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What are the symptoms of breast tumors?Source: Breast Disease Prevention and Treatment Manual of Beijing Puxiang Hospital
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Last Updated: 2005-11-30
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The symptoms of breast cancer can be varied, with common ones including: breast lumps, breast pain, nipple discharge, erosion or skin indentation, and axillary lymph node enlargement. Although these symptoms are not necessarily specific, understanding and recognizing them can help in the early detection, diagnosis, and treatment of breast cancer. Of course, the appearance of certain symptoms indicates that the disease may have already progressed beyond the early stage. A comprehensive and in-depth understanding of these symptoms can prevent missed treatment opportunities while avoiding excessive anxiety that affects daily life.
### I. Breast Lumps
Breast lumps are the most common symptom of breast cancer, with approximately 90% of patients presenting with this symptom. With the increasing awareness of tumor knowledge and the implementation of cancer screening programs, this proportion may continue to rise. If a breast lump is detected, the following aspects should be considered:
1. Location: The breast is centered around the nipple, and a cross can divide it into five regions: inner upper, outer upper, inner lower, outer lower, and central (areola). Breast cancer is most commonly found in the outer upper region, followed by the inner upper region. Inner lower and outer lower regions are less frequently affected.
2. Number: Breast cancer is more commonly presented as a single, unilateral lump. Multiple unilateral lumps and primary bilateral breast cancer are relatively rare in clinical practice. However, with advancements in tumor prevention and treatment, the survival rate of patients has improved, increasing the likelihood of a second primary cancer in the contralateral breast after surgery.
3. Size: Early-stage breast cancer lumps are generally small and may be difficult to distinguish from conditions like lobular hyperplasia or benign lesions. Even small lumps may sometimes affect the Cooper's ligaments, causing local skin indentation or nipple retraction, making them easier to detect early. In the past, due to poor healthcare conditions, lumps were often larger when patients sought medical attention. Today, with the of breast self-examinations and screening programs, early-stage breast cancer cases have increased.
4. Shape and Margin: Most breast cancers grow infiltratively with unclear margins. Some may appear flattened, with an irregular surface and a nodular sensation. However, it should be noted that smaller lumps may exhibit less of these characteristics. Additionally, some rare types of breast cancer may grow expansively with smooth, mobile, and well-defined margins, making them difficult to distinguish from benign tumors.
5. Hardness: Breast cancer lumps are generally hard, though medullary carcinoma with rich cellularity may be slightly softer. Occasionally, they may be cystic, such as in cystic papillary carcinoma. In some cases, the surrounding tissue may contain more fat, giving the lump a more elastic feel upon palpation.
6. Mobility: When small, lumps are more mobile, but this mobility involves the lump moving together with surrounding tissues, unlike fibroadenomas. If the tumor invades the pectoral fascia, mobility decreases; if it further involves the pectoral muscle, mobility disappears. When the patient crosses their arms and puffs out their chest, the affected breast may appear asymmetrical. In advanced breast cancer, the tumor may invade the chest wall, becoming completely fixed. If nearby lymph nodes are involved, the skin may appear orange-peel-like, known as the "orange peel sign," and subcutaneous nodules may form, referred to as "satellite nodules."
In benign breast tumors, lumps are also common, with the most frequent being fibroadenomas. This condition is more common in young women and less common in those over 40. The tumor is usually solid, firm, encapsulated, with a smooth surface and a sliding sensation upon palpation. It generally does not cause skin adhesion or nipple retraction.
Intraductal papillary tumors are often small and difficult to palpate. Larger ones may present as small nodules around the areola, with nipple discharge being the primary symptom. Lobular hyperplasia rarely forms distinct lumps and is more characterized by localized breast tissue thickening, firm texture, and a lack of encapsulation. Painful swelling often occurs before menstruation. Some cases may only show localized glandular thickening without obvious lumps, with unclear boundaries, and are often diagnosed as "breast hyperplasia." However, careful examination of the thickened area, especially if it is localized and accompanied by mild skin adhesion, should raise suspicion, and mammography may be recommended.
### II. Breast Pain
Breast pain is seen in various breast conditions but is not a common symptom of breast tumors. Benign or malignant breast tumors are typically painless. In early breast cancer, pain may occasionally be the only symptom, ranging from dull pain to a pulling sensation, which is more pronounced when lying on the affected side. Studies have shown that postmenopausal women experiencing breast pain accompanied by glandular thickening have a higher likelihood of breast cancer detection. Of course, if the tumor is accompanied by inflammation, it may cause or tenderness. In advanced tumors, shoulder pain may occur if the tumor invades nerves or if axillary lymph nodes are enlarged or compressed, affecting the brachial plexus.
