Running Head: BREAST CANCER: A CHANGING CELL

Breast Cancer: A Changing Cell December 6, 2011

BREAST CANCER: A CHANGING CELL Abstract Breast cancer is a leading disease in woman today. Breast cancer is when abnormal cell growth originates within the breast tissue. There are many factors associated with an increased chance of breast cancer. Breast cancer can be imaged within many medical imaging modalities. Once breast cancer is found, staging is done to better describe the degree of cancer in the body. Not all cancer is the same and therefore cannot be treated the same. Treatment options are available. Making a treatment plan with a care provider is the best plan of action for recovery and future health.

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Breast Cancer: A Changing Cell

The human body is amazing. It is amazing that such a complex system stared out with one cell. One cell has the power to create and multiply. One cell multiplies, then directs an intricate pattern of growth that soon becomes a beautiful, functioning body. Trillions of cells that work as an orchestra, blending, combining, uniting together with order and care to create a symphony of systems. Yet, with the power from one cell, the beauty can turn to dread. One cell can turn into an unforgiving force to destroy and overtake. One cell. One word. Cancer. When a cell’s DNA is damaged the body will either repair the cell or the cell will die. A cancer cell is an abnormal cell that does not follow these rules of the body. Instead, the cancer cell does not repair; it does not die; but takes its damaged DNA and starts to reproduce. The growth of these abnormal cells is cancer. Breast cancer is when this abnormal cell growth originates within the breast tissue. The female breast has three main structures. The lobules are glands that produce milk, the ducts are very small tubes that transport the milk from the lobules to the nipple, and stroma is fatty and connective tissue, blood vessels, and lymphatic vessels that surround the ducts and lobules.(See Fig. 1) Breast cancer can originate in any of these tissues. The lymphatic system plays a large role Fig. 1 Anatomy of the normal female breast. Note. From American Cancer Society Web site (2011). What is breast cancer?, Retrieved from http://www.cancer.org/Cancer/BreastCancer/Detai Detailed/breast-cancer-what-is-breast-cancer. Reprinted with permission.

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in the spread of the cancer cells. The lymphatic system has passage ways similar to a system of veins and has direct access to other areas all over the body. For this reason, if cancer enters into the lymphatic vessels there is a higher risk of cancer spreading into the bloodstream to other areas and organs of the body. The breast corresponds Fig. 2 Anatomy of lymphatic system near the female breast.

with four different regions of lymph nodes as shown in

Note. From American Cancer Society Web site (2011). What is breast cancer?, Retrieved from http://www.cancer.org/Cancer/BreastCancer/ detailedGuide/breast-cancer-what-is-breast-cancer. Reprinted with permission.

Fig. 2. Risk Factors There is no single cause that is responsible for the development of breast cancer. It is most often probable that many factors play a role in the deformation of the cells. Although it may be difficult to pinpoint the cause, there are many factors associated with an increased chance of breast cancer. According to Kopans (1989), “the major risk factors for breast cancer are as follows: gender, age, early menarche – late menopause, nulliparity, [meaning to have never given birth], late age at first full-term pregnancy, previous history of breast cancer, biopsy proof – atypical epithelial proliferation, and presence of lobular carcinoma in situ” (p.2).

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Other factors include, but are not limited to, family history, dense breast tissue, radiation exposure, hormone therapy, alcohol consumption, being over-weight or obese after menopause, lack of physical activity, and diet. Diagnosis Breast cancer can be found many ways but is most commonly found through breast selfexams, clinical breast exams, and mammograms. The American Cancer Society recommends that all women, even those who have no abnormal breast changes and have no abnormal symptoms, have an annual screening mammogram starting at age forty and onward. A screening mammogram is a medical image acquired through the use of

Fig. 3 Image shows compression of breast.

low-dose x-rays. “X-ray mammography is

Bontrager, K .L., Lampignano, J.P. (2010). Radiographic positioning and related anatomy, seventh edition. St. Louis, Missouri: Elsevier Inc. p. 568

clearly the single most important factor in early

detection [of breast cancer]” (Kopans, 1989. p. vii).

