Chapter 1: Screening, diagnosis & staging of breast cancer and multidisciplinary team working
Clinical examination and imaging
Family history of BC, age at menarche, number of births and pregnancies, age at first birth, history of breast biopsies and breast operations, date of the last menstrual period, use of hormone replacement therapy, and detection of a breast tumour in mammography screening are key histories to note.
Figure 1.4: Breast palpation and position of patient.
Credit: Dr Mazen Sudah, Department of Radiology, Kuopio University Hospital, Dr Katja Hukkinen, Department of Radiology, Helsinki University Hospital and Dr Päivi Heikkilä, Department of Pathology, Helsinki University Hospital.
The breasts should be palpated when the patient is sitting or standing, the arms hanging freely as well as elevated (A, B). The examination is repeated when the patient is lying supine (C, D).
Lesions located in the upper parts of the breast are best detected with the patient sitting or standing (A, B). Lesions in the lower parts of the breast may become obvious only when the patient is lying supine with the arms elevated (D).
Figure 1.5: The triple test approach to diagnosis.
Credit: Dr Mazen Sudah, Department of Radiology, Kuopio University Hospital, Dr Katja Hukkinen, Department of Radiology, Helsinki University Hospital and Dr Päivi Heikkilä, Department of Pathology, Helsinki University Hospital.
The triple diagnostic approach consists of breast inspection and palpation, breast imaging usually with mammography and US, and core needle biopsies (CNBs) of suspicious breast lesion(s).
When one of the components of the triple diagnostic approach is suspicious, a repeated core biopsy or surgical biopsy should follow, even when the other components do not suggest cancer.
Breast imaging should precede a biopsy, since a haematoma or other tissue alterations may interfere with image interpretation. Breast imaging usually consists of mammography and US examination of the breast and the axilla.
Figure 1.6: Mammography findings.
Credit: Dr Mazen Sudah, Department of Radiology, Kuopio University Hospital, Dr Katja Hukkinen, Department of Radiology, Helsinki University Hospital and Dr Päivi Heikkilä, Department of Pathology, Helsinki University Hospital.
Typical findings suggestive of cancer on mammography include an irregular mass, star-like (stellate) or specular lesions, microcalcifications and structural distortions. The sensitivity of mammography is lower in patients with dense breast tissue, typically associated with younger age.
BC usually causes an echo-poor irregular lesion on US.
Benign and malignant lesions cannot always be reliably distinguished by breast imaging. Some BCs resemble a benign lesion, viewed as a regular and well-defined mass.
Revision questions
- What are the key points to note in the patient’s history?
- What components are included in the triple diagnostic approach?
- What are the findings typical of BC on mammography?
