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[[Image:Peau d’ orange Appearance in Breast cancer.jpg|thumb|300px|'''Peau d’ orange''' appearance in breast cancer. Case courtesy of Rajendran MC. <nowiki>http://generalsurgeryclinics.blogspot.com/2013/06/peau-d-orange-appearance-in-carcinoma.html</nowiki>]]
{{Breast cancer}}
{{Breast cancer}}
{{CMG}}, [[User:Jack Khouri|Jack Khouri]]
{{CMG}} {{AE}}{{Soroush}}{{MGS}}


==Signs and symptoms==
==Overview==
Early breast cancer can in some cases present as breast pain ([[mastodynia]]) or a painful lump.  Since the advent of breast mammography, breast cancer is most frequently discovered as an asymptomatic nodule on a mammogram, before any symptoms are present. A lump under the arm or above the [[collarbone]] that does not go away may be present. When breast cancer associates with skin [[inflammation]], this is known as inflammatory breast cancer.  In inflammatory breast cancer, the breast tumor itself is causing an [[inflammatory]] reaction of the skin, and this can cause pain, swelling, warmth, and redness throughout the breast.
[[Patient|Patients]] with breast cancer usually are generally well appearing. [[Physical examination]] of [[Patient|patients]] with breast cancer is usually remarkable for [[lump]] in the breast, peau d'orange, and inverted [[nipple]].
==Physical Examination==


Changes in the appearance or shape of the breast can raise suspicions of breast cancer.
===General Appearance===
*[[Patient|Patients]] with breast cancer are generally well appearing. [[Patient|Patients]] are generally oriented to time, place, and person.<ref name="PE">Breast Cancer. Ganfyd (2015) http://www.ganfyd.org/index.php?title=Breast_cancer#Presenting_Symptoms Accessed on january 16, 2016</ref><ref name="ss">Breast cancer. Canadian Cancer Society (2015) http://www.cancer.ca/en/cancer-information/cancer-type/breast/signs-and-symptoms/?region=on#ixzz3xScycfqv Accessed on January 16, 2016</ref>
*Nevertheless, in late stages patients appear ill, pale, and might present with decreased level of consciousness.


Another reported symptom complex of breast cancer is [[Paget's disease of the breast]].  This [[syndrome]] presents as eczematoid skin changes at the nipple, and is a late manifestation of an underlying breast cancer.
===Skin===
With respect to the disease stage and complications, the skin could be either normal, pale, or icteric.


Most breast symptoms do not turn out to represent underlying breast cancer.  Benign breast diseases such as fibrocystic mastopathy], [[mastitis]], functional mastodynia, and [[fibroadenoma]] of the breast are more common causes of breast symptoms.  The appearance of a new breast symptom should be taken seriously by both patients and their doctors, because of the possibility of an underlying breast cancer at almost any age.
===Vital Signs===


Occasionally, breast cancer presents as [[metastatic]] disease, that is, cancer that has spread beyond the original organ. Metastatic breast cancer will cause symptoms that depend on the location of metastasis. More common sites of metastasis include bone, liver, lung, and brain. Unexplained weight loss can occasionally herald an occult breast cancer, as can symptoms of fevers or chills. Bone or joint pains can sometimes be manifestations of metastatic breast cancer, as can jaundice or neurological symptoms. Pleural effusions are not uncommon with [[metastatic]] breast cancer. Obviously, these symptoms are "non-specific," meaning they can also be manifestations of many other illnesses.
*Vital signs are generally normal in early stages.
*In the advanced disease state, almost any abnormality is possible due to brain, bone, liver, and lung metastases.
 
===HEENT===
 
* HEENT examination of patients with breast cancer is usually normal, particularly in the early stages.
*In metastatic breast cancer the following abnormalities might be present:
 
:*Icteric sclera due to liver metastasis
:*Ophthalmoscopic exam may be abnormal with findings of increased ICP due to brain metastasis.
:*Erythematous throat with/without tonsillar swelling, exudates, and/or petechiae due to chemotherapy or widespread disease immunosuppression.
 
