ORIGINAL ARTICLE

Early Metastasis in Different Types of Breast Carcinoma - A Personal Experience

*ATM M Rahman1

ABSTRACT
Background: Carcinoma breast is one of the leading causes of death in woman today and is the most common
cancer among women. More than 2.3 million of women are diagnosed breast cancer each year world-wide.
Carcinoma breast may present from an extent of non-palpable lump to a fixed mass with distal metastasis. As
presentation is highly variable, management strategy varies even in same stage of disease.

Objective: To identify early metastasis of different types of breast carcinoma and its management.

Materials and methods: This is a prospective type of observational study in 100 cases done in the different
surgical units of Dhaka Medical College Hospital (DMCH), Bangabandhu Sheikh Mujib Medical University
(BSMMU) and Bashundhara Ad-din Medical College Hospital (BAMCH).Patients were selected clinically and
by some standard investigation (FNAC and core biopsy) from January 2006 to December 2018.

Result: Patients at different age groups had suffered from different types of breast carcinoma. Early diagnosis
by triple assessments and proper surgical and post-surgical managements reduced both loco- regional and distant
metastasis and also reduced both morbidity as well as mortality. Results of treatment and histopathological
reports were recorded. It was found that FNAC is cheap and minimally invasive diagnostic procedure with high
sensitivity (100%) and specificity (95%).Core needle biopsy is more accurate tissue diagnostic in breast cancer.
Down staging has profound symptomatic and cosmetic benefit. In renders inoperable tumors become operable
and reduce morbidities.

Conclusion: Early diagnosis and treatment is the mainstay to achieve satisfactory outcome. Screening program
especially Self-Breast Examination (SBE) is very much helpful in early diagnosis of disease in our social setting.
Screening mammography has had the most substantial impact on the early diagnosis of, and subsequent decrease
in mortality from breast carcinoma. Women of 20-40 years of age should have a breast examination every 2-3
yearly. Women of more than 40 years of age should have a breast examination every yearly.

Key Wards: Carcinoma breast,metastasis, FNAC, mammography, mastectomy, systemic therapy, neo adjuvant therapy.
Introduction
Breast cancer is the second leading cause of cancer in 2021. About 1 in 8 U.S.women (about 13%) will
deaths in women today (After lung cancer) and is the develop invasivebreast cancer in their lifetime. Any
most common cancer among women, excluding age may be affected but it is rare below the age of 30
non-melanoma of skin cancers. According to the years. One in 10 breast lumps referred to a breast
World Health Organization (WHO) about 2.3 million clinic will prove to be malignant.2The above-
women were diagnosed with breast cancer in 2020. mentioned information indicates the importance of
The American cancer society estimates that 281,550 early diagnosis and prompt adequate management in
new cases of invasive breast cancer are expected to be breast carcinoma. In Bangladesh breast cancer in not
diagnosed in women and about 2,650 in men in2021. uncommon. Women at different age groups are
About 43,600 women in the U.S. are expected to die presented commonly in advanced stage, with both
1*Dr. ATM Mostafizur Rahman, Assistant professor, Department of Surgery, Bashundhara Ad-din Medical College
Hospital, Dhaka.
*Corresponding author
Date of submission: 18.09.2021, Date of acceptance: 12.10.2021

