Approximately one in nine women can be expected to develop breast cancer in their lifetime. Only 1 per cent of cases involve men. Survival rates have improved greatly in the past 30 years, largely due to improved early detection of the disease. Further work has shown that regular examination of the breasts increases the chances of detecting breast cancer at an early stage. It is important to teach patients self-examination and alert them to signs that should be investigated and taken seriously, as in this woman showing distortion of the breast near the nipple.
Inversion of the nipple
When checking the breasts it is always important to look for recent changes in the appearance of the nipple. Nipple inversion is not uncommon and may be a congenital problem in which shortened ducts restrict the nipple as the breast enlarges. It may also follow inflammatory problems that result in scarring and shortening of the ducts. Concern arises when the change is recent and it is not possible to evert the nipple, as this may be associated with an underlying malignancy. Sometimes an actual lump can be palpated below the nipple.
Paget's disease of the nipple with ulceration
In some cases there may be ulceration and/or a blood-stained discharge from the nipple. A palpable lump under the nipple may be felt. In 50 per cent of these there will also be axillary metastases. The patient will then have a poorer prognosis. Confirmation of the diagnosis involves cytology of a scrape from the nipple and a mammogram.
Inflammatory breast cancer
Inflammatory breast cancer may also present with symptoms suggesting an inflammatory mastitis. Malignancy may be a more likely cause in older, non-lactating women who are afebrile, with a more gradual onset. This 68-year-old woman gave a three-week history of inflammation. She was afebrile, the area was warm and indurated and there was an enlarged gland in the left axilla. Infective mastitis nearly always occurs in lactating women who are breastfeeding and cracked nipples can develop. Infection is associated with sudden onset of pain and inflammation of the breast in a patient who is unwell and febrile.
Breast cancer is most commonly suspected when a woman has felt a lump in the breast. If the lump is tethered to the skin, the overlying skin may be dimpled or puckered and the shape of the breast may be distorted. Pain is rarely a feature. Not every breast lump is malignant and in many cases cysts or fibroadenoma may be found to be the cause. Further investigation with needle aspiration, ultrasound, mammography and/or biopsy may be necessary to exclude breast cancer.
Paget's disease of the nipple
Paget's disease of the nipple is always associated with an underlying intraduct carcinoma. Unlike eczema of the nipple, one nipple only is affected. The patient complains of scaling, itching and erythema of the nipple and surrounding areola. In time the nipple is actually destroyed. In patients with eczema of the nipple there is often a personal or family history of eczema and an allergic response to an allergen may be suspected. Blistering, weepy changes to the nipple may present in acute cases.
Inflammatory breast cancer occurs when there has been invasion of the lymphatics or small vessels of the skin by malignant cells. This will lead to the effect known as peau d'orange, in which the skin takes on the appearance of orange peel. This is usually a late sign of breast cancer associated with oedematous skin around pitted hair follicles and carrying a poorer prognosis. Peau d'orange is not only associated with breast cancer but may occur with erysipelas.
Localised spread of breast cancer may result in secondary deposits in the breast or chest wall. This woman had undergone a mastectomy 14 years earlier when she presented with these ulcerating nodules. Spread of the disease may lead to secondary deposits that most frequently occur in bones, liver, lungs or the brain.