Invasive Ductal Carcinoma
Maria Victoria T. Martinez
June 29, 2006
What is Invasive Ductal Carcinoma?
Invasive ductal carcinoma, or IDC, accounts
for about 80% of all breast cancers. Invasive
means that it has "invaded" or spread to the
surrounding tissues. It is ductal because the
cancer began in the milk ducts, which are
the "pipes" that bring milk from the lobules to
the nipple (1).
Invasive Ductal Carcinoma
C Dilated section of duct
to hold milk
F pectoralis major muscle
G Chest wall/rib cage
A Normal duct cell
B Ductal cancer cells
breaking through the
C Basement membrane
• November 2005 – Patient noted suspicious lesion in her right breast.
• December 2005 – Ultrasound-guided biopsy showed invasive ductal
carcinoma, high grade, ER-PR negative, Her-2/neu negative.
• High grade or Grade III – The cells tend to grow more quickly. It is
sometimes described as “comedo necrosis” due to the areas of dead
(necrotic) cancer cells which build up inside the tumor (4).
• ER-PR negative - Estrogen-receptor and progesterone-receptor negative or
of "unknown" status, which may mean samples the lab received were too
small to get reliable results, or few estrogen and progesterone receptors
were present. If hormone receptors are present in breast cancer cells, it will
better response to hormonal therapy. The more receptors, the better (2).
• Her-2/neu negative – Her-2/neu is a gene that helps control how cells grow,
divide, and repair themselves, important in the control of abnormal or
defective cells that could become cancerous (3). It is also a marker that has
been associated with a poor prognosis and seems to be associated with
sensitivity or resistance to various forms of chemotherapy and hormonal
therapy (6). A positive result will respond better to a medication called
herceptin, which has a solid track record in helping women with advanced
Patient History & Physical
• Patient is fit, well-appearing, 77-year-old African-American female in
no acute distress, accompanied by her husband.
• She was originally from Cuba, and has lived in the Bay Area for over
• She is married with 5 children and 7 grandchildren.
• She lost 15 lbs., felt fatigue, decreased appetite, and increased skin
pigmentation during her chemotherapy treatment.
• In the right breast, there are two oblique scars, one in the upper
outer quadrant corresponding with the lumpectomy site measuring
approximately 4 cm, and a 3 mm scar in the right axilla
corresponding with the sentinel lymph node dissection.
• Chest x-ray showed a 3-mm nodule in the right lung apex consistent
with granuloma, which is a tumor composed of granulation tissue
resulting from injury or inflammation or infection.
• Bone scan came out negative.
• Hypertension, Hypercholesterolemia, and glaucoma
• Takes Norvasc and Benazepril, which are high blood pressure
medications, Tegretol, which is an epilepsy treatment, and
glaucoma eye drops, which relieves increased pressure in the
• She donated her right kidney many years ago to her son who
had kidney disease.
• She had a lumpectomy, sentinel lymph node dissection and
axillary node dissection.
• She had completed four cycles of AC and Taxol
chemotherapy, which is doxorubicin and cyclophosphamide
plus Taxol. She tolerated and recovered from it fairly well.
• Concurrently undergoing Aromatase Inhibitors Hormonal
Patient Diagnosis with Staging
• T1N1M0, Stage IIA, right breast cancer
• Ultrasound-guided biopsy showed invasive ductal
carcinoma, high grade, ER-PR negative, Her-2/neu
• Lumpectomy resected the primary tumor of 18 mm,
poorly differentiated infiltrating ductal carcinoma,
Grade III, with rare lymph-vascular invasion.
• Closest margin was 3 mm re-resected with new margin
10 mm > was clear of tumor.
• A total of 4 sentinel nodes were dissected, 2 of which
were involved with the tumor.
• An additional 6 right axillary nodes were dissected, all
negative for cancer.
Vascular and Lymphatic Invasion
Normal breast with cancer cells invading
the lymph channels and blood vessels
in the breast tissue (7).
A blood vessels
B lymphatic channels
A normal duct cells
B cancer cells
C basement membrane
D lymphatic channel
E blood vessel
F breast tissue
Negative and Positive Margins
Negative and positive
"margins" or "margins of
resection" is the distance
between the tumor and the
edge of the tissue.
The pathologist checks to
make sure the edges of the
tissue are free of cancer
cells. This indicates whether
all of the cancer has been
A Cancer cells removed. The pathologist
B Normal tissue also measures how far in
from the edge cancer cells do
C Ink marking the occur (8).
• Family history
– Her brother died from head-and-neck cancer.
– One of her children died from kidney disease.
– One of her children died from sickle cell disease.
– Diets high in saturated fat increase the risk of developing breast cancer.
The patient suffers from high blood pressure and high cholesterol.
– The incidence of breast gradually increases and plateaus at the age of
forty-five and increases dramatically after fifty (5). The patient is 77
– Menopause after 50 causes increased risk of developing breast cancer
– The mere fact that being female increases the risk of developing breast
Common Histological Type
• Infiltrating ductal carcinoma
– Carcinoma refers to a malignant neoplasm of
epithelial origin or cancer of the internal or
external lining of the body.
– Most carcinomas affect organs or glands
capable of secretion (12).
