Understanding Your Diagnosis
Not all breast cancers are the same. There are different types of breast cancer, as well as different stages. Understanding how cancer works and how your particular cancer affects your body will help you make decisions about your care and what is best for you.
The information in this section will help you plan and prepare for your treatment. However, it is not meant to replace the individual attention, advice, and treatment plan of your oncologist and medical team.
- What is a Cell? How does a Cell become a Cancer?
- Lobular Carcinoma In Situ (LCIS)
- Ductal Carcinoma In Situ (DCIS)
- Invasive or Infiltrating Lobular Carcinoma (ILC)
- Invasive or Infiltrating Ductal Carcinoma (IDC)
- Inflammatory Breast Cancer
- Interpreting Your Pathology Report
- Staging in Breast Cancer
What is a Cell? How does a Cell become a Cancer?
Cells are the building blocks of all tissue and organs in the human body. Each cell contains genetic material (DNA) and other elements. DNA controls the growth rate of cells.
Normal cells grow and multiply at a specific rate. Cells that grow and multiply without stopping are called cancerous or malignant. Cancerous cells are not detectable when they first start growing. At a certain point, the cancerous cells continue to multiply and form a mass which can be detected. Abnormal cell growth could go on for years before it is large enough to be detected.
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Lobular Carcinoma In Situ (LCIS)
Lobular Carcinoma In Situ (LCIS) is a change in the cells of the milk lobules – the tiny sacs or glands in the breast that make milk. In LCIS, the cells do not look like normal lobular cells, and there are too many of these abnormal cells. The abnormal cells stay in the milk lobule and do not spread outside of it. LCIS is detected through a breast biopsy.
At this time, we do not think that LCIS turns into cancer. We do know, however, that women who have had LCIS are more likely to develop breast cancer than women who have not had LCIS. In most cases, the abnormal lobular cells will not be removed, but the doctor may recommend a very thorough breast health screening program. In addition, a medication such as called cancerous or malignant. Cancerous cells are not detectable when they first start growing. At a certain point, the cancerous cells continue to multiply and form a mass which can be detected. Abnormal cell growth could go on for years before it is large enough to be detected. Tamoxifen may be reduce the risk of of the lobule breast cancer in the future. Sometimes, a doctor may decide that there is a chance that cancer may be present, even though it did not show up on the biopsy. In this case, further surgery may be recommended. Or some women may wish to consider prophylactic mastectomies (surgical removal of the breasts even though no cancer has been found) to reduce their future risk of breast cancer.
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Ductal Carcinoma In Situ (DCIS)
Ductal Carcinoma In Situ (DCIS) is a change in the cells that line the milk ducts, which are the "tubes" that bring milk from the milk lobules to the nipple. Normally, a thin layer of breast epithelial cells lines the inside of the milk duct. DCIS happens when the cells of this thin layer grow and multiply without stopping and have abnormal features that can be detected only under the microscope.
In DCIS, the abnormal breast cells are confined to the milk duct. They do not spread outside the milk duct into the surrounding breast tissue, lymph nodes or other parts of the body. We call this a non¬invasive type of cancer because it has not invaded other tissue. DCIS is a form of "Stage 0" breast cancer. That means it has been detected at the earliest stage possible.
If left untreated, sometimes DCIS will spread outside the milk duct and turn into an invasive or infiltrating cancer. At this point in time, we cannot predict which patients with DCIS will develop invasive or infiltrating cancers. Therefore, it is recommended that DCIS be surgically removed before it can become an invasive cancer. In addition, radiation treatment of the breast is often recommended following removal of the affected tissue. Radiation is not recommended following a mastectomy (removal of the entire breast) to treat DCIS.
DCIS is often found in a mammogram. The mammogram may show microcalcifications which are worrisome. These are small calcium deposits that form within or near the DCIS. Not all micro- calcifications seen on a mammogram indicate DCIS. Those that form a line, are new or have increased in number may be suspicious. Less common, DCIS may show up as a nodule or thickening of tissue on a mammogram. In rare cases, DCIS may be felt as a thickening or nodule in the breast on self-exam or during a physical exam by a health care provider.
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Invasive or Infiltrating Lobular Carcinoma (ILC)
Invasive or infiltrating lobular breast cancer (ILC) occurs when the cells in the milk lobule become abnormal. The lobular cancer cells look different from normal lobular cells and multiply without stopping. They spread outside the lobule into the surrounding breast tissue. ILC does not mean that the cancer has traveled to other parts of the body beyond the breast, but it has the ability to do so.
The terms well, moderately or poorly differentiated may also be used to describe ILC. Cancers that are well differentiated look more like normal cells in the milk lobules, while those that are poorly differentiated have lost many of their normal cell features. Moderately differentiated cancers fall in between.
