Tabar / Tot / Dean Breast Cancer: Early Detection with Mammography

1. Auflage 2007
ISBN: 978-3-13-257849-4
Verlag: Thieme
Format: EPUB
Kopierschutz: 6 - ePub Watermark

E-Book, Englisch, 324 Seiten, ePub

Reihe: Tabar Mammo

In "Breast Cancer: The Art and Science of Early Detection with Mammography-Perception, Interpretation, Histopathologic Correlation," László Tabár, one of the world's most renowned mammographers, has shared his decades of experience in presenting the fundamentals of perception and interpretation of mammographic images. This is the second volume in a series of books written by the team of Tabár, Tot, and Dean describing breast cancer in its earliest phase according to the imaging findings and correlating these findings with sophisticated histopathologic images and patient outcome. This volume covers a particularly troublesome subtype of breast cancer characterized by casting type calcifications.

Highlights:

- Extensive coverage of the morphology and outcome of this deceptive breast cancer subtype
- Nearly 1000 illustrations of stunning quality showing the full range of manifestations
- Photomicrographs of large, thin-section pathology slides and unique 3D pathology images which are carefully correlated with mammographic images to explain why mammograms appear as they do
- Stereoscopic images that demonstrate normal breast structures and the distortion caused by this unique malignant process
- Presentation of an original theory of neoductgenesis to explain the surprising disease outcome all too frequently observed
- Scientific rationale for using individualized treatment methods which include the mammographic prognostic features

Zielgruppe

Ärzte

Autoren/Hrsg.

Tabar, Laszlo

Tot, Tibor

Dean, Peter B.

Fachgebiete

• Medizin | Veterinärmedizin Medizin | Public Health | Pharmazie | Zahnmedizin Medizin, Gesundheitswesen Präventivmedizin, Gesundheitsförderung, Medizinisches Screening

Inhaltsverzeichnis

Chapter 1 Description of Calcifications Localized within the Ducts
Chapter 2 The Evolution of Casting Type Calcifications
Chapter 3 The Theory of Neoductgenesis
Chapter 4 The Deviant Nature of the Breast Cancer Subtype with Castings
Chapter 5 Recognition of the Unpredictable, Often Fatal Nature of the Breast Cancer Subtype Presenting with Casting Type Calcifications on the Mammogram
Chapter 6 Illustrative Cases with 3-Dimensional Stereoscopic Histological Images

