Signs and Symptoms

o Ductal carcinoma in situ (DCIS) is characterized by cancerous cells that are confined to the lining of the milk ducts and have not spread through the duct walls into surrounding breast tissue. If ductal carcinoma in situ lesions is left untreated, over time cancer cells may break through the duct and spread to nearby tissue, becoming an invasive breast cancer.

o DCIS is the most common type of noninvasive breast cancer, with about 60,000 new cases diagnosed in the United States each year. About one in every five new breast cancer cases is ductal carcinoma in situ.

o DCIS is divided into several subtypes, mainly according to the appearance of the tumor. These subtypes include micropapillary, papillary, solid, cribriform and comedo.

o Women with ductal carcinoma in situ are typically at higher risk for seeing their cancer return after treatment, although the chance of a recurrence is less than 30 percent. Most recurrences occur within five to 10 years after the initial diagnosis and may be invasive or noninvasive. DCIS also carries a heightened risk for developing a new breast cancer in the other breast. A recurrence of ductal carcinoma in situ will require additional treatment.

o The type of therapy selected may affect the likelihood of recurrence. Treating ductal carcinoma in situ with a lumpectomy (breast-conserving surgery) without radiation therapy carries a 25 percent to 35 percent chance of recurrence. Adding radiation therapy to the treatment decreases this risk to approximately 15 percent. Currently, the long-term survival rate for women with ductal carcinoma in situ is nearly 100 percent.

o Invasive ductal carcinoma (IDC) begins in the milk ducts and spreads to the fatty tissue of the breast outside the duct. IDC accounts for about 80 percent of invasive breast cancers.

o Invasive ductal carcinoma treatment options: Surgery typically is the first treatment for invasive ductal breast cancer. The goal of this treatment is to remove the cancer from the breast with a lumpectomy or mastectomy. The type of surgery recommended will depend on factors such as the location of the tumor, the size of the cancer and whether more than one area in the breast has been affected. For patients with ductal carcinoma, long-term systemic treatment with tamoxifen is recommended to prevent recurrence.

o Four types of invasive ductal carcinoma are less common:

• Medullary ductal carcinoma: This type of cancer is rare and accounts for only 3 percent to 5 percent of breast cancers. It is called “medullary” because under a microscope, it resembles part of the brain called the medulla. Medullary carcinoma may occur at any age, but it typically affects women in their late 40s and early 50s. Medullary carcinoma is more common in women who have a BRCA1 gene mutation. Medullary tumors are often “triple-negative,” which means they test negative for estrogen and progesterone receptors and for the HER2 protein. Medullary tumors are less likely to involve the lymph nodes, are more responsive to treatment, and may have a better prognosis than more common types of invasive ductal cancer.
• Surgery is typically the first-line treatment for medullary ductal carcinoma. A lumpectomy or mastectomy may be performed, depending on the location of the tumor. Chemotherapy and radiation therapy may also be used.
• Mucinous ductal carcinoma: This type of breast cancer accounts for less than 2 percent of breast cancers. Microscopic evaluations reveal that these cancer cells are surrounded by mucus. Like other types of invasive ductal cancer, mucinous ductal carcinoma begins in the milk duct of the breast before spreading to the tissues around the duct. Sometimes called colloid carcinoma, this cancer tends to affect women after they have gone through menopause. Mucinous cells are typically positive for estrogen and/or progesterone receptors and negative for the HER2 receptor.
• Surgery is typically recommended to treat mucinous ductal carcinoma. A lumpectomy or mastectomy may be performed, depending on the size and location of the tumor. Adjuvant therapy, such as radiation therapy, hormonal therapy, and chemotherapy, may also be required. Most mucinous carcinomas test negative for receptors for the protein HER2, so they are not typically treated with trastuzumab (Herceptin®).
• Papillary ductal carcinoma: This cancer is rare, accounting for less than 1 percent of invasive breast cancers. In most cases, these types of tumors are diagnosed in older, postmenopausal women. Under a microscope, these cells resemble tiny fingers or papules. Papillary breast cancers are typically small, and test positive for the estrogen and/or progesterone receptors and negative for the HER2 receptor. Most papillary carcinomas are invasive and are treated like invasive ductal carcinoma.
• Surgery is typically the first-line treatment for papillary breast cancer. A lumpectomy or mastectomy may be performed, depending on the size and location of the tumor. After surgery, adjuvant therapy may be required and may include radiation, chemotherapy and/or hormone therapy.
• Tubular ductal carcinoma: Another rare type of IDC, this cancer makes up less than 2 percent of breast cancer diagnoses. Like other types of invasive ductal cancer, tubular breast cancer originates in the milk duct, then spreads to tissues around the duct. Tubular ductal carcinoma cells form tube-shaped structures. Tubular ductal carcinoma is more common in women older than 50. Tubular breast cancers typically test positive for the estrogen and/or progesterone receptors and negative for the HER2 receptor.
• Treatment options for tubular ductal carcinoma depend on the aggressiveness of the cancer and its stage. Treatment often consists of surgery, which includes a lumpectomy or mastectomy, and additional (adjuvant) therapy, which may include chemotherapy, radiation and/or hormone therapy.

