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

Mammography

• 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

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

• 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

Cysts

• 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

Bibliography