Case 4 - Olivia Good
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Case 4 - Olivia Good
Chapter: Case 4
Screening
Olivia Good is a 50 year old female shop worker. She leads a very healthy lifestyle with a diet rich in fruit and vegetables and
enjoys playing tennis. She had eczema as a child but grew out of it and both her parents are still alive in their 80s. She is
currently taking no prescribed medication, only a daily over-the-counter multivitamin tablet.
Having recently turned 50, she receives an invitation to attend for a mammogram for breast cancer screening.
Open Question: In general, what are the requirements of a successful screening programme?
Not answered.
Feedback: Disease being screened for is an important health problem
Detectable latent/early symptomatic stage
Good screening test cheap, quick, acceptable, reliable and valid
Facilities available for diagnosis and treatment
Cost of programme considered in context of resource demands i.e. opportunity costs
Agreed policy on whom to treat as a patient
Does treatment confer benefit?
Multiple Choice Question: Which of the following cancers are screened for in Northern Ireland?
(More than one answer may be correct)
Possible answers:
1. Breast cancer [Correct]
2. Cervical cancer [Correct]
3. Colon cancer [Correct]
4. Thyroid cancer [Incorrect]
5. Uterine cancer [Incorrect]
Not answered.
Two key aspects of a screening test are the sensitivity and the specificity.
Open Question: Define a sensitive test and a specific test.
Not answered.
Feedback: A sensitive test has the ability to detect the disease when it is present therefore a sensitive test has fewfalse negatives.
A specific test has the ability to detect the absence of disease in healthy individuals therefore a specific test has few
false positives.
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Image caption: A new screening test has been devised for condition X
Open Question: Calculate the sensitivity and specificity for the above example.
Not answered.
Feedback: Sensitivity = true positives/(true positives + false negatives) = 15/(15+5) 75%
Specificity = true negatives/(true negatives + false positives) = 150/(150+30) 83%
Teacher's Comment: Two other important properties of screening test are the positive and negative predicitive values.
Positive predictive value (PPV) - proportion of individuals who test positive who have the condition
i.e. PPV=true positives/(true positives + false positives)
Negative predictive value (NPV) - proportion of individuals who test negative who do not have the condition
i.e. NPV = true negatives/(true negatives + false negatives)
Mammography
Mrs Good is due to go for her mammogram, and comes to see you, the locum GP, for advice.
Open Question: What is a mammogram?
Not answered.
Feedback: An X-ray of breast tissue
Usually 2 images cranio-caudal and oblique
Mrs Good is unsure as to what the mammogram will involve.
Open Question: Explain to Mrs Good what the mammogram will involve.
Not answered.
Feedback: Visit will last approx 30 mins She will be given a gown and asked to undress from the waist up
Each breast is placed between 2 plates in the X-ray machine
Will be mildly uncomfortable but it will be brief
Mammogram is then examined by a radiologist
If normal (95%) recalled via letter in 3 years
If there is a concern, invited to attend breast assessment clinic
Mrs Good attends for her mammogram. The mammogram shows microcalcification within the breast which warrants further
investigation. She therefore receives a letter asking her to attend the breast assessment clinic.
At the clinic
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Mrs Good is referred to the breast assessment clinic, where you also work.
Multiple Choice Question: Which of the following are components of the triple assessment?
(More than one answer may be correct)
Possible answers:
1. Clinical examination [Correct]
2. Pathology [Correct]
3. Quality of life (QOL) questionnaire [Incorrect]
4. Radiology [Correct]
5. Tumour markers [Incorrect]
Not answered.
Open Question: What breast symptoms might you ask about?
Not answered.
Feedback: Lump duration, changes in size, cyclical v constant, pain
Skin changes over breast
Nipple discharge
Pain
Teacher's Comment: At this point, review/look up examination of the breast.
Multiple Choice Question: For younger women, what is the preferred imaging modality?
Possible answers:
1. CT [Incorrect]
2. Mammogram [Incorrect]
3. MRI [Incorrect]
4. PET [Incorrect]
5. US [Correct]
Not answered.
A sample can be taken by either fine needle aspirate (FNA) or core biopsy (CB).
Open Question: What are the differences between the two in terms of
The type of sample taken?
The time taken for results to be issued?
Not answered.
Feedback: The type of sample taken FNA cells are taken, smeared on slide and stained
CB core of tissue removed and processed
The time taken for results to be issued
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FNA 10-15 mins
CB 24 hours
Open Question: What features suggest malignancy on a fine needle aspirate?