§ Lobular carcinoma begins in the lobes or lobules (glands that make breast milk). The lobules are connected to the ducts, which carry breast milk to the nipple.

§ Lobular carcinoma in situ (LCIS): It begins in the lobules and does not typically spread through the wall of the lobules to the surrounding breast tissue or other parts of the body. While these abnormal cells seldom become invasive cancer, their presence indicates an increased risk of developing breast cancer later. About 25 percent of women with LCIS will develop breast cancer at some point in their lifetime. This subsequent breast cancer may occur in either breast and may appear in the lobules or in the ducts.

§ Because LCIS is not actually cancer, treatment may not be recommended. If you are diagnosed with lobular carcinoma, you may want to discuss more frequent breast cancer screening with your doctor. Increasing surveillance may help ensure that any subsequent breast cancer is detected in its earliest, most treatable stages.

§ Invasive lobular carcinoma (ILC): It starts in the lobules, invades nearby tissue, and can spread (metastasize) to distant parts of the body. This breast cancer type accounts for about one out of every 10 invasive breast cancers.

§ The treatment options for invasive lobular carcinoma include localized approaches such as surgery and radiation therapy that treat the tumor and the surrounding areas, as well as systemic treatments such as chemotherapy and hormonal or targeted therapies that travel throughout the body to destroy cancer cells that may have spread from the original tumor.

– Unlike other breast cancers, inflammatory breast cancer (IBC) rarely causes breast lumps and may not appear on a mammogram. Inflammatory breast cancer symptoms include:

• Red, swollen, itchy breast that is tender to the touch.
• The surface of the breast may take on a ridged or pitted appearance, like an orange peel (often called peau d’orange)
• Heaviness, burning, or aching in one breast
• One breast is visibly larger than the other
• Inverted nipple (facing inward)
• No mass is felt with a breast self-exam
• Swollen lymph nodes under the arm and/or above the collarbone
• Symptoms unresolved after a course of antibiotics

– Unlike other breast cancers, inflammatory breast cancer usually does not cause a distinct lump in the breast. Therefore, a breast self-exam, clinical breast exam, or even a mammogram may not detect inflammatory breast cancer. Ultrasounds may also miss inflammatory breast cancer. However, the changes to the surface of the breast caused by inflammatory breast cancer can be seen with the naked eye.

– Symptoms of inflammatory breast cancer can develop rapidly, and the disease can progress quickly. Any sudden changes in the texture or appearance of the breast should be reported to your doctor immediately.

For women who are pregnant, or breast-feeding, redness, swelling, itchiness, and soreness are often signs of a breast infection such as mastitis, which is treatable with antibiotics. If you are not pregnant or nursing and you develop these symptoms, your doctor should test for inflammatory breast cancer. 

Lobular carcinoma in situ (LCIS) does not cause symptoms and cannot be seen with a mammogram. This condition is usually found when a doctor is doing a breast biopsy for another reason, such as to investigate an unrelated breast lump. If a person has LCIS, the breast cells will appear abnormal under a microscope.

– Male breast cancer symptoms can be like those experienced by women and may include:

• Lumps in the breast, usually painless
• Thickening of the breast
• Changes to the nipple or breast skin, such as dimpling, puckering or redness
• Discharge of fluid from the nipples

o Male breast cancer occurs when malignant cells form in the tissues of the breast. Any man can develop breast cancer, but it is most common among men who are 60 to 70 years old. About 1 percent of all breast cancers occur in men. About 2,000 men are diagnosed with breast cancer each year.

o Many men may be surprised to learn they can get breast cancer. Men have breast tissue that develops in the same way as breast tissue in women and is susceptible to cancer cells in the same way. In girls, hormonal changes at puberty cause female breasts to grow. In boys, hormones made by the testicles prevent the breasts from growing. Breast cancer in men is uncommon because male breasts have ducts that are less developed and are not exposed to growth-promoting female hormones.

o Just like in women, breast cancer in men may begin in the ducts and spread to surrounding cells. More rarely, men may develop inflammatory breast cancer or Paget’s disease of the breast, if a tumor that began in a duct beneath the nipple moves to the surface. Male breasts have few if any lobules, and so lobular carcinoma rarely, if ever, occurs in men.

