frequency is the time of the menopause and the succeeding years while the breast is undergoing atrophic changes. Sarcoma, forming about three and a half per cent of all malignant tumors of the breast, is found in women who are in the neighborhood of 40 years of age. Bloodgood puts the age at 40 to 50, but says that sarcoma occurs as a complication in intracanalicular myxoma, which commonly is found in younger women. This may account for Gross' earlier statistics. In 35 of his cases of 'cystic sarcoma' the average age was 33.7 years, and in 60 cases of 'solid sarcoma,' only 13 were in women over 40 years of age. Even at the present time the differentiation of sarcoma from medullary carcinoma is often a difficult problem for the pathologist, and a second examination of the specimen not infrequently brings a change in the diagnosis. To summarize, if the patient is under twenty-five the presumption is that a given tumor of the breast is benign; if over twenty-five it is either benign or malignant, with the probability of the latter increasing as the age of the patient becomes more advanced.
Duration of the Tumor. — A tumor which has been present a year or more and yet manifests no evidences of malignancy (see page 546) is generally benign; still, a scirrhous cancer may exist for as long as five years without involving the surrounding tissues to an appreciable extent.
Situation of the Tumor. — Cancer is more frequently found in the upper and axillary side of the breast, although it may be found in any portion; next in point of frequency is the region of the areola. Malignant tumors in this situation are apt to pull on the nipple and cause retraction more often than in the case of growths situated in the outer portions of the gland. Benign tumors are more frequently found in the sternal half of the breast, and are very rare in the areola.
Mastitis, with the exception of the tuberculous form, occurs chiefly in the outer, axillary side. 552 DISEASES OF THE BREAST Cancer generally involves one breast only, but has been found in both breasts in about five per cent of all malignant tumors. If a benign tumor has been removed from one breast, another tumor occurring in the opposite breast would probably be benign also. As a rule, multiple tumors are benign.
Mobility of the Tumor. — Inspection and Palpation. — If a tumor is freely movable and not adherent to the skin it is not cancerous. If, on the other hand, it is fixed either to the muscle below or, more important, to the skin, causing dimpling, — and when situated in the region of the areola, retraction of the nipple, — the growth is almost certainly cancer. To determine the connection of the tumor with the skin, expose both breasts fully, place the palm of each hand flat on the center of each breast, and move the breasts alike to and fro in every direction until asymmetry is produced in the diseased one by the adhesion of the tumor to the skin. This procedure is especially valuable in deep-seated growths in large and fatty breasts.
In palpating the breast a malignant growth, if it has reached the surface, is hard and of irregular outline; if situated deeply its connection with surrounding tissues limiting its mobility or causing asymmetry must be the determining diagnostic features. If the nipple is retracted it should be seized firmly and pulled out, comparing it with the nipple of the opposite breast. The physician should bear in mind that many women have ill-formed and retracted nipples from birth. Should both nipples show deformity the patient should be questioned as to their usual shape.
Atrophy of the subcutaneous fat, even if the tumor is not actually connected with the skin, is a strong indication of cancer. To determine any union between the tumor and the subcutaneous areolar tissue or the reticular layer of the corium some surgeons pick up the skin over the tumor and thus demonstrate a shortening of the fibrous trabecule of the subcutaneous tissue or corium, comparing this finding with the condition of the skin elsewhere in the breast; others use the test of moving both breasts about as just described. Another method is to grasp one breast with both hands, whereupon the skin intervening between the hands will show dimpling if cancer is present and a smooth bulging surface if a benign tumor is present.
In practising inspection and palpation the physician makes a DIAGNOSIS OF TUMORS IN GENERAL 553 mistake if, to save the patient's feelings, he does not expose thoroughly both breasts, the chest being in a good light. The slightest amount of asymmetry should lead to a thorough investigation as described above.
Retraction of the nipple, as has been pointed out, is a sign of cancer in the early stages of malignant disease situated in the neighborhood of the areola. Enlarged glands in the axilla, formerly thought to be an important diagnostic sign of cancer, are now found to be fairly constant signs of benign tumors and inflammations of the breast. Pain in the breast is a common symptom of the last two lesions also, and appears in cancer only in the inoperable, late stages.
Pain, unassociated with tumor, occurs also in neuralgia of the breast (mastodynia), a rare condition except where associated with menstruation or the menopause. In the latter event, it may be due to senile parenchymatous hypertrophy. Pain in the region of the breast may be due to rheumatism of the pectoral muscle. In this case it should be called forth by abducting the arms on the chest.