===Neck===
*Enlarged [[Supraclavicular lymph nodes|supraclavicular]] [[Lymph node|lymph nodes]]
 
===Lungs===
* Pulmonary examination of patients with breast cancer is usually normal, particularly in early stages.
*In metastatic breast cancer the following abnormalities might be present suggesting [[Consolidation (medicine)|consolidation]] and [[pleural effusion]] due to metastatic disorder::
 
:*Asymmetric chest expansion OR decreased chest expansion
:*Hyporesonant lung auscultation
:*Fine/coarse [[crackles]] upon auscultation of the lung bases either unilaterally or bilaterally
:*Rhonchi
:*Vesicular breath sounds OR distant breath sounds
:*Normal/reduced [[tactile fremitus]]
 
===Heart===
* Cardiovascular examination of patients with breast cancer is usually normal/none contributory.
 
===Breast===
*[[Lump]]
:*May be attached to the skin or [[chest]] wall and cannot be moved.
:*The [[lump]] may feel hard, irregular in shape and very different from the rest of the [[breast]] [[Tissue (biology)|tissue]]
:*The [[lump]] maybe [[Tenderness (medicine)|tender]], but it is usually not [[Pain|painful]].
*Dimpling of the skin
*[[Peau d'orange]]
:*Thickening and dimpling of the skin
*Change in size of affected [[breast]]
*Inverted [[nipple]]
*[[Redness]], [[swelling]] and increased warmth - in [[inflammatory breast cancer]]
*Crusting, [[Ulcer|ulcers]] or scaling on the [[nipple]] - in [[Paget's disease of the breast|Paget's disease of breast]]
*[[Discharge]] from [[nipple]] - mostly bloody
 
===Abdomen===
* Abdominal examination of patients with breast cancer is usually normal/none contributory, particularly in the early stages.  
*In metastatic breast cancer the following abnormalities might be present:
:*[[Abdominal distension]]
:*[[Abdominal tenderness]] in the right/left upper/lower abdominal quadrant
:*A palpable abdominal mass in the right/left upper/lower abdominal quadrant due to peritoneal seeding
:*[[Hepatomegaly]] / [[splenomegaly]] / [[hepatosplenomegaly]]
:*Shifting dollness suggesting [[Ascites]]
 
===Back===
*Back examination of patients with breast cancer is usually normal, particularly in the early stages.
*In metastatic disease, vertebrae is one of the most common sites of metastasis, hence point tenderness over the vertebrae is quite common.
 
===Genitourinary===
* Genitourinary examination of patients with breast cancer is usually normal.
 
===Neuromuscular===
* Neuromuscular examination of patients with breast cancer is usually normal.
*Patient is usually oriented to persons, place, and time
* Altered mental status is possible in late-stage disease with brain metastasis, electrolyte abnormality or severe lung or liver disease due to metastasis.
:* Clonus may be present
:* Reflex abnormalities either hyperreflexia/hyporeflexia/areflexia due to CNS metastasis or electrolyte disturbance
:* Positive (abnormal) Babinski / plantar reflex unilaterally/bilaterally in brain metastasis
:* Peripheral nephropathy is the common complication of breast cancer chemotherapy.  
::* Unilateral/bilateral sensory loss in the upper/lower extremity is probable finding in patients treated with
 
===Extremities===
* Extremities examination of patients with breast cancer is usually normal.
* The followings are suggesting metastatic disorder:
:*[[Cyanosis]] in lung metastasis
:*Pitting[[edema]] of the lower extremities suggesting malnutrition and liver involvement
:*Muscle atrophy due to malnutrition is late stage metastatic cancer
:*[[Bone]] [[tenderness]]
:*[[Pathology (disambiguation)|Pathological]] [[Bone fracture|fractures]]


==References==
==References==
{{reflist|2}}
{{reflist|2}}


[[Category:Disease]]
[[Category:Types of cancer]]
[[Category:Breast]]
[[Category:Hereditary cancers]]
[[Category:Mature chapter]]
[[Category:Oncology]]
[[Category:Oncology]]
[[Category:Breast]]


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[[Category:Up-To-Date]]
[[Category:Oncology]]
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Latest revision as of 23:13, 1 October 2019

Peau d’ orange appearance in breast cancer. Case courtesy of Rajendran MC. http://generalsurgeryclinics.blogspot.com/2013/06/peau-d-orange-appearance-in-carcinoma.html

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Soroush Seifirad, M.D.[2] Mirdula Sharma, MBBS [3]

Overview

Patients with breast cancer usually are generally well appearing. Physical examination of patients with breast cancer is usually remarkable for lump in the breast, peau d'orange, and inverted nipple.

