Adenocarcinoma

Adenocarcinoma. Adenocarcinoma is a cancerous tumor that appears in the glandular cells that line some internal organs . Most breast, colon and prostate cancers are adenocarcinomas. It represents 98% of malignant breast tumors . In the most typical cases, it is a woman between 40 and 60 years old, who comes with a breast injury , usually painless. You must begin by carrying out an exhaustive interrogation, in which you try to demonstrate the existence of some of the risk factors.

Physical exam

Upon palpation, a lesion is detected in the breast, with a hard and irregular consistency, fixed or slightly mobile, and generally painless. There may be bloody discharge from the nipple and upon examination of the armpit lymph nodes may be found whose number and size are in relation to the size and time of evolution of the neoplasia. A malignant breast tumor can take up to 8 years to reach 1 cm in diameter, but this does not prevent it from sending metastases to nearby or distant organs beforehand. Among these locations the most frequent are:

• Skeletal: spine , ribs and pelvis (50%).
• Pleura and lung (25%).
• Abdominals: liver and ovary (10%).
• Others: brain , skin , kidney , pancreas , intestine , among others (15%).

Logically, if these metastases appear, there will be associated local or general symptoms depending on their number and magnitude.

Complementary exams

The fundamental tests for the diagnosis of breast cancer are, in order of importance, FNAB, mammography, ultrasound and scintigraphy and all of them were explained in detail in previous pages of this topic.

TNM classification

After the diagnosis has been established, it is important to know the stage of the disease and for this the TNM classification is presented below:

T: primary tumor that can be:

• Tis: carcinoma in situ, non-infiltrating intracanalicular carcinoma, or Paget’s disease of the nipple, without demonstrable tumor (Paget’s disease associated with a palpable tumor is classified according to the size of the tumor).
• T0: no palpable tumor in the breast.
• T1: tumor up to 2 cm:
  • T1a: without fixation to the pectoral fascia or muscle .
  • T1b: with fixation to the pectoral fascia or muscle.
• T2: tumor between 2 and 4.9 cm:
  • T2a: without fixation to the pectoral fascia or muscle.
  • T2b: with fixation to the pectoral fascia or muscle.
• T3: tumor larger than 5 cm:
  • T3a: without fixation to the pectoral fascia or muscle.
  • T3b: with fixation to the pectoral fascia or muscle.
• T4: tumor of any size, with direct extension to the costal wall or skin :
  • T4a: with fixation to the costal wall.
  • T4b: with edema, infiltration or ulceration of the skin of the breast (includes “orange” peel) or satellite skin nodules confined to this breast.
  • T4c: when it presents the forms T4a and T4b.

N: regional lymph nodes:

• N0: non-palpable ipsilateral axillary nodes.
• N1: palpable and mobile ipsilateral axillary nodes:
  • N1a: nodes not considered tumorous.
  • N1b: nodes considered tumorous.
• N2: ipsilateral axillary nodes fixed to one or another structure.
• N3: ipsilateral supraclavicular or infraclavicular lymph nodes or arm edema.

M: distant metastases:

• M0: no evidence of distant metastases .
• M1: with the presence of distant metastases, includes invasion of the skin beyond the breast area.

Prognostic factors

They must be taken into account when deciding the treatment of patients and among these are:

• Percentage of metastatic nodes in the axillary fat studied.
• Tumor size .
• Tumor variety with chromaticism and mitosis of the nucleus.
• Hormonal receptors.

Treatment

The fundamental pillar of the treatment of a breast neoplasia is surgery. This is intended to eliminate the tumor lesion and, in cases where indicated, axillary dissection must also be performed. The latter consists of the removal of the nodes of the ipsilateral axilla, which not only has a curative function, but also allows, as will be seen later, to have an idea of ​​the prognosis of the disease in each particular case. The first surgeries were very mutilating, which at one time included castration and the destruction of the pituitary gland of patients with breast cancer . The knowledge of molecular biology and the conviction that these major mutilations did not necessarily lead to an improvement in long-term results has led to the entire situation being reconsidered, and other options have been created, also supported by radiotherapy and chemotherapy. At this time there are two fundamental options for surgery: total mastectomy and partial or conservative mastectomy, in each of which axillary dissection can be associated, as a complement to the surgical technique. Partial procedures aim to remove the tumor with the overlying skin , leaving a margin of healthy tissue. Among these procedures are:

• Lumpectomy: the resection of the tumor, with a safety margin.
• Quadrantectomy: when the resection includes an entire quadrant (to this technique can be added total axillary dissection of the first level or biopsy of the sentinel lymph node (stained and marked with supravital dyes or radioactive isotopes).

Indications for conservative surgery

It can be performed in patients with single tumors , smaller than 3 cm and in breasts voluminous enough to have a breast-tumor relationship, allowing reconstruction of the organ with the remaining tissue. It is essential that the patient has the required psychosocial conditions, to know the need to complete the surgery with adequate radiation and/or chemotherapy treatment, as well as strict control of her condition in the long-term postoperative period.

Total mastectomies

These can be:

• Subcutaneous: the breast is removed and the skin over it and the areola-nipple complex are preserved.
• Simple or total: the breast is removed with the skin that covers it on the outside and the aponeurosis of the pectoral muscle on the bottom.
• Extended total: to the procedure described for the simple one, the dissection of the first lymph node level in the axilla is added.
• Modified radical: the breast, the aponeurosis of the pectoralis major muscle and the axillary nodes are removed . In this resection some authors include the pectoralis minor muscle. *Classic radical: removes the breast and pectoral muscles in a single block and performs a complete axillary dissection.
• Supraradical: it is similar to the classic one, but in addition, dissection of the supraclavicular, mediastinal and internal mammary nodes is performed.

It is recommended that each particular case be discussed by the breast group in each center and thus choose the best surgical technique for each of the patients; as well as the subsequent decision to apply chemotherapy, radiotherapy or both or other symptomatic treatment. Whenever radical breast surgery is planned, in any of its modalities, the patient must be informed and surgery of this type can never be performed without her prior consent.

Radiotherapy

It can be of two types:

• Preoperative: indicated in voluminous tumors to achieve reduction of the tumor mass and subsequently allow excision.
• Postoperative: indicated in the following cases:

-As a complement to conservative surgery. -When axillary dissection was not performed or it was incomplete. -For the treatment of supraclavicular and mediastinal lymph nodes and at the level of the surgical bed in selected cases. -In the postoperative period of resection of recurrent lesions. -To relieve pain in patients with bone metastases .

Endocrine

It can be of two types:

• Medical: indicated in patients with hormone-dependent tumors , after demonstration of this activity through the dosage of hormone receptors. The most used is tamoxifen.
• Surgical: consists of oophorectomy of premenopausal patients, and entails the unpleasant consequences of castration of these still young women.

Chemotherapy

It is indicated in premenopausal women with positive nodes in axillary dissection, who did not respond adequately to hormonal treatment. It may include cyclophosphamide, 5-fluorouracil, anthracycline, and methotrexate, among others.

Preoperative therapy (neoadjuvant)

The main objective of preoperative (neoadjuvant) therapy is to reduce tumor size and make voluminous lesions resectable, which were not previously resectable, or because there are specific clinical characteristics such as those presented in acute breast carcinoma . Currently, very intense work is being done to achieve new ways to combat breast cancer and these include:

• Angiogenesis inhibitors: the formation of new vessels is prevented to stop tumor growth and/or the development of metastases.
• Vaccines with antigens derived from the tumor.
• Monoclonal antibodies.
• Suppressor genes or anti-oncogenic factors.