| Etiology | The etiology is multifactorial. It involves diet, genetic and reproductive factors, and related hormone imbalances. |
| Epidemiology | The annual incidence of breast cancer is about 43/100 000 per year in France, and the mortality rate is about 18/100 000 per year. Invasive breast cancer is the most common carcinoma in women, accounting for 22% of all female cancers. One million women worldwide are diagnosed with breast cancer every year. The main factors of risk are: gender : women's risk for the development of invasive breast carcinoma is approximately 400 times that of men. age : breast cancer incidence increases rapidly with age. The mean age at diagnosis is around 60 yrs genetic factors : rare (3 to 5% of cancers and 1/500-800 women) but highly predictive of the disease. The areas of higher risk are the affluent populations of North America, Europa and Australia, where 6% of women develop invasive breast carcinoma before age 75. |
| Pathology | The most common histologic type of invasive breast carcinoma is designated as ductal, NOS (not otherwise specified). It comprises about 80% of all cases. It is a proliferation of epithelial cells from galactophoral ducts; it may be preceded and accompanied by an in situ component characterized by a proliferation of cells within the ducts without interuption of the basal membrane; when this membrane is altered, the carcinoma is invasive. It can be graded on the basis of the architecture (amount of tubule formations), nuclear atypia and mitotic activity. The score resulting from the sum of these criteria (NottinghamÕs score) has been show to be an important prognostic indicator. A 3-grade system has been developed for in situ ductal carcinoma. Grade III in situ ductal carcinoma corresponds to the classic comedocarcinoma, whereas Grade I in situ ductal carcinoma merges with atypical ductal hyperplasia, to the point that some authors regard the two process as one and the same. Recently, a proposal has been made to embrace all of the various types of intraductal proliferative lesions under the term ductal intraepithelial neoplasia (DIN) and to divide this into 3 grades, having increasingly higher risk for the development of invasive carcinoma. Many morphologic variants of invasive ductal carcinoma exist, some of them extremely rare. They include: tubular, cribriform, medullary, mucinous, neuroendocrine, papillary, micropapillary, apocrine, metaplastic, lipid-rich, secretory, oncocytic, adenoid cystic, acinic cell, glycogen-rich (clear cell), sebaceous, and inflammatory carcinoma. The prognosis of these subtypes varies, some of them having a better and some a worse outcome than invasive ductal carcinoma, NOS. Invasive lobular carcinoma is the second major type (5-10%) of breast cancer. Like its ductal counterpart, it may be preceded or accompanied by an in situ component. It is histologically more homogeneous than ductal carcinoma, but some morphologic variation exist, such as pleomorphic and signet ring cell. Medullary carcinoma, already mentioned above as a rare subtype of invasive ductal carcinoma (1%) with a better prognosis, it has a very distinctive form: sharply circumscribed, accompanied by a heavy lymphoid infiltrate, of high nuclear grade, with a syncytial pattern of growth, and lacking in situ or microglandular features. When one of these features is lacking, the tumor is referred to as Òatypical medullary carcinoma". A high frequency of medullary carcinoma has been reported in patients with BRCA1 germ line mutation. The different steps in the progression of breast cancer are not well individualized. Hyperplasia is a proliferation of ductal or lobular epithelial cells, without criteria of malignancy; in contrast, atypical hyperplasia has incomplete malignant features and can be difficult to distinguish from in situ carcinoma. Fibroadenomas are the most common form of benign breast tumors. These different forms of breast cancer may occur with (hereditary or familial forms) or without (sporadic forms) a familial background. |
| Prognosis | There are over 100 factors that have been identified as having prognostic significance in breast carcinoma , but only a minority of them will retain this property when subjected to a multivariate analysis. The most important prognostic factors are: presence and number of positive lymph nodes; tumor size; microscopic grade; and presence of lymphovascular invasion. Other parameters examined pathologically - such as hormone receptors and ERBB2/Neu - have more of a predictive than a prognostic value, in the sense of anticipating a certain type of response to specific forms of therapy. Upon diagnosis, the different presentations are classified upon morphological study, and the gravity and prognosis of the disease is estimated with several parameters that are : tumor size, tumor grade: it is calculated from assessment of tubular differentiation, number of mitoses, and nuclear polymorphism, the absence of estrogen and progesterone receptors, the presence of lymph node metastasis, peritumoral vascular invasion. Other parameters such as the proliferating index (Ki 67, S-phase), the ploidy, and the presence of P53 or ERBB2 alteration may also be useful for prognostic evaluation or as predictive factors for therapeutic response. |
