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A
The physical examination • 235
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B
Fig. 10.12 A Sensor measuring interstitial glucose and B Continuous subcutaneous insulin infusion pump. (A) FreeStyle Libre is a trademark of Abbott or its
related companies. Reproduced with permission of Abbott, © 2021. All rights reserved. (B) Courtesy Tandem Diabetes Care, Inc.
10
acetone (a ketone), both of which suggest insulin deficiency
and diabetic ketoacidosis.
• Skin: look for signs of infection such as cellulitis, boils, ab-
scesses and fungal infections, paying particular attention to
the feet (see later). Look for signs of insulin resistance such as
acanthosis nigricans (Fig. 10.13A). Necrobiosis lipoidica, a
yellow, indurated or ulcerated area surrounded by a red
margin indicating collagen degeneration (see Fig. 10.13B),
may occur on the shins in type 1 diabetes and often causes
chronic ulceration.
• Look for xanthelasmata and xanthomata (Fig. 4.6, p. 52);
these are suggestive of dyslipidaemia, which may occur in
type 2 diabetes.
• Measure the pulse and blood pressure, and examine the
cardiovascular and peripheral vascular systems with a
particular emphasis on arterial pulses in the feet (p. 76).
• Examine the peripheral nervous system, with a particular
focus on sensation in the lower limbs (p. 144).
• Test visual acuity and perform fundoscopy (p. 183 and
Fig. 8.17, p. 188).
• Perform near-patient screening tests, such as capillary blood
samples and urinalysis, both of which can be used to check
for raised glucose or ketones. Diagnostic investigations are
covered in Box 10.8.
Microvascular, neuropathic and macrovascular complications
of hyperglycaemia can occur in patients with any type of diabetes
mellitus, and may be present at diagnosis in patients with slowonset type 2 disease.
Glycosuria is suggestive of diabetes; the presence of urinary
(or blood) ketones suggests insulin deficiency and the possibility
of diabetic ketoacidosis. Other investigations to consider are
summarised in Box 10.8.
Routine review of a person with diabetes
Examination sequence
• Weight: an increase in weight in type 2 diabetes is likely to be
associated with worsening insulin resistance, while weight
loss in type 1 diabetes often suggests poor glycaemic control
and inadequate insulin dosage.
• For patients using insulin, examine insulin injection sites or
pump sites (see Fig. 10.12B) for evidence of lipohypertrophy
(which may cause unpredictable insulin release; Fig. 10.13C),
lipoatrophy (rare) or signs of infection (very rare).
• Measure the pulse and blood pressure.
• Test visual acuity and perform fundoscopy (p. 183 and
Fig. 8.17, p. 188).
• Examine the feet (see the next section).
• Perform routine biochemical screening (see Box 10.8).
The diabetic foot
Up to 40% of people with diabetes have peripheral neuropathy and
40% have peripheral vascular disease, both of which contribute to
236 • THE ENDOCRINE SYSTEM
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A
B
C
Fig. 10.13 Diabetes and the skin. A Acanthosis nigricans. B Necro-
biosis lipoidica.
Istanbul Medeniyet University, Department of Dermatology; published in
Uzuncakmak TK, Akdeniz N, Karadag AS. Cutaneous manifestations of obesity
and the metabolic syndrome. Clin Dermatol. 2018;36(1):81–8. (C) From
James WD, Elston DM, McMahon PJ. Diseases of subcutaneous fat. Andrews’
Diseases of the Skin: Clinical Atlas. 1st ed. London: Elsevier; 2018.
a 15% lifetime risk of foot ulcers (Fig. 10.14). Early recognition of the
‘at-risk’ foot is essential. There are two main presentations:
• Neuropathic: neuropathy predominates but the major arterial
supply is intact.
• Neuroischaemic: reduced arterial supply produces ischaemia
and exacerbates neuropathy.
Infection may complicate both presentations.
C Lipohypertrophy at insulin injection sites. (A) Courtesy
Examination sequence (Video 5)
• Look for hair loss and nail dystrophy.
• Examine the skin (including the interdigital clefts) for excessive
callus, skin breaks, infections and ulcers. Distal pallor can
suggest early ischaemia, while purple/black discoloration
suggests gangrene.
