Chapter 1: Screening, diagnosis & staging of breast cancer and multidisciplinary team working
Chapter Authors:
H. Joensuu, Comprehensive Cancer Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
T. Meretoja, Comprehensive Cancer Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
Common symptoms and signs
Over 90% of breast cancers (BCs) are local or regional when first detected. At least 60% of patients present with a breast lump, which may or may not be painful, fixed or demarcated from the surrounding tissue.
Figure 1.1 Physical changes to the breast that may be cancer-related.
Credit: Dr Mazen Sudah, Department of Radiology, Kuopio University Hospital, Dr Katja Hukkinen, Department of Radiology, Helsinki University Hospital and Dr Päivi Heikkilä, Department of Pathology, Helsinki University Hospital.
BC may cause skin or nipple retraction, discharge from the nipple, and changes in breast size or shape. Skin rash, ulceration, erythema and eczema of the nipple–areola complex may also occur.
A lump in the axilla or the supraclavicular fossa may indicate regional lymph node (LN) metastases. Skeletal or abdominal pain, cough, breathlessness or neurological signs or symptoms may suggest metastatic cancer.
Figure 1.2: Inflammatory cancer in the left breast.
Credit: Dr Mazen Sudah, Department of Radiology, Kuopio University Hospital, Dr Katja Hukkinen, Department of Radiology, Helsinki University Hospital and Dr Päivi Heikkilä, Department of Pathology, Helsinki University Hospital.
Inflammatory carcinoma is characterised by erythema and oedema of the breast. It usually encompasses the entire breast or at least one third of the skin. The breast skin may resemble ‘orange peel’. A large diffuse mass is often present in the breast.
It is usually caused by poorly differentiated ductal cancer. Cancer cells obstruct the dermal lymphatic vessels and cause the skin oedema. A skin punch biopsy can provide the diagnosis, as tumour emboli are found in the dermal lymphatic vessels, but a negative skin biopsy does not exclude the diagnosis.
Breast infection-related skin redness and oedema is often associated with fever and tenderness, which is not typical of inflammatory BC.
Figure 1.3: Paget disease.
Credit: Dr Mazen Sudah, Department of Radiology, Kuopio University Hospital, Dr Katja Hukkinen, Department of Radiology, Helsinki University Hospital and Dr Päivi Heikkilä, Department of Pathology, Helsinki University Hospital.
Paget disease is an eczema-like in situ cancer that involves the areola, the nipple or both.
Paget disease is associated with invasive or in situ cancer in approximately 90% of affected individuals. On the other hand, fewer than 5% of BCs are associated with Paget disease.
A skin biopsy and breast imaging (mammography and breast ultrasound [US] examination) should always be performed when a patient has persistent eczema in the nipple or the areola.
Revision questions
- What proportion of BCs are local or locoregional at the time of diagnosis?
- What are the typical signs and symptoms of BC?
- What is the pathophysiology behind the typical symptoms and signs of inflammatory BC?
