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SU25.1-5 | Breast Surgery — PBL Case

CLINICAL SETTING

You are working in a one-stop breast clinic where patients are seen, imaged, and biopsied on the same visit. Across one clinic, three women present with breast complaints that span the benign-to-malignant spectrum. For each trigger, build your differential, apply triple assessment, and reason through management before revealing the next trigger. Pay attention to age, examination findings, and the patient's concerns.

Trigger 1: The young woman with a mobile lump

A 23-year-old university student presents anxiously with a 1.5 cm lump she found in her left breast. On examination it is smooth, firm, painless, and so mobile that it slips away under your fingers. She has no family history of note and is otherwise well. She is convinced she has cancer and wants the lump removed today.

DISCUSSION POINTS

  • What is the most likely diagnosis, and which examination features support it?
  • How does triple assessment apply here, and which imaging modality is first-line for a woman of her age and why?
  • Is immediate excision appropriate, or are there conservative options? Justify your answer.
  • How would you reassure and counsel this anxious young patient?
Click to reveal Trigger 2: The breastfeeding mother with a hot breast (discuss previous trigger first!)

Trigger 2: The breastfeeding mother with a hot breast

A 29-year-old woman who is six weeks postpartum and breastfeeding presents with a painful, red, swollen area in the lower half of her right breast and a fever of 38.5 degrees. Over two days it has become a tender, fluctuant lump. She has been taking oral antibiotics from her GP for three days with little improvement and is exhausted and worried about feeding her baby.

DISCUSSION POINTS

  • What is the diagnosis, and which organism is most commonly responsible?
  • Why have antibiotics alone failed, and what is the key management step once a fluctuant abscess has formed?
  • Should she continue breastfeeding, and what advice would you give?
  • What red-flag features would make you reconsider the diagnosis (e.g. inflammatory carcinoma) and prompt biopsy?
Click to reveal Trigger 3: The older woman with a hard, tethered lump (discuss previous trigger first!)

Trigger 3: The older woman with a hard, tethered lump

A 61-year-old postmenopausal woman presents with a 3 cm hard, irregular, painless lump in the upper outer quadrant of her left breast that is tethered to the skin, with overlying dimpling visible when she raises her arms. Core biopsy confirms invasive ductal carcinoma; receptors are ER-positive, PR-positive, and HER2-negative. There are no clinically palpable axillary nodes. She is terrified she will need her whole breast removed.

DISCUSSION POINTS

  • Why is the three-position inspection important and what did it reveal in this patient?
  • What do the ER-positive, PR-positive, HER2-negative results mean for her adjuvant systemic treatment?
  • What are her surgical options, and what does the evidence say about breast conservation plus radiotherapy versus mastectomy for survival?
  • How would you stage her clinically node-negative axilla while minimising morbidity, and how would you counsel her about the whole plan?

Group Task Assignments

  • Construct a table contrasting fibroadenoma, fibrocystic change, lactational abscess, and phyllodes tumour by typical patient, examination findings, and management.
  • Produce a triple-assessment algorithm that selects imaging by age and incorporates BI-RADS reporting and core biopsy.
  • Create a one-page counselling aid that maps breast cancer receptor status (ER/PR-positive, HER2-positive, triple-negative) to the appropriate systemic therapy.

Learning Issues

Research these questions and bring your findings to the discussion.

  1. [SU25.1] What are the three components of triple assessment, and how is imaging selected by patient age (ultrasound vs mammography) and reported (BI-RADS)?
  2. [SU25.2] How are the common benign breast diseases (fibroadenoma, fibrocystic change, lactational abscess, phyllodes tumour) differentiated and managed?
  3. [SU25.3] What are the histological types of breast cancer (DCIS, invasive ductal, invasive lobular) and how do they differ?
  4. [SU25.4] How do ER/PR/HER2 and triple-negative status determine systemic therapy, and how are surgical and axillary options chosen?
  5. [SU25.5] What is the correct technique and rationale for clinical breast examination, including the three-position inspection?