Symptoms of more advanced disease
Symptoms of more advanced disease
Axillary symptoms
Back / Bone pain
Chest wall pain
Dyspnoea
Fracture
Loco-regional recurrence
Lymphoedema/Swelling of arm
Metastatic disease
Skin changes
Axillary symptoms
The presence or absence of involved axillary lymph nodes is the single best predictor of survival of breast cancer.
Both the number of nodes involved and the level of involvement predict survival.
Consequently, the examination of the axilla is very important, however, the sensitivity of the examination is in the order of 50%.
Following examination of both breasts, the axillae should be carefully assessed. Axillary node involvement occurs in up to 50% of symptomatic breast cancers and small screen detected breast cancers (<1cm) have a substantially lower incidence of metastases to nodes.
Axillary surgery can be used to stage the axilla or to treat axillary disease or both. Radiotherapy may be given to the axilla where positive nodes have been removed by an axillary sampling procedure. Routine radiotherapy following axillary clearance can lead to unacceptable rates of lymphoedema.
Back / Bone pain
Back pain in a woman with a previous diagnosis of breast cancer, is a significant symptom.
Spinal secondary tumours must be excluded as a cause of back pain before any other condition is diagnosed.
Patients should be referred for investigation, which usually includes plain X-rays and bone scintigraphy. Magnetic Resonance Imaging (MRI) is used to evaluate the possibility of cord compression.
Bone pain is often associated with bony metastases. Breast cancer metastasises to the bony skeleton, representing secondary spread of disease.
Bone disease often responds well to hormonal treatment, but in younger patients cytotoxic therapy may be necessary. Localised bone pain often responds to a single dose of radiotherapy.
In more extensive spread or recurrence in previously irradiated areas, NSAIDs are helpful and may give total relief from pain on their own or in combination with opiate or non-opitate analgesics.
Bisphosphonates have also been found to be helpful on occasions. This treatment should be initiated in the Breast Unit.
Chest wall pain
Pain arising from the chest wall and outside the breast can be a cause of non-cyclical breast pain.
The condition is usually found in older women and may be associated with heavy physical activity.
In younger patients, costochondritis or Tietze's syndrome, is a common cause of chest wall pain.
A careful history and examination is required in order to establish a clear diagnosis. NSAIDs or simple analgesics are very effective.
Dyspnoea
Dyspnoea (difficulty breathing) is a significant symptom in women with a previous diagnosis of breast cancer.
Causes to be considered are chest infection, pleural and pericardial effusion, lymphangitis carcinomatosis, metastases to the lungs and mediastinal compression caused by lymphadenopathy.
Investigation of a patient with dyspnoea would include a chest X-ray and Computed Tomography (CT) scan.
Chest Xray
- effusion
- lymphangitis
- pulmonary/pleural metastases
CT Scan
- effusion
- lymphangitis
- pulmonary/pleural metastases
- pericardial effusion
Aspiration of a pleural effusion will achieve some symptomatic relief and provides fluid for cytological examination. More definitive measures to palliate pleural effusion includes surgical pleurodesis, pleuro- peritoneal shunting or systemic anti-cancer therapy.
Fracture
Pathological fractures may cause sudden localised pain and often require internal fixation.
Pathological fractures occur as a consequence of metastases weakening the bone.
Clinically, pathological fractures are typically characterised by sudden, severe, local pain.
Sites which may be involved are the vertebrae, long bones and ribs.
Treatment is usually by splint and immobilisation, internal fixation of long bones, if the condition of the patient will allow, and/or analgesics.
NSAIDs are often very helpful in controlling pain. Radiotherapy can also give relief from pain.
Loco-regional recurrence
Loco-regional recurrence is the recrudescence of disease at or near to the site of the primary breast cancer.
This can be in the surgical scar, adjacent breast tissue, chest wall or regional lymph nodes.
Recurrence may present as a discrete mass or skin lesions with or without ulceration.
One of the fundamental aims of primary treatment is to limit local recurrence. This is achieved by complete resection with clear margins at the site of breast conserving surgery or by mastectomy and with radiotherapy.
Treatment of loco-regional recurrence will be by a combination of radiotherapy and surgery and, where appropriate, systemic therapy to minimise the development of metastases.
Lymphoedema / swelling of arm
Swelling of the arm, due to blockage of the lymphatic or venous systems, is a complication of surgery of breast cancer, radiotherapy or a combination of both surgery and radiotherapy to the axilla.
The highest incidence occurs when both treatments are given. Lymphoedema may also be a clinical indication of loco-regional recurrence.
Referral to the lymphoedema service within the Breast Unit or the local Hospice can be beneficial. If cellulitis develops in conjunction with lymphoedema, it can be very difficult to treat.
There is no curative treatment for lymphoedema but often elastic support hosiery, or compression bandaging, elevation and massage can give good relief and in many cases control the lymphoedema. The patient should be encouraged to maintain normal use of their arm.
Metastatic disease
Overt metastases are rarely present at primary presentation, however the general consensus is that micro-metastases, not detectable by present techniques may be present in a significant proportion of patients.
Where metastases are present local treatment can only totally control the disease in particular circumstances, eg. isolated bone metastasis.
In general, disease control will require additional systemic treatment with chemotherapeutic or hormonal agents or a combination of treatments.
At this stage of breast cancer systemic treatment must be regarded as primarily palliative but there are encouraging signs from recently conducted clinical trials with newer endocrine and chemotherapeutic agents, of prolongation in survival in patients with metastatic disease.
Metastases occur in soft tissue (including lymph nodes) bone and viscera (lung, liver, CNS). The prognosis for patients with metastases present is better for soft tissue or bony metastases and worse for those with visceral or CNS involvement. Median survival for these groups are listed below:-
| Site of metastases | Median survival (months) |
| Soft tissue | 19 |
| Bone | 15 |
| Lung | 10 |
| Liver | 8 |
| Brain | 3 |
*Leonard et al, ABC of Breast Disease 45 (1995) BMJ Publishing Group.
Additional factors such as tumour burden and characteristics will also profoundly affect these values.
Bone and soft tissue metastases often respond well to endocrine treatment.
Skin changes
In primary breast cancer, the skin is sometimes involved. There may be erythema, induration, dimpling of skin and possibly ulceration present.
Occasionally, an advanced primary carcinoma will present as an ulcerating/ fungating lesion, particularly if it has been concealed.
Skin changes, which may be associated with locally advanced disease, include peau d'orange, induration, and erythema.
More commonly, skin changes are associated with local recurrence after previous treatment. Again, cellulitis may be present but the skin and/or the scar may be the site of recurrent nodules. Skin changes, in the form of erythema, skin darkening, and telangiectasia, can follow radiotherapy.
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