Cytogenetics Morphological | Many of the chromosomal aberrations observed in breast carcinomas are not specific of this type of tumour; karyotypes of breast tumours frequently show multiclonality, suggesting the existence of a high degree of intratumoural heterogeneity. Alterations of chromosome arms 1q, 3p, 6q, 8p are often present; i(1q) and der t(1;16) are frequent as sole anomalies; +7, +8 and +20 are also frequent; cytogenetic signs of DNA amplification, such as homogeneously staining regions (HSR), are commonly observed in breast carcinomas and seem preferentially associated to 8p. |
| Cytogenetics Molecular | LOH studies : loss of heterozygosity (LOH) has been associated with physical deletion of large genomic segments containing tumour suppressor genes; common regions of LOH in breast cancer are located on several chromosomes: 1p, 1q, 3p, 6q, 8p, 11q, 13q, 16q, 17p, 17q; almost all breast tumours show LOH in one or several regions; some regions are lost in more than 50% of tumors: 8p, 16q, 17p; precancerous lesions also show LOH. CGH : Comparative genomic hybridization (CGH) is a molecular cytogenetics method designed to detect and map chromosomal regions showing abnormal copy numbers in tumors; theoretically, it is possible to detect equally copy number gains (DNA amplification or polyploidies) or losses using this approach; it appears, however, that CGH has a greater sensitivity for gains than for losses; this could be related to the fact that gains are generally of higher magnitude than losses and that losses can be obscured by intratumoral heterogeneity; Overall CGH data show that breast tumor genomes undergo severe rearrangements; on average, breast tumors show 5-7 copy number changes/tumor; less than 10% of the tumors analyzed by CGH show neither gains nor losses; almost every chromosome presents at least one site with aberrant copy numbers, however, gains or losses are not evenly distributed throughout the genome. Hot spots for gains are routinely observed at 1q (50-55% of the tumors), 8q (60%), 17q (25-30%), 20q (20-25%); gains generally involve subregions of each chromosomal arm and most prevalent regions are 1q31-q32, 8q12 and 8q24 (with MYC and other genes), 17q12 (ERBB2) and 17q23-q24, and 20q13; other regions of recurrent gains are 11q13 (20%, with CCND1), 8p12 (10-15%, and FGFR1), 16p (10-15%); recurrent losses are observed at 1p, 6q, 8p, 11q23-qter, 13q, 16q, 17p and 22q CGH has revealed that copy number gains are common in breast tumors and involve 26 (!) chromosomal arms; these data somewhat contradict karyotypical analysis and LOH studies which indicate that losses are more frequent that gains; furthermore, it appears from CGH data that the number of events (gains and losses) increases in advanced cancer. |
| Gene Name | BRCA1 |
| Location | 17q21 |
| Dna / Rna | Large gene of 22 coding exons spaning more than 70 kb of genomic DNA; exon 11 corresponds to almost 50% of the total coding sequence (5592 nucleotides); the BRCA1 mRNA has a size of 7.8 kb, and a complex pattern of alternative splicing has been reported; it is expressed in numerous tissues (breast, ovary, testis, spleen, thymus ...). |
| Protein | the corresponding protein has 1863 amino acids, and 190-220 kDa; BRCA1 is not a member of any known gene family; there is only two stretches of evolutionary conserved sequences between humans and mice: at the N-terminus (the RING finger motif), and at the C-terminus (the BRCT domain); the function of BRCA1 is still unknown but it seems to act as a tumor suppressor gene with transcriptional activity; it is involved in cell proliferation processes of mammary epithelial cells in response to hormonal stimulation, in apoptosis, control of recombination and genome integrity after binding to proteins involved in these activities. |
| Germinal mutation | more than 300 sequence variations at the germline level have been reported; a list is available on the BIC website: the germline mutations are dispersed throughout the coding sequence; although a majority of these variations are unique, recurrent mutations such as 185delAG and 5382insC are observed; they were initially described in the Ashkenazy Jewish population; more than 80% of the sequence variants lead to a truncated protein; in contrast, the majority of missense mutations are of unknown clinical significance, excepted those in the RING finger region; in the BRCA1 families, an excess of breast, ovarian, and prostate cancers are seen; all mutations combined, penetrance at age 70 years works out at 56% to 87% in the case of breast cancer, and 16% to 63% in that of ovarian cancer BRCA1-associated breast cancers have specific morphological features; they are more frequently of histoprognostic grade 3, highly proliferating and poorly differentiated tumors with a very pleomorphotic nuclear pattern; high frequencies of P53 alterations and negativity of steroid receptors are found in these tumors; a high rate of medullary breast carcinomas is observed among BRCA1-associated breast cancers; evidence for possible genotype-phenotype correlations have been provided concerning the tumor spectrum (breast/ovarian cancer incidence rate), the penetrance, and the proliferation rate of tumors |
| Somatic mutation | in contrast, somatic mutations of BRCA1 coding sequence are rare in breast/ovarian cancers |
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