When the diagnosis of a breast cancer has been made, the patient should be informed in a compassionate manner by an experienced clinician and introduced to a breast care nurse who acts as a point of future contact and provides information and support (Figures 8.1,8.2,8.3). To determine the most appropriate management plan it is important to know the stage or extent of disease. The UICC (Union Internationale Contre le Cancre) TNM (Tumour/Node/Metastasis) classification is commonly used but is not ideally suited to breast cancer (Table 8.1). Clinical examination provides some information of the likely size of the lesion, the presence of involvement of the skin or chest wall, and whether the cancer has inflammatory features. Clinical assessment of axillary and supraclavicular lymph node involvement is essential but insensitive. To improve the TNM system, a separate pathological classification has been added which allows tumour size and node status, as assessed by a pathologist, to be taken into account. Prognosis in breast cancer relates to the stage of the disease at presentation.
Ultrasound scan of a normal small intramammary lymph node in the axillary tail with hypoechoic cortex and bright central medulla.
Enlarged lymph node in axilla with abnormal and irregular appearance due to metastatic involvement. Irregularities of the lymph node cortex or a cortical thickness of greater than 2 mm raise suspicions of metastasis.
A bone scan in progress. About 4 hours after injection of 600 MBq technetium-labelled methylene diphosphonate, the patient is scanned. The label concentrates in active areas of bone and is used to attempt to exclude bone metastases as part of preoperative staging.
Table 8.1TNM staging |Favorite Table|Download (.pdf) Table 8.1 TNM staging
|T - Primary tumour |
|TX ||Primary tumour cannot be assessed |
|T0 ||No evidence of primary tumour |
|Tis ||Carcinoma in situ: intraductal carcinoma, or lobular carcinoma in situ, or Paget's disease of the nipple with no tumour |
|T1 ||Tumour 2 cm or less in greatest dimension |
|T1mic ||Microinvasion 0.1 cm or less in greatest dimension |
|T1a ||More than 0.1 cm but not more than 0.5 cm in greatest dimension |
|T1b ||More than 0.5 cm but not more than 1 cm in greatest dimension |
|T1c ||More than 1 cm but not more than 2 cm in greatest dimension |
|T2 ||Tumour more than 2 cm but not more than 5 cm in greatest dimension |
|T3 ||Tumour more than 5 cm in greatest dimension |
|T4 ||Tumour of any size with direct extension to chest wall or skin |
|T4a ||Extension to chest wall wall (not including pectoralis muscle) |
|T4b ||Oedema (including ...|