10.8 Investigations in diabetes
Investigation Indication/comment
Diagnostic investigations
Fasting glucose, random
glucose, oral glucose tolerance
test
HbA1c Can be used for diagnosis of type 2
Urine or blood ketone
measurement
Pancreatic antibodies (antiGAD, anti-IA-2 and anti-ZnT8)
C peptide Used in established diabetes to
Annual review investigations
HbA1c A measure of glycaemic control over
Urea and electrolytes To assess for diabetic nephropathy
Lipid profile To aid estimation of cardiovascular
Thyroid function tests To screen for the commonly
Urine albumin: creatinine ratio To assess for early diabetic
Digital retinal photography or
fundoscopy
GAD, glutamic acid decarboxylase, IA-2, insulinoma antigen 2, ZnT8,
zinc transporter 8.
• Ask the person to stand so that you can assess the foot arch;
look for deformation of the joints of the feet.
• Feel the temperature of the feet.
• Examine the dorsalis pedis and posterior tibial pulses. If ab-
sent, arrange for Doppler studies and evaluate the ankle:
brachial pressure index (p. 76).
• Test for peripheral neuropathy: use a 10-g monofilament to
apply a standard, reproducible stimulus. The technique and
the best sites to test are shown in Fig. 10.15. Avoid areas of
untreated callus. Sensory loss typically occurs in a stocking
distribution.
• Assess dorsal column function by testing vibration and
proprioception.
• Undertake a foot risk assessment to guide management
(Box 10.9).
When a consultation is being performed remotely and the
clinician cannot examine the feet, they can direct the individual to
the Diabetes UK website, which has videos demonstrating the
self-administered ‘Touch the Toes’ test (www.diabetes.org.uk/
guide-to-diabetes/complications/feet/touch-the-toes).
To make a diagnosis of diabetes.
Patients also monitor capillary blood
glucose to adjust their treatment
diabetes and to assess glycaemic
burden
Ketones suggest insulin deficiency,
which occurs in type 1 diabetes and in
diabetes due to pancreatic pathology
To confirm a diagnosis of autoimmune
diabetes
distinguish between insulin-deficiency
(low C peptide) and insulin-resistance
(high C peptide)
the preceding 3 months; predicts risk
of complications
risk and guide treatment with lipidlowering therapy
associated hypothyroidism
nephropathy (microalbuminuria)
To screen for diabetic retinopathy
and/or maculopathy
The physical examination • 237
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AB
A
Fig. 10.15 Monofilament sensory testing of the diabetic foot. A Apply
sufficient force to allow the filament to bend. B Sites at highest risk (toes and
metatarsal heads).
10
10.9 Risk assessment of the diabetic foot
Level of
risk Definition Action required
Low No sensory loss, peripheral
Moderate One risk factor present, e.g.,
B
High Previous ulceration or
Active
foot
disease
vascular disease or other risk
factors
absent pulses or reduced
sensation
amputation, or more than
one risk factor present
Ulceration, spreading
infection, critical ischaemia
or an unexplained red, hot,
swollen foot
Annual foot screening can
be undertaken by any
trained healthcare
professional
Annual foot screening
should be undertaken by a
podiatrist
Annual screening should
be undertaken by a
specialist podiatrist
Prompt referral to a
multidisciplinary diabetic
foot team is required
C
Fig. 10.14 Diabetic foot complications. A Infected foot ulcer with
cellulitis and ascending lymphangitis.
C Charcot arthropathy with plantar ulcer.
Hair loss and nail dystrophy occur with ischaemia. Feet are
warm in neuropathy and cold in ischaemia. Ischaemic ulcers
are typically found distally, at the tips of toes (see Fig. 10.14B),
for example. There may be skin fissures or tinea infection (‘athlete’s foot’). Loss of sensation to vibration (p. 161) and
B Ischaemic foot: digital gangrene.
proprioception (p. 161) are early signs of diabetic peripheral
neuropathy. Sensory neuropathy is present if the person cannot
feel the monofilament on the sites shown in Fig. 10.15. This
suggests loss of protective pain sensation and is a good predictor of future ulceration.
With significant neuropathy, the foot arch may be excessive or
collapsed (rocker-bottom sole). Both conditions cause abnormal
pressures and increase the risk of plantar ulceration (see
Fig. 10.14C), particularly in the forefoot. Charcot’s arthropathy is
disorganised foot architecture, acute inflammation, fracture and
bone thinning in a person with neuropathy. It presents acutely as
a hot, red, swollen foot and is often difficult to distinguish clinically
from infection.
238 • THE ENDOCRINE SYSTEM
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OSCE example 1: Neck swelling
Miss Tan, 27 years old, presents with a 6-month history of palpitations, weight loss and neck swelling.
Please examine her thyroid status
• Introduce yourself and clean your hands.
• Carry out a general inspection, observing dress, body habitus, agitation, restlessness, diaphoresis, anxiety, exophthalmos, goitre and neck scars.
