{"id":6217,"date":"2017-07-07T15:04:32","date_gmt":"2017-07-07T07:04:32","guid":{"rendered":"http:\/\/https:\/\/medicine.nus.edu.sg\/pathweb\/?page_id=6217"},"modified":"2023-11-15T17:10:39","modified_gmt":"2023-11-15T09:10:39","slug":"pathology-in-action-a-breast-lump","status":"publish","type":"page","link":"https:\/\/medicine.nus.edu.sg\/pathweb\/pathology-demystified\/pathology-in-action-real-life-cases\/pathology-in-action-a-breast-lump\/","title":{"rendered":"Pathology in Action: A Breast Lump"},"content":{"rendered":"\n\n\t<p>See how a team of doctors manages a patient with a breast lump. At each step, think about what your role would be if you were the GP, or the medical officer in the specialist clinic.<\/p>\n<p>&nbsp;<\/p>\n<h3>\n\t\tI. Clinical History\n\t<\/h3>\n\t<p><strong>Mdm Suppiah is a 63 year old lady with a breast lump. Her family brings her to the polyclinic.<\/strong><\/p>\n<p><strong>1. Question:\u00a0What would you do if you were the GP or polyclinic doctor seeing her for the first time?\u00a0<\/strong><\/p>\n<p>Here are some options to consider, \u00a0which would you choose?<\/p>\n<ul> \t\n<li>Order a mammogram and tell her to come back in 2 weeks.<\/li>\n\n<li>Refer her directly to the breast clinic in a restructured hospital for specialist assessment.<\/li>\n\n<li>Take a detailed history and examine her clinically before deciding what to do next.<\/li>\n<\/ul>\n\t\t\t\t\t<a href=\"#\" id=\"fl-accordion--label-0\" tabindex=\"0\" aria-controls=\"fl-accordion--panel-0\">Click here to see what was done<\/a>\n\t\t\t\t\t\t\t\t\t\t\t<a href=\"#\" id=\"fl-accordion--icon-0\" tabindex=\"0\" aria-controls=\"fl-accordion--panel-0\"><i>Expand<\/i><\/a>\n\t\t\t\t\t<p>After taking a directed history, a breast examination was done.<\/p>\n<p>Summary of findings:<\/p>\n<p>History &#8211; Self-palpated breast lump 2 months ago, not noticed to be enlarging. No noted loss of weight. \u00a0No family history of malignancy.<\/p>\n<p>Physical examination &#8211; 4cm firm, irregular non-tender right upper outer quadrant mass.<\/p>\n<p><strong>Action taken: Refer to specialist breast clinic in a restructured hospital for further investigation.\u00a0<\/strong><\/p>\n\t<p><strong>Mdm Suppiah is seen at the Breast Clinic in the National University Hospital one week later.<\/strong><\/p>\n\t\t\t\t\t<a href=\"#\" id=\"fl-accordion--label-0\" tabindex=\"0\" aria-controls=\"fl-accordion--panel-0\">Here are the Clinical Findings<\/a>\n\t\t\t\t\t\t\t\t\t\t\t<a href=\"#\" id=\"fl-accordion--icon-0\" tabindex=\"0\" aria-controls=\"fl-accordion--panel-0\"><i>Expand<\/i><\/a>\n\t\t\t\t\t<p><a href=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2017\/05\/Clinic-examination.jpg\" target=\"_blank\" rel=\"noopener noreferrer\"><img decoding=\"async\" loading=\"lazy\" src=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2017\/05\/Clinic-examination.jpg\" alt=\"\" width=\"1672\" height=\"903\" \/><\/a><\/p>\n\t<p><strong>2. Question: What is your clinical diagnosis?\u00a0<\/strong><\/p>\n<p>&nbsp;<\/p>\n\t\t\t\t\t<a href=\"#\" id=\"fl-accordion--label-0\" tabindex=\"0\" aria-controls=\"fl-accordion--panel-0\">Clinical Diagnosis<\/a>\n\t\t\t\t\t\t\t\t\t\t\t<a href=\"#\" id=\"fl-accordion--icon-0\" tabindex=\"0\" aria-controls=\"fl-accordion--panel-0\"><i>Expand<\/i><\/a>\n\t\t\t\t\t<p>The diagnosis is breast cancer until \u00a0proven otherwise.<\/p>\n<p>The findings of a new lump that is hard and irregular in a patient of this age is very suspicious. The presence of palpable axillary lymph nodes is worrying for axillary nodal metastases.<\/p>\n\t<p><strong>3. Question: What would you do to confirm the diagnosis?