Showing posts with label Biology. Show all posts
Showing posts with label Biology. Show all posts

Wednesday, 25 September 2019

Stages of Breast Cancer

September 25, 2019 0

Breast Cancer: Stages

The way in which a cancer spread or grow is called staging. Staging basically describes the location of cancer, the extent of growth of cancer, and area of spreading of cancer. The stage of cancer is confirmed by diagnostic tests. The confirmation of staging helps the doctor to decide the best kind of treatment and can predict prognosis of a patient, which are chances of recovery. Different types of cancer have different stage description.
Stages of ductal carcinoma of breast cancer
Stages of ductal carcinoma of breast cancer

TNM staging system

The commonly used tool to describe the stages of cancer is the TNM system. Doctors take the results from diagnostic tests and employ them to find the answer of following questions:

·         Tumor (T): How large is the extent of primary tumor? Where is it’s location?

·         Node (N): Has the tumor grow to the lymph nodes? If yes, where and how many?

·         Metastasis (M): Has the cancer spread to certain other parts of the body? If yes, where and how much?

The stages of cancer for each person are determined from the combined results.
There are mainly five type of stages: A stage which is non-invasive ductile carcinoma in situ (DCIS) is called stage 0 (zero). The other stages from I through V are employed for invasive breast cancer.
Staging can be pathological or clinical. Pathological surgery is based on removing breast tissue and lymph nodes during surgery. The results are usually obtained after many days after surgery. Generally, pathological staging gives the complete information for determining prognosis of a patient. While clinical staging depends on results of tests before surgery which may include mammogram, MRI scans, physical examination and ultrasound.
The further detail of the TNM system for the breast cancer is given below:

Tumor (T)

Utilizing the TNM system, the “T” with a letter or number from 0 to 4 is used for describing the location and size of the tumor. The size of tumor is measured in centimeter (cm). A centimeter is nearly equal to the width of a standard pencil or pen.
Stages may also be divided into further smaller groups in order to explain the more detail of tumor. The information of specific stages of tumor are listed below:

TX: The primary tumor cannot be graded


T0 (T plus zero): This indicates no evidence of cancer in the breast.


Tis: This indicates to carcinoma in situ. The cancer is restricted within the ducts of breast tissue and has not proliferate into the surrounding tissue of the breast. Breast carcinoma in situ has 2 types.

·         Tis (DCIS): DCIS is noninvasive type of cancer, but it can develop into invasive breast cancer later if it is not removed. DCIS refers to the situation where cancer cells have been confined into ducts of breast and have not proliferate past the layer of tissue where they began.

·         Tis (Paget’s): Paget’s disease of the nipple is a rare and early noninvasive form of cancer that is present only in the skin cells of nipple. Paget’s disease sometimes become associated with invasive breast cancer. If another invasive breast cancer is present, it is classified depending on the stage of invasive tumor.

T1: The tumor in the breast at its widest area is 20 milli-meters or smaller in size. Its size is little less than an inch. This stage is further divided into four substages based on the size of the tumor:

·         T1mi is a tumor having size 1 mm or even smaller
·         T1a is a tumor having size larger than 1 mm but 5 mm or even smaller
·         T1b is a tumor having size larger than 5 mm but 10 mm or even smaller
·         T1c is a tumor having size larger than 10 mm but 20 mm or even smaller

T2: The tumor having size larger than 20 mm but not larger than 50 mm.

T3: The tumor having size larger than 50 mm.

T4: The tumor falls into 1 of the groups given below:


·         T4a refers to the tumor that has grown into the chest wall.
·         T4b refers to the tumor that has grown into the skin.
·         T4c refers to the tumor that has grown into the chest wall and the skin.
·         T4d is refers to inflammatory breast cancer.

Node (N)

The “N” in the TNM staging system refers for lymph nodes. Regional lymph nodes include:
·         Lymph nodes that are lacated under the arm are termed as axillary lymph nodes
·         Below and above the collarbone
·         Under the breastbone which is termed as internal mammary lymph nodes
Lymph nodes that are present in other parts of the body are termed as distant lymph nodes. If the doctor diagnosis lymph nodes without surgery using various tests and physical examination, the letter “N” is placed by “C” for clinical staging. If the doctor diagnosis lymph nodes after surgery which is a more authentic evaluation, the letter “N” is replaced by “P” for pathological staging. The pathological staging is described by the following information.

NX: Refers to the lymph nodes were not evaluated.


N0: Either of the following situations:

·         No cancer was diagnosed in the lymph nodes.
·         Lymph nodes contain areas of cancer that are smaller than 0.2 millimeter (mm).