Routes of Dissemination
• Local dissemination may occur, either to the underlying
chest wall and related structures including the ribs,
pleura and brachial plexus, or to overlying skin.
• Lymphatic spread is to axillary lymph nodes,
supraclavicular, internal mammary and/or contralateral
• Blood-borne metastasis is the route to distant sites,
particularly to bone (especially the axial skeleton), liver,
lung, skin and central nervous system (both brain and
spinal cord). Intra-abdominal and pelvic metastases,
including ovarian and adrenal deposits, are common.
Blood and lymphatic systems
Common Metastatic Sites
• Lungs, bone and brain
Most women with stage II breast cancer have chemotherapy and/or hormonal therapy
after primary treatment with surgery or surgery and radiation therapy (5).
Breast Conserving Therapy is as effective as Radical Mastectomy when combined
with Radiation Therapy (9).
– With lumpectomy, the surgeon removes only the part of your breast containing
the tumor (the "lump") and some of the normal tissue that surrounds it.
– All the tissue removed from your breast is examined carefully to see if cancer
cells are present in the margins, which are the normal tissue surrounding the
Chemotherapy is a systemic therapy that affects the whole body by going through the
bloodstream. The purpose systemic treatments is to get rid of any cancer cells that
may have spread from where the cancer started to another part of the body.
– The patient took four cycles of AC chemotherapy from Jan. 25th to Mar. 8th, 2006,
and Taxol chemotherapy from Mar. 21st to May 2nd, 2006.
• Radiation Therapy
Radiation therapy is a highly targeted, highly effective way to destroy cancer cells
that may linger after surgery. This reduces the risk of recurrence (11).
• Hormonal Therapy
The goal of hormonal therapy a.k.a. "anti-estrogen therapy" is to starve the breast
cancer cells of the hormone they thrive on, which is estrogen (2).
– Aromatase inhibitors have become the standard of care for post-menopausal
women, because they reduce the risk or delay the cancer from coming back in
the breast or lymph nodes, they decrease the risk of cancer spreading to other
parts of the body, and they lower the risk of a new breast cancer developing in
the other breast.
Radiation Therapy Set-Up
– Right arm up
• Sheet and pillowcase
• Knee sponge #4
• Table-top measurement
– CT ISO CV: 119.5 cm
• Set to medial reference
– 4.1 Post, 9.3 Rt, 0 Sup/Inf
• Field numbers: 1, 1W, 2 (medial, medial wedged, lateral)
• Site: Right breast
• Energy & Modality: 6 MV
• Field arrangement: Tangents
• Deliver dose to: 98%
• Dose per fraction: 266 cGy
• Fractions per week: 5
• Number of fractions: 16
• Total site dose with these fields: 4256 cGy
• Final site dose: 4256 cGy
Short & Long Term Effects
1. Short Term
a) Skin Reactions – It is similar to a sunburn.
b) Sensitive Skin Areas – This includes skin folds, and radiated
skin irritated by our own clothes.
c) Armpit Discomfort - After lymph node surgery, many patients
report discomfort and fullness in their armpit, which can be
made worse by radiation.
f) Chemotherapy Side Effects – hair loss, nausea, loss of
appetite, tiredness, low blood count
g) Surgery Side Effects – pain or tenderness, reaction to
anesthesia, bleeding, lymphoedema
Short & Long Term Effects
2. Long Term (14)
a) Telangiectasia– It is the abnormal formation of tiny blood
vessels that can cause redness.
b) Fat necrosis– It is a benign change of fat tissue in the breast.
• AC + T chemotherapy treatments are considered very aggressive.
However, research has found that aggressive chemotherapy - as
opposed to less aggressive chemotherapy - improved overall
survival, and had more years of disease-free survival. The chances
of survival went up by an extra 27%, and 42% respectively for those
age 65 and older (2).
• Stage II has a Five Year
Survival Rate of 71% (13).
(1) “IDC - Invasive Ductal Carcinoma.” breastcancer.org. 24 Oct. 2005
(2) “What Role Do Hormones Play in Breast Cancer Treatment?” breastcancer.org. 26 Jan. 2006
(3) “Chromosome Number, Her2 Status, and Oncogenes .” breastcancer.org. 24 Oct. 2005
(4) “Type and Grade of DCIS.” breastcancer.org. 27 Jan. 2006
(5) “Signs and Symptoms.” National Breast Cancer Foundation, Inc . 2006
(6) “Sept. 2000: Your Pathology Report .” breastcancer.org. 28 Oct. 2005
(7) “Vascular and Lymphatic Invasion.” breastcancer.org. 4 Jan. 2006
(8) “Margins of Resection.” breastcancer.org. 16 Mar. 2006
(9) “Effective Therapies for Young Women.” breastcancer.org. 27 Oct. 2005
(10) “Lumpectomy.” breastcancer.org. 16 Mar. 2006
(11) “Radiation Therapy.” breastcancer.org. 20 Oct. 2005
(12) “Cancer Types.” Life Enthusiast Co-op . 2004 <http://www.cancer-
(13) “Breast cancer prognosis.” Life Enthusiast Co-op . 2004
(14) “Side Effects Mild from Accelerated Partial Breast Radiation Therapy .” American Cancer Society,
Inc. 27 Mar. 2006