### III. Nipple Discharge
Nipple discharge can be either physiological or pathological. Physiological discharge is primarily seen in pregnant or lactating women. Pathological discharge refers to breast duct secretion outside of physiological states, usually referring to the latter. Nipple discharge can be caused by various breast conditions and is more easily noticed by patients, accounting for about 10% of reasons for seeking medical attention. Among the symptoms of breast diseases, its incidence is second only to breast lumps and breast pain.
1. Types of Discharge: Based on physical characteristics, nipple discharge can be categorized as bloody, serous, seromucous, watery, purulent, or milky. Serous, watery, and milky discharges are more common, while bloody discharge accounts for only 10% of cases. Bloody discharge is more likely when the lesion is in larger ducts; in smaller ducts, it may be light bloody or serous. If blood remains in the ducts for too long, it may appear dark brown. Inflammation combined with infection in the ducts may mix with pus, and liquefied necrotic tissue may appear as watery, milky, or brown fluid. In breast duct ectasia, the fluid is typically serous. Bloody discharge is mostly caused by benign conditions, though a few cases of breast cancer may also present this way. Physiological discharge is usually bilateral and may appear milky or watery.
2. Causes of Discharge: The causes are primarily divided into extramammary factors and intramammary factors. About 5%–10% of breast cancer patients have nipple discharge, but only 1% present with discharge as the sole symptom. The discharge is often unifocal and can vary in appearance, such as bloody, serous, watery, or colorless. Breast cancer originating in larger ducts or ductal carcinoma in situ with papillary features is more likely to be associated with nipple discharge, such as papillary ductal carcinoma or papillary eczematoid carcinoma. It is worth noting that although many believe breast cancer rarely accompanies nipple discharge, and even if it does, it usually appears alongside a lump or simultaneously, cases without a lump are rarely considered cancerous. However, recent studies suggest that nipple discharge is an early clinical manifestation of certain breast cancers, especially ductal carcinoma in situ, and can exist alone before a lump becomes apparent.
Papillary ductal tumors are among the most common causes of nipple discharge, accounting for the majority of nipple discharge lesions, with the areolar region being the most frequently affected. They can be single or multiple, with ages ranging from 18 to 80, most commonly between 30 and 50. The tumor diameter ranges from 0.3 to 3.0 cm, with an average of 1.0 cm. Those larger than 3.0 cm are more likely to be malignant. The discharge is mostly bloody or serous, with other types being less common. It is generally believed that papillary tumors originating in larger ducts are mostly single and rarely malignant, while those in smaller ducts are often multiple and may become malignant. Both are similar lesions but differ in location and growth process.
Cystic hyperplasia, though not a tumor, is the most common benign breast condition, more prevalent in women around 40 and rare after menopause. Its discharge is based on three pathological changes: cysts, ductal epithelial hyperplasia, and papillary tumor disease. The discharge is mostly serous, and only 5% of cases with discharge are associated with this condition.
### IV. Nipple Changes
If breast cancer patients exhibit abnormal nipple changes, they are often nipple erosion or nipple retraction.
1. Nipple Erosion: A typical feature of Paget's disease of the breast, often accompanied by itching. About 2/3 of patients may also have a lump in the areola or other breast areas. Initially, only scaling or small fissures may be present. The scaling is often accompanied by a small amount of discharge and crust formation. When the crust is removed, a fresh red eroded surface is revealed, which does not heal. As the entire nipple is affected, it may further invade surrounding tissues. With progression of the disease, the nipple may completely disappear. Some patients may first develop a breast lump before noticing nipple changes.
2. Nipple Retraction: When the tumor invades the nipple or the subareolar region, the breast's fibrous tissue and duct system may shorten, pulling the nipple inward, causing it to deviate or even retract completely behind the areola. At this stage, the affected nipple may appear higher than the healthy side. This sign may appear in early breast cancer but is sometimes a late-stage manifestation, depending on the tumor's growth location. If the tumor is located under or near the nipple, this sign may appear early. If the tumor is deep within the breast tissue and far from the nipple, this sign is usually indicative of late-stage disease.
