Triple Assessment Flashcards
What is triple assessment?
Triple assessment is the mainstay of assessment of breast disease. Its aims are to allow a diagnosis to be established in the majority of patients without the need for diagnostic surgical excision, and to minimise the changes of missing a cancer.
How is the triple assessment used to detect breast cancers?
• Each component of triple assessment is scored on a 1-5 scale.
o normal
o benign
o indeterminate/probably benign
o suspicious
o malignant
• Different prefixes are given to the various components – for example ‘P’ stands for ‘palpation’, and ‘M’ stands for ‘mammography’.
• Not all cancers are palpable, and not all cancers are seen on imaging, so the use of all three components together with concordance (agreement) between them at MDT, helps to minimise the chance of missing a cancer.
What are the 3 components of the triple assessment?
Clinical assessment
Imaging
Biopsy
What suggests breast cancer in a history?
Breast lump: Site, onset, character- soft, hard, smooth or irregular, any pain, other associated symptoms, time course of lump.
Key symptoms in a breast history to ask about include:
• Nipple discharge or bleeding: associated with infection (e.g. mastitis and breast cancer).
• Nipple inversion: recent onset nipple inversion is typically associated with breast cancer.
• Erythema: associated with breast abscess, mastitis and underlying breast cancer.
• Ulceration: typically associated with breast cancer.
• Dimpling (peau d’orange): associated with underlying breast cancer.
• Fever: may indicate underlying infection (e.g. breast abscess).
• Weight loss: may indicate underlying breast cancer.
• Malaise: associated with breast abscess and breast cancer.
• Lymphadenopathy: typically involving the lymph nodes of the axilla and neck (e.g. breast cancer, breast abscess).
• Bone pain: consider the possibility of metastatic breast cancer.
Ask about menarche and menopause
Treatment with HRT
Breastfeeding
PMH, FHx, DH, SH
Risk factors include obesity and alcohol
Obesity means increased fat which produces more oestrogen increasing risk of breast cancer.
What suggests breast cancer in an examination?
Describe mass in terms site, size, shape, consistency, fixity to skin or mobility, tethering to muscle and any associated skin changes.
Skin tethering means that the lump is attached to the skin, but can be moved in an arc without moving the skin. If the lump is pulled outside the arc, the skin indents.
Skin fixation is where the lump cannot be moved without moving the skin.
Which categories is used to differentiate breast cancer?
o Breast imaging falls into two broad categories:
Symptomatic breast imaging is performed on women who present with a breast symptom, usually in the setting of a symptomatic breast clinic.
Breast screening refers to mammography performed on asymptomatic women as part of a breast screening programme.
Which imaging is always performed in a patient complaining of a breast lump?
o When a patient complains of a breast lump, ultrasound is always performed, regardless of whether the woman has also had a mammogram.
Should you do imaging of the breast if there is no clinically palpable abnormality?
o Imaging is also performed regardless of whether or not there is a clinically palpable abnormality.
What is a mammogram?
This is an X-ray examination of the breast.
Mammograms are usually displayed back-to-back to highlight any asymmetry between the two breasts.
It is used to detect and diagnose breast disease in women who either have breast problems, such as a lump, pain, or nipple discharge, as well as for women who have no breast complaints.
The procedure allows detection of breast cancers, benign tumours, and cysts before they can be detected by palpation (touch).
How many views does a standard mammogram contain?
A standard mammogram consists of two views of each breast: a mediolateral oblique (MLO) view and a craniocaudal (CC) view.
MLO is used to help see the axillary tail of breast tissue.
MLO decides if lesion is in the upper or lower quadrant and CC view decides if lesion is in the inner or outer region.
The outer region is at the top of the film in a CC view.
In common with other radiological examinations, images are displayed so that the patient’s right is on the viewer’s left, and vice versa.
How many film readers is required to interpret a mammogram?
All mammograms read by 2 trained film readers (radiologists, breast physicians or radiographers).
What is the duration of background radiation associated with a mammogram?
It gives 2 months’ worth of radiation.
Can the radiographer that perform the mammogram be male?
the radiographer that performs the scan is always female. As the profession is exempt from the Sex Discrimination Act
Can a mammogram confirm that an abnormal area is cancerous?
Mammography cannot prove that an abnormal area is cancer, but if it raises a significant suspicion of cancer, tissue will be removed for a biopsy. Tissue may be removed by needle or open surgical biopsy and examined under a microscope to determine if it is cancer.
