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Breast assessment

Symptoms that may indicate breast cancer

  • Breast lump
  • Breast pain
  • Change in the size or shape of the breast
  • Swelling of the arm (lymphoedema)
  • Dimpling of the breast skin
  • Involution or inversion of the nipple
  • Axillary lymphadenopathy
  • Nipple discharge or bleeding
  • Ulceration of the breast skin
  • Bone or abdominal pain / jaundice

Symptoms requiring specialist referral

  • Lumps
    • All new discrete breast lumps
    • A new lump in pre-existing nodularity
  • Asymmetrical nodularity persisting after menstruation
  • Breast abscess
  • Persistently refilling or recurrent cysts
  • Axillary lymphadenopathy
  • Breast pain
    • Pain associated with a lump
    • Persistent unilateral pain in a postmenopausal woman
  • Nipple discharge
    • All women aged over 50 years
    • Women aged below 50 years with:
      • Bilateral discharge sufficient to stain clothes
      • Blood-stained nipple discharge
      • Persistent discharge from a single duct
  • Family history

Triple assessment

  • Triple assessment comprises of
    • Clinical examination
    • A radiological assessment mammography or ultrasound
    • A pathological assessment cytology or biopsy

Breast imaging

  • The breast can be imaged with mammography, ultrasound or MRI
  • Mammography is the most sensitive of breast imaging modalities
  • Sensitivity is reduced in young women due to the presence of increased glandular tissue
  • For symptomatic patients, imaging always be performed as part of triple assessment


  • Abnormalities detected on mammography are classified as:
    • Spiculated masses
    • Stellate lesions
    • Circumscribed masses
    • Microcalcification

Spiculated masses

  • Soft tissue mass with spicules extending into surrounding tissue
  • 95% of spiculated masses are due to invasive cancer
  • Other causes of spiculated masses include:
    • Ductal carcinoma in-situ (DCIS)
    • Radial scar / complex sclerosing lesion
    • Fat necrosis
    • Fibromatosis
    • Granular cell myoblastoma
Spiculated mass on mammography - craniocaudal view Spiculated mass on mammography - lateral view

Stellate lesions

  • Localised distortion of the breast parenchyma with no perceptible mass lesion
  • Differential diagnosis of stellate lesions includes:
    • Radial scar
    • Invasive cancer
    • DCIS
    • Surgical scar

Circumscribed masses

  • Circumscribed masses should be analysed according to density, outline and size
  • Differential diagnosis of circumscribed masses includes:
    • Fibroadenoma
    • Cyst
    • Mucinous or medullary carcinoma
    • Lipoma
    • Abscess


  • Microcalcification is due to debris within the duct wall or lumen
  • Sole feature of 33% of screen-detected cancers
  • Malignant microcalcification is usually linear or branching
  • Benign microcalcification is usually rounded and punctate
  • Differential diagnosis of microcalcification includes:
    • DCIS
    • Invasive cancer
    • Papilloma
    • Fibroadenoma
    • Fat necrosis

Breast ultrasound

  • Ultrasound is useful in the assessment of breast lumps
  • Complements mammography and is able to differentiate solid and cystic lesions
  • Also able to guide fine needle aspiration and core biopsies
  • Can be used to assess tumour size and response to therapy
  • In the diagnosis of malignancy it has a sensitivity and specificity of 75% and 97% respectively
  • Cysts and solid lesions have typical appearances

Circumscribed lesion on breast ultrasound


  • On ultrasound examination cysts have:
    • Smooth walls
    • Sharp anterior and posterior borders
    • Black hypoechoic centres without internal echoes

Solid lesions

  • Solid lesions have internal echoes
  • Malignant tumours have:
    • Hypoechoic areas interspersed between brighter echoes
    • Irregular edges
    • Cast hypoechoic shadows
  • Benign tumours have:
    • Isoechoic or hypoechoic patterns
    • Smooth well defined borders
    • Cast no hypoechoic shadows



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