AKMMC J 2022; 13(1) : 14-21

15 AKMMC J 2022 : 13(1) ATM M Rahman el al.

local and systemic manifestation, due to variety of tumor grade. Treatment of early breast cancer will
causes like poverty, ignorance, shame, religion, poor usually involve surgery with or without radiotherapy.
health knowledge, lack of social awareness, reluctant Systemic therapy such as chemotherapy and hormone
to attend a male doctor, and blind dependency on therapy are added if there are adverse prognostic
indigenous and non-scientific measures compels our factors such as lymph node invasion including
patients to present in a stage beyond cure. metastatic relapse. Advanced or metastatic breast
cancer is usually treated by systemic therapy to
Common formsof breast carcinoma-invasive ductal
relieve symptoms and extend a women’s life time.
carcinoma (IDC), invasive lobular carcinoma (ILC),
Fortunately, the mortality rate of breast cancer has
ductal carcinoma in situ (DCIS) and Lobular
reduced in recent years with an increased emphasis on
carcinoma in situ (LCIS). Less common forms of
early detection and more effective treatment.3 It is
breast carcinoma: medullary carcinoma, tubular
observed that breast cancer survival rate has greatly
carcinoma, inflammatory carcinoma, Paget’s disease
increased over the past 20 years due to early detection
of the nipple, malignant phylloides tumors, papillary
and improved multidisciplinary approach in the form
carcinoma and metaplastic carcinoma.1,2
of neo-adjuvant therapy and per operative
Metastasis of breast carcinoma commonly occurs radiotherapy.3 The cycle started with Beatson in 1896
through lymphatic and hematogenous routes. The and is currently resting with ATAC trial 2002.5
main lymph channels pass directly to the axillary and Considering various case reports, Breast Conserving
internal mammary lymph nodes. Later spread occurs Surgery (BCS) is getting popular as 5 years survival
to the supraclavicular, abdominal, mediastinal, groin rate is almost equal with mastectomy alone1.
and opposite axillary lymph nodes.1,2 Hematogenous Additionally psychological trauma of losing breast
metastasis is most commonly to bones (at the sites of will be reduced from BSC. Recent advances like
red bone marrow i.e. vertebrae, skull, pelvis, ribs, BRCA-1, BRCA-2 and other (chromosomal) genetic
sternum, upper end of femur, upper end of humerus), factors, newer drugs and advances in targeted
liver, lung andbrain. The ovaries and suprarenal radiotherapy all added to hopes in successful
glands are also frequent of deposits.1-2 management of breast cancer patient, only when
To determine a cancer’s histologic grade, examine the disease is diagnosed early.
breast cancer cells and their patterns under a Materials and methods:
microscope. A sample of breast cells may be taken
from a breast biopsy; lumpectomy or mastectomy.1-2 Type of study: Prospective study.
Diagnosis depends on clinical breast examination,
Study place: The study was conducted in the admitted
ultrasound,mammography,biopsy, cancer marker and
patients of different surgical units ofDhaka Medical
certain imaging test such as chest X-ray, CT scan,
College Hospital (DMCH), Bangabandhu Sheikh
MRI and bone scan. Blood tests are needed to
Mujib Medical University (BSMMU) and Bashundhara
evaluate a patient’s overall health and detect whether
Ad-din Medical College Hospital (BAMCH).
cancer has spread to certain organs.1-2
Study period: From January 2006 to December 2018.
Introduction of mammogram and other imaging
techniques has tremendous impact in developed Selection of cases: Patients presenting with clinical
countries. Many patients were diagnosed carcinoma features of carcinoma breast and only who
breast at a stage when they were clinically impalpable volunteered after proper explanation were selected
5 to 10 years disease free survival has improved to finally for the study.
very satisfactory level.
Inclusion criteria: All clinically diagnosed cases of
Treatment depends upon clinical stage of the disease carcinoma breast irrespective of age & sex.
at presentation and other tumor characteristics such as
Early Metastasis in Different Types of Breast Carcinoma 16

Exclusion criteria: post-menopausal women respond to hormone therapy

1. Patients who had a history of mastectomy and significantly.9 Irrespective of age estrogen receptor
recurrence. positive cases respond well to hormone therapy.9
2. Sarcoma and malignancies other than carcinoma. Observations & Results:
3. Patients who willingly withdrawn themselves
After data collection, individual cases were analyzed
from the study.
and the presented in this section by tables and
Sample size: Total 100 patients. pictures.