Late Signs of Cancer. — Late signs of cancer interest us only in so far as they indicate whether or no the disease has passed a stage where operation may be attempted with hope of a favorable result. They are: pain, a discharge of blood from the nipple, ulceration,- skin metastases, metastases in other organs, enlarged supraclavicular glands, and cachexia.
Discharge from the Nipple. — Besides being found in late cancer, a discharge from the nipple is present in the following conditions: — during pregnancy and lactation, in the infantile breast, in senile parenchymatous hypertrophy, and in papillomatous cysts. In the last case it is apt to be bloody.
Ulceration of the Skin over the Cancerous Growth. — This is a very grave sign and few, if any, patients presenting ulceration have been cured by operation. Skin Metastases. — Occasionally two or more shot-like bodies are found in the skin of the breast at a distance from the malignant tumor. These are metastases from the tumor and are of serious import, for no case of permanent cure where skin metastases were present has been reported.
Metastases in other Organs. — These are always an indication of the 554 DISEASES OF THE BREAST hopelessness of radical operation. M. H. Richardson has recently called attention (Jour. Amer. Med. Assn., May 15, 1909, Vol. LIL, p. 1556) to the importance of making a complete physical examination in the case of mammary cancer, saying that he has twice opened the abdomen for abdominal tumors of doubtful diagnosis without examining the breasts; and in both cases there were extensive cancerous infiltrations, which were metastatic from the breasts. He says also that any persistent cerebral or spinal symptoms in cancer of the breast should lead to an examination of the nervous system for metastases in the cerebro-spinal axis, of which he has now seen many cases; and a persistent cough should call for an examination of the lungs to find metastases there.
Enlarged Supraclavicular Glands. — Palpable enlarged glands above the clavicle are of grave significance, the most favorable statistics showing only 7.5 per cent of cures following operation where the sign had been present. In the opinion of many operators, the presence of these enlarged glands places the patient in the list of the hopeless.
Cachexia. — When the disease has reached the point where the patient's health has failed and anemia, constipation, anorexia, loss of strength, a yellow color of the skin, and other symptoms of derangement of bodily function are present, there will be found also metastases, lack of mobility of the tumor, — because of the involvement of surrounding structures, — and ulceration, and the prognosis is absolutely bad. In all cases of clinically doubtful diagnosis, it is not wise to make an exploratory incision into the tumor with the knife, or the hollow Mixter punch, because of the very great danger of autoinfection. If a tumor is of doubtful diagnosis it should be removed, the pathologist in attendance at the operation deciding, by means of sections of the tumor, the need of radical extirpation of surrounding structures.
<Callout type="warning" title="Warning: Nipple Retraction">Retraction of the nipple is a sign of cancer in the early stages.</Callout>
<Callout type="important" title="Important: Comprehensive Exam">Always perform a complete physical examination, including breast checks, to avoid missing metastatic signs.</Callout>
<Callout type="risk" title="Risk: Autoinfection">Avoid making exploratory incisions without proper diagnosis; it can lead to autoinfection and worsen the condition.</Callout>
Key Takeaways
- Age is a significant factor in diagnosing breast tumors.
- Nipple retraction can indicate early-stage cancer.
- Comprehensive physical examinations are crucial for detecting metastatic signs.
Practical Tips
- Perform regular self-examinations of your breasts to detect any changes or lumps early.
- If you notice any nipple retraction, consult a healthcare professional immediately.
- Always seek a complete medical examination if you suspect breast cancer.
Warnings & Risks
- Avoid making exploratory incisions without proper diagnosis; it can lead to autoinfection and worsen the condition.
- Nipple retraction is often an early sign of cancer, so do not ignore this symptom.
- Persistent symptoms such as pain or discharge should be evaluated by a medical professional.
Modern Application
While the techniques described in this chapter are historical, the importance of regular breast self-examinations and comprehensive physical examinations remains critical. Modern tools like mammograms can enhance early detection, but understanding these traditional methods provides valuable context for recognizing potential issues.
Frequently Asked Questions
Q: What is a key sign that might indicate cancer in the early stages?
Retraction of the nipple is a significant early sign of cancer and should be evaluated by a healthcare professional.
Q: Why is it important to perform comprehensive physical examinations for breast cancer diagnosis?
Comprehensive exams can help detect metastatic signs that might not be apparent through self-examinations alone, ensuring a more thorough assessment of the patient's condition.
Q: What should you do if you notice any discharge from your nipples?
Any nipple discharge, especially bloody or non-lactational, should be evaluated by a healthcare professional to rule out potential issues like cancer or other conditions.