What affects the sensitivity of the mammogram the most?
The sensitivity of mammography is dependent on the density of the breasts. In dense breasts (those with a high proportion of fibro glandular tissue compared to fat), mammography is much less effective in detecting signs of breast cancer.
Younger women tend to have denser breasts, and also a lower incidence of breast cancer, and therefore mammography tends to be performed only on women over 40, unless there is a strong clinical suspicion of malignancy.
Ultrasound is used first line in younger women who need breast imaging.
What are the indications for mammography?
- Women older than 30 years should undergo diagnostic mammography if they have symptoms, such as a palpable lump, breast skin thickening or indentation, nipple discharge or retraction, erosive sore of the nipple, or breast pain.
- Women who are at high risk for breast cancer or with a history of breast cancer may be routinely screened with mammography.
Why do you compress the breast for mammography?
- Firstly, the compression ‘spreads out’ the glandular tissue of the breast, reducing the problem of overlapping structures.
- Compression also holds the breast still during exposure, reducing the risk of blurring of the mammogram which may obscure small details.
- A compressed breast is uniformly thin which helps to avoid problems with under- or overexposure of parts of the image.
- Finally, making the breast thinner reduces the radiation dose that a woman receives during mammography.
- Breast compression cannot cause cancer to spread.
What are factors that interfere with a mammogram?
- Talcum powder, deodorant, creams, or lotions applied under the arms or on the breasts
- Breast implants, as they may prevent complete visualization of the breast. This is important because breast implants can hide some breast tissue, which could make it difficult for the radiologist to see breast cancer when looking at mammogram images.
- Previous breast surgery
- Hormonal breast changes
What are the features seen on a normal mammogram?
- Tissue that is denser, including connective tissue and glands, shows up white.
- Some people have more dense tissue in their breasts. This can make it harder to detect abnormalities on a mammogram as a tumour is made up of dense tissue and will also appear white.
- The breasts tend to become less dense with age. Less dense tissue, such as fat, shows up grey on a mammogram.
- A standard mammogram will usually be mostly grey, with some white areas showing healthy dense tissue. More white on the image does not always indicate a health problem.
What are the abnormal features of a mammogram?
- Any area that does not look like normal tissue is a possible cause for concern.
- The radiologist will look for areas of white, high-density tissue and note its size, shape, and edges.
- A lump or tumour will show up as a focused white area on a mammogram. Tumours can be cancerous or benign.
- Other abnormalities include:
o Cysts, which are small fluid-filled sacs. Most are simple cysts, which have a thin wall and are not cancerous.
o Calcifications, which are deposits of calcium. Larger deposits of calcium are called macrocalcifications and they usually occur as a result of aging. Smaller deposits are called microcalcifications. Depending on the appearance of the microcalcifications, a doctor may test them for possible signs of cancer.
o Fibroadenomas, which are benign tumours in the breast. They are round and may feel like a marble. People in their 20s and 30s are more likely to have a fibroadenoma, but they can occur at any age.
o Scar tissue, which often appears white on a mammogram. It is best to make a doctor aware of any scarring on the breasts beforehand.
How are mammograms interpreted?
When mammograms are interpreted, they are given a score which conveys the level of concern about the findings on the mammogram, in the same way as the P score is used in clinical examination.
o Mammography scores use the prefix ‘M’ followed by a number: M1: normal M2: benign M3: probably benign/uncertain M4: suspicious M5: malignant
Why is ultrasound used in breast imaging?
Ultrasound is a method of imaging which uses high-frequency sound waves to form an image of the tissues. It does not involve ionising radiation.
Ultrasound is especially effective for investigating focal breast symptoms such as a lump and can be very useful in women with dense breasts.
Ultrasound is very good at distinguishing between cystic and solid masses.
Fluid appears black on ultrasound scan, whereas solid tissue appears as varying shades of grey.
Ultrasound is also useful at distinguishing benign from malignant masses, although there is some overlap in their appearances.
When is ultrasound the first choice in breast imaging?
It is the technique of choice in women under 40 years of age, and is used in conjunction with mammography for those over 40.
How are ultrasound findings interpreted?
Ultrasound findings are scored from 1-5 in the same way as clinical examination and mammography findings, but the prefix ‘U’ is used.
