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Breast cancer
The earliest form of the disease is pre-cancer; to understand this one must first realise that all breast cancers arise from the milk duct lining cells and therefore the early cancer cells remain confined within the milk ducts. Here, they have no access to the pathways of spread viz. the lymphatics or blood vessels.
This early state of the disease is called Ductal Carcinoma In Situ (or Lobular Carcinoma In Situ – LCIS) and is a precancer that is always curable by local excision. This condition is of great contemporary interest as it is so often picked up on mammography – usually as an area of microcalcification (small flecks of calcium, easily seen on xray mammography) on the mammogram, and was previously not often encountered except as an incidental discovery by the reporting pathologist adjacent to a resected invasive cancer. The importance of the higher pick up rate and the treatment of these DCIS/LCIS is that the cure of this precancer forestalls the development of invasive cancer (where the cancer has broken through the milk duct walls and gained potential access to the routes of cellular spread outside the breast- viz. the lymphatics and the blood vessels).
Two subtypes of breast cancer have already been mentioned: the ductal breast cancer which is the commonest form (75% of all cases) arising from the ductal wall cells, and the lobular type (10% of all cases) arising from the milk duct lobules.
The pathologist/histologist will also describe the tumours according to a histological classification which relates to aggressive behaviour: for example, a cancer that looks like fairly normal breast milk ducts under the microscope and amongst the cells of which it is difficult to see any cells dividing (in mitosis) is likely to behave in a relatively indolent way compared to a tumour which demonstrates many mitoses under the microscope and in which the patterns of the composite cells bare no relation to the originating breast milk ducts. By these descriptive means, the reporting histologist/pathologist gives a grading to the tumour from a grade one tumour (the first example given above) to three (the more aggressive example given above).
There are other recognised subtypes: medullary (5% of all cases) which may have a better outlook than some ductal tumours and then there are a group of others recognised by their microscopic features (e.g. colloid, papillary, mucinous, cribriform etc. – of relevance in that some of the generalisations quae hormone sensitivity etc. may not so generally apply to some of these subtypes).
Other useful points to mention here are that the pathologist (the man who advises the treating doctor as to what type of cancer he is dealing with by microscopic analysis of the biopsy or surgical specimen) will do some further analyses beyond straightforward microscopy to tell if the tumour is hormone receptor positive. All milk duct cells possess receptors for the female hormones oestrogen and progesterone – this is how cells respond to hormonal stimulation viz. by having receptors on their surfaces that respond to the stimulus provided by the hormone in question. In some breast tumours, the cancer cells retain these hormone receptors and this can be of relevance to the treating clinician; the pathologist will report the cancer as being oestrogen and progesterone receptor positive or negative.
The pathologist will also look for other molecular markers, of which the most relevant to the treating clinician is the possession or not of the oncogene HER-2 previously called c-ERB-2 in the tumour cells – vide infra.
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