N1: The cancer has proliferated to 1 to 3 internal mammary lymph nodes and axillary lymph nodes. If the size of tumor located in the lymph nodes is larger than 0.2 mm but equal to 2mm or smaller, it is termed as “micrometastatic” (N1mi).

N2: The cancer has proliferate to 4 to 9 axillary lymph nodes. Or it has proliferate to the internal mammary lymph nodes, but not found the axillary lymph nodes.
N3: The cancer has proliferate to 10 or more axillary lymph nodes. Or it has proliferate to the lymph nodes present under the collarbone or clavicle. It may have also proliferate to the internal mammary lymph nodes. Tumor that has proliferate to the lymph nodes above the clavicle is termed the supraclavicular lymph nodes, is also described as N3.
If the tumor is present in the lymph nodes, it is important to find the number of lymph nodes that are involved in cancer and also their location to help the doctors to plan treatment. The pathologists can evaluate the number of axillary lymph nodes that are involved in cancer after removing them during surgery. If the cancer is located in axillary lymph nodes, treatments other than surgery such as chemotherapy, radiation therapy and hormonal therapy are used during early stages of treatment.

Metastasis (M)

The “M” in the TNM system refers to whether has proliferated to various parts of the body which is termed as distant metastasis. This is no longer falls into the category of early-stage or locally advanced cancer.

MX: Refers to distant proliferation that cannot be evaluated.


M0: Refers to the disease that has not metastasized.

M0 (i+): It refers to the condition where no clinical or radiographic evidence of distant metastases are evaluated. Microscopic evidences of cancer cells is found in the bone marrow, blood or other lymph nodes that have size 0.2 mm or smaller.
M1: Evidences have reveal the metastasis to another part of the body which means that breast cancer cells are growing in other organs.

Cancer stage grouping

Doctors have assigned the stage of the cancer by combination of T, N, and M classifications and the grade of tumor and the results of PR/ER and HER2 testing. This information is used in determining the prognosis. T, N and M classification is the simple approach for explaining the stages of cancer. Different stages are described below on the basis of this approach.
The exact stage of cancer is finalized after surgery usually about 5 to 7 days after surgery. Doctor may termed stage I to stage IIA cancer as early stage cancer and stage IIB to III as locally advanced cancer.

Stage 0: When the disease is only in the ducts of breast tissue and has not proliferate to the surrounding tissue of the breast. It also termed as noninvasive cancer.

Stage IA: The tumor is invasive, small and has not proliferate to the lymph nodes.

Stage IB: Cancer has proliferate to the lymph nodes having size larger than 0.2 mm but smaller than 2 mm in size. There are no evidences of tumor in the breast having size 20 mm or smaller.


Stage IIA: Any 1 of these conditions:

·         The cancer has proliferate to 1 to 3 axillary lymph nodes but there are no evidences of tumor in the breast. It has not proliferate to the distant parts of the body.
·         The size of tumor is 20 mm or smaller and has proliferate the axillary lymph nodes.
·         The size of tumor is larger than 20 mm but smaller than 50 mm and has not proliferate to the axillary lymph nodes.

Stage IIB: Either of these conditions:

·         The size of tumor is larger than 20 mm but smaller than 50 mm and has proliferate to 1 to 3 axillary lymph nodes.
·         The size of tumor is larger than 50 mm but has not proliferate to the axillary lymph nodes.

Stage IIIA: The cancer of any size has proliferate to internal mammary lymph nodes or to 4 to 9 axillary lymph nodes. It has not proliferate to other body parts. Stage IIIA can also be a tumor larger than 50 mm that has proliferate to 1 to 3 axillary lymph nodes.

Stage IIIB: The tumor has proliferate to the chest wall or caused ulceration or swelling of the breast or may be diagnosed as inflammatory breast cancer. It may or may not have proliferate to up to internal or 9 axillary mammary lymph nodes. It has not proliferate to other parts of the body.

Stage IIIC: A tumor of any size that has proliferate to the internal mammary lymph nodes, 10 or more axillary lymph nodes and the lymph nodes under the collarbone. It has not proliferate to other parts of the body.


Stage IV (metastatic): .The tumor can be of any size and has proliferate to other organs such as the lungs, bones, liver, brain, chest wall and distant lymph nodes. When the tumor is first diadnosed occurs about 6% of the time, then it leads to metastatic breast cancer. Mostly, metastatic breast cancer is evaluated after previous diagnosis of early breast cancer.

Recurrent: The cancer that comes back after treatment is termed as recurrent cancer and can be described as regional, local and distant. If there is recurrence of cancer after treatment, another round of test will begin to learn about the extent of recurrence. These tests and scans are nearly similar to those at the time of the original diagmosis.