Leseproben

Chapter 2 The Evolution of Casting Type Calcifications Introduction
Consecutive series of mammograms provide the opportunity to observe the development of breast disease. Concerning the specific breast cancer subtype presenting with casting type calcifications on the mammogram, it appears that one breast lobe might have been genetically malconstructed or damaged during intrauterine life. These genetic alterations of the lobe may remain subclinical for decades. The emergence of this specific breast cancer subtype may show different patterns on the mammogram and on other imaging modalities, as follows: No apparent abnormality on the previous mammogram. In some cases the malignant type calcifications seem to appear “suddenly” over a surprisingly large area on the mammogram although the previous examination showed no abnormalities. In these distressing cases the defective lobe with its numerous new branches due to “neoductgenesis” may appear on the mammogram in its entirety within a relatively short period, similarly to a submarine surfacing suddenly from beneath the water (Example on pages 76–79). Cluster of calcifications as the earliest sign. In many of the cases, a cluster of crushed stone-like calcifications may be seen on the previous mammogram(s), often associated with one or two linear calcifications, that progress to extensive casting type calcifications on subsequent mammograms (Examples on pages 80–117). Subtle casting type calcifications as the earliest sign. In some cases, the earliest mammographically detectable phase of the casting cases may be subtle casting type calcification(s) that have been overlooked (Examples on pages 118–125). When the initial, subtle sign of this already extensive disease is missed (or the patient is placed on short-term follow-up), the rapid development of this highly malignant process may be manifest on the next mammogram by the appearance of innumerable casting type calcifications over a surprisingly large region of the breast. To pursue the analogy, the conning tower of a submarine will be visible first, while the emergence of the body will follow later. Magnetic resonance imaging can demonstrate the true extent of the disease earlier and far beyond the mammographically detectable calcifications, because genetic changes predisposing to malignant transformation appear to occur simultaneously throughout much of the lobe. A Possible Biological Explanation for the Above Observations The development of the ductal system of the breast is initiated in early embryological life, at which time the number of main ducts is determined. The final arborization of the ducts takes place at puberty. While the number of TDLUs is subject to continuous proliferation and involution during the next few decades, the number of lobes, each with a main duct, will remain constant. If one of the lobes becomes genetically altered during embryological or adult life and acquires a propensity for malignant change, this unique breast cancer subtype can develop. It is characterized by both a malignant transformation of the epithelial cells within preexisting ducts and also by a rapid, disorderly formation of new duct branches. This pattern is in stark contrast to that of other breast cancer subtypes, which are characterized by malignant transformation of the TDLUs involving only part of a lobe. The genetic changes predisposing to malignancy and the subsequent malignant process are both able to involve the duct system of an entire lobe (whatever its size). The result is a complex conglomerate of both preexisting and newly formed neoplastic ducts. This suggested process may explain the seemingly sudden emergence of extensive disease on the mammogram, although functional imaging methods, such as contrast-enhanced MRI of the breast, may detect the presence of disease considerably earlier and over a larger extent than does the mammogram. In any case, the diagnostic and therapeutic team members need to be aware of the frequently extensive and highly fatal nature of this special subtype of breast cancer.1–9 No Apparent Abnormality on the Previous Mammogram
Only one case (Ex. 2.1) is presented here. The first group comprises cases in which no mammographic sign of the presence of the disease was present at the time of the previous examination. Example 2.1 A 69-year-old asymptomatic woman, screening examination. Ex. 2.1-1 & 2 Right and left breasts, MLO projections. No mammographic abnormality is seen. Ex. 2.1-3 & 4 Nineteen months later the patient felt a lump in the upper outer quadrant of herright breast. Corresponding to the clinically palpable lesion, the mammogram shows innumerable calcifications. Mammogram, MLO projection (Ex. 2.1-3) and microfocus magnification (Ex. 2.1-4): de novo casting type calcifications with an associated nonspecific density. Ex. 2.1-5 Right breast, detail of the MLO projection, microfocus magnification. Ex. 2.1-6 Preoperative localization: bracketing the pathological lesions using multiple wires. Ex. 2.1-7 & 8 Subgross, thick section 3D histological images demonstrate a large number of ducts packed tightly together, distended by cancer cells, necrosis and amorphous calcifications. Ex. 2.1-9 Specimen radiograph demonstrating the calcifications. Ex. 2.1-10 Large-section histology (H&E). The calcifications within the contorted cancerous ducts surrounded by desmoplastic reaction correspond to the mammographic findings. The presence of an abnormally high concentration of the pathological ducts over a confined area makes it highly unlikely that these could be preexisting ducts. Ex. 2.1-11 Higher-power large-section histological image. The palpable lesion is formed by the mass of abnormal ducts surrounded by the desmoplastic reaction. Ex. 2.1-12 & 13 Comparative mammographic and thick-section histological images of this rapidly developing Grade 3 “in situ” process. The millimeter scale shows that the individual ducts are extremely distended by the pathological process. Ex. 2.1-14 Demonstration of the dense desmoplastic reaction surrounding the ducts and the extensive periductal lymphocytic infiltration. Histological diagnosis: 48 mm × 34 mm Grade 3 DCIS with a few areas of microinvasion up to 1 mm. No metastases were found in seven axillary lymph nodes. Ex. 2.1-15 High-power magnification histological image (H&E): Grade 3 carcinoma in situ with central necrosis. Treatment and follow-up: Mastectomy. The patient was recurrence-free at the most recent follow-up examination seven years after surgery. Cluster of Calcifications as the Earliest Sign
The second group comprises cases in which very subtle early signs of the presence of the disease have not been fully appreciated. The crushed stone-like calcifications may represent a precursor of castings. We can speculate from the underlying histology that if the malignant process producing crushed stone-like calcifications is not removed surgically, it could progress to widespread disease producing casting type calcifications. Judging from the underlying histology, these would have developed to casting type calcifications over a large area had they not been removed surgically. Example 2.2 A 43-year-old asymptomatic woman, screening examination. A single cluster of calcifications was not perceived at screening. Ex. 2.2-1 Detail of the left MLO screening mammogram. The circle outlines the tiny cluster of calcifications. Ex. 2.2-2 Photographic magnification of the cluster of crushed stone-like calcifications. Ex. 2.2-3 & 4 Twenty-five months later, still asymptomatic, screening examination. Left MLO (3) and CC (4) projections. Innumerable casting type calcifications have appeared since the previous examination, and are spread over two-thirds of the breast. No associated tumor mass is visible.
Although the first visible calcification cluster was localized in the upper outer quadrant, the calcifications are now found not only in the upper half of the breast but also fill part of the lower half of the breast, with the corresponding main duct being also filled with malignant type calcifications (rectangle). Ex. 2.2-5 Detail of the lateromedial horizontal projection. Ex. 2.2-6 & 7 Microfocus magnification images demonstrate the presence of both types of casting type calcifications, fragmented and dotted. Ex. 2.2-8 & 9 Subgross (8) and low-power conventional (9) histological images of ducts containing micropapillary DCIS and calcifications. Ex. 2.2-10 The calcifications demonstrate a plethora of ducts containing both types of casting type calcifications. Ex. 2.2-11 Large-section histological image. The cancerous ducts occupy a large area (rectangle). Ex. 2.2-12 & 13 Medium-power histological images of solid and micropapillary DCIS with intraluminal necrosis and central calcifications. Ex. 2.2-14 Additional magnification image of this case. Ex. 2.2-15 & 16 Histological diagnosis: 120 mm × 60 mm area with Grade 3 DCIS. No metastases...

Über Autor(innen)

László Tabar, Tibor Tot, Peter B Dean