Surgery for AMC MCQ

A 62 year old woman finds a hard, irregular lump in her left breast that feels fixed to the surrounding tissue, with dimpling of the overlying skin. She had a normal BreastScreen mammogram eight months ago and believes this means the lump cannot be serious. She has no pain and is otherwise well. What is the most likely diagnosis?

1. Breast cancer correct Correct. A hard, irregular, fixed lump with skin dimpling in a 62 year old is breast cancer until triple assessment proves otherwise.
2. Breast cysts A smooth, sometimes tender, fluctuant lump that resolves on aspiration. A hard fixed lump with skin dimpling despite a recent normal screen suggests it.
3. Fibroadenoma A smooth, mobile, firm lump in a younger woman, benign but confirmed on triple assessment. A hard fixed lump with skin dimpling despite a recent normal screen points to it.
4. Breast abscess/mastitis A tender, red, warm area with fever, usually in a lactating woman. A hard fixed lump with skin dimpling despite a recent normal screen raises it.
5. Fat necrosis A firm lump after trauma or surgery that can mimic cancer on imaging. A hard fixed lump with skin dimpling despite a recent normal screen argues for biopsy.

The point: A new breast lump in an adult is assessed by triple assessment: clinical examination, imaging with mammography and ultrasound, and needle biopsy. Any discordance between the three components is resolved before reassurance. BreastScreen Australia offers free two-yearly screening mammography to women aged 50 to 74, with 40 to 49 and over 74 able to attend, and screening is for the asymptomatic; a symptomatic woman is investigated regardless of a recent normal screen. Features raising concern are a hard, irregular, fixed lump, skin tethering or dimpling, nipple retraction or bloody discharge, and peau d'orange. Treatment is planned by a multidisciplinary team and combines surgery, either breast-conserving with radiotherapy or mastectomy, with systemic therapy guided by hormone receptor and HER2 status. A woman with a strong family history may warrant earlier and more intensive screening and genetic assessment.

Source: Cancer Council Australia / Cancer Australia — early breast cancer diagnosis and management Cancer Council Australia · tier 2, specialty society or college

A 62 year old woman finds a hard, irregular lump in her left breast that feels fixed to the surrounding tissue, with dimpling of the overlying skin. She had a normal BreastScreen mammogram eight months ago and believes this means the lump cannot be serious. She has no pain and is otherwise well. What is the most appropriate initial investigation?

1. Assessment of family history and genetic risk A strong family history changes screening and may prompt genetic testing. A hard fixed lump with skin dimpling despite a recent normal screen makes it worthwhile.
2. Triple assessment correct Correct. Examination, imaging and biopsy together are how a suspicious lump is worked up, and any discordance is resolved before she is reassured.
3. Sentinel lymph node biopsy Assesses nodal spread with less morbidity than clearance. A hard fixed lump with skin dimpling despite a recent normal screen makes it standard staging.
4. Mammography Detects a spiculated mass and microcalcification, and is the screening and diagnostic imaging in older women. A hard fixed lump with skin dimpling despite a recent normal screen makes it necessary.
5. Breast ultrasound Characterises a lump and guides biopsy, and is the preferred imaging in younger dense breasts. A hard fixed lump with skin dimpling despite a recent normal screen makes it complementary.

The point: A new breast lump in an adult is assessed by triple assessment: clinical examination, imaging with mammography and ultrasound, and needle biopsy. Any discordance between the three components is resolved before reassurance. BreastScreen Australia offers free two-yearly screening mammography to women aged 50 to 74, with 40 to 49 and over 74 able to attend, and screening is for the asymptomatic; a symptomatic woman is investigated regardless of a recent normal screen. Features raising concern are a hard, irregular, fixed lump, skin tethering or dimpling, nipple retraction or bloody discharge, and peau d'orange. Treatment is planned by a multidisciplinary team and combines surgery, either breast-conserving with radiotherapy or mastectomy, with systemic therapy guided by hormone receptor and HER2 status. A woman with a strong family history may warrant earlier and more intensive screening and genetic assessment.

Source: Cancer Council Australia / Cancer Australia — early breast cancer diagnosis and management Cancer Council Australia · tier 2, specialty society or college

A 62 year old woman finds a hard, irregular lump in her left breast that feels fixed to the surrounding tissue, with dimpling of the overlying skin. She had a normal BreastScreen mammogram eight months ago and believes this means the lump cannot be serious. She has no pain and is otherwise well. What is the most appropriate next step in management?

1. Endocrine therapy for hormone-receptor-positive disease Tamoxifen or an aromatase inhibitor for years, reducing recurrence. A hard fixed lump with skin dimpling despite a recent normal screen makes it targeted.
2. Mastectomy For larger or multifocal tumours or by patient choice, with reconstruction offered. A hard fixed lump with skin dimpling despite a recent normal screen makes it the alternative.
3. Chemotherapy for higher-risk disease Neoadjuvant or adjuvant, guided by tumour biology and stage. A hard fixed lump with skin dimpling despite a recent normal screen makes it appropriate.
4. Refer for triple assessment correct Correct. The correct action is prompt referral, not reassurance based on the recent screen.
5. Sentinel lymph node biopsy or axillary clearance Stages and treats the axilla according to nodal involvement. A hard fixed lump with skin dimpling despite a recent normal screen makes it part of surgery.

The point: A new breast lump in an adult is assessed by triple assessment: clinical examination, imaging with mammography and ultrasound, and needle biopsy. Any discordance between the three components is resolved before reassurance. BreastScreen Australia offers free two-yearly screening mammography to women aged 50 to 74, with 40 to 49 and over 74 able to attend, and screening is for the asymptomatic; a symptomatic woman is investigated regardless of a recent normal screen. Features raising concern are a hard, irregular, fixed lump, skin tethering or dimpling, nipple retraction or bloody discharge, and peau d'orange. Treatment is planned by a multidisciplinary team and combines surgery, either breast-conserving with radiotherapy or mastectomy, with systemic therapy guided by hormone receptor and HER2 status. A woman with a strong family history may warrant earlier and more intensive screening and genetic assessment.

Source: Cancer Council Australia / Cancer Australia — early breast cancer diagnosis and management Cancer Council Australia · tier 2, specialty society or college