To obtain a

mammogram image, the breast is compressed between two plates (See Fig. 3 and 4). The compression is very important because it spreads out the tissue to a more uniform thickness, separates structures in the breast for less superimposition, and pulls the Fig. 4 Image shows compression of breast. Note. From Bontrager, K .L., Lampignano, J.P. (2010). Radiographic positioning and related anatomy, seventh edition. St. Louis, Missouri: Elsevier Inc. p. 578

breast out from the chest wall. Compression “greatly improve[s] the visibility of detail in the breast images” (Bontrager, 2010. p. 568). Breast cancer can be imaged within many medical imaging

modalities. Mammography is the golden standard for breast imaging. Mammography

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screenings generally take place first and depending on the results, more images may be requested from mammography and/or other modalities. Diagnostic x-ray may be used with imaging the chest to check for metastases in the lungs. Magnetic resonance imaging (MRI) uses strong magnets and radio waves to obtain an image of the breast. This method can help “determine the actual size of the cancer and to look for any other cancers in the breast” ( How is breast cancer diagnosed Section, Magnetic resonance imaging (MRI) of the breast Subsection, paragraph 5). MRI can also be used to image metastases in other organs of the body. Ultrasonography (US) uses sound waves to image the breast. US is often used to determine if a spot of concern from a mammogram is a fluid-filled or solid tumor. Bone scans use a radioactive tracer that is injected into the blood stream and then picked up by areas in the body with high metabolic rate. These areas usually show metastasizing cancer. Computed tomography (CT) is not generally used for the breasts, but to search for metastases in the chest and/or abdomen or other areas of the body. CT uses x-rays in a rotating scanner to record many images through different planes of the body. Breast Abnormalities Detecting the abnormalities that could be a sign of breast cancer are of the upmost importance when viewing the medical images. During annual mammography screenings, the main abnormalities that are cause for concern are masses, distortion, and calcifications. If these abnormalities are found more imaging or biopsies will usually be suggested. Breast cancer most commonly presents as a mass. A mass is defined as “a three dimensional area of density with margins distinguishing it from the surrounding parenchyma that if removed is likely to be distinctly different histologically from the surrounding “normal” breast tissue” (Kopans, 1989, p. 68).

BREAST CANCER: A CHANGING CELL Differential Diagnosis of Well-Defined Masses Type of Lesion

Mammographic Characteristics

Cyst

Medium density, round, any size, oriented toward the nipple Medium density, lobulated, any size, coarse calcification Medium to high density, slightly irregular, microcalcification. Medium density, small, may calcify

Fibroadenoma Carcinoma Papilloma Hematoma Hamartoma

Medium to high density, slightly irregular, skin thickening Mixed density, encapsulated

Lipoma

Low density, encapsulated

Metastases

Medium density, round, superficial location

Inclusion cyst

Medium density, round, superficial location

Intramammary node

Mixed density, small, lateral location

Cystosarcoma phylloides Abscess

Medium to high density, large, lobulated

Fat necrosis(oil cyst)

Radiolucent with calcific rim

Galactocele

Fat density or mixed density

Skin lesion(nuerofibroma)

Medium density or mixed density, crenulated surface, extremely well defined (air halo) Medium to high density, different appearance on orthogonal view

Nipple out of profile

7 Due to the many different types of masses, a table is given to provide the information (See Table 1). A mass is evaluated by location, density, size, shape, margins, and presence of associated calcifications. At times the mass is not seen on the mammogram, but distortion of tissue in the area often suggests a mass.

Medium to high density, skin thickening

Table 1 Table shows types of masses and their characteristics. Note. From Paredes, E. S. (1992). Atlas of film-screen mammography, second edition. Baltimore, Maryland: William & Wilkins.

Within the normal anatomy of the female breast, the structures and tissue, including the duct lines, have a loose flow toward the nipple. Distortion occurs when this normal flow is disrupted. A mass is often

the cause of architectural distortion of the breast. In the image of the breast, the lines of tissue look pulled to the center of a spot that is not eccentrically aligned with the nipple. Fig. 5 shows a patient who was diagnosed with invasive lobular carcinoma. The image shows how the normal tissue flow is being pulled into the center of the cancer. This finding would be cause for extra imaging and biopsy.

