Case history

A 50 year old climateric woman presented to surgical outpatients complaining of a lump in her right breast. She had noticed the lump while showering four weeks previously and came to the hospital after encouragement from her partner. She did not complain of any nipple discharge or mastalgia. On examination the right nipple was slightly retracted. The lump was 20 x 20 mm in size, firm in nature, irregular to feel, and situated in the upper lateral quadrant of the breast. No axillary nodes were palpable. There was no hepatomegaly.

A mammogram taken during the course of these investigations is shown.

Questions

1. What series of investigations should be undertaken in this lady?
2. What two views of the breast are done as standard on mammography and which is shown in this case?
3. What abnormal radiological features can be seen on this film?
4. It was decided to perform surgery on the woman's right breast.
5. How does a radiologist help the surgeon to prepare the patient for surgery?
6. What does the UK NHS Breast Screening Programme entail?

Answers

1. For a woman of this age complaining of a breast lump, triple assessment is necessary. This entails:
   • Physical examination (breasts, axillary, and supraclavicular lymph nodes, liver and the spine).
   • Imaging: mammography and/or an ultrasound scan of the breasts. (This should be performed before the fine needle aspiration or core biopsy.)
   • Pathology: fine needle aspiration cytology and/or a core biopsy of the breast lump.

   Eighty to ninety per cent of suspected cases of breast malignancy are diagnosed with this triple assessment. Ultrasound helps to distinguish solid from cystic lesions and is of more value in the under 40 year olds in whom the higher glandula:dipose ratio of the breast makes mammography more difficult to interpret.

2. A mediolateral (across the breast) and craniocaudal (from head to toe) view is taken. The mediolateral view is especially valuable in visualising the axillary tail of the breast.
3. The three main features seen on this film, all of which are characteristic of breast malignancy are:
   • A distortion of the normal structure, especially the outline, of the breast.
   • Microcalcification (seen as "bright dots").
   • A mass lesion which is spiculated in nature.

   The axillary nodes in this film also lack fat centrally which suggests infiltration.

4. For those women not having a partial mastectomy--that is, part of the breast is to be retained--preoperative wire guided localisation can be undertaken if the lesion is not palpable. The radiologist inserts a fine hooked wire into the lump under ultrasound guidance, or, if not visible on ultrasound, using stereotaxis, so that the surgeon can accurately locate the lump in theatre.
5. The UK NHS Breast Screening Programme invites women between the ages of 50 and 64 years of age to attend screening every three years. At the initial consultation two view mammography is done comprising mediolateral and craniocaudal view of each breast. It is government policy to increase the screening age to 69 by 2004.

For more professional information on breast cancer visit www.cancerbacup.org.uk/info/breast.htm.

For details on mammography and its indications see Making the Best Use of a Department of Clinical Radiology, 4th edition, from the Royal College of Radiologists (London, 1998), pp 68-71.

Key terms

• Mastalgia: pain arising from the breasts.
• Mammography: x ray examination of the breasts.
• Spiculated: splinter-like in appearance.
• Stereotaxis: The use of two radiographs taken 5 degrees from vertical which using computer software give a 3D coordinate set for the lesion, allowing image guided wire placement.

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