Past exam of the medicine course of the University of Oxford / 1866 / Second examination / Diseases of women and children; principles of surgery / 8 / Solution

The expected historical picture is a hard, infiltrating breast tumour, often initially painless, followed variably by local tethering, lymphatic spread, ulceration and distant disease. “Scirrhus” describes a fibrous pattern of carcinoma, not a complete modern subtype. A soft or painless lump cannot thereby be excluded from breast cancer, and a hard lump alone is not proof of it.

The person may notice a small firm lump or an altered contour before experiencing substantial discomfort. An irregular hard mass can become less mobile as it involves surrounding tissues. Skin dimpling, tethering or puckering, nipple retraction, altered nipple discharge and enlargement of axillary lymph nodes are important associated findings. Later local disease may fix the breast to deeper structures, ulcerate, bleed or produce malodorous discharge. Pain can be lancinating or persistent, but waiting for pain is unsafe because early breast cancer often causes none.^[ref]

The course varies over months or years; not every sign appears in sequence. Local growth can coexist with initially good general health. Subsequent metastasis may affect bones, lungs, liver or other organs and cause symptoms distant from the breast. Historical observers could recognize recurrence after apparently complete removal without possessing modern staging or receptor classification. A temporary reduction in pain, apparent softening or improved appetite did not establish elimination of malignant tissue.^[ref]

In an 1866 decision, reasons favouring operation included a localized lesion that could apparently be removed, reasonable general strength, no evidence of distant dissemination and willingness to accept the considerable contemporary risks. The prospect of effective local removal argued against waiting for ulceration and exhaustion. Extensive fixation, very widespread nodal or skin involvement, distant disease, severe intercurrent illness or a risk disproportionate to expected benefit argued against an attempted curative removal. Axillary findings needed assessment rather than a simplistic rule that any enlarged node either guaranteed or prohibited success. Palliation and the woman's preferences remained relevant even when cure was implausible.

Treatment other than removal had included local protection or compression, dressings for ulceration and bleeding, analgesia, dietary or tonic measures and destructive chemical applications. A 1865 clinical text records plasters, iron, cod-liver oil and treatment directed at ulcer discharge and haemorrhage. Those are observations of symptomatic management, not proof of tumour eradication.^[ref] Contemporary discussion also proposed caustics or injections of chemicals such as zinc chloride, sometimes after cutting or removing tissue. These methods could damage tissue and relieve or alter a surface lesion without demonstrating durable control of the whole disease. They should not be represented as effective alternatives to evidence-based treatment.^[ref]

Modern correction: establish tissue diagnosis and stage, then plan local and systemic treatment together. Clinical examination and appropriate breast imaging lead to a core needle biopsy or another indicated sampling method. Histology, extent of disease and relevant biomarkers guide management; “scirrhous” appearance cannot substitute for these. Axillary assessment forms part of pretreatment evaluation.^[ref] Depending on the cancer and circumstances, treatment may include breast-conserving surgery with appropriate radiotherapy, mastectomy, systemic treatment before or after surgery, endocrine therapy or targeted therapy. Some locally advanced disease needs systemic treatment before a surgical decision, so the historical judgement “fixed, therefore never operable” is not a universal modern rule.^[ref] For advanced disease, treatment also addresses pain, wound problems and other symptoms. Palliative benefit is a valid aim, but must be distinguished from a claim of cure.