Painless lump in the breast
A 54-year-old postmenopausal woman finds a firm, painless lump in the upper outer quadrant of the right breast. It is 2 cm, hard, irregular and tethered to skin. There is one mobile axillary node.
Questions & answers
Q1 What is triple assessment?
Clinical examination, imaging (mammography plus ultrasound; ultrasound alone under 40) and tissue diagnosis by core biopsy. Each component is scored 1–5 and concordance between them determines management; discordance mandates further sampling.
Q2 Which receptors are reported and why do they matter?
Oestrogen and progesterone receptors and HER2, with Ki-67 as a proliferation index. They define the biological subtype and hence adjuvant therapy: endocrine therapy for ER-positive disease, anti-HER2 antibodies for HER2-positive disease, chemotherapy for triple-negative and high-risk tumours.
Q3 How is the axilla staged and treated?
Preoperative axillary ultrasound with biopsy of any suspicious node. If the axilla is clinically and radiologically negative, sentinel lymph node biopsy using dual localisation with blue dye and radioisotope. Node-positive disease is treated by axillary clearance or axillary radiotherapy depending on burden and multidisciplinary discussion.
Q4 Breast-conserving surgery or mastectomy?
Breast-conserving surgery with whole-breast radiotherapy gives survival equivalent to mastectomy when clear margins are achievable and the tumour-to-breast volume ratio is favourable. Mastectomy is indicated for multicentric disease, large tumour relative to breast size, inability to obtain clear margins, contraindication to radiotherapy, or patient preference.
References
- NICE NG101: Early and locally advanced breast cancer, diagnosis and management.
- AJCC Cancer Staging Manual, 8th ed., breast chapter.