Case Discussion: Bilateral Periareolar Breast Masses and Bloody Nipple Discharge

Molecular investigation has a definite role in systemic treatment: where chemotherapy is used, molecular analysis can replace it with targeted therapy or immunotherapy in some cases. For localised cancer, surgery remains the mainstay and the most curative treatment, and cannot be replaced, though in advanced disease chemotherapy can be replaced by immunotherapy or targeted therapy. For radiation, adding radiosensitising drugs identified through molecular analysis can sometimes allow the radiation dose to be decreased. The larger goal should be prevention: a cervical cancer vaccine already exists, and a breast cancer vaccine within two to three years, with vaccines against most cancers within ten to fifteen years, would be the golden day of mankind.

As a tumour breaks down, its cells release DNA that circulates in the blood. Finding this DNA in a blood sample can be used as a screening test, prompting further investigation like colonoscopy, CT scan or mammography to locate the source. Measured before and after treatment, for example after three months of chemotherapy, a drop to absent or minimal levels indicates a good response. Checked every six months for years after treatment, a previously absent reading reappearing can signal recurrence. It is not yet fully specific and is still being researched, but is expected to be used more heavily in screening, diagnosis, prognosis, monitoring and recurrence detection.

CAR-T cell therapy, and immunotherapy generally, works on a simple concept: our own immune cells are competent enough to fight infection and cancer, but whenever cancer is present, immunity goes down. Immunotherapy retrains the remaining immune cells to fight again, rather than killing the tumour directly. The drugs make our own immunity more competent, cells that were lying idle are retrained and made to recognise the cancer as the enemy, and then they go and fight it.

The exact mechanism is still not fully known. But one clear factor is genetic aberrations that occur over time because of environmental exposure: if a patient achieves a cure but resumes alcohol or smoking, the damage caused by tobacco or other carcinogens affects the DNA again and dormant cells can get reactivated. That is one reason recurrence happens, though most of the time the actual mechanism is not known.

For bone metastasis, use a nuclear bone scan; if that is unavailable, do a skeletal survey, plain X-rays of the spine, ribs, pelvis and limbs. For liver metastasis, a CT abdomen substitutes for PET, and an ultrasound is a fair investigation if CT is also unavailable. For the lungs, a CT chest is the alternative, and a plain chest X-ray is fair enough if CT is not available. Also check the uterus and ovaries with a pelvis ultrasound in every breast cancer patient, to rule out Krukenberg tumours. Ultrasound and X-rays are available almost everywhere in the world, and while less precise than PET-CT, this combination is enough to establish metastatic staging.

Central-quadrant (periareolar) disease is better managed with mastectomy and axillary clearance rather than breast conservation, even when the rest of the breast is otherwise normal on mammography.

Duct papilloma (which can transform into papillary carcinoma), invasive ductal carcinoma itself, and duct ectasia in perimenopausal women. A microdochectomy establishes the diagnosis in all three.