Surgery, radiation, hormonal therapy andchemotherapy can all be used to treat ILC. Most women will receive a combination of treatments, although not necessarily all four types of treatments. The types of treatment recommended will depend upon the size of the cancer, whether the cancer is in the lymph nodes, features of the cancer cells themselves and your general health.
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Invasive or Infiltrating Ductal Carcinoma (IDC)
Invasive or infiltrating ductal carcinoma (IDC) is the most common type of breast cancer. IDC occurs when the cells that line the milk duct become abnormal. The ductal cancer cells look different from normal milk duct cells, and the body produces too many of them. They spread outside the milk duct into the surrounding breast tissue. IDC does not mean that the cancer has traveled to other parts of the body beyond the breast, but it has the ability to do so. It is not uncommon to have DCIS along with IDC. 
The terms well, moderately or poorly differentiated may also be used to describe IDC. Cancers that are well differentiated look more like normal cells lining the milk duct, while those that are poorly differentiated have lost many of their normal cell features. Moderately differentiated cancers fall in between.
Surgery, radiation, hormonal therapy and chemotherapy can all be used to treat IDC. Most women will receive a combination of treatments, although not necessarily all four types of treatment. The types of treatment recommended will depend upon the size of the cancer, whether the cancer is in the lymph nodes, features of the cancer cells themselves and your general health.
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Inflammatory Breast Cancer
Inflammatory breast cancer occurs when the cells lining the milk duct become abnormal. They begin to look different from normal milk duct cells, and the body produces too many of them. The cancer cells spread outside the milk duct into the surrounding breast tissue and the small lymphatic vessels in the breast, particularly those in the skin of the breast. The invasion of the cancer cells into the lymphatic vessels of the breast skin causes the breast to look inflamed, i.e., red, warm and even swollen. It often looks like there is an infection in the breast. A biopsy of the breast and the skin is necessary to diagnose inflammatory breast cancer.
Inflammatory breast cancer behaves differently than ductal breast cancer and must be treated differently.
It is important to control the growth of the imflammatory breast cancer cells, and chemotherapy is often recommended first. Once chemotherapy is completed, the need for surgery and radiation will be determined.
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Interpreting Your Pathology Report
It is important to control the growth of the inflammatory breast cancer cells, and chemotherapy is often recommended first. Once chemotherapy is completed, the need for surgery and radiation will be determined.
Tissue removed from the breast, lymph nodes or other parts of the body are sent to a laboratory to be viewed by a pathologist, a doctor who identifies diseases by studying cells and tissues under a microscope. The pathologist's written report of his or her findings is called a pathology report, which usually includes:
- A detailed record of the specimens received and examined
- A complete description of the appearance of the tissue cells, such as size, color and the presence of any visible abnormality
- A report of all of the diagnostic findings after microscopic examination
- A complete documentation of all of the studies performed on the tissue
Final microscopic diagnosis
This section summarizes the pathologist's findings.
- Infiltrating/invasive ductal breast carcinoma (IDC): cancer that started in the milk duct of the breast and has spread into surrounding breast tissue.
- Infiltrating/invasive lobular breast carcinoma (ILC): cancer that started in the milk lobule of the breast and has spread into surrounding breast tissue.
- Ductal carcinoma in situ (DCIS): early cancer cells growing in the lining of the milk duct in the breast.
- Lobular carcinoma in situ (LCIS): early cancer cells growing in the milk lobule of the breast.
- Grade: describes how much the cancer cells look like their normal cell counterparts. The Scarff-Bloom-Richardson scale is used to determine the grade.
- Well-differentiated (grade 1) - the cells still have many of the features of normal cells.
- Moderately differentiated (grade 2) - the cells have some of the features of normal cells.
- Poorly differentiated (grade 3) - the cells have few of the features of normal cells.
- Tumor size: size of the tumor measured under the microscope.
- In situ component: If invasive cancer was found, there may be surrounding DCIS as well (see definition above), which will be noted in this section. If an extensive intraductal component (EIC) is noted, it means that the invasive cancer contains at least 25% DCIS.
- Necrosis: cells that have died. Necrosis is usually associated with a more aggressive DCIS.
- Architectural pattern: the pattern of growth of the DCIS cells. Descriptions used include cribiform, comedo, solid, micropapillary and papillary.
- Angiolymphatic invasion: cancer cells have entered the small blood vessels or lymphatic vessels in the breast.
- Margins: the area of normal tissue around the tumor that is removed during surgery. Ideally there are no cancer cells at the margin (clear or negative margin), only a rim of normal tissue. The pathologist will measure the distance between the cancer and the edge of normal tissue. If cancer cells are detected at the edge of the tissue removed, it is called a positive margin, and more surgery may be required.