Physical Examination

General Appearance

  • Patients with breast cancer are generally well appearing. Patients are generally oriented to time, place, and person.[1][2]
  • Nevertheless, in late stages patients appear ill, pale, and might present with decreased level of consciousness.

Skin

With respect to the disease stage and complications, the skin could be either normal, pale, or icteric.

Vital Signs

  • Vital signs are generally normal in early stages.
  • In the advanced disease state, almost any abnormality is possible due to brain, bone, liver, and lung metastases.

HEENT

  • HEENT examination of patients with breast cancer is usually normal, particularly in the early stages.
  • In metastatic breast cancer the following abnormalities might be present:
  • Icteric sclera due to liver metastasis
  • Ophthalmoscopic exam may be abnormal with findings of increased ICP due to brain metastasis.
  • Erythematous throat with/without tonsillar swelling, exudates, and/or petechiae due to chemotherapy or widespread disease immunosuppression.

Neck

Lungs

  • Pulmonary examination of patients with breast cancer is usually normal, particularly in early stages.
  • In metastatic breast cancer the following abnormalities might be present suggesting consolidation and pleural effusion due to metastatic disorder::
  • Asymmetric chest expansion OR decreased chest expansion
  • Hyporesonant lung auscultation
  • Fine/coarse crackles upon auscultation of the lung bases either unilaterally or bilaterally
  • Rhonchi
  • Vesicular breath sounds OR distant breath sounds
  • Normal/reduced tactile fremitus

Heart

  • Cardiovascular examination of patients with breast cancer is usually normal/none contributory.

Breast

  • May be attached to the skin or chest wall and cannot be moved.
  • The lump may feel hard, irregular in shape and very different from the rest of the breast tissue
  • The lump maybe tender, but it is usually not painful.
  • Thickening and dimpling of the skin

Abdomen

  • Abdominal examination of patients with breast cancer is usually normal/none contributory, particularly in the early stages.
  • In metastatic breast cancer the following abnormalities might be present:

Back

  • Back examination of patients with breast cancer is usually normal, particularly in the early stages.
  • In metastatic disease, vertebrae is one of the most common sites of metastasis, hence point tenderness over the vertebrae is quite common.

Genitourinary

  • Genitourinary examination of patients with breast cancer is usually normal.

Neuromuscular

  • Neuromuscular examination of patients with breast cancer is usually normal.
  • Patient is usually oriented to persons, place, and time
  • Altered mental status is possible in late-stage disease with brain metastasis, electrolyte abnormality or severe lung or liver disease due to metastasis.
  • Clonus may be present
  • Reflex abnormalities either hyperreflexia/hyporeflexia/areflexia due to CNS metastasis or electrolyte disturbance
  • Positive (abnormal) Babinski / plantar reflex unilaterally/bilaterally in brain metastasis
  • Peripheral nephropathy is the common complication of breast cancer chemotherapy.
  • Unilateral/bilateral sensory loss in the upper/lower extremity is probable finding in patients treated with

Extremities

  • Extremities examination of patients with breast cancer is usually normal.
  • The followings are suggesting metastatic disorder:

References

  1. ↑ Breast Cancer. Ganfyd (2015) http://www.ganfyd.org/index.php?title=Breast_cancer#Presenting_Symptoms Accessed on january 16, 2016
  2. ↑ Breast cancer. Canadian Cancer Society (2015) http://www.cancer.ca/en/cancer-information/cancer-type/breast/signs-and-symptoms/?region=on#ixzz3xScycfqv Accessed on January 16, 2016

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