o Men should also be aware of gynecomastia, the most common male breast disorder. Gynecomastia is not a form of cancer but does cause a growth under the nipple or areola that can be felt, and sometimes seen. Gynecomastia is common in teenage boys due to hormonal changes during adolescence, and in older men, due to late-life hormonal shifts. Certain medications can cause gynecomastia, as can some conditions, such as Klinefelter syndrome. Rarely, gynecomastia is due to a tumor. Any such lumps should be examined by your doctor.

o Male breast cancer treatment typically consists of mastectomy, followed by radiation therapy, chemotherapy, hormone therapy and/or targeted therapy. Since many male breast cancers are hormone receptor-positive, the drug tamoxifen (Nolvadex®) is often a standard therapy for male breast cancer.

o For men, whose cancer has not spread to the lymph nodes, adjuvant therapy (therapy given after surgery) is generally the same as for a woman with breast cancer. For men, whose cancer has spread to the lymph nodes, adjuvant therapy may include chemotherapy plus tamoxifen and/or other hormone therapy. Treatment for men with cancer that has spread to other parts of the body may include hormone therapy and/or chemotherapy.

– The most common molecular subset of breast cancer is defined by its ability to respond to the female hormone, estrogen. Genomic research has led to more detailed ways to classify breast cancers, based on their genes and proteins, by dividing them into four main molecular subtypes: HER2, luminal A, luminal B, and triple negative.

  HER2-positive

• One in five invasive breast cancers is HER2-positive, making this one of the more common breast cancer subtypes in the United States. HER2-positive cancers are ER- and PR-negative and human epidermal growth factor receptor 2 (HER2)-positive.
• HER2-positive breast cancer cells carry too many copies of the HER2 gene, which makes HER2-protein receptors, found on breast cells. When they work normally, HER2 receptors control how a healthy breast cell grows, divides, and repairs itself. When they proliferate, the receptors tell the cells to divide and grow rapidly and without control. That is because their cells absorb too much of a substance called human epidermal growth factor 2, which energizes cell growth. Doctors often test breast cancer tissue for excess HER2-positive genes to determine whether the patient may benefit from targeted therapy options, which are designed to block HER2 from energizing cancer cell growth.
• Symptoms of HER2-positive breast cancer are like those of other breast cancer types. They include a lump in the breast, changes to the breast’s shape, pain, swelling and abnormal discharge.
• Depending on the cancer’s stage, treatment options for HER2-positive breast cancer may include a combination of surgery, radiation therapy, chemotherapy and/or administration of a targeted therapy such as the immune monoclonal antibody, trastuzumab (Herceptin®). Learn more about advanced treatments for breast cancer.

  Luminal A

• Luminal A is the most common subtype for every race and age. These tumors tend to be estrogen receptor (ER)-positive and progesterone receptor (PR)-positive and are typically slow growing. Treatment typically involves hormonal therapy. 

  Luminal B

• § Luminal B includes tumors that are estrogen receptor positive, progesterone receptor negative and HER2 positive. These tumors tend to grow more quickly than luminal A tumors. Luminal B breast cancers are likely to benefit from chemotherapy and may benefit from hormone therapy and treatments targeting the HER2 receptor.

Triple-negative breast cancer

• What is triple-negative breast cancer? In this type of cancer, the cells do not contain receptors for estrogen, progesterone or HER2. This type of breast cancer is usually invasive and usually begins in the breast ducts.
• Healthy breast cells contain receptors for the hormone’s estrogen and progesterone. They also contain receptors for a protein called HER2, which stimulates normal cell growth. About two out of three women with breast cancer have cells that contain receptors for estrogen and progesterone, and about 20 percent to 30 percent of breast cancers have too many HER2 receptors.
• Breast cancer that is estrogen receptor (ER)- and progesterone receptor (PR)-positive can be treated with hormone therapy. Breast cancer with excess amounts of HER2 can be treated with anti-HER2 targeted therapy drugs such as trastuzumab.
• In women with triple-negative breast cancer, the malignant cells do not contain receptors for estrogen, progesterone or HER2. Breast cancer that is ER-, PR- and HER2-negative cannot be treated with hormone therapy or medications that work by blocking HER2, such as trastuzumab.
• Fortunately, triple-negative breast cancer can be treated with other drugs, such as chemotherapy, radiation therapy and non-HER2 targeted therapy.

– Angiosarcoma is rare cancer that starts in the cells that line blood vessels or lymph vessels. Many times, it is a complication of previous radiation treatment to the breast. It can happen 8-10 years after getting radiation treatment to the breast.

