Triple Assessment

Question 1

What is triple assessment?

Answer 1

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.

Question 2

How is the triple assessment used to detect breast cancers?

Answer 2

• 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.

Question 3

What are the 3 components of the triple assessment?

Answer 3

Clinical assessment
Imaging
Biopsy

Question 4

What suggests breast cancer in a history?

Answer 4

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.

Question 5

What suggests breast cancer in an examination?

Answer 5

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.

Question 6

Which categories is used to differentiate breast cancer?

Answer 6

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.

Question 7

Which imaging is always performed in a patient complaining of a breast lump?

Answer 7

o When a patient complains of a breast lump, ultrasound is always performed, regardless of whether the woman has also had a mammogram.

Question 8

Should you do imaging of the breast if there is no clinically palpable abnormality?

Answer 8

o Imaging is also performed regardless of whether or not there is a clinically palpable abnormality.

Question 9

What is a mammogram?

Answer 9

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).

Question 10

How many views does a standard mammogram contain?

Answer 10

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.

Question 11

How many film readers is required to interpret a mammogram?

Answer 11

All mammograms read by 2 trained film readers (radiologists, breast physicians or radiographers).

Question 12

What is the duration of background radiation associated with a mammogram?

Answer 12

It gives 2 months’ worth of radiation.

Question 13

Can the radiographer that perform the mammogram be male?

Answer 13

the radiographer that performs the scan is always female. As the profession is exempt from the Sex Discrimination Act

Question 14

Can a mammogram confirm that an abnormal area is cancerous?

Answer 14

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.

Question 15

What affects the sensitivity of the mammogram the most?

Answer 15

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.

Question 16

What are the indications for mammography?

Answer 16

• 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.

Question 17

Why do you compress the breast for mammography?

Answer 17

• 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.

Question 18

What are factors that interfere with a mammogram?

Answer 18

• 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

Question 19

What are the features seen on a normal mammogram?

Answer 19

• 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.

Question 20

What are the abnormal features of a mammogram?

Answer 20

• 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.

Question 21

How are mammograms interpreted?

Answer 21

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

Question 22

Why is ultrasound used in breast imaging?

Answer 22

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.

Question 23

When is ultrasound the first choice in breast imaging?

Answer 23

It is the technique of choice in women under 40 years of age, and is used in conjunction with mammography for those over 40.

Question 24

How are ultrasound findings interpreted?

Answer 24

Ultrasound findings are scored from 1-5 in the same way as clinical examination and mammography findings, but the prefix ‘U’ is used.

Question 25

What are the two useful features for distinguishing benign and malignant masses?

Answer 25

Two very useful features for distinguishing benign and malignant masses are the shape and the margin of the mass.

Question 26

What is the difference in shape of a benign mass and a malignant mass?

Answer 26

In terms of shape, benign masses tend to be round/ovoid whereas malignant masses tend to be irregular.

Question 27

What is the difference in margin of a benign mass and a malignant mass?

Answer 27

In terms of margin, benign masses tend to be well-defined whereas malignant masses tend to be ill-defined.

Question 28

Why is ultrasound image better when doing a biopsy?

Answer 28

Ultrasound produces a real-time image of the tissues, whereas mammography produces a static image.

Real-time imaging means that you can use the ultrasound image to guide the needle to ensure it is correctly placed in the lesion during biopsy.

Question 29

What other structure do you image when assessing breast cancer with ultrasound?

Answer 29

It is essential to scan the axilla in a patient with suspected breast cancer with ultrasound.

Axillary nodal status is a very important prognostic factor (together with size and grade of cancer), with a direct correlation seen between survival and the number of involved axillary nodes.

Question 30

What treatment do you offer patients with abnormal axillary lymph nodes?

Answer 30

patients with abnormal axillary nodes demonstrated on ultrasound and confirmed by FNA/core biopsy, will be offered axillary node clearance.

Question 31

What is offered to invasive breast cancer patients with normal lymph nodes?

Answer 31

Patients with a normal pre-operative axillary assessment will be offered a sentinel node biopsy. In this patient the axillary scan is normal.

Question 32

Which other imaging is offered to patient with lobular carcinoma?

Answer 32

Most patients with invasive lobular carcinoma will have an MRI scan prior to surgical planning, to define the extent of the cancer, and to identify multifocal and contralateral disease.

Question 33

What is core needle biopsy?

Answer 33

• Ultrasound or stereotactic mammographic guidance can be used.
• A core needle biopsy consists of using a small needle to take out a thin core of tissue from the abnormal area.
• This is often done under radiographic guidance by breast radiologists and can be done in association with a mammogram, an MRI or an ultrasound.
• A core needle biopsy is the most common type of specimen obtained for initial evaluation of a breast mass or radiographic abnormality.

Question 34

What is open biopsy?

Answer 34

• Radio-opaque needles used to guide biopsy.

* It can usually be done under local anaesthetic.

Question 35

What is fine needle aspiration?

Answer 35

• High accuracy combined with mammography.
• Negative results do not exclude carcinoma.
• False negatives are high and false positives are very low.
• An FNA consists of using a fine needle to pull out (aspirate) cells from the lesion. A lesion which appears to be a simple benign cyst may be aspirated by FNA.
• Most FNAs are done in association with imaging, such as an ultrasound.

Question 36

What is excisional biopsy?

Answer 36

• Excisional biopsies consist of removal of a larger amount of tissue than is removed with a core needle biopsy.
• For instance, the tissue may measure 2 x 2 cm. These are performed by surgeons in an operating room.
• If a mass is very deep in the breast, such as adjacent to the chest wall, it may be too deep to be reached by a core needle biopsy. In these cases, excisional biopsy may be the only way to sample the tissue.
• Can be done under local anaesthesia.
• Margins should be inked after removal.

Question 37

What is incisional biopsy?

Answer 37

Part of lesion removed.

For lesions 4cm or larger.

Question 38

What are the advantages of FNA over core biopsy?

Answer 38

• FNA is quick and easy to perform.
• Processing times are rapid, with a result available in as little as 30 minutes (compared to several days for a core biopsy)
• It is a low-cost procedure.
• It has very few complications.

Question 39

What are the disadvantages of FNA over core biopsy?

Answer 39

• FNA interpretation requires a highly trained and experienced pathologist.
• It is difficult to classify a 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.