Size Surprise Tumour Size Nodal Status And Outcome After Breast Cancer
When it comes to tumour size, axillary lymph node status, and outcome after invasive ductal breast carcinoma, several facts have been established. The first is that the larger the tumour in diameter, the greater the number of axillary lymph nodes that will be found to be affected by metastatic cancer1. The second is that that the larger the tumour size, the worse the outcome1,2. The third is that the greater the number of lymph nodes involved by metastatic cancer, the worse the outcome1.
Tumour size and axillary lymph node status are highly correlated, but they are independent measures of outcome. Even in very large tumours, the number of involved lymph nodes highly significantly influences outcome, and when 4 or more nodes contain metastatic tumour, a woman with a 10- to 20-mm primary tumour has a better 5-year survival than does a woman with the same number of lymph nodes involved by cancer, but a primary tumour size of 2030 mm1.
So, what of Narods idea that the better course would be to focus efforts on lowering tumour sizes from 5 cm to 2 cmspecifically, by encouraging breast examination and mammography in developing countries and in poor and underserved populations in the developed world?
Treatment Of Local Recurrence After Previous Mastectomy
Most commonly the lesion is removed surgically and followed by radiation to the chest wall if the woman has not previously had radiation Treatment of local recurrence after mastectomy can involve a variety of different approaches, including surgery to remove the recurrence if it is confined to a limited area. Other options for treatment include radiation, chemotherapy, and endocrine therapy, or a combination of these.
Despite aggressive local treatment, many women with an isolated local recurrence following mastectomy eventually develop distant metastases. This is not because the local recurrence spreads, but rather because it is a sign that things have changed and dormant cells in other organs may also be waking up.
Dilemmas Of Stage Iv Breast Cancer
Indeed, there are many serious and personal questions involving stage IV breast cancer. So, overall survival is less likely, and gains from intensive breast cancer treatment are unfortunately rather modest. A serious consideration is, therefore, quality of life during the course of treatment.
These decisions tend to be a dynamic process, based on individual cases, between patients and physicians. Respect needs to be given to the expectations for treatment, the status of the disease and the patient wishes.
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The Types Of Radiotherapy
The type of radiotherapy you have will depend on the type of breast cancer and the type of surgery you have. Some women may not need to have radiotherapy at all.
Types of radiotherapy include:
- breast radiotherapy after breast-conserving surgery, radiation is applied to the whole of the remaining breast tissue
- chest-wall radiotherapy after a mastectomy, radiotherapy is applied to the chest wall
- breast boost some women may be offered a boost of high-dose radiotherapy in the area where the cancer was removed however, this may affect the appearance of your breast, particularly if you have large breasts, and can sometimes have other side effects, including hardening of breast tissue
- radiotherapy to the lymph nodes where radiotherapy is aimed at the armpit and the surrounding area to kill any cancer that may be in the lymph nodes
A Little Bit About The Internal Mammary Lymph Nodes
The internal mammary nodes are located behind the ribs. Ribs are made of bone, but in the front, they turn into cartilage just before they join the sternum.
So, each rib attaches to the sternum with cartilage and each of these cartilage bars is around 5 cm long. Thus, it can be very difficult to remove an internal mammary node. There is an internal mammary artery and vein along with the lymph ducts and other veins.
If you need to remove an internal mammary node, the cartilage in front needs to be cut out. Cartilage, unfortunately, does not grow back or heal and this will leave a gap which makes the rib essentially useless.
So, it is a judgement call by the surgeon as to whether or not one should attempt a surgical approach to remove internal mammary nodes with positive metastasis. This is because surgical removal is just too damaging to the function of the chest and ribs.
However, electron beam radiotherapy is an effective treatment for internal mammary nodes. The electrons penetrate to about the correct depth to reach the internal mammary nodes.
Treatment of Stage IIIa Breast Cancer
The treatment for women with stage IIIa breast cancers tends to be a modified radical mastectomy and locoregional radiotherapy.
Often, chemotherapy is given as adjuvant therapy, but in some cases , pre-operative chemotherapy is also recommended. Breast conservation is generally not a good option with stage IIIa breast cancers.
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What Is A Sentinel Lymph Node
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A network of lymphatic vessels and lymph nodes drain fluid from the tissue in the breast. The lymph nodes are designed to trap foreign or abnormal cells that may be contained in this fluid. Sometimes cancer cells pass through the nodes into the lymphatic vessels and spread to other parts of the body. Although fluid from breast tissue eventually drains to many lymph nodes, the fluid usually drains first through one or only a few nearby lymph nodes. Such lymph nodes are called sentinel lymph nodes because they are the first to warn that cancer has spread. |
Who Is Mainly Affected By Breast Cancer
Breast cancer is one of the most common cancers among women, second only to skin cancer. Its most likely to affect women over the age of 50.