\u00a0<\/strong><\/p>\n<p>&nbsp;<\/p>\n\t\t\t\t\t<a href=\"#\" id=\"fl-accordion--label-0\" tabindex=\"0\" aria-controls=\"fl-accordion--panel-0\">Here&#8217;s how the diagnosis was confirmed<\/a>\n\t\t\t\t\t\t\t\t\t\t\t<a href=\"#\" id=\"fl-accordion--icon-0\" tabindex=\"0\" aria-controls=\"fl-accordion--panel-0\"><i>Expand<\/i><\/a>\n\t\t\t\t\t<p>What Mdm Suppiah needs is rapid tissue diagnosis (biopsy) so that definitive management can be planned.<\/p>\n<p>Remember the Triple Test: Clinical examination, Imaging and Pathology.<\/p>\n<p>1.<strong> Imaging:<\/strong> A mammogram is ordered on the same day.<\/p>\n<p><a href=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2017\/05\/Mammo-Pic.jpg\" target=\"_blank\" rel=\"noopener noreferrer\"><img decoding=\"async\" loading=\"lazy\" src=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2017\/05\/Mammo-Pic.jpg\" alt=\"\" width=\"617\" height=\"902\" \/><\/a><\/p>\n<p>2. A <strong>core biopsy<\/strong> is ordered:<\/p>\n<p><a href=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2017\/05\/Core-bx-2lol5n8.jpg\" target=\"_blank\" rel=\"noopener noreferrer\"><img decoding=\"async\" loading=\"lazy\" src=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2017\/05\/Core-bx-2lol5n8.jpg\" alt=\"\" width=\"1499\" height=\"1129\" \/><\/a><\/p>\n<p>The pathologist&#8217;s diagnosis was:<\/p>\n<p><a href=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2017\/05\/Core-Dx-zzgo1i.jpg\" target=\"_blank\" rel=\"noopener noreferrer\"><img decoding=\"async\" loading=\"lazy\" src=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2017\/05\/Core-Dx-zzgo1i.jpg\" alt=\"\" width=\"716\" height=\"138\" \/><\/a><\/p>\n<p><strong>The\u00a0TRIPLE TEST is now done (clinical examination, imaging, biopsy), and the diagnosis is now made. The next step is to plan definitive management.\u00a0<\/strong><\/p>\n\t<p><strong>4. Question: The diagnosis is made. What is the needs to be done next?<\/strong><\/p>\n<p>&nbsp;<\/p>\n\t\t\t\t\t<a href=\"#\" id=\"fl-accordion--label-0\" tabindex=\"0\" aria-controls=\"fl-accordion--panel-0\">Click here to see what was done next<\/a>\n\t\t\t\t\t\t\t\t\t\t\t<a href=\"#\" id=\"fl-accordion--icon-0\" tabindex=\"0\" aria-controls=\"fl-accordion--panel-0\"><i>Expand<\/i><\/a>\n\t\t\t\t\t<p>After the diagnosis is made, the next step is to STAGE the tumour.<\/p>\n<p>1. Staging: This usually involves imaging.<\/p>\n<p>CT thorax, abdomen and pelvis was done to look for metastases (eg lung, liver, etc)<\/p>\n<p>A bone scan was performed to look for bony metastases.<\/p>\n<p><strong>Results: All were negative.\u00a0<\/strong><\/p>\n<p>2. The case was then discussed at the Breast multidiscplinary meeting &#8211; oncologists, radiation oncologists, surgeons, nurse managers, pathologists, radiologists attend.<\/p>\n<p><strong>Decision: Offer neoadjuvant chemotherapy (due to large size) and then surgery; \u00a0OR surgery.\u00a0<\/strong><\/p>\n<p><strong>The patent opted for surgery. \u00a0Mastectomy was performed, with axillary lymph node clearance.\u00a0<\/strong><\/p>\n<h3>\n\t\tII. In the Pathology Lab \n\t<\/h3>\n\t<p><strong>1. Handling the Breast specimen.<\/strong> After surgery, the excised breast specimen (mastectomy) arrives in the Pathology Lab. The pathologist examines it and samples selected areas &#8211; this is known as\u00a0<strong>Grossing<\/strong>\u00a0or\u00a0<strong>Trimming. <\/strong>Here is the pathologist in action.<\/p>\n<p>If you can&#8217;t play the video, watch it here on Youtube: <a href=\"https:\/\/youtu.be\/0UbVpZSAEG4\">https:\/\/youtu.be\/0UbVpZSAEG4<\/a><\/p>\n\t<iframe loading=\"lazy\" src=\"https:\/\/player.vimeo.com\/video\/204989306\" width=\"640\" height=\"358\" frameborder=\"0\" webkitallowfullscreen mozallowfullscreen allowfullscreen><\/iframe>\n\t<p><strong>2. Microscopic examination.