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Saturday, 21 September 2019

Diagnostic Tests for Breast Cancer

September 21, 2019 0

Breast Cancer: Diagnosis

Tests for Diagnosis of Breast Cancers:

Doctors use several methods to diagnose cancer. They also perform tests to confirm the spreading of cancer to a part of body other than breast and the lymph nodes under the arm. This condition is called metastasis. Doctors may also compare the efficiency of tests to determine which treatment could work better. The sure way to confirm the area of cancer is biopsy. In biopsy, a small sample of tissue is taken for testing in a laboratory.
The list of tests below may not be used for every person. The selection of diagnostic test depends on following factors.
·         Suspected type of cancer
·         Symptoms and signs
·         General health and age
·         The results of all earlier medical tests
The series of tests for possible test cancer begins with the discovery of a mass or abnormal calcification on a screening mammogram or a nodule or lump in the woman’s breast self or clinical examination. A woman may notice a mass or nodule under the arm or a red or swollen breast.
The following tests can be used for diagnosis of breast cancer or for follow-up testing after a breast cancer has been diagnosed.

Imaging tests

Imaging tests are used to show inside pictures of the body. The suspicious area found in the breast during screening can be further evaluated by using following imaging tests.

·         Diagnostic mammography 

Diagnostic mammography is nearly similar to screening mammography having exception of taking more pictures of breast. It is generally used when a woman has experienced signs such as discharge of a new lump or nipple. Diagnostic mammography is also applicable in case of finding something suspicious during screening mammography.
Diagnostic Mammography
A snapshot of mammography

·         Ultrasound

An ultrasound involves the use of sound waves for creating a picture of the breast tissue. An ultrasound can be used to distinguish between a solid mass, which may be a fluid filled cyst and may be a cancer.

·         MRI

An MRI involves the use of magnetic field not x-rays for creating the complete image of the body. A contrast medium which is a special dye is given before the scan for creating a clear picture of the possible cancer. This special dye is injected into patient’s vein. A breast MRI may be used when a woman has been diagnosed with breast cancer to scan the other breast for cancer or for finding the extent of cancer throughout the breast. Along with mammography, breast MRI is also a screening option for women having higher risks of developing cancer.

Biopsy

A biopsy is the removal of a small amount of tissue for examination under a microscope. Other tests can suggest that cancer is present, but only a biopsy can make a definite diagnosis. A pathologist then analyzes the sample(s). A pathologist is a doctor who specializes in interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose disease. There are different types of biopsies, classified by the technique and/or size of needle used to collect the tissue sample.
Biopsy procedure used to diagnose cancer
Biopsy

A biopsy involves the removal of a small amount of tissue for analysis under microscope. Other tests direct the presence of cancer but only a biopsy can make a clear diagnosis. Biopsies are classified into different types on the basis of technique and size of needle used to collect the tissue sample.

·   Fine needle aspiration biopsy. This type of biopsy involves the usage of a thin needle for removing a small sample of cells.

·         Core needle biopsy. This type of biopsy involves the usage of wider needle for removing a larger sample of tissue. This is generally preferred type of biopsy to find whether an abnormality is cancer. The patient’s discomfort is lessened by using local anesthesia to block the pain during the procedure.

·         Surgical biopsy. This type involves the removal of largest amount of tissue. A surgical biopsy is generally not recommended for diagnosis of breast cancer. Mostly non-surgical core needle biopsies are recommended for diagnosis of breast cancer.

·         Image-guided biopsy.  This procedure involves the guidance of a needle to locate the cancer by using an imaging technique such as ultrasound, mammography, or MRI. A stereotactic biopsy is done by utilizing mammography to guide the needle. The breast where the biopsy sample was taken is marked by putting a small metal clip. This clip is usually made of titanium so it will not cause future problems.

·         Sentinel lymph node biopsy. This type is used to find the location of cancer in the lymph nodes near the breast.

Analysing the biopsy sample

The sample obtained during biopsy is then analysed to determine specific features of a cancer for further treatment options.

· Tumor features. The tumor is examined under microscope for determining the nature of tumor that either it is invasive or in situ, lobular or ductal and to determine the spreading of cancer to the lymph nodes. The margin width is also determined to confirm the margins or edges of the tumor and their distances from tumor.

·         ER and PR. Both the patient’s risk of recurrence and the type of treatment for lowering the risk of recurrence are determined by testing for ER and PR. DCIS are often measured by ER and PR as well. Hormonal therapy is usually best for ER-negative and ER-positive cancers.

·         HER2. HER2 status helps to find out whether drugs targeting HER2 receptor such as trastuzumab (Herzuma, Ontruzant, Herceptin, Ogivri), may help for treating the cancer. This test is only applicable for invasive cancers. ASCO and CAP recommend that HER2 test is only done after the diagnosis confirmation of invasive breast cancer.

