Surgery Essay

Describe the procedures you would adopt to reach a

diagnosis in a fifty-year-old woman who presents
with a lump in her breast.

In order to reach a diagnosis regarding the breast lump, the

following procedures have to be undertaken: history taking,
clinical examination, imaging and fine-needle aspiration
cytology and/or core biopsy.

The most important pointer to the diagnosis is the age of the

patient: the older the woman, the likelier it is to have a
malignant condition. In the process of history taking it is
important to determine the duration of the breast lump: breast
cancers usually grow slowly, but cysts may appear overnight.
Family history, drug history and other risk factors can be
assessed during the history taking.

For the clinical examination the patient must undress till the
waists and inspection should be done with the patient’s arms
by her side, above her head, and then pressing on her hips.
Skin dimpling is present in a high percentage of patients with
breast cancer. With the patient lying down, arms under head,
all breast tissue are examined, using the fingertips to detect
any abnormalities. When the lump is felt, it should be assessed
for texture, and outline. In order to see if the breast has a deep
fixation, the patient is asked to press their hands on their hips,
in this way tensing the pectoralis muscle, on which the breast
lies. All palpable lesions should be measured with callipers and

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Surgery Essay

the position (o’clock) is recorded. Next the nodal areas are

palpated, in the axilla and above the clavicle for the
supraclavicular nodes. Enlarged nodes are found in patients
with no clinically significant breast disease, and at times people
with breast cancer may have no palpable nodes.

Since the patient is 50 years old, mammography is useful in

this age group. This requires compression of the breast
between two plates. It allows the detection of mass lesions,
areas of parenchyma distortion and micro calcifications.
Ultrasonography is another option, where high frequency
waves are beamed to the breast and reflections are turned into
pictures. It is easy to differentiate cysts and other benign
lesions, which have well demarcated edges from cancers with
an indistinct outline. Another option is MRI, which has a high
sensitivity for breast cancer.

Fine-needle aspiration cytology can be used to differentiate

between solid and cystic leaisons. In core biopsy several cores
are removed from a mass or an area of micro calcification by
means of cutting needle technique. Palpation can be used to
guide the biopsy but better to use with ultrasound.

False-positive results occur with all diagnostic techniques.

Image guided core biopsy is the most accurate of the various
techniques used to diagnose breast masses.

19/01/09