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The symptomatic breast patient revision of history, examination and basic investigations

Basis of triple assessment". Clinical examinationImaging: mammogram, ultrasoundCellular or tissue diagnosis. History: Presenting complaint. LumpPainNipple dischargeSkin or nipple changeAlteration in size or shape of breast . Breast lump. SiteDurationMobilityVariationPain/tenderness. Brea

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The symptomatic breast patient revision of history, examination and basic investigations

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    1. The symptomatic breast patient – revision of history, examination and basic investigations Roger Watkins, Consultant Surgeon, Derriford Hospital, Plymouth

    2. Basis of “triple assessment” Clinical examination Imaging: mammogram, ultrasound Cellular or tissue diagnosis

    3. History: Presenting complaint Lump Pain Nipple discharge Skin or nipple change Alteration in size or shape of breast

    4. Breast lump Site Duration Mobility Variation Pain/tenderness

    5. Breast pain (mastalgia) Site Description Radiation Variation including cyclical changes Exacerbating and relieving factors

    6. Nipple discharge Spontaneous - expressible Single duct –multi-duct Colour Amount

    7. Relevant past history Age at menarche and menopause Oral contraceptive and HRT usage Pregnancies and breast feeding Previous breast disease Family history breast and ovarian cancer

    8. Breast examination Skin and nipple - Dimpling or nipple inversion Ulceration Erythema Oedema Discrepancy in size

    9. Examination of the axillary and supra-clavicular lymph nodes Number Size Consistency Position Mobility

    10. Investigations Standard investigations: Mammogram, ultrasound Additional investigations: MR1, PET, thermograms, scintigraphy

    11. Mammograms: Indications Patient aged over 40 years with significant symptoms or signs Recent nipple inversion Blood stained discharge Mass lesion Axillary lymphadenopathy Family history

    12. Mammograms: Standard views Medio-lateral oblique Cranio-caudal

    13. Mammograms: medio-lateral oblique

    14. Mammograms: cranio-caudal

    15. Mammograms: additional views Extended cranio-caudal (medial or lateral extension) True lateral (medio-lateral) Spot views with compression +magnification Eklund technique to displace prostheses

    16. Magnification mammograms; spot views

    17. Mammographic features Technical quality General appearance (density of tissue - Wolfe pattern) Abnormalities Asymmetry Abnormal density Stromal distortion Mass lesion Calcification

    18. Ultrasound: Indications Discrete mass v diffuse nodularity? Mass lesion: solid versus cystic? Solid mass lesion: benign versus malignant?

    19. Ultrasound

    20. Breast ultra-sound Standard images characteristics of discrete lesions outline, echogenicity, shape, shadowing or attenuation Colour flow Doppler blood flow

    21. Cytology versus Histology FNAC versus WBCNB Ease Speed of procedure and diagnosis Patient acceptability Accuracy of diagnosis, sensitivity and specificity Diagnosis of invasion? Repeat procedure?

    22. Evolution of Core Biopsy Needles Manual - TruCut Semi-automatic – SuperCore (spring loaded) Automatic – Bard Gun – UltraCore, TruCore Vacuum assisted – Vacora

    23. FNAC v WBCNB Results FNAC C1 inadequate C2 benign C3 probably benign C4 suspicious of malignancy C5 malignant WBCNB B1 normal tissue B2 benign lesion B3 probably benign B4 suspicious of malignancy B5 malignant B5a in situ B5b invasive B5c indeterminate

    24. WB CNB: Additional information In situ versus invasive tumour Histological grade and type of tumour ER and PR status HER2 status Marker placement

    25. Special problems (1)– Paget’s disease Nipple inflammation, erosion, ulceration, bleeding Paget’s disease versus eczema Nipple sparing, areola only affected Unilateral versus bilateral? Other lesions?

    27. Paget’s disease – punch or wedge biopsy

    28. Paget’s disease – exfoliative cytology

    29. Special problems (2) – inflammatory carcinoma Generalised enlargement of breast but no discrete mass Oedema of overlying skin (peau d’orange) Erythema Nodal enlargement Negative imaging Skin biopsy: tumour cells in dermal lymphatics

    30. Special problems (3) – Augmentation mammoplasty

    32. Special problems (3) – Augmentation mammoplasty Careful mammography Very careful FNAC and CB (ultrasound control)

    33. Conclusions: Diagnosis Accurate history Careful examination Appropriate investigations – not every patient requires full triple assessment

    34. Conclusions: Diagnosis Unequivocal diagnosis: benign v. malignant Plan treatment Equivocal diagnosis (discordant results) Assume most suspicious result(s) to be accurate: repeat initial investigations plan further investigations open biopsy but not frozen section

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