The symptoms of breast cancer can be various, the common ones are: breast lumps, breast pain, nipple overflow, erosion or skin indentation, and enlarged axillary lymph nodes. Although these symptoms may not be specific, understanding these symptoms and recognizing these manifestations will help us in early detection, early diagnosis and early treatment of breast cancer. Of course, the appearance of certain symptoms indicates that the lesion is not at an early stage, so a comprehensive and deeper understanding and mastery of these symptoms can help us not only not to be distressed by missing the time for treatment, but also not to worry too much and affect our normal life.
I. Breast lump
Breast lump is the most common symptom of breast cancer, about 90% of patients come to the clinic with this symptom. With the popularization of tumor knowledge and cancer screening, this percentage may increase. If a lump appears in the breast, the following aspects should be understood.
1. Location: With the nipple as the center and a cross, the breast can be divided into five zones: upper inner, upper outer, lower inner, lower outer and central (areola). Breast cancer is mostly found in the upper part of the breast, followed by the upper part of the breast. Lower internal and lower external areas are less common.
2.Number: Breast cancer is most common in unilateral breast with a single lump, unilateral multiple lumps and primary bilateral breast cancer are not common in clinical practice. However, with the improvement of tumor prevention and treatment, patients’ survival period will be prolonged, and the chance of second primary cancer in the opposite breast will increase after surgery of one side of breast cancer.
3.Size: The lump of early breast cancer is usually small and sometimes it is not easy to distinguish from lobular hyperplasia or some benign lesions. However, even a small lump can sometimes involve the suspensory ligament of the breast and cause symptoms such as local skin indentation or nipple retraction, which are easier to detect at an early stage. In the past, due to poor health care, lumps were often larger when they came to the clinic. Nowadays, with the popularization of breast self-examination and screening, there is an increase of early breast cancer in clinical practice.
4.Morphology and boundary: Most of the breast cancers are infiltrative in growth and the boundary is not clear. Some of them may be flattened, with an unsmooth surface and nodular feeling. However, it should be noted that the smaller the lump is, the less obvious the above mentioned symptoms are. Moreover, a few special types of breast cancer can be less infiltrated and have a swollen growth, showing smooth, active and clear borders, which are not easily distinguished from benign tumors.
5.Hardness: breast cancer lumps are hard in texture, but cell-rich medullary carcinoma can be slightly soft, and individual can be cystic, such as cystic papillary carcinoma. A few lumps are surrounded by more fatty tissues and have a tender feeling when palpated.
6.Mobility: When the mass is small, the mobility is larger, but this activity is together with the surrounding tissues, which is different from the mobility of fibroadenoma. If the tumor invades the fascia of the pectoralis major muscle, the activity will be reduced; if the tumor involves the pectoralis major muscle, the activity will disappear. If the tumor involves the pectoralis major muscle, the activity will be lost. If the patient is asked to cross her arms and raise her chest, the pectoralis muscle will be contracted. In advanced stage, breast cancer may invade the chest wall, then it is completely fixed, the lymph nodes around the tumor are invaded, the skin edema can be orange peel-like, which is called “orange peel sign”, and the nodes under the skin around the tumor are called “satellite nodes”.
Among benign breast tumors, breast lumps are not uncommon, and the most common one is breast fibroadenoma.
The disease is more common in young women and has a low incidence over the age of 40. The tumor is often solid, tough, with an intact envelope, smooth surface, and a sliding sensation to the touch, usually without skin adhesions, and does not cause nipple retraction. In intraductal papilloma, the mass is often small and not easily palpable. In slightly larger cases, small nodules can be found around the areola, with nipple discharge as the main clinical symptom. Lobular hyperplasia rarely forms a clear lump, but is mainly a thickening of the local breast tissue, with a tough texture and no sense of envelope, often with swelling and pain before menstruation.
Some of them only show localized glandular thickening and no obvious lumps without clear borders, and most of them are diagnosed as “mammary gland hyperplasia”. However, careful examination of the thickened area should be noted when it is limited and accompanied by a small amount of skin adhesions, and breast radiographs can be taken.
Breast pain
Although breast pain can be seen in many breast diseases, pain is not a common symptom of breast tumor, no matter benign or malignant breast tumor is usually painless. In early stage of breast cancer, there are occasional cases where pain is the only symptom, which may be dull pain or pulling sensation, especially when lying on the side. Some studies have shown that postmenopausal women with breast pain and glandular thickening will have a higher detection rate of breast cancer. Of course, if the tumor is accompanied by inflammation, there may be swelling pain or pressure pain. In advanced stage, if the tumor invades the nerve or the axillary lymph node enlarges and compresses or invades the brachial plexus nerve, there may be swelling and pain in the shoulder.