Though rare, men can also develop breast cancer. Approximately 2,600 men develop male breast cancer every year in the United States, making up less than 1% of all cases.
Transgender women are more likely to develop breast cancer compared to cisgender men. Additionally, transgender men are less likely to develop breast cancer compared to cisgender women.
What age does breast cancer occur?
Breast cancer is most often diagnosed in adults over the age of 50, but it can occur at any age.
What race is most affected by breast cancer?
Overall, women who are non-Hispanic white have a slightly higher chance of developing breast cancer than women of any other race or ethnicity. Women who are non-Hispanic Black are almost as likely as non-Hispanic white women to develop the disease. Statistically, women who are Asian, Hispanic or Native American are the least likely to develop breast cancer.
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Testing Lymph Nodes For Cancer
A swollen lymph node can be felt with your fingertips and sometimes, and if large enough, can be seen. However, there are other areas of the body where lymph nodes are more difficult to find and dont present symptoms on the surface. The only way to confirm a cancer diagnosis in the lymph nodes is through a biopsy.
A biopsy is performed by using a long, thin needle to remove part of the lymph nodes or lymphatic tissue and reviewing it under a microscope to see if there are cancerous cells. The number of cancer cells will determine the course of treatment. There are additional tests to also determine how far cancer has spread and the cancer stage. All of this plays a part in the type, frequency, and outlook of treatment.
If you are wondering, is cancer of the lymph nodes terminal, understand that cancer spreadto the lymph nodes does not automatically determine which stage its in.3 Typically, if its traveled far from its originating tumor source, it could indicate a later stage, though there are several tests that can be performed to get a clearer picture. These include:
Not all of these tests are necessary to confirm cancer staging, but they each help deliver more information to make an accurate diagnosis. Furthermore, cancer staging is assigned at the time of diagnosis but can be restaged following treatment. This is based on if cancer has stopped its growth or metastasized to other areas of the body.
A New View Of Cancer Metastasis
In the lymph nodes, immune cells learn what to attack and what to protect .
But this study suggests that, in lymph nodes invaded by cancer, immune cells learn to protect the cancer cells rather than attack them, Dr. Engleman said. This phenomenon is called immune tolerance.
The research team suspects that those specialized cellsonce theyre educated by the tumorleave the lymph node, go all over the body, and instruct the immune system not to attack other cancer cells, he explained.
If thats the case, it would make distant organs more hospitable to the cancer, he said.
Thus, we propose a new model of metastasis we call Metastatic Tolerance, tweeted the studys lead scientist, Nathan Reticker-Flynn, Ph.D., of Stanford University.
Theres missing pieces about how exactly the T-regulatory cells get sent around the body, Dr. Dueck noted. But the idea is that there might be tolerance from the immune system by the time the cells get to distant organs.
With this new view of metastasis, the two prevailing theories on lymph nodes can be reconciled, Dr. Dueck explained. By spreading to lymph nodes and turning immune tolerance on, its easier for cancer cells in the primary tumor or in the lymph nodes to metastasize to distant organs.
Dr. Engleman and his team think it may be possible to develop therapies that switch off this tolerance. If used at the right time, such therapies could prevent cancer metastasis.
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Why Are Lymph Nodes Important
One main lymph node area and two secondary lymph node areas filter the lymph fluid draining away from the breast area.
Since the job of the lymph nodes is to filter out âbad guysâ like cancer cells, this is a logical place to look for breast cancer cells that have escaped the original tumor and are trying to go elsewhere in the body. Cancer cells may also leave the breast through the bloodstream and bypass the lymph nodes. However, the presence or absence of cancer in the lymph nodes is one of the most important signposts your doctor will use to determine the best treatment for you.
Another purpose of lymph node dissection is to remove cancer that might be in the nodes. This is done, so that the cancer canât grow further in the lymph node area or shed cells that could go elsewhere.
Doctors once believed that removing as many lymph nodes as possible would reduce the risk of cancer ever spreading to the rest of the body. The hope was that if you caught every last possible cell that could be in those lymph nodes and âcuredâ the armpit and breast of any cancer, you could âcureâ the rest of the body. But lymph node removal does nothing to fight cancer cells that may have already spread elsewhere. Thatâs where systemic, or whole-body, treatment comes in to kill any cells that escaped the original breast cancer or the adjacent lymph nodes.
Stages Of Breast Cancer
Staging describes or classifies a cancer based on how much cancer there is in the body and where it is when first diagnosed. This is often called the extent of cancer. Information from tests is used to find out the size of the tumour, what part of the breast has cancer, whether the cancer has spread from where it first started and where the cancer has spread. Your healthcare team uses the stage to plan treatment and estimate the outcome .
The most common staging system for breast cancer is the TNM system. For breast cancer there are 5 stages stage 0 followed by stages 1 to 4. Often the stages 1 to 4 are written as the Roman numerals I, II, III and IV. Generally, the higher the stage number, the more the cancer has spread. Talk to your doctor if you have questions about staging.
