Clinical Features and Investigation of Breast Cancer

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1 Clinical Features and Investigation of Breast Cancer Professor Clement A. Adebamowo BM ChB Hons., FWACS, FACS, D.Sc. Division of Oncology, Department of Surgery, College of Medicine, University of Ibadan, University College Hospital, Ibadan, Oyo State, Nigeria

2 This lecture is available at You will also find resources on cancer care, ethics and other interesting activities at the site

3 Clinical presentation Painless breast lump this is the paradigm of breast cancer where there is no population based screening. The tumor increases in size until the whole breast is involved or there is early involvement of the overlying skin. Lump may be painful in about of quarter of patients Involvement of overlying skin leads to skin dimpling and tethering. Peau d orange occurs as a result of obstruction of skin lymphatics. Tumor may ulcerate through the skin and show features of malignant ulcers raised ulcer with everted edges, foul-swelling, purulent and bloody discharge. Multiple skin nodules may occur leading to thickening and roughness of skin cancer en cuirais Skin may look reddish and be warm in inflammatory breast cancer

4 Clinical presentation Nipple retraction, elevation and distortion Nipple ulceration (Paget s disease) may be associated with an underlying breast lump Bloody nipple discharge which may also be associated with a lump Axillary nodal involvement may present with swelling, ulcer and pain. Obstruction of lymphatics may lead to swelling of the upper limb Features of metastasis Pulmonary cough, chest pain, respiratory distress Bones pain, pathological fractures Spinal cord compression paraplegia and paralysis Liver anorexia, abdominal swelling and pain

5 Typical presentation in Africa, young to middle aged woman with advanced breast cancer. Note size of tumor, complete replacement of breast tissue, nipple retraction and deviation, edema and ulceration of overlying skin. Note further the abdominal swelling which was due to liver metastases and ascites in this patient

6 Young pregnant woman with breast cancer. Common problem as incompetent doctors attempt treatment. Breast is incompletely resected and tumor has recurred in the residual breast tissue. No further treatment nor counseling given so patient became pregnant soon after surgery

7 Old woman with prominent axillary involvement as well as right breast swelling. There is increase in size of the areola and edema of the nipple areola complex

8 Paget s disease: Ulcerated nipple in a middle aged woman

9 Breast lump. Note the breast lump with inverted, elevated nipple. Note also the prominent blood vessels suggesting neo-angiogenesis

10 Breast cancer presenting with unilateral enlargement of the nipple in a middle aged woman

11 Clinical examination Clinical examination of the patient with breast complaints needs to be systematic Adequate description of the steps are available in standard textbooks of clinical signs and symptoms Breast examination prosthesis are available for practicing breast examination However, nothing can replace learning from clinicians with expertise in breast examination and frequent clinical practice

12 Diagnosis Biopsy Excisional biopsy if lump is small Otherwise incisional biopsy Core needle biopsy FNAC Histological diagnosis Routine H/E ER/PR and HER2/neu Molecular subtyping luminal, triple negative, etc If patient has advanced disease then investigate common sites of metastasis Chest X-ray, Abdominal ultrasound, X-ray of the spine, Nuclear bone scan

13 Pathology Carcinoma, NOS (not otherwise specified) Ductal Intraductal (in situ) Invasive with predominant intraductal component Invasive, NOS (not otherwise specified) Comedo Inflammatory Medullary with lymphocytic infiltrate Mucinous (colloid) Papillary Scirrhous Tubular Other

14 Pathology Lobular In situ Invasive with predominant in situ component Invasive Nipple Paget's disease, NOS (not otherwise specified) Paget's disease with intraductal carcinoma Paget's disease with invasive ductal carcinoma Other Undifferentiated carcinoma

15 DCIS with invasive ductal carcinoma: The arrow heads outline a focus of intraductal carcinoma. This DCIS has a smooth outer contour, and the extracellular matrix has a normal concentric arrangement around this duct. The fibroblasts around this duct (thin arrows) are thin, arranged in the normal parallel orientation to the duct, and they appear inactive since they do not have much euchromatin or nucleoli. In contrast, the other ductal cells are all "invasive" and show a ragged contour without an organized concentric wrap of extracellular matrix around them. The fibroblasts near the invasive ductal cells appear highly active (thick arrows) with open chromatin and nucleoli. The products of the active fibroblasts include bubbly bluish mucopolysaccharides and young finely fibrillar collagen.

16 Microscopy invasive breast cancer

17 ER (a), PR (b) and Her2/neu (c) positive breast cancer (a) (b) (c)

18 Differential diagnosis Benign breast diseases Fibroadenoma usually occurs in younger patients, but note that breast cancer patients in Africa are also young Fibrocystic change in the breast which may present with lumps, cysts, irregularity, thickening, nipple changes and bloody discharge Phylloides tumor Infections Acute bacterial mastitis and breast abscess may be mistaken for inflammatory breast cancer. Usually associated with lactation Antibioma Chronic specific and non-specific mastitis, including tuberculosis Chronic subareolar infections associated with duct ectasia

19 Differential diagnosis Nipple discharge Physiological Drug induced - estrogens, tranquilizers Galactorrhea Intraductal papilloma Duct ectasia Breast pain Mastalgia Cyclical or non-cyclical Fat necrosis Tietze s disease Mondor s disease

20 AJCC Cancer Staging Manual, Sixth Edition Breast

21 AJCC Cancer Staging Manual, Sixth Edition Breast

22 AJCC Cancer Staging Manual, Sixth Edition Breast

23 AJCC Cancer Staging Manual, Sixth Edition Breast

24 AJCC Cancer Staging Manual, Sixth Edition Breast

25 AJCC Cancer Staging Manual, Sixth Edition Breast

26 AJCC Staging method

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