Clinical forms of Breast Cancer
The most common manifestation of breast cancer is the appearance of breast tumors which untreated lead to local and long distance complications. Beside these cases there are other unusual clinical forms which pose a great difficulty for diagnosis.
1. Impalpable breast cancer. The tumor is very small, unable to be discovered just through a clinical examination. American authors have called it minimal breast cancer. It is usually discovered through mammography either in a screening program or incidentally. An early diagnosis allows for a conservatory treatment and ensures a high percentage of healing. In order to locate the tumor special techniques are required. It can be performed under ultrasound guidance or by simple or stereotaxic mammography. Thus, you can enter in the proximity of the lesion dye, which does not diffuse, or a radioactive isotope or needle with a metal guiding wire. The method using radioactive isotope is more difficult and requires special equipment.
2. Paget’s disease of the breast. It is a rare form of breast cancer, about 2-3% of breast carcinomas. It occurs more frequently in women over 40 years and the progress is slow. It is characterized by itching, erythema and then nipple ulceration. The ulceration will regularly cover itself with scales, giving the false impression of a cure. It originates in the epithelial cells of the high caliber ducts and is characterized by the presence of Paget cells which are large with pale cytoplasm and coarse chromatin arranged in thick piles.
The histiogenesis of this type of cancer has aroused controversy leading to two hypotheses. The first one claims that the disease would originate in the epidermal cells and that the Paget cells are likely to arise from a degenerative process leading to the installation of epidermal cancer. This hypothesis is currently abandoned in favor of the theory that the tumorgenesis is located in the galactophorous channels, the disease spreading through the invasion of the skin. The arguments are immunohistochemistry related.
This type of cancer is considered by some authors as a skin disease (especially by dermatologists) while most oncologists consider it a cancer of the ducts. It may present under three clinical forms:
- the lesion is limited to the nipple and areola without the breast tumor
- breast tumor without nipple damage, the diagnosis is reached only after histopathological examination of the tumor
- nipple and areola lesion associated with breast tumors
Sometimes bloody nipple discharge may occur. Axillary node invasion is relatively common. It is easily confused with dermatitis which delays correct treatment.
3. Hidden breast cancer with axillary onset is a rare form, less than 1% of all breast cancers. It is characterized by the absence of the breast tumor and frequent involvement of axillary lymph nodes. The diagnosis is often difficult, because axillary lymph node metastasis can have as a starting point another cancer than breast cancer.
4. Medullary cancer and coloid cancer have the characteristics of a benign tumor, which can lead to errors in diagnosis.
5. Multicentric cancer is characterized by multiple locations disseminated throughout the mammary gland. In the presence of mammary tumors it is mandatory to have a carefully clinical and paraclinical examination of the entire mammary gland and its extensions. Tumors are of variable sizes and the evolution is usually serious.
6. Rapid progressive cancer. It is characterized by rapid tumor growth. It is an aggressive cancer and has no initial indication of surgery. Diagnosis is based on patient history.
7. Inflammatory breast cancer. It is the most serious form of breast cancer characterized by inflammatory phenomena which may be first limited, but then cover the breast completely. There is no palpable tumor but an increase in breast consistency. It leads to very early nodal and systemic metastases. The diagnosis of certainty is established by fine needle biopsy in the most dense area of the breast, and if the cytological examination is not conclusive then biopsy and removal of the axillary nodes is recommended. If neither method is conclusive then skin incisional biopsy is practiced.
8. Complex sclerosing lesion. It occurs more commonly in old age. It is characterized by a slow and progressive evolution which causes skin retraction around the lesion, leading to global breast retraction.
9. Breast cancer associated with pregnancy. Although it was argued that this form of cancer is very rare, there are an important number of cases. It can appear even in very young in women, between 23 and 25 years old. Diagnosis is generally easy to establish, yet 10-year survival is only 33%, and recurrences and bilateral lesions are more frequent.
10. Bilateral breast cancer represents 7% of all breast cancers. It can appear either simultaneously in both breasts, when it is discovered less than a year after the first cancer diagnosis, or successively. If both are stage I cancers, the prognosis is not worse because it is bilateral. However, if one cancer is more advanced than stage I, the prognosis is worse than for unilateral cancer of the same stage. Staging is done separately for each breast.
11. Armor-like cancer. It manifests by skin thickening and breast tenderness that give the appearance of an armor with purplish red disseminated spots. Through extension it can reach the axilary region, the controlateral region and the supraclaviculary region.
12. Teleangiectatic carcinoma. It is characterized by malignant proliferation of vascular nodes which consist of dilated vessels filled with cancer cells, located in the superficial epidermis. The vessels are both lymphatic and blood vessels. These nodules are purple and by merging a reddish endured area appears that can include the entire breast eventually.
13. Breast cancer in men. It is much rarer than in women and represents less than 1% of all cancers in men. Its incidence is slowly increasing, and according to studies from IOB “Prof. Dr. Alex. Trestioreanu” the prognosis is not worse than in women provided they are treated correctly. The etiology involves hormonal disorders, chromosomal instability syndrome, Klinefelter syndrome, and local trauma and exposure to ionizing and ultraviolet radiation.