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, uneven, fixed lump with dimpled skin in a 62 year old is breast cancer until triple assessment proves otherwise.
2. Breast cysts A smooth, sometimes tender, fluid-filled lump that goes away once the fluid is drawn off. Here, the picture of a hard, fixed lump with skin dimpling despite a recent normal screen points elsewhere.
3. Fibroadenoma A smooth, firm lump that moves under the skin, in a younger woman. It is harmless but is still confirmed with triple assessment. It does not fit the picture of a hard, fixed lump with skin dimpling despite a recent normal screen.
4. Breast abscess/mastitis A tender, red, warm area with fever, usually in a breastfeeding woman. But the picture of a hard, fixed lump with skin dimpling despite a recent normal screen does not point to it.
5. Fat necrosis A firm lump after an injury or surgery, which can look like cancer on imaging. That does not match the picture of a hard, fixed lump with skin dimpling despite a recent normal screen.

The point: A new lump in the breast in an adult is checked with three things together, called triple assessment: a physical exam, imaging (a mammogram and an ultrasound), and a needle sample (biopsy). If any of the three do not agree, this is sorted out before anyone is reassured. BreastScreen Australia offers a free mammogram every two years to women aged 50 to 74. Women aged 40 to 49 and over 74 can also go. This screening is for women with no symptoms. A woman with a symptom is checked properly no matter how recent her last normal screening mammogram was. Signs that raise concern are a hard, uneven, fixed lump, skin that is pulled in or dimpled, a nipple that has pulled inward, bloody discharge, and skin that looks like orange peel. Treatment is planned by a whole team of specialists together, and combines surgery, either breast-conserving surgery with radiotherapy or removing the whole breast (mastectomy), with body-wide treatment guided by whether the cancer responds to hormones and a marker called HER2. A woman with a strong family history may need earlier, closer screening and a genetic check.

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 can change how often screening happens and may lead to genetic testing. But the picture of a hard, fixed lump with skin dimpling despite a recent normal screen does not point to it.
2. Triple assessment correct Correct. Examination, imaging and biopsy together are how a worrying lump is worked up. Any disagreement between them is sorted out before she is reassured.
3. Sentinel lymph node biopsy Checks whether the cancer has spread to lymph nodes, with less harm than removing all of them. That does not match the picture of a hard, fixed lump with skin dimpling despite a recent normal screen.
4. Mammography Picks up a spiky-edged lump or tiny calcium spots. This is the screening and diagnostic scan in older women. Here, the picture of a hard, fixed lump with skin dimpling despite a recent normal screen points elsewhere.
5. Breast ultrasound Shows more detail about a lump and guides the biopsy needle. It is the better scan in younger women with dense breast tissue. It does not fit the picture of a hard, fixed lump with skin dimpling despite a recent normal screen.

The point: A new lump in the breast in an adult is checked with three things together, called triple assessment: a physical exam, imaging (a mammogram and an ultrasound), and a needle sample (biopsy). If any of the three do not agree, this is sorted out before anyone is reassured. BreastScreen Australia offers a free mammogram every two years to women aged 50 to 74. Women aged 40 to 49 and over 74 can also go. This screening is for women with no symptoms. A woman with a symptom is checked properly no matter how recent her last normal screening mammogram was. Signs that raise concern are a hard, uneven, fixed lump, skin that is pulled in or dimpled, a nipple that has pulled inward, bloody discharge, and skin that looks like orange peel. Treatment is planned by a whole team of specialists together, and combines surgery, either breast-conserving surgery with radiotherapy or removing the whole breast (mastectomy), with body-wide treatment guided by whether the cancer responds to hormones and a marker called HER2. A woman with a strong family history may need earlier, closer screening and a genetic check.

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 A hormone-blocking tablet, taken for years, for cancers that respond to hormones. It lowers the chance of the cancer coming back. It does not fit the picture of a hard, fixed lump with skin dimpling despite a recent normal screen.
2. Mastectomy Removing the whole breast, for larger tumours, tumours in more than one spot, or if the woman chooses it. Breast reconstruction is offered. That does not match the picture of a hard, fixed lump with skin dimpling despite a recent normal screen.
3. Breast-conserving surgery with radiotherapy For tumours where it is suitable, this gives the same chance of survival as removing the whole breast. But the picture of a hard, fixed lump with skin dimpling despite a recent normal screen does not point to it.
4. Refer for triple assessment correct Correct. The right action is a prompt referral, not reassurance based on the recent screening mammogram.
5. Sentinel lymph node biopsy or axillary clearance Checks and treats the lymph nodes under the arm, depending on how much they are involved. Here, the picture of a hard, fixed lump with skin dimpling despite a recent normal screen points elsewhere.

The point: A new lump in the breast in an adult is checked with three things together, called triple assessment: a physical exam, imaging (a mammogram and an ultrasound), and a needle sample (biopsy). If any of the three do not agree, this is sorted out before anyone is reassured. BreastScreen Australia offers a free mammogram every two years to women aged 50 to 74. Women aged 40 to 49 and over 74 can also go. This screening is for women with no symptoms. A woman with a symptom is checked properly no matter how recent her last normal screening mammogram was. Signs that raise concern are a hard, uneven, fixed lump, skin that is pulled in or dimpled, a nipple that has pulled inward, bloody discharge, and skin that looks like orange peel. Treatment is planned by a whole team of specialists together, and combines surgery, either breast-conserving surgery with radiotherapy or removing the whole breast (mastectomy), with body-wide treatment guided by whether the cancer responds to hormones and a marker called HER2. A woman with a strong family history may need earlier, closer screening and a genetic check.

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