Management: Table-01: Age distribution of patients

Breast carcinoma should be managed by Age Number Percentage (%)

multidisciplinary approach of general surgeon and 20-29 04 04
reconstructive surgeon.1 Great dispute is present 30-39 10 10
regarding the management of carcinoma breast since
the history of treatment available. To reach a 40-49 14 14
consensus is very difficult as the management 50-59 22 22
depends upon the patient status, modalities available
60-69 42 42
and other different factors. Two methods of treatment
are accepted till date. One is systemic therapy in the 70-79 06 06
form of chemotherapy and hormone therapy. Another 80-89 02 02
is local therapy, which includes surgery and
Total 100 100
radiotherapy.1

Early breast cancers are managed by surgery and The above table shows distribution of patients
radiotherapy. On the other hand, locally advanced or according to age group. It shows majority of patients
metastatic cases are usually treated by systemic 42 (42%) were between the ages of 60-69 years. Next
therapy to palliate symptoms and surgery playing a highest percentage of patients 22 (22%) were in the
much smaller role. Treatment of breast carcinoma is age range of 50-59 years and a quiet number of
highly variable in different centers. Roughly stage I patients 14 (14%) were below 40 years; among them
and stage II diseases are managed by curative surgery. maximum 10 (10%) were between 30-39 years. Mean
Patients in stage I and II can be managed by breast
age is 46.19 years and age range from 25-80 years. It
conserving surgery followed by local radiotherapy to
indicates that younger age group is not escaped from
the breast. Intra operative radiotherapy may help.
developing malignancy.
Axillary sampling can be done by separate incision in
the axilla. Sentinel lymph node biopsy can help in the Table-02: Side of breast involvement
management of axilla in negative cases. If properly
Side Number Percentage (%)
evaluated it can avoid extensive axillary dissection
and reduce ultimate morbidity. Stage II cases can be Right 64 64
managed by Patey’s mastectomy effectively. In stage Left 34 34
III disease down staging may avoid radical surgery
and breast conserving surgery still might be possible Both 02 02
in those cases after appropriate neo-adjuvant therapy. Total 100 100
In stage IV diseases there is no scope of curative
surgery. Various palliative measures may help. The above table shows right breast was mostly
Patients with fungating or necrosed lesions are involved in 64 (64%) cases. Both breasts were
managed by toilet mastectomy. Pre-menopausal involved only in 02 (04%) cases. Left sided breast
women respond to chemotherapy and was involved in 34(34%) cases.
 17 AKMMC J 2022 : 13(1) ATM M Rahman el al.

Table-03: Area of breast involved in malignancy The above table (table-05) indicates lymph node status
and accuracy of clinical examination. Clinically
Quadrant Number Percentage
forty-two (42%) cases were in N0. Among them per
Upper outer 40 40 operative N0 was only 22 (22%) and rest of the twenty
Upper inner 32 32 (20%) cases had N1. It indicates though axillary
Central 08 08
lymph nodes were assumed clinically impalpable, per
Lower outer 12 12
Lower inner 04 04 operatively they were found enlarged. In the same way
Multiple 04 04 18 (18%) patients had mobile axillary lymph nodes
Total 100 100 clinically i.e. N1. Among them 10(10%) were mobile
and 08 cases (08%) had fixed lymph nodes (N2)per
This table summarizes the area of involvement. It
operatively. Again 40 patients (40%) showed fixed
shows that in majority of patients, 40 (40%) there was
lymph nodes (N2)clinically. Six (06%) of them were
involvement of upper outer quadrant. This indicates
mobile (N1) per operatively and 34 (34%) cases had
maximum patients presented in early stage. Upper
inner quadrant was involved in 32 (32%) cases. 12 fixed lymph nodes actually. Sensitivity of clinical
(12%) patients were presented with lower outer examination was calculated as 42%. This table also
quadrant lump. Eight (08%) patients had involvement unfolds the inaccuracy rate of clinical examination.
of the central part and lower inner part was involved Table-06: Types of breast carcinoma (invasive)
in four (04%) cases.
Types of breast Number Percentage (%)
Table-04: Associated signs found during examination
carcinoma (Invasive)
Sign Number Total
Invasive ductal Ca 80 80
Peau-d-orange 04
Oedema 00 Invasive lobular Ca 16 16
Skin infiltration 10 Medullary Ca 02 02
Ulcer 02
Mucinous Ca 02 02
Nipple retraction 08 44
Puckering 04 Others 00 00
Satellite nodules 16 Total 100 100
Skin infiltration was involved in 10 (10%) of which 02 This table was shown 80 patients (80%), most of the
(02%) had ulceration of different sizes. Nipple patients suffered frominvasive ductalCa, 16 patients
retraction was found in eight (08%) patients. Sixteen (16%), suffered from invasive ductal lobular Ca. Only
(16%) had satellite nodule away from the tumour site. 02patients (02%) suffered from both medullary and
All these figures are tabulated in table 04. Clinical mucinous Ca of breast. Others type not found.
features documented above were present singly or in
combination. So the incidence of symptoms does not Table-07: Grading of breast carcinoma
correlate with total numbers of patients. Grade Differentiation Total Percentage
Table-05: Lymph node status (Axillary) Grade-I 00 Well 00 00 00
Clinical Examination Classification based on preoperative findings Grade-II 28 Moderate 28 28 28
Trait Number (%) N0 N1 N2
Grade-III 72 Undifferentiated 72 72 72
Number (%) Number (%) Number (%)
Total 100 100
N0 42 42 22 22 20 20 00 00
N1 18 18 00 00 10 10 08 08 This table was showed all patients presented at
N2 40 40 00 00 06 06 34 34
Grade-II and Grade-III, on patient at Grade-I. There
were 72% at grade-III and 24% at grade-II.
Total 100 100 22 22 36 36 42 42
Early Metastasis in Different Types of Breast Carcinoma 18

