OSCE — triple assessment of a breast lump · MBBS OSCE

Clinical scenario

Brief (to candidate)

A 47-year-old woman presents with a 6-week history of a painless lump in the upper outer quadrant of her left breast. On examination there is a 2.5 cm hard, irregular, fixed mass with no skin changes. There is one hard mobile 1.5 cm lymph node in the left axilla. You have a mammogram and ultrasound image available.

[1]

You have 8 minutes to: (1) describe the focused clinical examination you would perform, (2) interpret the imaging shown, (3) state what tissue diagnosis you would obtain and how, and (4) explain the biopsy plan to the patient in plain language and obtain verbal consent.

[1]

Candidate instructions

Perform a structured clinical breast examination on a manikin or simulated patient (inspection in four positions, palpation supine, axillary assessment).

[1]

Interpret the mammogram and ultrasound findings using BI-RADS categories and state what the findings suggest.

[1]

State the tissue diagnosis you would obtain, the technique, and the information the pathology report must contain.

[1]

Communicate with the patient — explain the procedure, the rationale, risks (bleeding, bruising, false negatives, need for re-biopsy), and obtain verbal consent.

[1]

Examiner checklist (mark each domain / 10)

Domain	Key actions expected
Clinical examination structure	Inspection with arms by side / hands on hips / arms raised / leaning forward; palpation supine with arm raised; all four quadrants + axillary tail + axillary nodes (five groups) + supraclavicular; documents lump by site (clock), size, consistency, surface, edge, fixity
Mammogram interpretation	Identifies spiculated mass ± clustered pleomorphic microcalcifications; states BI-RADS 4 or 5 (suspicious / highly suggestive of malignancy — biopsy indicated)[1]
Ultrasound interpretation	Identifies hypoechoic, taller-than-wide mass with indistinct margins and posterior shadowing (malignant features); states need for ultrasound-guided core biopsy
Tissue diagnosis + technique	States 14-gauge core needle biopsy under ultrasound or stereotactic guidance (multiple cores); is gold standard because provides histology, grade, ER/PR/HER2 and Ki-67
Information to patient / consent	Explains the procedure in plain language, the reason for biopsy, risks (bleeding, bruising, infection, rarely pneumothorax for deep lesions), what the result means, and that further receptor testing will be performed on the specimen
Triple assessment verbalised	States the concept: clinical + imaging + pathology = ~98% accuracy when all three agree[1]
Communication & breaking-bad-news	Uses clear language, avoids jargon, checks understanding, offers support person, signposts next steps (result in 5–7 working days, MDT discussion), documents consent

Model key actions

Structured CBE: inspection in four positions, palpation supine, all quadrants + axillary tail + axillary + supraclavicular, documents lump by site/size/consistency/surface/edge/fixity.[1]

[1]

Mammogram: spiculated mass with architectural distortion and pleomorphic microcalcifications; BI-RADS 4c–5.

[1]

Ultrasound: hypoechoic, taller-than-wide, indistinct margins, posterior shadowing — suspicious.

[1]

Tissue diagnosis: ultrasound-guided 14-gauge core needle biopsy (multiple cores); histology provides type, grade, ER/PR/HER2 and Ki-67 — the four pieces of information that drive systemic therapy.[1][3]

[1]

Communication: explain the procedure in plain language, the rationale, risks (bleeding, bruising, infection), what the result means, and that receptor testing will be performed.

[1]

Triple assessment: clinical + imaging + pathology = ~98% accuracy when all three agree.

[1]

Common errors

Skipping the supraclavicular fossa or the contralateral breast during examination.

[1]

Failing to state BI-RADS category explicitly on the mammogram.

[1]

Confusing FNA cytology with core needle biopsy — FNA cannot assess invasion or receptor status and is not the gold standard.

[1]

Not mentioning ER/PR/HER2 testing as a required part of the pathology report.

[1]

Using jargon with the patient ("spiculated mass, BI-RADS 5") instead of plain language.

[1]

Not warning the patient that a benign core does not exclude cancer if imaging is discordant — image-pathology discordance mandates excision biopsy.

[1]

Failing to mention that the case will be discussed at the multidisciplinary team (MDT) meeting before definitive treatment planning.