Nipple overflow
There are physiological and pathological nipple overflow. Physiological nipple overflow is mainly seen in women during pregnancy and lactation. Pathological nipple overflow refers to the secretion of milk ducts in a non-physiological state. The latter is commonly referred to. Nipple overflow can be caused by a variety of breast diseases and is also easier for patients to notice. It is one of the main reasons why about 10% of patients come to the clinic, and its incidence is second only to breast lumps and breast pain among the symptoms of various breast diseases.
1. Nipple discharge can be classified according to its physical properties: bloody, serous, plasma, watery, purulent, and milk-like. Among them, plasma, watery and lactic-like overflows are more common, and bloody overflows account for only 10% of overflows. When the lesion is located in the large duct, the overflow is mostly bloody; when it is located in the smaller duct, it can be light blood or plasma; if the blood stays in the duct for too long, it can be dark brown; when there is inflammation combined with infection in the duct, it can be mixed with pus, liquefied necrotic tissue can be watery, lactic or brown liquid; the fluid of ductal dilatation is often plasma. Most hemorrhagic overflows are caused by benign lesions, but a few breast cancers can also be hemorrhagic. Physiological nipple overflow is mostly bilateral, and the overflow is often lactic or watery.
The causes of nipple overflow are mainly divided into extramammary factors and intramammary factors.
In breast cancer patients, 5% to 10% have nipple overflow, but only 1% have nipple overflow as the only symptom. The discharge is often monoductal and can be of various shapes, such as bloody, plasma, watery or colorless. It is more common for breast cancer to originate in the large ducts or to combine nipple discharge with intraductal carcinoma, such as malignant intraductal papilloma and eczema-like carcinoma of the nipple. It is worth noting that although most people believe that breast cancer is rarely associated with nipple discharge, and even if it does occur, it is almost always followed or accompanied by a lump, and those without a lump are seldom considered to be cancerous. However, recent studies have shown that nipple discharge is an early clinical manifestation of some breast cancers, especially intraductal carcinomas, and can be present alone before the formation of a significant lump.
Intraductal papilloma is a disease that occurs more often in nipple discharge, accounting for the first of all nipple discharge lesions, among which intraductal papilloma in the areola area is the most common, either solitary or multiple, with an age distribution ranging from 18 to 80 years old, but mainly common in 30-50 years old. The diameter of the tumor varies from 0.3 to 3.0 cm, with an average of 1.0 cm, and more than 3.0 cm is often malignant. The nature of the overflow is mostly bloody or plasma, but others are rare. It is generally believed that papillomas occurring in large ducts are mostly solitary and rarely carcinogenic, while those in small and medium ducts are often multiple and can be carcinogenic. The two are similar lesions, but the site of occurrence and growth process are different.
Although cystic hyperplasia is not a tumor, it is the most common benign lesion of the breast tissue, mostly seen around the age of 40 and rarely after menopause. Among them, three pathological changes, cysts, ductal epithelial hyperplasia and papillomatosis, are the basis of its overflow. The nature is mostly plasmacytic, and the combined overflow of this disease accounts for only 5%.
Four, the nipple changes
1, nipple erosion: there is a typical manifestation of breast Paget’s disease, often accompanied by itching, about 2/3 patients can be accompanied by lumps in the areola or other parts of the breast. At first, only nipple desquamation or small nipple fissures. Nipple desquamation is often accompanied by a small amount of discharge and crusting, and removal of the crust reveals a bright red vesicular surface that does not heal over time. When the entire nipple is involved, it can invade the surrounding tissues, and as the lesion progresses, the nipple can disappear as a result. Some patients may also first develop a breast lump and then a nipple lesion.
Nipple retraction: When the tumor invades the nipple or the subareolar area, the fibrous tissue and duct system of the breast may shorten and pull the nipple, making it sunken, deflected, or even completely retracted into the back of the areola. In this case, the affected nipple is often higher than the healthy side. It may appear in early breast cancer, but is sometimes a late sign, depending on where the tumor is growing. When the tumor is under or near the nipple, it can appear early; if the tumor is located in the deeper breast tissue, far from the nipple, this sign is usually advanced. Of course, nipple retraction and indentation are not all malignant lesions, but some of them can be caused by congenital dysplasia or chronic inflammation, at this time, the nipple can be pulled out by fingers and not fixed.