When describing the stage of breast cancer, sometimes doctors group them as follows:
In situ breast cancer The cancer cells are only in the duct or lobule where they started and have not grown into nearby breast tissue . It is stage 0.
Early stage breast cancer The tumour is smaller than 5 cm and the cancer has not spread to more than 3 lymph nodes. It includes stages 1A, 1B and 2A.
Locally advanced breast cancer The tumour is larger than 5 cm. The cancer may have spread to the skin, the muscles of the chest wall or more than 3 lymph nodes. It includes stages 2B, 3A, 3B and 3C. Inflammatory breast cancer is also considered locally advanced breast cancer.
Find out more about .
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Diagnostic Tests That Inform The Clinical Stage
Many methods are used to detect and stage cancer. Some of the common tests include:
Biopsy: The doctor uses a needle to extract breast tissue or fluid, which is then sent to a lab. There, various techniques are used to examine different attributes, such as hormone receptor or HER2 status.
Tumor markers: Rapidly dividing cancerous cells interrupt some of the normal mechanisms of cell growth. This causes the cell to overproduce certain molecules. Lab tests detect these compounds, known as tumor markers, in blood or tissue samples.
Imaging techniques: Several different scans are used to examine characteristics of your cancer. Below are some of the noninvasive imaging techniques you might encounter:
- MRI scans use magnets and radio waves to generate detailed pictures of your tissues.
- CT scans use X-rays to look at your organs. Nuclear scans trace the flow of an injected safe radioactive dye in your body.
- PET scans are similar to nuclear scans but specifically examine glucose consumption in the bodysince cancer cells use more glucose than normal cells.
- Ultrasound imaging uses sound waves to see inside your body.
The Lymphatic System And Metastasis
The inherent characteristics of the lymphatic physiology serve as the primary route for tumor cell metastasis. The increasing size of the tumor triggers a rise in the intratumoral interstitial fluid pressure, and interstitial fluid is released as the system attempts to achieve homeostasis. Unlike the vascular vessels, the lymphatic vessels are highly permeable the flow rate is approximately 100500x slower, and coupled with lesser shearing stresses due to vasodilation. Therefore, the lymphatic route is superior in facilitating tumor cell dissemination . Distinguishing between lymphatic endothelial and systemic endothelial cells via immunohistochemical staining has allowed studies to confirm tumor cell dispersion via afferent lymphatics and lymphangiogenesis, and implicates the lymphatics as the most significant metastatic route .
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Concerns About Screening For Breast Cancer
It can be challenging to keep up with the latest recommendations for breast cancer screening, such as when to start mammograms. Also, medical organizations may change their recommendations over time, or different organizations may have different recommendations.
Some people think that more testing is better, but testing may also have disadvantages. For example, screening tests for breast cancer sometimes indicate a cancer is present when no cancer is present . When results of a breast screening test are positive, a breast biopsy Breast biopsy Breast cancer occurs when cells in the breast become abnormal and divide uncontrollably. Breast cancer usually starts in the glands that produce milk or the tubes that carry… read more is usually done. Having a false-positive result means having a biopsy that is not needed and being exposed to unnecessary anxiety, pain, and expense. Because of these potential issues, organizations recommend that some people do not need to have a screening test. These people include those who are younger or older than a certain age . Women should discuss current recommendations and their own risk and priorities with their health care practitioner and decide which type of screening, if any, is appropriate for them.
Breast Cancer Stage Groups
In breast cancer, stage is based on the size and location of the primary tumor, the spread of cancer to nearby lymph nodes or other parts of the body, tumor grade, and whether certain biomarkers are present. To plan the best treatment and understand your prognosis, it is important to know the breast cancer stage.
There are 3 types of breast cancer stage groups:
- Clinical Prognostic Stage is used first to assign a stage for all patients based on health history, physical exam, imaging tests , and biopsies. The Clinical Prognostic Stage is described by the TNM system, tumor grade, and biomarker status . In clinical staging, mammography or ultrasound is used to check the lymph nodes for signs of cancer.
- Pathological Prognostic Stage is then used for patients who have surgery as their first treatment. The Pathological Prognostic Stage is based on all clinical information, biomarker status, and laboratory test results from breast tissue and lymph nodes removed during surgery.
- Anatomic Stage is based on the size and the spread of cancer as described by the TNM system. The Anatomic Stage is used in parts of the world where biomarker testing is not available. It is not used in the United States.
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Examples Using The Full Staging System
Because there are so many factors that go into stage grouping for breast cancer, it’s not possible to describe here every combination that might be included in each stage. The many different possible combinations mean that two women who have the same stage of breast cancer might have different factors that make up their stage.
Here are 3 examples of how all of the factors listed above are used to determine the pathologic breast cancer stage: