A 45-year-old lady presents with a hard lump in the left breast. On examination, the lump is found to be 4 cm x 6 cm in size, not fixed to the skin, but fixed to the underlying pectoralis major muscle. The T stage of this is
cT4a
The correct answer is cT4a. In breast TNM staging, T4 means a tumour of any size with direct extension beyond the breast, and size then becomes irrelevant. T4a is extension to the chest wall; T4b is skin ulceration, satellite skin nodules or skin oedema (peau d'orange); T4c is both; T4d is inflammatory carcinoma. Here the lump is fixed to pectoralis major, taken as deep fixity, giving cT4a, and it is explicitly not fixed to skin, excluding T4b. Deep fixity is elicited by loss of mobility when the patient contracts pectoralis major by pressing her hand on her hip. T4 disease is stage IIIB and is treated with neoadjuvant chemotherapy followed by surgery and radiotherapy.
cT2 is greater than 2 cm but not more than 5 cm and cT3 is greater than 5 cm, but both require a tumour confined to the breast with no chest wall or skin involvement, so neither applies despite the 4 x 6 cm size. cT4b is wrong as there is no ulceration, oedema or satellite nodule.
Key point: Deep fixity equals T4a, skin involvement equals T4b; once a breast tumour is T4, its diameter no longer alters the T stage.
Important Questions from Neck & Breast Surgery
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2. Radiological assessment
3. Histopathological assessment
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