Types of Breast Cancer

Paget’s disease of the breast is a noninvasive cancer of the nipple, meaning the cancer is limited to the nipple itself and has not entered the ducts nor the tissue within the breast. Symptoms of Paget’s disease include a subtle but persistent area of dry, scaly skin or eczema of the nipple and areola. Patients and physicians frequently misdiagnose it as a skin issue or an allergy and treat it with creams. With time, the nipple and surrounding areola will get crusty and bleed. Any persistent dry, itchy or painful nipple should be biopsied to rule out Paget’s disease. Anyone diagnosed with Paget’s disease should undergo mammogram and MRI to confirm there is no associated deeper (often invasive) malignant tumor within the breast. In 30 percent of cases, an associated tumor is found during diagnostic screening.

Treatment of Paget’s disease depends upon any associated tumors discovered. Generally treatment involves removal of the nipple with radiation therapy of the remaining breast. Plastic surgery can fashion a new nipple with excellent cosmetic result. A total mastectomy may be indicated in some cases. The nipple-areola complex and breast is completely removed with or without reconstruction. The prognosis depends upon associated tumors but is generally excellent.

DCIS is noninvasive cancer of the ducts (limited to the breast ducts and not spread). It is generally diagnosed from a mammogram finding of suspicious calcifications or masses which then prompts a needle biopsy. Occasionally, it is a palpable lump found during a breast self-exam or a clinical breast exam. Further diagnostics include a breast ultrasound and an MRI. Once DCIS is confirmed by pathology, the entire area will be removed with a rim of normal breast tissue around the cancer. This confirms no cancer tentacles are left behind. An axillary lymph node biopsy is generally recommended. Radiation therapy is indicated in all but those women with tiny tumors and wide margins (surgical term for the distance of “normal” tissue from the tumor), to minimize the risk of the cancer returning. Chemotherapy is not required in a noninvasive cancer, but an anti-hormone pill may be indicated to protect both the affected and opposite breasts. Extensive DCIS which cannot be removed completely without acceptable breast distortion may require total mastectomy with or without breast reconstruction. In this case, radiation is not required.

LCIS is confusing to patients and non-breast specialists alike. Although it has the name “carcinoma” in the term, it is not considered to be a cancer. Rather it is considered to be a “MARKER” which indicates a higher risk of developing breast cancer in either breast. If discovered by needle or core breast biopsy, an open larger biopsy is performed to confirm that no cancer is associated with it. Needle biopsy is a sample biopsy; if any atypical or suspicious cells are identified such as LCIS, a larger area of tissue around the needle biopsy site is taken to make sure nothing more serious lies beside the area.

Treatment generally involves close surveillance including frequent breast exam, mammogram and MRI. If a patient has multiple other risk factors for breast cancer, in addition to LCIS, the likelihood that she may develop the disease warrants more aggressive preventative treatment. This may include removing both breasts as a preventive measure. This is a highly personal decision that requires serious discussion with a breast specialist. Removal of the affected breast is not adequate protection, as LCIS predicts a higher risk of getting breast cancer in EITHER breast.

Invasive or infiltrating ductal carcinoma refers to cancer that has broken through the wall of the milk duct and begun to invade the tissues of the breast. This is the most common type of breast cancer in women, representing about 80 percent of all breast cancers. It is found 50 percent of the time by finding a lump – either by the patient herself or by her physician. The remaining cancers are identified by mammogram and ultrasound. Prognosis is excellent if found early and treated promptly.

Usually treatment involves lumpectomy, in which the cancer is removed with a rim of normal tissue (margin), and an axillary lymph node biopsy. This determines whether the cancer has spread to the armpit nodes. This is followed by radiation and chemotherapy and an anti-hormone pill. Radiation is recommended in all patients who undergo breast preserving surgery to minimize recurrence of the cancer in the breast. Thirty percent of women treated with lumpectomy with clear margins (areas of normal tissue around the cancer) but who do not receive radiation, will recur within 10 years.