Fig. 5 Image shows architectural distortion

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Most women have calcifications of some sort within their breasts. Not all calcifications are cancerous. Homogeneous, round, and smooth are generally benign, but are closely monitored and often biopsied. Calcifications that tend to be cancerous are the small microcalcifications that lie within an abnormal duct of the breast. Malignant calcification can be identified as such when they have linear branching, with irregular, jagged, sharp edges. “About 50% of all breast cancers are associated with calcifications” (Paredes, 1992, p. 299). Also, clustered microcalcification can be an indicator of cancer. Fig. 6 shows a good example of both vascular calcifications that are not cancerous or of malignant concern, and a microcalcification cluster (circled in

Fig. 6 Vascular calcifications vs. abnormal calcifications

bottom image) that later is diagnosed as intraductal carcinoma. All abnormalities and cancers cannot be seen or found on a mammogram. It is important to have regular annual mammograms so that changes in the breasts can be monitored exam to exam. Health providers and physicians do all they can to provide the best care possible. Staging Once breast cancer is found, staging is done to better describe the degree of cancer in the body. This staging has multiple cancer dynamics including invasive versus non-invasive, size of the tumor, how many lymph nodes are involved, and if it has spread or metastasized to other areas of the body. Below is a chart showing the most commonly used process of staging, the

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American Joint Committee on Cancer (AJCC) TNM system. This information was gathered directly from the American Cancer Society Web site (2011). How is breast cancer staged?.

The letter T followed by a number The letter N followed by a number The letter M followed by a 0 or 1 from 0 to 4 describes the tumor's from 0 to 3 indicates whether the indicates whether the cancer has size and spread to the skin or to the cancer has spread to lymph nodes spread to distant organs -- for chest wall under the breast. Higher T near the breast and, if so, how many example, the lungs or bones. numbers mean a larger tumor and/or lymph nodes are affected. wider spread to tissues near the breast. TX: Primary tumor cannot be assessed. T0: No evidence of primary tumor. Tis: Carcinoma in situ (DCIS, LCIS, or Paget disease of the nipple with no associated tumor mass) T1 (includes T1a, T1b, and T1c): Tumor is 2 cm (3/4 of an inch) or less across. T2: Tumor is more than 2 cm but not more than 5 cm (2 inches) across. T3: Tumor is more than 5 cm across. T4: Tumor of any size growing into the chest wall or skin. This includes inflammatory breast cancer. NX: Nearby lymph nodes cannot be assessed (for example, removed previously). N0: Cancer has not spread to nearby lymph nodes. N0(i+): Tiny amounts of cancer are found in underarm lymph nodes by using special stains. The area of cancer spread contains less than 200 cells and is smaller than 0.2 mm. N0(mol+): Cancer cells cannot be seen in underarm lymph nodes (even using special stains), but traces of cancer cells were detected using a special test (called PCR). N1: Cancer has spread to 1 to 3 axillary (underarm) lymph node(s), and/or tiny amounts of cancer are found in internal mammary lymph nodes (those near the breast bone) on sentinel lymph node biopsy. N1mi: Micrometastases (tiny areas of cancer spread) in 1 to 3 lymph nodes under the arm. The areas of cancer spread in the lymph nodes are 2 mm or less across (but at least 200 cancer cells or 0.2mm across). N1a: Cancer has spread to 1 to 3 lymph nodes under the arm with at least one area of cancer spread greater than 2 mm across. N1b: Cancer has spread to internal mammary lymph nodes, but this spread could only be found on sentinel lymph node biopsy (it did not cause the lymph nodes to become enlarged). N1c: Both N1a and N1b apply. N2: Cancer has spread to 4 to 9 lymph nodes under the arm, or cancer has enlarged the internal mammary lymph nodes (either N2a or N2b, but not both). N2a: Cancer has spread to 4 to 9 lymph nodes under the arm, with at least one area of cancer spread larger than 2 mm. N2b: Cancer has spread to one or more internal mammary lymph nodes, causing them to become enlarged. N3: Any of the following: N3a: either  Cancer has spread to 10 or more axillary lymph nodes, with at least one area of cancer spread greater than 2mm, OR  Cancer has spread to the lymph nodes under the clavicle (collar bone), with at least one area of cancer spread greater than 2mm. N3b: either:  Cancer is found in at least one axillary lymph node (with at least one area of cancer spread greater than 2 mm) and has enlarged the internal mammary lymph nodes, OR  Cancer involves 4 or more axillary lymph nodes (with at least one area of cancer spread greater than 2 mm), and tiny amounts of cancer are found in internal mammary lymph nodes on sentinel lymph node biopsy. N3c: Cancer has spread to the lymph nodes above the clavicle with at least one area of cancer spread greater than 2mm