V. Skin changes
1, skin adhesions: the mammary gland is located between the deep and superficial fascia, the superficial layer of the superficial fascia is connected to the skin, and the deep layer is attached to the superficial surface of the pectoralis major muscle. The superficial fascia forms lobular interval in the breast tissue, i.e. breast suspensory ligament. When the tumor invades these ligaments, it can shrink and shorten them and pull the skin to form a depression, which is like a dimple, so it is called “dimple sign”. When the tumor is small, it can cause very slight skin adhesion, which is not easy to be detected. At this time, we need to lightly hold the affected breast under better lighting conditions to increase its surface tension, and when we move the breast, we can see that the skin on the surface of the tumor is slightly pulled and sunken. If you have this symptom, you should be alert to the possibility of breast cancer, but benign tumors rarely have this symptom.
2. Superficial varicose veins: When the tumor is large or growing fast, the surface skin can become thin and the superficial blood vessels and veins under it can often be varicose. It is more clear in LCD thermogram and infrared scan, and is commonly seen in giant fibroadenoma and lobulated cystic sarcoma of breast. Superficial varicose veins are also often present in tumors during acute inflammation, pregnancy, and lactation.
3. Redness of skin: In acute and chronic mastitis, the skin of breast can be red and swollen. However, in breast cancer, it is mainly seen in inflammatory breast cancer. The skin color is light red to deep red, which is limited at the beginning and soon expands to most of the breast skin, accompanied by skin edema, thickening and skin temperature increase.
4.Skin edema: Because the subcutaneous lymphatic ducts of breast are blocked by tumor cells or the central area of breast is infiltrated by tumor cells, the reflux of breast lymphatic ducts is blocked, lymphatic fluid accumulates in the lymphatic ducts, the skin thickens, the opening of hair follicle is enlarged and deepened, showing “orange peel-like changes”. In obese and sagging breasts, mild skin edema is often seen underneath the outer part of the breast.
In addition, advanced breast cancer may directly invade the skin and cause ulcers, which may smell bad if combined with bacterial infection. If the cancer cells infiltrate into the skin and grow, they may form scattered hard nodules in the skin around the main lesion, that is, “skin satellite nodules”.
Enlarged axillary lymph nodes
Breast cancer can gradually develop and invade the lymphatic vessels and metastasize to its local lymphatic drainage area. Among them, the most common site of lymphatic metastasis is the ipsilateral axillary lymph node. At first, the enlarged lymph nodes can be pushed, but eventually they fuse with each other and become fixed. If the enlarged lymph nodes invade and compress the axillary vein, it can often cause edema in the ipsilateral upper limb; if it invades the brachial plexus nerve, it can cause shoulder pain. When examining the axillary lymph nodes, the upper limb on the affected side should be relaxed as much as possible so that the top of the axilla can be palpated. If enlarged lymph nodes can be palpated, the number, size, texture, mobility and surface condition of the lymph nodes should be noted to differentiate them from inflammation and tuberculosis.
If there is no lump in the breast and the first symptom is swollen lymph nodes in the axilla, it is rare to come to the clinic. When the swollen lymph nodes in the axilla are pathologically confirmed to be metastatic cancer, in addition to examining the lymphatic drainage area, lung and gastrointestinal tumors should be excluded. If the pathology suggests metastatic adenocarcinoma, we should pay attention to the possibility of “occult breast cancer”. In this case, the breast lesion is usually not detected and mammography may be useful for diagnosis. If the lymph nodes are positive for hormone receptors, even if all tests fail to detect a breast lesion, it is still important to consider a tumor of breast origin.
Breast cancer can metastasize to the ipsilateral axillary lymph nodes and also to the contralateral axillary lymph nodes through the intercommunication between the anterior chest wall and the internal breast lymph network, with an incidence of about 5%. In addition, advanced breast cancer may also have ipsilateral supraclavicular lymph node metastasis or even contralateral supraclavicular lymph node metastasis.
The above is just a brief description of the basic symptoms of breast cancer, especially breast cancer. As long as women can have a strong awareness of cancer prevention, understand and master these knowledge comprehensively, and do self-examination carefully, with the improvement of medical care, I believe cancer is never an incurable disease.