Signs and symptoms of angiosarcoma

– Angiosarcoma can cause skin changes like purple colored nodules and/or a lump in the breast. It can also occur in the affected arms of women with lymphedema, but this is not common. (Lymphedema is swelling that can develop after surgery or radiation therapy to treat breast cancer.) 

How is angiosarcoma of the breast diagnosed?

– One or more of the following imaging tests may be done to check for breast changes:

• Diagnostic mammogram
• Breast ultrasound
• Breast MRI (magnetic resonance imaging) scan

– Angiosarcoma is diagnosed by a biopsy, removing a small piece of the breast tissue, and looking at it in the lab. Only a biopsy can tell for sure that it is cancer.

Treating angiosarcoma

– Angiosarcomas tend to grow and spread quickly. Treatment usually includes surgery to remove the breast (mastectomy). The axillary lymph nodes are typically not removed. 

o Paget’s disease of the breast is a form of breast cancer that causes distinct skin changes on the nipple. A rare disease, accounting for fewer than 3 percent of all breast cancers, it is named for Sir James Paget, the English surgeon who first documented the condition in 1874. Under a microscope, Paget’s cells look very different from normal cells, and divide rapidly. About half of the cells test positive for estrogen and progesterone receptors, and most test positive for the HER2 protein. Although women with Paget’s disease of the breast sometimes have tumors inside the breast tissue, its most noticeable symptoms involve changes to the skin of the nipple or areola (the darker, circular area around the nipple of the breast), creating oozing or the appearance of eczema. The cancer is typically diagnosed with a biopsy of the tissue, sometimes followed by a mammogram, sonogram, or MRI to confirm the diagnosis. Paget’s disease of the breast is not related in any medical way to other conditions named after Sir James Paget, such as Paget’s disease of the bone.

o The main symptoms of Paget’s disease of the breast are superficial skin changes, limited to the nipple or areola, that are sometimes mistakenly dismissed as innocuous. Those symptoms include:

• A skin rash on the nipple or areola, resembling eczema, with the skin developing flakiness, redness, or itchiness
• Discharge from the nipple
• A burning, painful or tingling sensation, especially in advanced stages of the disease
• Nipple changes, such as inverted nipples
• Changes to the breast, such as a lump, redness, oozing, crustiness, or a sore that does not heal

o The primary treatment for Paget’s disease of the breast is most often the surgical removal of the tumor. Cancers that are diagnosed in the early stages may be treated with breast-conserving lumpectomy, while more advanced malignancies may require a mastectomy.

o As with other breast cancers, your care team may recommend chemotherapy, radiation therapy or other treatments for Paget’s disease of the breast. Learn more about advanced treatments for breast cancer.

o In papillary carcinoma, the cancer cells are arranged in finger-like projections, or papules. Under a microscope, the cells appear fern-like.

o Papillary carcinoma is a rare type of breast cancer, accounting for about three percent of all breast cancers. Papillary carcinoma typically has a better prognosis than other, more common breast cancers.

o The primary difference between papillary carcinoma and other types of breast cancer is that the cancer cells are arranged in finger-like projections, or papules. Under a microscope, the cells appear fern-like. Sometimes, the cancer cells are very small in size, in which case the cancer may be called micropapillary.

o Most papillary carcinomas are invasive and are treated like invasive ductal carcinoma. However, invasive papillary carcinoma usually has a better prognosis than other invasive breast cancer. Most often, invasive papillary carcinoma occurs after the development of noninvasive papillary carcinoma.

o Papillary carcinoma may also be detected when it is still noninvasive. Noninvasive papillary carcinoma is usually considered a variety of ductal carcinoma in situ (DCIS). In its earliest stages, when the cancer cells are just beginning to affect the ducts, this disease may be referred to as infiltrating papillary carcinoma.

o Treatment for papillary carcinoma often consists of a combination of surgery, radiation, chemotherapy, hormone therapy and/or therapy that targets the HER2 protein.

– Metastatic breast cancer symptoms depend on the part of the body to which the cancer has spread and its stage. Sometimes, metastatic disease may not cause any symptoms.

• If the breast or chest wall is affected, symptoms may include pain, nipple discharge, or a lump or thickening in the breast or underarm.
• If the bones are affected, symptoms may include pain, fractures, constipation, or decreased alertness due to high calcium levels.
• If tumors form in the lungs, symptoms may include shortness of breath or difficulty breathing, coughing, chest wall pain or extreme fatigue.
• If the liver is affected, symptoms may include nausea, extreme fatigue, increased abdominal girth, swelling of the feet and hands due to fluid collection and yellowing or itchy skin.
• If breast cancer spreads to the brain or spinal cord and forms tumors, symptoms may include pain, confusion, memory loss, headache, blurred or double vision, difficulty with speech, difficulty with movement or seizures.