[1]

References

[1]Waks AG, Winer EP. Breast Cancer Treatment: A Review. JAMA, 2019.PMID 30667505
[2]Early Breast Cancer Trialists' Collaborative Group (EBCTCG), Darby S, McGale P, et al. Effect of radiotherapy after breast-conserving surgery on 10-year recurrence and 15-year breast cancer death. Lancet, 2011.PMID 22019144
[3]Leon-Ferre RA, Goetz MP. Advances in systemic therapies for triple negative breast cancer. BMJ, 2023.PMID 37253507

Clinical scenario

Brief (to candidate)

[1]

Candidate instructions

Perform a structured clinical breast examination on a manikin or simulated patient (inspection in four positions, palpation supine, axillary assessment).

[1]

Interpret the mammogram and ultrasound findings using BI-RADS categories and state what the findings suggest.

[1]

State the tissue diagnosis you would obtain, the technique, and the information the pathology report must contain.

[1]

Communicate with the patient — explain the procedure, the rationale, risks (bleeding, bruising, false negatives, need for re-biopsy), and obtain verbal consent.

[1]

Examiner checklist (mark each domain / 10)

Domain	Key actions expected
Clinical examination structure	Inspection with arms by side / hands on hips / arms raised / leaning forward; palpation supine with arm raised; all four quadrants + axillary tail + axillary nodes (five groups) + supraclavicular; documents lump by site (clock), size, consistency, surface, edge, fixity
Mammogram interpretation	Identifies spiculated mass ± clustered pleomorphic microcalcifications; states BI-RADS 4 or 5 (suspicious / highly suggestive of malignancy — biopsy indicated)[1]
Ultrasound interpretation	Identifies hypoechoic, taller-than-wide mass with indistinct margins and posterior shadowing (malignant features); states need for ultrasound-guided core biopsy
Tissue diagnosis + technique	States 14-gauge core needle biopsy under ultrasound or stereotactic guidance (multiple cores); is gold standard because provides histology, grade, ER/PR/HER2 and Ki-67
Information to patient / consent	Explains the procedure in plain language, the reason for biopsy, risks (bleeding, bruising, infection, rarely pneumothorax for deep lesions), what the result means, and that further receptor testing will be performed on the specimen
Triple assessment verbalised	States the concept: clinical + imaging + pathology = ~98% accuracy when all three agree[1]
Communication & breaking-bad-news	Uses clear language, avoids jargon, checks understanding, offers support person, signposts next steps (result in 5–7 working days, MDT discussion), documents consent

Model key actions

Structured CBE: inspection in four positions, palpation supine, all quadrants + axillary tail + axillary + supraclavicular, documents lump by site/size/consistency/surface/edge/fixity.[1]

[1]

Mammogram: spiculated mass with architectural distortion and pleomorphic microcalcifications; BI-RADS 4c–5.

[1]

Ultrasound: hypoechoic, taller-than-wide, indistinct margins, posterior shadowing — suspicious.

[1]

Tissue diagnosis: ultrasound-guided 14-gauge core needle biopsy (multiple cores); histology provides type, grade, ER/PR/HER2 and Ki-67 — the four pieces of information that drive systemic therapy.[1][3]

[1]

Communication: explain the procedure in plain language, the rationale, risks (bleeding, bruising, infection), what the result means, and that receptor testing will be performed.

[1]

Triple assessment: clinical + imaging + pathology = ~98% accuracy when all three agree.

[1]

Common errors

Skipping the supraclavicular fossa or the contralateral breast during examination.

[1]

Failing to state BI-RADS category explicitly on the mammogram.

[1]

Confusing FNA cytology with core needle biopsy — FNA cannot assess invasion or receptor status and is not the gold standard.

[1]

Not mentioning ER/PR/HER2 testing as a required part of the pathology report.

[1]

Using jargon with the patient ("spiculated mass, BI-RADS 5") instead of plain language.

[1]

Not warning the patient that a benign core does not exclude cancer if imaging is discordant — image-pathology discordance mandates excision biopsy.

[1]

Failing to mention that the case will be discussed at the multidisciplinary team (MDT) meeting before definitive treatment planning.

[1]

References

[1]Waks AG, Winer EP. Breast Cancer Treatment: A Review. JAMA, 2019.PMID 30667505
[2]Early Breast Cancer Trialists' Collaborative Group (EBCTCG), Darby S, McGale P, et al. Effect of radiotherapy after breast-conserving surgery on 10-year recurrence and 15-year breast cancer death. Lancet, 2011.PMID 22019144
[3]Leon-Ferre RA, Goetz MP. Advances in systemic therapies for triple negative breast cancer. BMJ, 2023.PMID 37253507