Updated: 12/26/2021

Invasive Ductal Carcinoma

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  • Snapshot
    • A 51-year-old woman presents to her primary care physician with a lump in her right breast. She says it has been there for around a year. Mammography shows a dominant mass with an irregular fibrotically stranded boundary, with some of the strands seeming to extend toward the nipple. A core biopsy was done and showed the following histology.
  • Introduction
    • Overview
      • most common type of breast cancer
        • infiltrating ductal carcinoma accounts for ~76% of breast cancer cases
      • forms a solid tumor
      • most common cancer diagnosis in women
  • Epidemiology
    • Demographics
      • commonly women in mid-30s to late-50s
    • Incidence
      • 260,000 cases per year in U.S.
      • 40,000 deaths per year
    • Risk factors
      • increasing age
      • female sex
        • breast cancer can occur in men
        • < 3,000 cases per year in U.S.
      • Caucasian race
      • obesity in post-menopausal women
      • hormone replacement therapy
  • ETIOLOGY
    • Genetics
      • inheritance
        • increased risk with BRCA1 and BRCA2 gene mutation
      • mutations
        • cancer cells can be estrogen (ER)-positive, progesterone (PR)-positive, or HER2/neu-positive
        • guides targeted treatment
  • Presentation
    • Symptoms
      • asymptomatic
      • breast lump
        • most often in upper/outer quadrant
      • nipple discharge
    • Physical exam
      • firm immobile, painless lump
      • +/- inverted nipple
      • +/- skin changes
        • redness
        • ulcerations
        • edema
        • nodularity
          • skin retraction indicates involvement of Cooper ligament
      • axillary lymohadenopathy
        • more advanced cases
      • breast skin edema with dimpling ("peau d' orange") is a finding with a poor prognosis
        • represents obstruction of the lymphatics cancer
    • See Breast Cancer General
  • Imaging
    • Mammography
      • indications
        • regular screening mammography
        • evaluation following detection of a breast lump
      • findings
        • mass with an irregular, fibrotically stranded border
    • Core or excisional biopsy
      • indications
        • diagnosis
      • findings
        • gross pathology
          • hard grey-white gritty mass invading surrounding tissue in an irregular stellate shape
        • histology
          • solid nest of neoplastic cells invading the surrounding structures
          • more poorly differentiated = higher grade
          • stains positive for E-cadherin
    • Stage with TNM Staging System
  • Studies
    • Serum calcium level
      • may be elevated
    • Alkaline phosphatase
      • elevation may indicate metastasis
    • Hormone receptor tests
      • ER
      • PR
      • Her2/neu
  • Differential
    • Invasive lobular carcinoma
      • key distinguishing factors
        • gross pathology
          • often no mass lesion is evident
        • histology
          • individual invasive cells or cells in a single file
          • negative E-cadherin staining
    • Ductal carcinoma in situ (DCIS)
      • key distinguishing factor
        • no evidence of invasion on biopsy
  • Treatment
    • Medical
      • chemotherapy
        • indications
          • tumors with high risk features
          • locally advanced tumors
          • neoadjuvant chemotherapy prior to lumpectomy
        • modalities
          • trastuzamab
            • HER2/neu-positive tumors
      • hormone therapy
        • indications
          • hormone receptor-positive tumors
        • modalities
          • tamoxifen or raloxifene
            • ER-positive tumors
            • reduces risk of metastasis
      • radiation
        • indications
          • following breast lumpectomy
    • Surgical
      • modified radical mastectomy
        • indications
          • multicentric disease
          • large tumor size in relation to breast
          • presence of diffuse malignant-appearing calcifications on imaging
          • prior chest radiation
          • pregnancy
          • positive margins after lumpectomy/re-excision
      • lumpectomy
        • indications
          • smaller tumors relative to breast size
          • patients who desire breast-conservinig therapy
        • always followed by postoperative radiation therapy
      • sentinel lymph node biopsy
        • indications
          • used for staging to detect spread of cancer
          • must be performed prior to mastectomy
          • if positive nodes detected and patient underwent lumpectomy, then sentinel lymph node biopsy may be performed again to search for additional nodes
  • Complications
    • Metastasis
    • Recurrence
      • majority of recurrences occur within first 5 years
    • Death
  • Prognosis
    • Tumor size is most important prognostic factor
    • Metastasis associated with poorer prognosis
    • Second most common cause of cancer-related death in women

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