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MX: Presence of distant spread (metastasis) cannot be assessed. M0: No distant spread is found on x-rays (or other imaging procedures) or by physical exam. cM0(i +): Small numbers of cancer cells are found in blood or bone marrow (found only by special tests), or tiny areas of cancer spread (no larger than 0.2 mm) are found in lymph nodes away from the breast. M1: Spread to distant organs is present. (The most common sites are bone, lung, brain, and liver.)

Table 2. Table showing the TNM system. Note. From American Cancer Society Web site (2011). How is breast cancer staged?. Retrieved from http://www.cancer.org/Cancer/BreastCancer/DetailedGuide/breast-cancer-staging.

After the TNM categories are in place, stage grouping is an additional course expressed from Stage I to Stage IV. These stages express the level of invasiveness, Stage 0 being noninvasive and Stage IV being the most invasive. The combination of the TNM system and the stage grouping help the care providers assemble the best care plan for the specific type of cancer. Treatment All cancer is not the same and therefore cannot all be treated the same. “Women with breast cancer have many options. The choice of treatment depends mainly on the stage of the disease” (U.S. Department of Health and Human Services, 2005, p. 23). Surgery is the most common treatment for breast cancer. Surgery for breast cancer can differ from only removing the cancerous legion and nearby surrounding tissue, up to removing the entire breast and lymph nodes, called a mastectomy. Radiation therapy is another treatment choice, where high-energy radiation is used to kill the cancer cells. Both surgery and radiation therapy are considered local therapy treatments. This means that these types of treatments act upon the specific area that has the cancer.

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Systemic therapy treatments are different by entering the bloodstream and attacking the cancer throughout the entire body. This type of therapy is to treat cancer that has spread and metastasized. Systemic therapy treatments often have many adverse side effects. Chemotherapy uses a drug that enters into the bloodstream to kill cancer cells. Hormone therapy stops certain cancer cells from receiving or using the hormones they need to grow. Biological therapy treatments help the body’s natural immune defense fight off the cancer cells. Conclusion One in every eight women will one day be diagnosed with breast cancer. “Breast cancer is the most common cancer among women in the United States, other than skin cancer. It is the second leading cause of cancer death in women, after lung cancer” (American Cancer Society (2011). How many women get breast cancer?). Breast cancer may not be preventable but early detection is possible. Making a treatment plan with a care provider is the best plan of action for recovery and future health. There are many support systems for those with breast cancer. Know that there is help. Know that there is hope. There is continual and ongoing research for a cure with hope that one day there will not be one person burdened with one cell of breast cancer.

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References Bontrager, K .L., Lampignano, J.P. (2010). Radiographic positioning and related anatomy, seventh edition. St. Louis, Missouri: Elsevier Inc. How is breast cancer diagnosed? (2011). American Cancer Society Web site, Retrieved from http://www.cancer.org/Cancer/BreastCancer/DetailedGuide/breast-cancer-diagnosis How is breast cancer staged? (2011). American Cancer Society Web site, Retrieved from http://www.cancer.org/Cancer/BreastCancer/DetailedGuide/breast-cancer-staging How many women get breast cancer? (2011). American Cancer Society Web site, Retrieved from http://www.cancer.org/Cancer/BreastCancer/OverviewGuide/breast-canceroverview-key-statistics Kopans, D. B. (1989). Breast Imaging. Philadelphia, Pennsylvania: J.B. Lippincott Company Paredes, E. S. (1992). Atlas of film-screen mammography, second edition. Baltimore, Maryland: William & Wilkins. U.S. Department of Health and Human Services. (2005). What you need to know about breast cancer . National Institute of Health. What is breast cancer? (2011). American Cancer Society Web site, Retrieved from http://www.cancer.org/Cancer/BreastCancer/DetailedGuide/breast-cancer-what-is-breastcancer