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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
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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.
BREAST CANCER: A CHANGING CELL
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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).
BREAST CANCER: A CHANGING CELL
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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
BREAST CANCER: A CHANGING CELL
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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
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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
BREAST CANCER: A CHANGING CELL
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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
BREAST CANCER: A CHANGING CELL
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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
BREAST CANCER: A CHANGING CELL
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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.
BREAST CANCER: A CHANGING CELL
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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