Clincal Assessment

Question 0

What is the affect of age on developing breast cancer?

Answer 0

Risk of developing breast cancer by:

• age 29 = 1/2900
• age 39 = 1/215
• age 49 = 1/50
• age 59 = 1/22
• age 69 = 1/13
• age 79 = 1/11

Question 1

What is the lifetime risk of developing breast cancer?

Answer 1

1 in 8

Question 2

How does parity affect the incidence of breast cancer?

Answer 2

Reduces risk:
- A mother of 5 has half the risk of nulliparous woman.

Younger age at 1st full-term pregnancy also reduces risk:
- If 1st baby at 20, has half risk than if at 30.

Question 3

By what percentage is the risk of breast cancer lowered for each year of breastfeeding?

Answer 3

4%

Question 4

What is the significance of breast symptoms that are associated with the menstrual cycle?

Answer 4

Breast symptoms that vary with menstrual cycle are very likely to be associated with benign breast disease.

Question 5

What affect can taking HRT have on breast disease?

Answer 5

Associated with a 55-100% increase in beast cancer risk compared to never-users.

Both post menopausal and menopausal women taking HRT may extend the age at which they are likely to suffer from benign breast conditions such as cysts.

Question 6

What do we do with any discharge in examination of the breast?

Answer 6

Send for cytology and microbiology

Question 7

How do we get a sample of breast lump?

Answer 7

Cystic lumps - aspirated (FNA)

Solid lumps - core biopsy for histology

Question 8

What imaging does a lady with a breast symptoms get?

Answer 8

If over 35, mammography (X-ray) +- US

If under 35, US

Question 9

What is the P score?

Answer 9

When a clinical breast examination is performed, the findings are recorded on a diagram and given a P score for the level of suspicion for malignancy.

P1: normal 
P2: benign
P3: uncertain/probably benign
P4: suspicious
P5: malignant

Question 10

What is Paget’s disease of the breast?

Answer 10

Eczema-like scaly red rash in skin of the nipple related to an underlying breast malignancy

Question 11

Where do accessory (supranumerary) nipples occur?

Answer 11

Along the mammary ridge that develops in the embryo along the trunk on either side from the axilla to the groin.

May be just nipples or have associated breast tissue.

May be mistaken for moles, but have characteristic appearance and site and are present from birth.

Relatively common (lily Allen, zac efron)

Question 12

What are the two views obtained at a mammogram?

Answer 12

Mediolateral oblique (MLO) 
Craniocaudal (CC)

Mammogram is X-ray of breast.

Question 13

Why is the breast compressed during mammography?

Answer 13

• To spread out the glandular tissue, reducing the problem if overlapping structures
• To hold the breast still, reducing blurring which may obscure small details
• A breast which is uniformly thin helps to avoid problems with over or under exposure of parts of the image
• Making the breast thinner reduces the radiation received

Question 14

Why is a mammogram not done on women under 35?

Answer 14

Mammogram is sensitive to density of breasts - much less effective in detecting signs of breast cancer in dense breasts (have a high proportion of fibroglandular tissue compared to fat).

Younger women have denser breasts (and lower incidence of breast cancer) therefore only done over 35 (40 in some units) unless strong clinical suspicion of malignancy.

Question 15

State four abnormal features that could indicate breast cancer on a mammogram.

Answer 15

Asymmetry - a difference in the pattern of glandular tissue in one breast compared to another.

Architectural distortion - pulling in of breast tissue such that normal pattern of breast tissue is distorted.

Microcalcification - tiny deposits of calcium salts which show up a dense white specks on mammogram.

Mass - space occupying lesion within the breast tissue.

Question 16

How is the level of concern about the findings of a mammogram scored?

Answer 16

M score:

M1: normal 
M2: benign 
M3: probably benign/uncertain
M4: suspicious
M5: malignant

Question 17

How much background radiation is a standard mammogram equivalent to?

Answer 17

2 months worth. (Same as flying London to Australia and back)

(CXR is about 2 days worth)
(Skull X-Ray is about 2 weeks worth)

Question 18

When is ultrasound used in breast assessment?

Answer 18

In women under 35 or in conjunction with mammogram in women older than 35.

Especially effective for investigating focal breast symptoms such as a lump and can be very useful in women with dense breasts.

Ultrasound allows for real time imaging which is very useful when guiding biopsy needle

Question 19

How is the level of concern about the findings of an ultrasound scored?

Answer 19

U score:

U1: normal 
U2: benign
U3: probably benign/uncertain
U4: suspicious
U5: malignant 

Eg U2 for a well defined mass with a smooth ovoid shape and wider than it is fat. Also v black (indicating fluid rather than liquid).

Question 20

When is MRI useful in breast assessment?

Answer 20

• identifying abnormalities in younger women with very dense breast tissue
• evaluating the size of breast cancers that are not clearly seen on mammography and ultrasound
• assessment of breast implants
• unable to distinguish between cancerous and benign abnormalities and therefore many false positives and unnecessary biopsies
• unable to identify microcalcifications

(Patient lies on front between two parts so breasts hanging)

Question 21

What should you tell patients about having MRI breast scan?

Answer 21

• usually need IV contrast during scan
• need to lie on front with breasts hanging through openings on couch
• lasts about 30mins and need to keep still
• scanner is noisy, may be given headphones to wear
• scanner is cylindrical shape and some people may feel claustrophobic
• leave watches and credit cards outside as may stop working
• screen for pacemakers (CI as can malfunction), metal work, 1st trimester of pregnancy

Question 22

What is sentinel node biopsy?

Answer 22

A technique used to assess lymph node spread - the sentinel node is the first axillary node along the lymphatic chain where lymph drains to first.

Identified by injecting a solution of radioactive isotope technithium and blue dye around nipple/areola tissue and around the canacer itself and then using a hand held counter to see which node has turned most blue. This node can then be removed and sent for histology.

Question 23

Which score does FNA use?

Answer 23

C score 1-5

1 is insufficient cells for analysis

Question 24

Which score does core biopsy use?

Answer 24

B score 1-5

5 splits into 5a = non invasive, 5b = invasive

Question 25

4 advantages of FNA to core biopsy in assessment of breast?

Answer 25

• FNA is quicker and easier to perform
• processing times are rapid with results available from 30 minutes (biopsy takes several days)
• low cost procedure
• very few complications

Question 26

4 disadvantages of FNA to core biopsy in assessment of the breast?

Answer 26

• FNA interpretation requires highly trained and experienced pathologist
• difficult to classify malignant lesion as invasive or non invasive
• cytology preparations do not provide the same amount of tissue as a core biopsy
• cytology preparations cannot ascertain receptor status of a cancer

Question 27

What three things is triple assessment made up of?

Answer 27

Triple assessment is a diagnostic method comprising of:

• clinical assessment
• imaging assessment
• pathological scoring

Triple assessment has 97-99% diagnostic accuracy.

Each component is scored on a 1-5 scale.

If the scores all match there is concordance, if not there is disconcordance. Disconcordance will usually get an MDT to decide what will happen next.

Named dual assessment if nothing on scan or examination.