A routine mammogram showed a large mass in the right breast of Mrs. H, age 42 ye

Question

A routine mammogram showed a large mass in the right breast of Mrs. H, age 42 years. A biopsy confirmed the presence of a malignant tumor. Mrs. H was concerned because her mother and an aunt had had breast cancer. No metastases were detected at this time. A mastectomy was performed, and a number of axillary and mediastinal lymph nodes were removed. Pathologic examination showed that several nodes from each area contained malignant cells. Given that this case was considered to be stage IlI, it was recommended that Mrs. H have chemotherapy and radiation treatment following surgery and later have her ovaries removed to reduce her estrogen levels.

Explanation / Answer

Cancer(Neoplasm): Cancer is characterised as uncontrolled cell proliferation which may or may not metastasize to other parts of the body. The uncontrolled cell division leads to the formation of tumour, which consumes more glucose(Due to faulty metabolism by Pyruvate kinase and lactate dehydrogenase), more oxygen and other nutrients, angiogenesis occurs depriving the healthy cells of the body from the essential resources. Basing on the site where Neoplasm occurs specific symptoms occur and complications also arise when tumors occlude the nearby tissues or major blood vessels.

Differences between Benign and Malignant Tumour:

Benign Tumour:

1. Metastasis (able to spread to other parts of the body by gaining acces to blood circulation) do not occur due to capsule formation on the tumour

2. Surgical intervention is usually enough to treat benign tumour, where removal(-ectomy) of the extra growth is done

3. Usually it affects the connective tissues

4. There is usually no recurrence of the tumour once it is removed. But if there is recurrence it may be in the same site where it is previously occured

5. Complications arise due to the site of the body on which benign tumour occured and occlusion of the nearby tissues/ blood vessels due to increased tumour mass

6. Dysplasias are less frequent

Malignant Tumour:

1. Malignant tumours are characterised by Metastasis and spread to the other parts of the body apart from the primary site where they occured.

2. As it is spreading cancer, surgical intervention may not always be the treatment. It involves radio-therapy or chemo-therapy.

3. It may affect any tissues like Skin and other tissues lining organs(Cacinoma), muscle, bone, cartilage(Sarcoma), melanocytes(melanoma), cells of immune system, white blood cells(lymphoma), blood cells(leukaemia).

4. Metastatic cancers always tend to return as the treatment strategy suppress the growth of neoplasms, abrupt withdrawl may lead to multiple loci of cancers and even more predominant growth

5. Primary and secondary complications occur due to metastasis both the primary site as well as the other sites where they metastasize

6. Dysplasias are more frequent

Signs and symptoms Mrs. H can experience:

They include sudden unexplained weight loss, severe pain due to the pressure exerted by the tumour cells on the nearby nerves, lump in the breast, nipple discharges, changes in nipple size and texture, erythema, swollen lymph nodes

Local and systemic effects:

Local effects include obstruction of nearby tissues or blood vessels, haemorrhage, pain, tenderness, infection, ulceration. Systemic effects include Harmonal imbalance as seen in Adrenal cell carcinoma, weight loss, auto immune responses leading to destruction of normal cells assuming as foreign cells.

Other Diagnostic tests: Positron emission tomography, Magnetic resonance imaging, ultrasound, scintigraphy, Immunohistochemistry.

Reason for removal of lymph nodes: Removal of lymph nodes helps in more specific examination of the spread of cancerous cells as the lymph nodes trap the metastasizing cells. It helps in planning the treatment course in an efficient manner.

Continuation of radiotherapy and chemotherapy after mastectomy: Stage III cancer may be IIIb or IIIc which is characterised by orange peel like appearance of the breast, pain, erythema and tenderness in the breast. The cancer cells quickly become non respondent to therapy and difficult to treat. This is also called as Inflammatory breast cancer where after surgical intervention, more chemotherapy is provided before radiotherapy starts. The chemotherapy provided depends on the diagnosis of HER2 protein and hormone positivity(ER(Oestrrogen) positive and PR(progesterone) positive) of the cells. Both the chemotherapy and radiation therapy reduces/ shrinks the tumour mass. Removal of ovaries reduces the hormones Oestrogen and progesterone and help in reduction of cancerous cell growth.

Chemotherapy: It is treating the cancer with drugs like alkylating agents, antimetabolites, antibiotics, hormonal agents etc. Chemotherapy is advantageous as it is non invasive and its flexibility to change according to the needs of the patient. But drugs cannot differnetiate the healthy and cancerous cells leading to generalised side effects to rapidly growing cells. Outcomes include ulceration of GIT, alopecia, azoospermia, dysamenorrhea, vomiting, diarrhoea. The treatment should have adeqaute gap periods where in the dormant cancerous cells in compartment B(slowly dividing cells) move to compartment A(rapidly dividing cells) leading to complete destruction of cancer cells.

Radiation therapy: It is also used as an adjuvant therapy. It is also a non invasive procedure but has side effects like vertigo, nausea, vomiting, destruction of healthy cells, alopecia

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