breast malignancy. The imaging and clinical correlate point to a diagnosis of invasive breast carcinoma.
(b) Grossly, breast cancers usually appear as hard, irregular masses that are gritty on cut section. They often demonstrate infiltration into surrounding breast parenchyma and skin. Histologically, most breast cancers originate from mammary ductal or lobular epithelium. The most common type is invasive ductal carcinoma. Microscopic examination shows malignant epithelial cells infiltrating fibrous breast stroma in a disorganized pattern. The cancer cells exhibit nuclear pleomorphism, increased nuclear to cytoplasmic ratios, cellular discohesion, and lack of normal ductal orientation or tubule formation. Other features include necrotic debris, calcifications, and inflammatory cells. Special stains help highlight cellular atypia. Immunohistochemistry helps classify cell origin.
(c) Major prognostic and predictive factors in breast cancer:
– Stage – Tumor size, nodal status, and metastases determine stage which predicts prognosis. This patient has a large T3 tumor and N1 nodal disease indicating advanced stage IIIB breast cancer.
– Grade – Histologic grade based on cellular differentiation and proliferation helps determine aggressiveness. High grade tumors have a worse prognosis.
– ER/PR receptors – Hormone receptor positive cancers can be treated with anti-estrogen therapy. This predicts response.
– HER2 status – Overexpression or amplification predicts response to anti-HER2 agents like trastuzumab.
– Proliferation index – Measured by Ki-67 percent. High Ki-67 predicts increased risk of recurrence.
– Genomic testing – Oncotype Dx and Mammaprint help further define recurrence risk and chemotherapy benefit.
In summary, this clinical scenario is most consistent with locally advanced invasive breast cancer. Prognostic and predictive factors will help determine the stage, appropriate systemic treatment, and overall recurrence risk.