Of course, nipple retraction or indentation is not always malignant. Some cases may be due to congenital developmental abnormalities or chronic inflammation, where the nipple can be pulled out with fingers and is not fixed.
### V. Skin Changes
Skin changes caused by breast tumors depend on the tumor's location, depth, and extent of invasion. Common manifestations include:
1. Skin Adhesion: The breast is located between superficial and deep fasciae. The superficial layer of the superficial fascia is connected to the skin, while the deep layer is attached to the superficial surface of the pectoral muscle. The superficial fascia forms small lobular intervals within the breast tissue, known as Cooper's ligaments. When the tumor invades these ligaments, they may contract and shorten, pulling the skin to form an indentation, resembling a "divot sign." When the tumor is small, it may cause minimal skin adhesion, which is difficult to detect. In such cases, good lighting is needed to gently support the affected breast, increasing surface tension. When the breast is moved, slight pulling or indentation of the skin over the tumor may be observed. This symptom should raise suspicion of breast cancer, as benign tumors rarely exhibit this.
2. Superficial Vein: When the tumor is large or grows rapidly, the overlying skin may become thin, and superficial veins may become dilated. This is more clearly visible under liquid crystal thermography and infrared scanning, commonly seen in giant fibroadenomas and cystic fibromas. Tumors during acute inflammation, pregnancy, or lactation may also exhibit superficial vein.
3. Skin Redness: In acute or chronic mastitis, the breast skin may appear red and swollen. In breast cancer, this is primarily seen in inflammatory breast cancer. Since all subcutaneous lymphatic vessels are occupied by cancerous thrombi, it can cause lymphangitis, leading to skin discoloration from pale red to deep red. Initially, it may be localized but soon spreads to most of the breast skin, accompanied by swelling, thickening, and increased skin temperature.
4. Skin Edema: Due to tumor cell blockage of subcutaneous lymphatic vessels or infiltration of the breast central area by tumor cells, lymphatic is obstructed. Lymph fluid accumulates in the lymphatic vessels, causing the skin to thicken, hair follicles to expand and sink, displaying the "orange peel-like change." Mild skin edema is common in obese or pendulous breasts, particularly in the outer lower region. If bilateral symmetry is present, it is likely due to local circulatory disorders; if unilateral, caution is needed to rule out cancer. Additionally, in advanced breast cancer, the tumor may directly invade the skin, causing ulcers. If bacterial infection occurs, the odor may be unpleasant. If cancer cells infiltrate the skin and grow, scattered hard nodules may form around the primary lesion, known as "skin satellite nodules."
### VI. Axillary Lymph Node Enlargement
As breast cancer progresses, it can invade lymphatic vessels and metastasize to regional lymph nodes. The most common site of lymphatic metastasis is the ipsilateral axillary lymph nodes. Lymph nodes typically enlarge gradually, with an increasing number of nodes over time. Initially, enlarged nodes may be movable, but they eventually fuse and become fixed. If enlarged lymph nodes invade or compress the axillary vein, it may cause edema in the ipsilateral arm. If they invade the brachial plexus, shoulder pain may occur.
When examining axillary lymph nodes, the affected arm should be relaxed as much as possible to palpate the axillary apex. If enlarged nodes are detected, attention should be paid to their number, size, texture, mobility, and surface characteristics to differentiate them from inflammation or tuberculosis. It is relatively rare for patients to present with axillary lymph node enlargement as the first symptom without a breast lump. If axillary lymph node enlargement is confirmed as metastatic cancer, a thorough examination of the lymphatic drainage area is necessary, along with exclusion of tumors in the lungs and digestive tract. If the pathology suggests metastatic adenocarcinoma, "occult breast cancer" should be considered. At this stage, the breast lesion may not be detected, and mammography may aid in diagnosis.
Lymph nodes with positive hormone receptor tests should still be considered as potentially originating from the breast, even if no breast lesions are found in other examinations.
Breast cancer can metastasize to the ipsilateral axillary lymph nodes and may also spread to the contralateral axillary lymph nodes through communication between the anterior chest wall and internal mammary lymphatic networks, with an incidence of about 5%. Additionally, advanced breast cancer may metastasize to ipsilateral supraclavicular lymph nodes or even contralateral supraclavicular lymph nodes.
The above is a brief description of the basic symptoms of breast tumors, particularly breast cancer. As long as women have a strong awareness of cancer prevention and thoroughly understand and master this knowledge, while performing serious self-examinations, with the improvement of healthcare, cancer will no longer be an incurable disease.