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Adeola Ashaye1, Dr Simon Cross2 Prof. Malcolm Reed3 1Level 5 Medical Student, 2Academic Unit of Pathology, 3Department

Clinical Sciences Case Studies. these case studies are designed to be used as self-directed study resources to reinforce your learning from teaching blocks and clinical attachmentsat each question write down your answers and check them with the explanatory answers which are given on the next screen

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Adeola Ashaye1, Dr Simon Cross2 Prof. Malcolm Reed3 1Level 5 Medical Student, 2Academic Unit of Pathology, 3Department

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    1. Adeola Ashaye1, Dr Simon Cross2 & Prof. Malcolm Reed3 1Level 5 Medical Student, 2Academic Unit of Pathology, 3Department of Surgery School of Medicine and Biological Sciences University of Sheffield

    2. Clinical Sciences Case Studies these case studies are designed to be used as self-directed study resources to reinforce your learning from teaching blocks and clinical attachments at each question write down your answers and check them with the explanatory answers which are given on the next screen

    4. History The next patient in your Monday morning breast clinic is Sheila Harris. She presents to clinic with a referral letter from her GP:

    6. History On further questioning, you discover that Sheila thinks she may have noticed a tiny lump in the same region about 6 months ago, but she only felt it once and couldnt find it again The present lump has been there for 5 weeks Since the referral letter was sent, she has also discovered that she is now 7 weeks pregnant

    7. What is at the top of your list of differentials? Question

    8. Fibroadenoma Fibroadenomas are benign and account for almost 60% of all palpable symptomatic breast masses in women aged 20 or less They are mixed tumours, arising from both the loose connective tissue stroma and the glands of the breast lobule They therefore undergo some of the same hormonally induced changes as the surrounding breast Answer

    9. Examination On examination you find that the lump is a smooth mobile mass with a diameter of 2cm

    10. What other features associated with the lump would you like to assess? Question

    11. Site of the lump Shape and size of the lump Condition/ appearance of the overlying skin colour, temperature...etc. Texture of the lump stony hard/ rubbery hard/ soft Fixation of the lump to the overlying skin Tethering to ligaments / axilla presence of skin dimpling at extremities of movement Tenderness of the lump or of an associated area Answer

    12. What investigations will you consider in order to make a definitive diagnosis? Question

    13. A definitive diagnosis can be made from a combination of: clinical examination ultrasonography fine needle aspiration or needle core biopsy You decide to send her for an ultrasound scan and ask the radiologist to take a needle core biopsy of the lesion Answer

    14. Investigations Ultrasound scan and report:

    15. List three types of fibroadenoma Question

    16. There are three separate types of fiibroadenoma: Common fibroadenoma Juvenile fibroadenoma Giant fibroadenoma (as juvenile but >5cm in diameter) Phyllodes tumours can be difficult to distinguish from fibroadenomas clinically, but they are distinct pathological entities Answer

    17. You see her in clinic with the ultrasound scan (report shown on a previous slide) and histology report. The microscopic image is shown on the next slide The sample was reported as containing elongated duct-like structures surrounded by loose connective tissue History

    18. High power view of core biopsy

    19. What is your diagnosis and what are Sheilas treatment options? Question

    20. She has a fibroadenoma Fibroadenomas of this size diagnosed by clinical examination, ultrasonography and cytology or histology in women under 40 do not need excision unless requested by the patient Fibroadenomas over 4 cm in diameter should be excised Answer

    21. Sheila does not want to undergo any surgery, but she seeks reassurance as to why her lump seemed to grow so quickly, all of a sudden What do you tell her? Question

    22. Sheila is pregnant and so under the influence of hormones such as oestrogens, progesterone and prolactin, her fibroadenoma is, as is the rest of her breast, developing and increasing in size She needs to be reassured that this is not malignant growth Answer

    23. Recommended sources of information Dixon M Ed. ABC of Breast Diseases. 2nd Ed. BMJ, 2000. pgs 1-9 J C E Underwood Ed. General and Systemic Pathology. 3rd Ed. Edinburgh: Churchill Livingstone, 2000. pgs 470-494 Evans AJ, Wilson ARM, Blamey RW, Robertson JFR, Ellis IO, Elston CW. Atlas of Breast Disease Management. 50 Illustrative cases. Saunders, 1998. pgs 1-9, 63-64 Friedlander E. Pathology Lecture notes: http://www.pathguy.com/lectures/breast.htm Kettlewell S. The Breast Clinic: http://www.thebreastclinic.com/

    24. End of case study

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