- Calcification: notes whether calcium deposits were found in the tumor.
- Biopsy site: if a prior biopsy has been done, it will be noted whether the biopsy site is seen in the sample.
- Nipple: if the nipple was removed (with a mastectomy), it will be noted if cancer is present in the nipple.
- Sentinel node biopsy: if a sentinel lymph node biopsy was done, the report will note the number of lymph nodes containing cancer cells (positive lymph nodes), the size of the lymph nodes, and the total number of lymph nodes removed with the sentinel lymph node biopsy.
- Axillary lymph node dissection: if cancer cells were found in the sentinel lymph nodes, the report will note the number of additional lymph nodes removed, the number containing cancer cells (positive lymph nodes), and the size of the lymph nodes. If an axillary lymph node dissection was planned, the report will note the total number of lymph nodes removed, the number that had cancer and the size of the lymph nodes.
- Extracapsular extension: if cancer cells were found in the lymph nodes, the report will note whether the cancer cells are completely inside the lymph node (absent) or whether they extended outside of the lymph node (present).
- Pathologic tumor stage (AJCC): a scale used by pathologists to summarize features of the tumor (T), number of lymph nodes with cancer (N), and metastatic sites (M).
- Comments: includes specific pathologic findings and clarifications of what was seen in the pathologic specimen.
This section contains information on why the surgery is needed.
Gross description
This section gives specific details on what was given to the pathologist at the surgery and what it looks like without a microscope.
Addendum
Additional pathology reports will be made for invasive or infiltrating cancers. These reports will contain the following information:
- Estrogen and progesterone receptors: the tissue will be sent to an outside laboratory to be tested for estrogen and progesterone hormone receptors in the cancer cells. These receptors receive and interpret messages by the hormones. Both hormones stimulate the growth of normal breast cells and some breast cancer cells. The results are usually available two weeks after surgery. If hormone receptors are present, then any hormones circulating in the body may affect the cancer’s growth. The report will list the percentage of cancer cells that had hormone receptors. Any percentage over 5% is considered hormone receptor positive.
- HER2 staining intensity: The tissue will be sent to an outside laboratory to be tested to see if the cancer cells contain an overactive gene called HER2. The gene may make the cancer grow faster. The result may be listed as absent, 1+, 2+ or 3+. The report may also contain a second type of HER2 testing called FISH testing, which will be reported as either positive or negative.
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Staging in Breast Cancer
Once your cancer is diagnosed, your doctors will want to know exactly how big the cancer is and whether it has spread to the lymph nodes or other parts of your body. This is called staging a cancer. Knowing the stage of your cancer will help your doctors develop the best treatment plan for you.
Staging is most commonly done following surgery. Sometimes a stage may be divided into an A and B category depending upon the characteristics of the tumor or lymph nodes. Your doctor may order specific tests to help determine the stage of your cancer.
- Stage 0
The lining of the milk duct contains abnormal cells, but the cells have not spread to the surrounding breast tissue or to the lymph nodes. This stage is also called preinvasive or noninvasive carcinoma, carcinoma in situ, or intraductal carcinoma. - Stage 1
Tumor is smaller than 2 cm (about 1 inch) and no cancer cells are found in the lymph nodes or in other parts of the body. - Stage 2
Tumor is smaller than 2 cm (about 1 inch), and cancer cells are found in the lymph nodes but not in another part of the body.
or
Tumor is 2-5 cm (about 1-2 inches), and cancer cells may or may not be found in the lymphy nodes but not in another part of the body.
or
Tumor is greater than 5 cm (about 2 inches), and cancer cells are not found in the lymph nodes or another part of the body. - Stage 3
Tumor is greater than 5 cm (about 2 inches), and cancer cells have spread to lymph nodes but not to another area of the body.
or
Any size tumor that has spread to lymph nodes that have grown together (fixed or matted lymph nodes), but not to another area of the body.
or
Any size tumor which has grown into the skin or the chest muscles, or caused a skin ulcer with or without cancer in the lymph nodes - Stage 4
Tumor is any size and has spread behyond the breast and lymph nodes to other parts of the body (usually bone, liver, lung or brain). This is often called metastatic cancer.
Stage 1 through 4 breast cancers are all referred to as invasive or infiltrating cancers. This means that the cancer cells have spread, invaded or infiltrated into the tissue surrounding the milk duct or lobule in the breast.
Updated 5/18/06
The information in this section will help you plan and prepare for your treatment. However, it is not meant to replace the individual attention, advice, and treatment plan of your oncologist and medical team.
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