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RD7.{1,6} | Imaging in Obstetrics, Gynecology and Breast Care — PBL Case
CLINICAL SETTING
Mrs Lakshmi, a 48-year-old schoolteacher, attends the breast clinic after noticing a firm, painless lump in the upper-outer quadrant of her right breast three weeks ago. She has no significant family history and has never had a mammogram. She is anxious and asks the team to explain, at each step, why each test is being done. The clinic runs a triple-assessment pathway, and the team will integrate clinical examination, imaging and pathology as the picture unfolds.
Trigger 1: The presenting lump and choosing the first imaging step
On examination there is a 2 cm firm, irregular, non-tender mass in the upper-outer quadrant of the right breast with no overlying skin change. The axilla is clinically unremarkable. The team must decide on the imaging strategy for a 48-year-old woman with a discrete breast lump and explain it to Mrs Lakshmi.
DISCUSSION POINTS
- What is the triple-assessment pathway and where does imaging sit within it?
- In a 48-year-old with a palpable lump, how do you decide between mammography and ultrasound, and why might both be used?
- What clinical examination features of this lump raise concern for malignancy?
Click to reveal Trigger 2: The imaging findings and the BI-RADS language (discuss previous trigger first!)
Trigger 2: The imaging findings and the BI-RADS language
Mammography shows a spiculated mass in the upper-outer quadrant of the right breast with associated clustered pleomorphic microcalcifications. Targeted ultrasound confirms an irregular hypoechoic mass with indistinct margins and posterior acoustic shadowing. The radiologist assigns a BI-RADS category 5. The team must interpret these findings and explain what the category means for the next step.
DISCUSSION POINTS
- What mammographic and ultrasound features distinguish a suspicious mass from a benign one in this case?
- What does BI-RADS 5 signify, and how does it differ from categories 3 and 4?
- How does the imaging category drive the decision to obtain tissue, completing the triple assessment?
Click to reveal Trigger 3: From diagnosis to staging and treatment planning (discuss previous trigger first!)
Trigger 3: From diagnosis to staging and treatment planning
Image-guided core biopsy confirms invasive ductal carcinoma. The team must now plan staging and consider how imaging continues to inform management, including assessment of the axilla and the role of MRI, while keeping Mrs Lakshmi informed throughout.
DISCUSSION POINTS
- How does imaging contribute to local staging (tumour extent, multifocality) and assessment of the axilla?
- When is breast MRI indicated in staging, and what added value does it provide?
- How would the integrated clinical, imaging and pathology findings shape the multidisciplinary treatment plan?
Group Task Assignments
- Construct a one-page flowchart of the triple-assessment pathway for a palpable breast lump, showing where mammography, ultrasound, MRI and biopsy enter.
- Prepare a patient-friendly explanation of the BI-RADS 0–6 scale and what each category means for the next step.
- Summarise the indications for mammography, ultrasound and MRI in breast care by age, breast density and clinical scenario.
Learning Issues
Research these questions and bring your findings to the discussion.
- [RD7.6] What is the triple-assessment pathway and how is breast imaging integrated with clinical examination and pathology?
- [RD7.6] What is the BI-RADS classification (0–6) and how does each category drive management decisions?
- [RD7.6] What are the indications for mammography, ultrasound and MRI in breast cancer screening and management, considering age, breast density and pregnancy?
- [RD7.6] How does imaging contribute to staging invasive breast cancer, including local extent and axillary assessment?