Chemotherapy is given to those patients whose tumors have a high likelihood of spreading outside of the breast even after surgery. Chemotherapy consists of drugs that are given by mouth or vein and go throughout the body to kill any cancer cells that may have gotten away. Anti-hormone pills target hormone sensitive tumor cells and this dramatically reduces the risk of those cancers returning in the breast or body. Anti-hormone pills do not decrease the risk of hormone-negative cancers from recurring or spreading.

Invasive lobular carcinoma is a type of breast cancer that begins in the milk-producing glands (lobules) of the breast. It is less common than invasive ductal cancer but is generally treated the same. Stage for stage the prognosis for this type of cancer is the same. Invasive lobular cancer does have some unique qualities which must be considered in the diagnosis, surgical treatment and post-surgical followup.

Invasive lobular cancer tends to grow in sheets rather than lumps and may be difficult to discover by a physical exam or imaging studies such as mammogram. Once identified, the tumor size may be underestimated preoperatively which requires re-operation to ensure the entire tumor is removed with clear margins (distance of normal tissue surrounding the cancer). Invasive lobular carcinoma has a higher risk of occurring in the opposite breast; as high as 50 percent in some studies. Removing both breasts (bilateral mastectomies) should be considered and discussed in all cases of invasive lobular cancer. Personalized treatment is then tailored to the individual. Post surgical treatment depends upon the final pathology and may include radiation (in all breast preserving procedures), chemotherapy and/or anti-hormone therapy.

Triple negative cancer refers to invasive cancers of either ductal or lobular origin which either express NO estrogen or progesterone receptors, or have the HER2/neu gene. This has been found to be such an aggressive tumor that chemotherapy is recommended in all cases to optimize cure. Anti-hormone medications are not useful in this type of cancer. This cancer is still curable, however, with research ongoing to determine the optimal chemotherapeutic regimen to achieve the best survival rates.

Tubular carcinoma is a rare type of invasive ductal carcinoma that derives its name from its microscopic appearance, in which the cancer cells resemble small tubes. It represents 2 percent of breast cancers and has a very favorable prognosis.

Cystadenocarcinoma of the breast is a rare cancer that forms in glandular tissues. It occurs in less than 1 percent of breast cancers and is generally nonaggressive. It rarely involves lymph nodes and is more likely to be hormone negative than the more common breast cancers. It does not have the aggressive features of hormone negative invasive ductal or lobular cancers. Treatment generally includes lumpectomy and lymph node biopsy followed by radiation and anti-hormone therapy (if indicated). Mastectomy is necessary only if there are multiple tumors in the breast or partial mastectomy cannot remove the entire tumor or if it is cosmetically unfavorable. Prognosis is excellent.

Inflammatory breast cancer is a rare but aggressive form of breast cancer that either grows very rapidly or has been neglected and becomes very large due to slow long-term growth. The hallmark of the disease is the reddened, thickened skin of the breast which is commonly mistaken for an infection. When treated with antibiotics it does not respond. A lump may or may not be palpable, but a biopsy of the affected area will determine whether cancer is present in the lymph nodes. In a disease which was once considered to be universally fatal, treatment has resulted in many cures. Treatment includes a combination of chemotherapy, surgery (mastectomy and lymph node dissection) and radiation therapy.

Angiosarcoma of the breast is a rare, extremely aggressive malignancy which starts in the cells that line the blood vessels of the breast and shows as a bruise or ill-defined purplish mass. Only about .04 percent of breast cancers are angiosarcoma and these are generally associated with prior radiation to the breast, although some angiosarcomas develop without a history of radiation. Treatment is similar to that given to the other types of breast cancer except that lymph node involvement is rare so lymph node biopsy is generally not done. Prognosis is poor. Please note: this is a rare tumor and must be watched for in all women, particularly in women who have had prior breast radiation. It is absolutely not a contraindication for breast cancer. Radiation has proven to be a safe, life and breast-preserving treatment in breast cancer and allows for cure without sacrificing a women’s breasts in many cases. The value of radiation cannot be overstated despite the remote possibility of angiosarcoma.

Multiple cancers from other parts of the body can spread to the breast including lymphoma (cancer originating in the lymph nodes), and melanoma. Pathology can determine the source of the tumors and appropriate treatment prescribed. The vast majority of breast tumors, however actually come from the breast itself.