Not answered.
Feedback: Large nuclei with variation in shape and size (pleomorphism)
Loss of normal cohesion between cells
Absence of normal myoepithelial cells (bipolar bare nuclei)
Results
24 hours later, the results from the core biopsy are ready.
The image on the left shows the core biopsy result and the image on the right shows normal breast tissue at a different
magnification.
Histological examination shows breast ducts expanded by a solid cellular proliferation of epithelial cells associatd with
calcification. There is no invasion.
Multiple Choice Question: Which of the following pathologies is in keeping with the above information?
Possible answers:
1. Acute inflammation [Incorrect]
2. Ductal carcinoma in situ [Correct]
3. Granulomatous inflammation [Incorrect]
4. Invasive ductal carcinoma [Incorrect]
5. Invasive lobular carcinoma [Incorrect]
Not answered.
Open Question: List 2 other anatomical sites of malignancy in situ.
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Not answered.
Feedback: Squamous carcinoma in situ/Bowens disease (skin)
Malignant melanoma in situ/lentigo maligna (skin)
Cervical carcinoma in situ [equivalent to CIN grade III]
Carcinoma in situ of the bladder
Open Question: Compare and contrast ductal carcinoma in situ (DCIS) and in situ lobular neoplasia (ISLN) [formerly known
as LCIS] in terms of:-
Presentation Site
Risk of invasion
Not answered.
Feedback: Presentation
DCIS calcification on mammogram (or lump rare)
ISLN incidental finding on biopsy
Site
DCIS unilateral
ISLN bilateral
Risk of invasion
DCIS significant risk of invasion ISLN lower risk of invasion but both breasts are at risk
Mrs Good receives the diagnosis from the surgeon. She explains the procedure to remove the region of DCIS, and arranges
a slot on her operating list.
Worries
Mrs Good is anxious about her forthcoming surgery.
Open Question: Explain why patients might be anxious about admission to hospital.
Not answered.
Feedback: Lack of information about the diagnosis may be real or perceived
Lack of information about the treatment
Unfamiliar nature of the environment
Loss of autonomy and control over their own activities
Concern about dependents e.g. children/elderly relatives (especially for female patients)
Open Question: How can patients be psychologically prepared to reduce their anxiety?
Not answered.
Feedback: Provide information about procedure what it involves, how they will feel afterwards ...
Behavioural instructions inform patient what to do before and after surgery, especially what to do after the procedure
to improve healing and reduce pain
Autonomy allow patients choice about date/time if appropriate or give recovery exercises that they can choose when
to do
Discuss their worries and allow them to ask questions
Cognitive coping focus on the long-term benefits of the procedure
Allow patient to discuss problems with a patient who has experienced the procedure
Open Question: Give 2 differences between males and females with regard to hospital anxiety.
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Not answered.
Feedback: Females
Benefit from expressing emotion and sharing with other patients
Main care givers worried about children/elderly relatives
More concerned about procedure leading to a change in physical appearance e.g. mastectomy
Males
Dont talk about symptoms or share with other patients
More concerned about procedure leading to a deterioration in physical function
It's complicated
Mrs Good undergoes the excision of the abnormal area. She is kept under observation until that evening and is then
discharged with an upcoming outpatient appointment.
6 days later, Mrs Good presents to her GP with redness around the wound. It is swollen and tender, with some pus.
Open Question: What is the most likely diagnosis?
Not answered.
Feedback: Surgical site infection
Multiple Choice Question: What type of operation was the breast surgery?
Possible answers:
1. Clean [Correct]
2. Clean-contaminated [Incorrect]
3. Contaminated [Incorrect]
4. Dirty [Incorrect]
Not answered.
Multiple Choice Question: What type of organism is most likely the cause in this case?
Possible answers:
1. Anaerobes [Incorrect]
2. Coliforms [Incorrect]
3. Enterobacter [Incorrect]
4. Staph. aureus [Correct]
5. Strep. viridans [Incorrect]
Not answered.
Open Question: What is the management of this infection?
Not answered.
Feedback: Swab wound and send sample of pus if available
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Open and drain wound - if appropriate
Empirically treat with flucloxacillin (if non-penicillin allergic) and consult microbiology
Further results
Her infection improves and Mrs Good attends her appointment for discussion of her pathology report.
Open Question: What are the clinical implications of this report?
Not answered.
