T5: Triple assessment of breast lumps

Question 1

Give a brief description of the structure of the breast.

Answer 1

Lies on top of the chest wall on top of the pectoralsi major. The breast is composed of lobules, these are joined by stem, branches and stalks. The lobules are the glandular parts of the breasts and can develop into carcinoma. The lobules are surrounded by fat. The whole thing is then covered in skin. On the skin is nipple and nipple areola complex (more pigmented). This is the area of the breast that will excrete the milk through the Lactiferous ducts that converge on the nipple. The Lactiferous ducts branch to link up the lobules of the breasts.

Question 2

What percentage of breast lumps are due to benign breast disease?

Answer 2

80%

Question 3

List causes of breast lumps.

Answer 3

• Carcinoma
• Hamartoma - normal elements in an unorganised way
• Fibroadenoma p:
  Fibroadenoma - most common - benign tissue composed of a proliferation of the stroma and glandular element
• Lipoma
• Cyst
• Fibrocystic change - constellation of benign changes between stromal and glandular elements

Question 4

What is involved in the triple assessment of breast lumps?

Answer 4

1. Clinical assessment (examination)
2. Imaging (Ultrasound and mammography)
3. Pathology (Biopsy and/or cytology)

Question 5

Give features of breast lumps.

Answer 5

• Mobile/fixed
• Well-defined or not
• Smooth/Irregular?
• Firmness?
• Location?

Question 6

How is the breast split into locations?

Answer 6

Using Quadrants or using a clock

Question 7

List features of nipple symptoms.

Answer 7

• Inversion (can be normal)
• Discharge (milky, blood stained, green etc.)
• Rash

Question 8

List skin changes screened for in clinical examination.

Answer 8

• Oedema
• Ulceration /fungating lesion
• Orange skin like “Peau d’orange)
• Retraction/tethering

Question 9

What is the P code?

Answer 9

Used in examination: 
P1 - Normal 
P2 - Benign lesion
P3 - Atypical, probably benign lesion
P4 - Atypical, probably malignant lesion
P5 - Malignant

Question 10

How is the breast radiologically examined? What code is used?

Answer 10

Ultrasound - fat appears white and fibro-glandular tissue appears white
Mammogram - X-ray of the breast from several angles. The picture is various shades of grey. fat appears black and any other solid masses white. Mammograms also show calcification specks of white. Often we are not looking for calcifications in vessels. But we can see this in glandular breast tissue that can be a signs of malignancy or benign change.

Use the R code;
R1 - Normal 
R2 - Benign lesion
R3 - Atypical, probably benign lesion
R4 - Atypical, probably malignant lesion
R5 - Malignant

Question 11

How is the breast pathologically examined? what code is used?

Answer 11

• In most cases a core biopsy is taken
  
  • If thought to be a cyst, the fluid can be taken out and taken to cytology
  • If the lesion is difficult to feel you can do it under imaging guidance
    This is then taken to the lab and put in cassettes and the tissue is embedded in wax to be cut, laid on a glass slide and stained.

Use the B code or C code for cystic samples.
Follows the same meaning.

B/C1 - Normal (insufficient for C)
B/C2 - Benign lesion
B/C3 - Atypical, probably benign lesion
B/C4 - Atypical, probably malignant lesion
B/C5 - Malignant