Clinical features

The majority of women present with a breast lump, which is confirmed on examination. In two-thirds of patients it is in the upper outer quadrant of the breast and characteristically is well defined, hard and with an irregular surface. The lump may be fixed to the skin or to the underlying chest wall and retraction or dimpling of the skin may be seen. The skin of the breast must be carefully examined for the presence of erythema which may indicate an inflammatory cancer (see

Table 17.7. Staging of breast cancer UICC staging.

Stage Corresponding TNM

Figure 17.27. Locally advanced carcinoma of the breast with associated skin ulceration.

above). Locally advanced cancers are characterised by oedema, skin infiltration, satellite skin nodules, ulceration, fixity to the chest wall and/or large fixed axillary nodes (N2) (Fig. 17.27). Some patients may also have oedema of the ipsi-lateral arm. However, not all cancers have these features and occasionally some may be difficult to differentiate clinically from benign tumours such as fibroadenomas. Other breast cancers may present as a diffuse nodularity, with no localised lump being found, and up to 10% of patients with breast cancer may present with pain as the predominant complaint.

The nipple should also be carefully examined for the presence of distortion or inversion. A nipple discharge may be present. This often contains blood and emanates from one duct. However, a variety of other nipple discharges (clear, coloured) may be present (see section on Nipple discharge). The presence of a scaly, erythematous nipple should raise the suspicion of Paget's disease of the nipple (see later).

Less commonly, patients may present with features of regional tumour spread (e.g. involved and enlarged axillary lymph nodes). Alternatively, metastatic disease in distant sites may be responsible for symptoms; for example, breathlessness (intra-thoracic metastases), bone pain and pathological fractures, jaundice and abdominal pain (liver metastases), ascites (intra-abdominal metastases), neurological symptoms (intracerebral metastases), difficulty in walking (spinal cord compression), etc.

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