The symptomatic breast patient

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

• Roger Watkins,
• Consultant Surgeon,
• Derriford Hospital, Plymouth

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Basis of triple assessment

• Clinical examination
• Imaging mammogram, ultrasound
• Cellular or tissue diagnosis

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History Presenting complaint

• Lump
• Pain
• Nipple discharge
• Skin or nipple change
• Alteration in size or shape of breast

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Breast lump

• Site
• Duration
• Mobility
• Variation
• Pain/tenderness

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Breast pain (mastalgia)

• Site
• Description
• Radiation
• Variation including cyclical changes
• Exacerbating and relieving factors

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Nipple discharge

• Spontaneous - expressible
• Single duct multi-duct
• Colour
• Amount

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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

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Breast examination

• Skin and nipple - Dimpling or nipple inversion
• Ulceration
• Erythema
• Oedema
• Discrepancy in size

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Examination of the axillary and supra-clavicular
lymph nodes

• Number
• Size
• Consistency
• Position
• Mobility

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Investigations

• Standard investigations
• Mammogram, ultrasound
• Additional investigations
• MR1, PET, thermograms, scintigraphy

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Mammograms Indications

• Patient aged over 40 years with significant
  symptoms or signs
• Recent nipple inversion
• Blood stained discharge
• Mass lesion
• Axillary lymphadenopathy
• Family history

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Mammograms Standard views

• Medio-lateral oblique
• Cranio-caudal

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Mammograms medio-lateral oblique
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Mammograms cranio-caudal
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Mammograms additional views

• Extended cranio-caudal (medial or lateral
  extension)
• True lateral (medio-lateral)
• Spot views with compression magnification
• Eklund technique to displace prostheses

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Magnification mammograms spot views
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Mammographic features

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

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Ultrasound Indications

• Discrete mass v diffuse nodularity?
• Mass lesion solid versus cystic?
• Solid mass lesion benign versus malignant?

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Ultrasound
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Breast ultra-sound

• Standard images
• characteristics of discrete lesions
• outline, echogenicity, shape, shadowing
• or attenuation
• Colour flow Doppler
• blood flow

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Cytology versus HistologyFNAC versus WBCNB

• Ease
• Speed of procedure and diagnosis
• Patient acceptability
• Accuracy of diagnosis, sensitivity and
  specificity
• Diagnosis of invasion?
• Repeat procedure?

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Evolution of Core Biopsy Needles

• Manual - TruCut
• Semi-automatic SuperCore (spring loaded)
• Automatic Bard Gun UltraCore, TruCore
• Vacuum assisted Vacora

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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

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WB CNB Additional information

• In situ versus invasive tumour
• Histological grade and type of tumour
• ER and PR status
• HER2 status
• Marker
  placement

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Special problems (1) Pagets disease

• Nipple inflammation, erosion, ulceration,
  bleeding
• Pagets disease versus eczema
• Nipple sparing, areola only affected
• Unilateral versus bilateral?
• Other lesions?

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Pagets disease punch or wedge biopsy
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Pagets disease exfoliative cytology
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Special problems (2) inflammatory carcinoma

• Generalised enlargement of breast but no discrete
  mass
• Oedema of overlying skin (peau dorange)
• Erythema
• Nodal enlargement
• Negative imaging
• Skin biopsy tumour cells in dermal lymphatics

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Special problems (3) Augmentation mammoplasty
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Special problems (3) Augmentation mammoplasty

• Careful mammography
• Very careful FNAC and CB (ultrasound control)

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Conclusions Diagnosis

• Accurate history
• Careful examination
• Appropriate investigations not every patient
  requires full triple assessment

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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