Table-08: Metastasis Pie chart-1: Surgical treatment

Status Number Percentage (%)
M0 86 86
M1 14 14
Total 100 100

Above table indicates that only fourteen patients (14%)

presented with metastasis at the time of diagnosis and
86 patients (86%) had no distal metastasis.
This pie chart shows the spectrum of surgical
Table-09: Duration of distant metastasis in relation to procedures 60 (60%) patients were managed by simple
histopathological types of breast Ca mastectomy with axillary dissection; 36 (36%) patients
by radical mastectomy and only 04 (04%) patient by
Types of breast Duration of distant Site of
carcinoma metastasis (from history) metastasis Patey’s mastectomy.

Invasive ductal 1 month Bone Table-11: Site of distal metastasis

carcinoma
1 ½ months Liver Site Number Percentage (%)
6 months Bone Bone 06 42.86%
4 months Bone Lung 04 28.58%
Invasive lobular 3 months Lung Liver 04 28.58%
carcinoma
2 ½ months Lung Brain 00 00
6 months Liver
Total 14 100
This table showed more aggressiveness of breast This table shows the site of distal metastasis with their
carcinoma to the distant metastasis like bones, lungs frequency. In six (42.86%) i.e. most of the cases, bones
and liver within 6 months. were the site of involvement. In four (28.58%) cases, it
involved lungs, and in only in four (28.58%) cases, liver
Table-10: Comparison between FNAC and histopathology was involved. These were documented from bone scan,
report Chest CT scan and Ultra sonogram of whole abdomen.

Report FNAC Positive for malignancy Discussion:

Number (%) Number (%) Breast cancer is nota disease of modern society; the
ancient Egyptians recognized it as long as ago 1600
Benign 06 06 00 00
BC. However, breast cancer has become a major
Malignant 94 94 100 100 health problem over the last 50 years, affecting as
Total 100 100 100 100 many as one in twelve women during their lifetime.1,2
The burden of breast cancer worldwide in both
Out of 100 patients six (06%) patients were reported developed and developing countries are increasing
benign and 94 (94%) patients were diagnosed as and evidence suggests that unless action is taken it
malignant by FNAC. In histopathology report all will continue to grow for the foreseeable future.
patients were diagnosed as malignant and no case as Breast cancer is a significant health problem in the
benign. Three cases were therefore false negative. industrialized western world, where it is the most
Specificity of FNAC was calculated to be 100% and common form of cancer among women in North
sensitivity was 96%. America and almost all of Europe. It is estimated that
19 AKMMC J 2021 : 13(1) ATM M Rahman el al.