<\/strong> After Grossing the specimen, the tissue is processed into microscopic slides. Here is how the pathologist then evaluates the slides to obtain important <strong>Diagnostic<\/strong> and <strong>Prognostic<\/strong> information.<\/p>\n<p>If you can&#8217;t play the video, watch it here on YouTube:\u00a0<a href=\"https:\/\/youtu.be\/iM0wOdCYe3E\" target=\"_blank\" rel=\"noopener\">https:\/\/youtu.be\/iM0wOdCYe3E<\/a><\/p>\n\t<iframe loading=\"lazy\" src=\"https:\/\/player.vimeo.com\/video\/204849612\" width=\"640\" height=\"313\" frameborder=\"0\" webkitallowfullscreen mozallowfullscreen allowfullscreen><\/iframe>\n\t<p>Here is a walk-through of how pathologists perform GRADING of breast carcinoma. This is from a different case, where the overall grade is 2.<\/p>\n\t<iframe loading=\"lazy\" width=\"1280\" height=\"609\" src=\"https:\/\/www.youtube.com\/embed\/G3MZuzP-b68?list=PL2TaQ3CT3zlBAcWwVgm0pOLBpdp3Tir2H\" frameborder=\"0\" allow=\"accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture\" allowfullscreen><\/iframe>\n<h3>\n\t\tIII. Final Pathology Report\n\t<\/h3>\n\t<p>The pathologist documents his\/her findings into a succinct report. This a summary of the final histology report, with the most prognostically important information presented.<\/p>\n\t\t\t\t<a href=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2017\/05\/Final-Dx-2gyiifv-1024x248-1.jpg\" target=\"_self\" itemprop=\"url\" rel=\"noopener\">\n\t\t\t\t<img decoding=\"async\" src=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2017\/05\/Final-Dx-2gyiifv-1024x248.jpg\" alt=\"Final-Dx-2gyiifv-1024x248\" itemprop=\"image\" title=\"Final-Dx-2gyiifv-1024x248\" onerror=\"this.style.display='none'\"  \/>\n\t\t\t\t<\/a>\n<h3>\n\t\tiV. Follow-up\n\t<\/h3>\n\t<p>Mdm Suppiah&#8217;s pathology and intraoperative findings would be again presented at the multidisciplinary Breast Team meeting, and the decision made on the post-operative management, follow-up and surveillance.<\/p>\n\t<p><em>Acknowledgements: The videos feature Dr Wang Shi, Dr Wu Bing Cheng, and Dr Nga Min En, and are created by Dr Noel Chia (Department of Pathology, National University Hospital, Singapore)<\/em><\/p>\n\t\t\t<a href=\"https:\/\/medicine.nus.edu.sg\/pathweb\/pathology-demystified\/pathology-in-action-real-life-cases\/\" target=\"_self\" role=\"button\" rel=\"noopener\">\n\t\t\t\t\t\t\tBack to Pathology in Action: Real Life Cases\n\t\t\t\t\t<\/a>\n\t\t\t<a href=\"https:\/\/medicine.nus.edu.sg\/pathweb\/pathology-demystified\/breast-pathology\/\" target=\"_self\" role=\"button\" rel=\"noopener\">\n\t\t\t\t\t\t\tBreast Pathology Chapter Home\n\t\t\t\t\t<\/a>\n\n","protected":false},"excerpt":{"rendered":"<p>See how a team of doctors manages a patient with a breast lump. At each step, think about what your role would be if you were the GP, or the medical officer in the specialist clinic. &nbsp; I. Clinical History Mdm Suppiah is a 63 year old lady with a breast lump. Her family brings [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":10154,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":[],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v21.3 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>NUS Pathweb<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/medicine.nus.edu.sg\/pathweb\/pathology-demystified\/pathology-in-action-real-life-cases\/pathology-in-action-a-breast-lump\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:description\" content=\"See how a team of doctors manages a patient with a breast lump. At each step, think about what your role would be if you were the GP, or the medical officer in the specialist clinic. &nbsp; I. 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