Feedback: As several of the surgical margins are involved by DCIS, the patient will require a second operation, possibly a
mastectomy.
In contrast to the previous pathology report, the following is an example of a standard pathology report template that is
normally used for patients with invasive breast cancer.
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At the start of the report, two fields to complete are the hospital number and NHS number (known more commonly as the
Health and Care Number in N. Ireland).
Open Question: What is the difference between a hospital number and a Health and Care Number?
Not answered.
Feedback: Any given patient could have multiple hospital numbers, as they attend for appointments at various different
hospitals. The Health and Care number on the other hand is a 10 digit number that is unique to each individual. Use of the
Health and Care number reduces the risk of medical information from patients with similar names and date of births being
mixed up.
Open Question: What is the signficance of a tumour being
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Oestrogen receptor +ve?
Her2 receptor +ve?
Not answered.
Feedback: Oestrogen receptor +ve tumours will benefit from Tamoxifen/aromatase inhibitors
Her2 receptor +ve tumours will benefit from treatment with Herceptin
Open Question: Why are axillary nodes removed in patients with invasive breast cancer but not with DCIS?
Not answered.
Feedback: By definition, as DCIS is non-invasive, there is no possibilty of tumour spreading to local lymph nodes, whereas
in invasive cancer, there is this risk and either the sentinel node or all the axillary nodes are removed.
CPC 4
Teacher's Comment: A key skill in medicine is being able to summarise and present a case to a colleague in a concise and
precise manner. Prior to the CPC try to summarise this case in 4-5 sentences.
It would be useful to revise the following topics, which will be explored in more detail at the CPC.
Wound healing
Invasive and in situ cancer
Laboratory handling of surgical specimens
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Assessment Summary
Case 4
Open Question: In general, what are the requirements of a successful screening programme?
Answered
Not answered
Multiple Choice Question: Which of the following cancers are screened for in Northern Ireland?
(More than one answer may be correct)
Answered Correctness Retries Score
Not answered - 0 0 / 1
Open Question: Define a sensitive test and a specific test.
Answered
Not answered
Open Question: Calculate the sensitivity and specificity for the above example.
Answered
Not answered
Open Question: What is a mammogram?
Answered
Not answered
Open Question: Explain to Mrs Good what the mammogram will involve.
Answered
Not answered
Multiple Choice Question: Which of the following are components of the triple assessment?
(More than one answer may be correct)
Answered Correctness Retries Score
Not answered - 0 0 / 1
Open Question: What breast symptoms might you ask about?
Answered
Not answered
Multiple Choice Question: For younger women, what is the preferred imaging modality?
Answered Correctness Retries Score
Not answered - 0 0 / 1
Open Question: What are the differences between the two in terms of
The type of sample taken?
The time taken for results to be issued?
Answered
Not answered
Open Question: What features suggest malignancy on a fine needle aspirate?
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Answered
Not answered
Multiple Choice Question: Which of the following pathologies is in keeping with the above information?
Answered Correctness Retries Score
Not answered - 0 0 / 1
Open Question: List 2 other anatomical sites of malignancy in situ.
Answered
Not answered
Open Question: Compare and contrast ductal carcinoma in situ (DCIS) and in situ lobular neoplasia (ISLN) [formerly known
as LCIS] in terms of:-
Presentation
Site
Risk of invasion
Answered
Not answered
Open Question: Explain why patients might be anxious about admission to hospital.
Answered
Not answered
Open Question: How can patients be psychologically prepared to reduce their anxiety?
Answered
Not answered
Open Question: Give 2 differences between males and females with regard to hospital anxiety.
Answered
Not answered
Open Question: What is the most likely diagnosis?
Answered
Not answered
Multiple Choice Question: What type of operation was the breast surgery?
Answered Correctness Retries Score
Not answered - 0 0 / 1
Multiple Choice Question: What type of organism is most likely the cause in this case?
Answered Correctness Retries Score
Not answered - 0 0 / 1
Open Question: What is the management of this infection?
Answered
Not answered
Open Question: What are the clinical implications of this report?
Answered
Not answered
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Open Question: What is the difference between a hospital number and a Health and Care Number?
Answered
Not answered
Open Question: What is the signficance of a tumour being
Oestrogen receptor +ve?
Her2 receptor +ve?
Answered
Not answered
Open Question: Why are axillary nodes removed in patients with invasive breast cancer but not with DCIS?
Answered
Not answered
Total score: 0 / 6 (0%)
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