each year the disease is diagnosed in over 2.3 million specificity of 98.1%. our result is not far from others. So
women in worldwide and is the cause of death in over FNAC is an extremely reliable diagnostic tool. It
400000 women.16 The incidence and prevalence of appears that clinical examination of axilla remains
breast cancer increases with increasing age. It is incomplete so significant number of cases remains
known that incidence rates for breast cancer is rare under staged pre operatively. One reason may be that
below the age of 20 years and then steadily rises so patients are conservative in exposure and examination
that by the age 90, 20% women are affected.1 In our cannot be done freely specially in outpatient department
study it shows that majority if patients i.e. 42 (42%) and ward. All patients should be examined in a room
were between the age of 60-69 years. Next highest with special arrangements for privacy and comfort. So
percentage of patients i.e. 22 (22%) as in the age range that, patients can relax. Using examination gloves will
of 50-59 years. Median age for carcinoma of breast is also help examination in a clinical setup. There is 30%
60 years.10 In our study median age was 46.19 years. error rate in clinical evaluation of axillary lymph nodes
This is alarming that earlier age groups are affected in and tumour size.12 Physical examination is notoriously
comparison to western world in our country. In the in accurate in lymph node assessment having false
USA, 75% of new diagnosed cases are women aged 50 positive result in 25-31% cases and false negative result
years or older, and the lifetime risk of a diagnosis of in 27-33% cases.11 Another finding has quoted that
breast cancer is approximately 12.5%.1,2 clinical examination has 86% sensitivity and 90%
specificity.8 Sensitivity of clinical examination in our
Breast cancer presents with various features extending
study in lymph node assessment was 55.75%. Lesions
from non-palpable mass to invasive lesions. About
assuming malignant clinically proved benign in biopsy
70% patients of breast cancer present with lump.9 Our
were 60% and 30% lesions assuming benign clinically
observation was 100%. Though there is no predilection
proved malignant in biopsy.9
to the right or left breast, in our study it revealed 64%
in the right and 34% in left breast was involved. Less 5% patients in UK present as locally advanced disease
than 01% percent patient presents with bilateral breast and 20% in developing countries. In 1980 American
involvement.9 Our study shows it as 02%. This is not College of Surgeons showed that 85% first seen with
far from standard results. 60% of the lesions arise in the stage-I or Stage-II disease. Positive lymph node was
upper and outer quadrant.1In our study it was 40%. 40%. Average size presenting to doctor was less than
Most of the lesion occupied upper quadrants of the 2cm.7 In our study 40% patients were in Stage-III and
breast. This was due to the advanced stage of disease 14% patients were in stage-IV at presentation. About
Males are affected 0.5% by carcinoma breast1 but in 8% patients had distal metastasis at their first
our study we got no male patients. Family history of presetation.10 Lack of awareness and aversion to male
breast cancer may be present in 5% cases. 65 None of surgeon was the leading cause of this advanced
our patients had positive family history. presentation. Neo adjuvant therapy is an important
modality of management which simultaneously down
Although benign breast lump are six times more
stage the disease and combats systemic disease. 70%
common than malignant. The persistence of any mass in
cases responded to neo adjuvant therapy by tumor
the breast raises the suspicion of carcinoma, which are
shrinkage.8 Significant clinical response was
the most malignant lesion of breast and leading cause of
observedin about 70-90% cases after neo adjuvant
death from cancer in women. Therefore, no mass is
therapy but complete pathological response was
trivial to be investigated. There are various diagnostic
observer in less than 15% cases.6 In our study about
tools among them FNAC is the cheapest and easiest to
50% patients showed significant clinical improvement
perform. False positive result of FNAC is extremely low
after neo adjuvant therapy and more cosmetic result
(<1%) and false negative result is albeit higher (10%).9
was achieved. Cancer WG et al demonstrated 84%
In our study, FNAC gives sensitivity to 96% and patients had significant clinical response to neo
specificity of 100%. Amin el Tahir et al13 showed adjuvant therapy.13 This difference might be due to
predictive values of 97.3% with sensitivity of 93.5% and inadequate use of chemotherapy agents.
Early Metastasis in Different Types of Breast Carcinoma 20

