20th June 2023

Diagnosis and Prognosis

Usual presentations are a painless breast lump, distortion of breast, or nipple discharge. All breast lumps should undergo triple assessment which consists of clinical examination in combination with imaging and histological assessment. Breast examination may reveal a non-tender, well- or ill-defined lump with or without fixity to the skin or chest wall and changes in overlying skin. Lymph nodes in the axilla and supraclavicular fossa may be involved. Clinical examination may contribute to tumour and nodal staging. Ultrasound is more accurate in detecting invasive breast cancer, though mammography remains most accurate at detecting ductal carcinoma in situ (DCIS). MRI is used in the assessment of multifocal/bilateral disease and patients with cosmetic implants who are identified as high risk. Pathological diagnosis can be obtained by FNA or core biopsy or open surgical biopsy. TNM staging is used for staging the disease and planning for management. Immunohistochemistry (IHC) evaluation is mandatory nowadays for treatment decision making.
Less than 10% of patients initially present with metastatic disease. The most common sites of distant disease include bones (70%), lungs (60%), liver (55%), pleura (40%), adrenals (35%), skin (30%) and brain (10-20%). Staging investigations should include CXR, bone scan, liver USS, CT/MRI or PET-CT, LFT and calcium.
Overall prognosis depends on tumour size, grade, lymph node status, oestrogen (ER) and progesterone receptors (PR) status, and presence, or absence of vascular invasion.