HER2 tests are generally clearly positive or negative which means that your cancer contains either high levels or low levels of HER2. If the test results are not clearly positive or negative, testing should be done again, either with a different test or on a different tumor sample.
If the cancer is HER2 is positive, treatment may be followed by HER-targeted therapy. If the cancer is HER2 negative, then the treatment may not be recommended by HER2 targeted therapy.

·         Grade. Biopsy is also used to determine tumor grade. Grade gives the extent of difference between healthy cells and tumor cells and also the rate of their growth. If the cancer cell is looking similar to healthy cell and having different cell groupings, it is called “low grade” or “well differentiated tumo”r. If the cancer tissue is looking very different from healthy tissue, it is called “high grade” or “low differentiated tumor”.

Molecular testing of the tumor

If the cancer is locally advanced or metastatic breast cancer, the testing having the following molecular features may be recommended:
o    PD-LI, that protein is present on the surface of cancerous cells and also on some of the immune cells of the body. This protein inhibits the immune cells of the body from destroying the cancer.
o    Microsatellite instability-high (MSI-H) or DNA mismatch repair deficiency (dMMR). Tumors having MSI-H or dMMR contain difficulty repairing damage to their DNA. This refers that they are developing several changes or mutations. These changes prepare abnormal proteins on the tumor cells that allow it easier to immune cells of finding and attacking the tumor.
o    NTRK gene fusions is a specific genetic change encounter in a range of cancers as well as breast cancer.
o    PI3KCA gene mutation, which is a specific genetic mutation usually encounter in breast cancer.

Genomic tests for the prediction of recurrence risk

Doctors perform genomic tests to identify specific substances by the genes called proteins that are present on or in cancerous cells. Doctors can better diagnose the unique features of each patient’s breast cancer by using these genomic tests. These tests also give estimation of the risk of cancer coming back after cancer. These tests allow the doctor and patient to make suitable decision for appropriate treatment.
The following genomic tests can be done on a tumor sample that was removed during surgery or biopsy. There is no need of more surgery or extra biopsy for these tests.
·         Oncotype Dx™. This test can be adopted for people with PR-positive and/or ER-positive, HER2-negative breast cancer that has not been spread to the lymph nodes. This test tells whether the chemotherapy should be added in addition to hormone therapy. This test looks 5 reference genes and 16 cancer related genes for calculating a “recurrence score” that gives the estimation of risk the cancer coming back within a duration of 10 years after diagnosis. This recurrence score also determine the use of chemotherapy which may also vary with age. These recommendations by age group are listed below:

For patients of 50 or younger age

o    Recurrence score less than 16: Chemotherapy is normally not recommended along with hormonal therapy
o    Recurrence score of 16 to 30: Chemotherapy may be recommended in addition to hormonal therapy
o    Recurrence score of 31 or higher: Chemotherapy is generally recommended to hormonal therapy

For patients older than age of 50

o    Recurrence score less than 26: Chemotherapy is usually not recommended in addition to hormonal therapy
o    Recurrence score of 26 to 30: Chemotherapy may be recommended in addition to hormonal therapy
o    Recurrence score of 31 or higher: Chemotherapy is usually recommended along with hormonal therapy

·         Mamma Print™

This test is an option for people with PR-positive and/or ER-positive, HER2-negative breast cancer that has only spread to 1 to 3 lymph nodes or has not spread. This test adds information from 70 genes for estimation of the risk of recurrence for developing early-stage breast cancer.This test is recommended for high risk of cancer coming back and allows the doctor and patient to make decisions for chemotherapy. This is not a recommended test for people having low risks of cancer coming back

·         Breast Cancer Index™

This test is an option for people with PR-positive and/or ER-positive, HER2-negative breast cancer that has not been spread to the lymph nodes. This test helps the doctor and the patient to estimate the actual duration of taking hormonal therapy.
There is also need to do vatious types of blood tests. These tests may be performed before or after the surgery. These are listed below:
·         Complete blood count. A complete blood count (CBC) is employed for measuring the number of various types of cells, such as white blood cells and red blood cells in a sample of blood of a person. This gives the surety of proper functioning of bone marrow
·         Blood chemistry. This test is done to evaluate the proper working of liver and kidneys.

·         Hepatitis tests. These tests are employed for checking the evidences of prior exposure to hepatitis B and hepatitis C. If there are evidences of an active infection of hepatitis C, there is need to take special medication to deactivate the virus before receiving chemotherapy. Chemotherapy without this medication can grow the virus and can cause the liver to damage.



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