Lymph node response after neo adjuvant therapy was 33% that exceeds 80% and 5 years survival rates exceeding
in our set up. Lisa A Newman MD et al showed the 50% are not ususal.15 Although clinically worth while
response as 33%.14 In my study both tumor and lymph the benefit of adjuvant systemic therapy for operable
node responders were 12%. Lisa A Newman M D et al carcinoma breast are modest and in range of 20-30%
showed the response was 21%.14 Our result is consistent reduction in the odds of recurrence or death.7
with others observations. Neo adjuvant therapy has no
Management strategy depends upon stage of disease
role in long term survival of patients after management
and modalities available. 75% treated with mastectomy
rather it aids in down staging with a view to make fit for
and 25% with breast conserving surgery.9 Despite an
breast conserving surgery and in advanced cases to make
increasing trend toward breast conserving surgery up
the dissection easy and limited.7 So that primary closure
to 50% of women still require mastectomy.1 Breast
after mastectomy would be possible avoiding skin
conserving surgery was not possible at all in our setup
grafting. Ideally stage-III patients are eligible for neo
as about 93% patients were in stage-III and stage-IV.
adjuvant therapy but in our study stage-IV patients were
Other patients were not convinced for breast
also included only to ease closure after toilet mastectomy
conserving surgery. So, it’s outcome could not be
or to control aggressive features like bleeding from lesion.
assessed in my study. So, surgical management was
Management of axillary lymph nodes became easier after
Paty’s mastectomy in 04 % of the cases.
neo adjuvant therapy.Newman M D et al shows that after
completion of neo adjuvant therapy 59% patients were Carcinoma of breast is more aggressive in younger than
eligible for breast conserving surgery. Before completion elderly. Local recurrence happened in the form of
it was 39%.14In our set up breast conserving surgery was nodule, ulceration, local pain and swelling. Systemic
not performed but surgery became easier and less invasive spread may involve bones, lungs, brain, liver, spinal
after completion of neo adjuvant therapy. cord etc. Metastasis to bone observed in 49-60% cases,
15-20% cases in lungs, 10-15% to pleura, 7-15% to soft
Local recurrence and distal metastasis are major problem
tissue and 5-15% to liver.12 In our limited observation
in the management of carcinoma of breast. Dital
we found 42.86% bony metastasis, 28.58% pulmonary
metastasis will be found at local relapse in about 20%
metastasis and 28.58% in hepatic metastasis. The low
cases.10 In our study distal metastasis was observed in
percentage of this prospective study is not very far from
23.26% patients. Whereas Cance W G et al observed 31%
others. The low accuracy rate can be improved by
in their study.13 Our study reveals that distant is more in
increasing practice and number of cases.
patients with advanced stage if disease and patients who
didn’t use adjuvant chemotherapy adequately. Conclusion:
Local recurrence after complete treatment is the main Breast cancer is an extremely emotional topic by
barrier of management outcome. Systemic micro virtue of its anatomical location and the importance of
metastasis causes it. Recurrence in breast, chest wall, female breast in today’s society. Breast is a common
axilla clinically found 80% cases within 2 years. So, in site of cancer in women and carcinoma breast is the
our study local recurrence occurred in 36.84% patient. leading cause of death among middle aged women in
Cancer W G et al showed in their study it was 14% only.13 western countries.1 Although it is common in western
In the study by Scholl by et al the rate if local recurrence and affluent populations but it is not uncommon in our
by neo adjuvant chemotherapy users group was 27%.6 It country. Early age groups are not escaped rather
was greater in our setup as majority of patients could not suffer more aggressive form of disease. Twelve years
avail chemotherapeutic agents regularly and presented in study was performed to observe early metastasis of
advanced stage of disease and who didn’t use adjuvant different types of breast carcinoma. The aims of this
therapy regularly as per schedule. study to identify different histopathological types of
breast carcinoma in our country were more common,
Multidisciplinary approach with neo adjuvant therapy early diagnosis of metastasis and different modalities of
followed by local surgery and radiation therapy and treatment according to patient’s condition. 100
chemotherapy has resulted on rates of local control diagnosed case of carcinoma breast were studied.
21 AKMMC J 2021 : 13(1) ATM M Rahman el al.

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