• Inspect the hands for vitiligo, palmar erythema, thyroid acropachy and fine tremor (hands outstretched with paper over the dorsum).
• Palpate the pulse for bounding pulse, tachycardia and atrial fibrillation.
• Inspect the eyes for lid retraction (scleral show) and exophthalmos (look down from above and behind the patient).
• Test eye movements for ophthalmoplegia and lid lag.
• Examine the neck for scars, goitre, lymphadenopathy. Ask the patient to swallow to see the thyroid gland rise on swallowing.
• Palpate the thyroid (again on swallowing) and cervical lymph nodes; percuss manubrium for retrosternal goitre.
• Auscultate any goitre for bruit.
• Assess the patient for proximal myopathy (ask them to stand from sitting, with their arms crossed).
• Examine the shins for pretibial myxoedema and test for hyper-reflexia.
• Thank the patient and clean your hands.
Summarise your findings
The patient is thin, with a fine tremor, tachycardia, exophthalmos and lid lag. In the neck there is a smooth, non-tender goitre.
Suggest a diagnosis
These findings suggest autoimmune thyrotoxicosis (Graves’ disease).
Suggest investigations
Thyroid function tests, thyroid receptor autoantibodies and thyroid scintigraphy.
Advanced level comments
Thyrotoxicosis may cause elevated alkaline phosphatase and hypercalcaemia due to increased bone turnover and normochromic normocytic anaemia.
OSCE example 2: The diabetic foot
Mr Birnam, 67 years old, has type 2 diabetes and presents with pain in his lower limbs.
Please examine his feet
• Introduce yourself and clean your hands.
• Carry out a general inspection of the lower limbs, looking for hair loss, nail dystrophy or discoloration.
• Inspect the skin for excessive callus, skin breaks, infections and ulcers.
• Inspect the joints. Ask the patient to stand so that you can assess the foot arch and look for deformation of the joints of the feet.
• Palpate the feet to assess the temperature of the skin.
• Palpate the dorsalis pedis and posterior tibial pulses.
• Test for peripheral neuropathy using a 10-g monofilament and tuning fork.
• Thank the patient and clean your hands.
Summarise your findings
The patient has pale, cool feet with absent dorsalis pedis pulses bilaterally. The skin is intact but there is loss of sensation in stocking distribution in both feet.
Suggest a diagnosis
The most likely diagnosis is peripheral vascular disease and peripheral neuropathy secondary to diabetes.
Suggest investigations
Doppler studies to evaluate the ankle: brachial pressure index. Review of diabetes control.
Advanced-level comments
With peripheral neuropathy, also take an alcohol history and check vitamin B12levels to take other common causes of peripheral sensory loss into account.
Peripheral neuropathy can be confirmed in nerve conduction studies. Offer an examination for other microvascular complications, such as retinopathy
(fundoscopy) and nephropathy (test urine for microalbuminuria).
Christina Yip
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Colin Duncan
Kirsty Dundas
Alexander Laird
11
The reproductive system
Breast 240
Anatomy and physiology 240
The history 240
Common presenting symptoms 241
The physical examination 242
Examination sequence 242
Investigations 244
Female reproductive system 245
Anatomy and physiology 245
The history 246
Common presenting symptoms 247
Drug history 249
Family and social history 249
Sexual history 249
The physical examination 249
Passing a speculum 249
Taking a cervical smear 251
Bimanual examination 252
Investigations 253
Obstetric history and examination: the booking visit 254
The history 254
Past medical history 254
Drug history 254
Family history 254
Social history 255
Investigations 256
Routine antenatal check in later pregnancy 257
The history 257
Common presenting symptoms 258
The physical examination 258
Investigations 260
Male reproductive system 262
Anatomy and physiology 262
The history 263
Common presenting symptoms 263
Past medical history 265
Drug history 265
Social history 265
The physical examination 265
Skin 265
Penis 266
Scrotum 266
Prostate 268
Investigations 268
OSCE example 1: Breast examination 268
OSCE example 2: Scrotal pain history 269
OSCE example 3: Gynaecological examination 269
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BREAST
Anatomy and physiology
The adult breast lies over the pectoralis major and serratus
anterior muscles; it extends from the lateral border of the sternum into the lower axilla as the tail of Spence. The centre of the
breast is the nipple, which is composed mostly of smooth
muscle fibres. The areola is the pigmented skin around the nipple
that contains numerous Montgomery glands. The breast is
divided into four quadrants by two invisible lines running horizontally and vertically through the nipple (Fig. 11.1). Accessory
breast tissue (Fig. 11.2) is usually found in the axilla, whilst
accessory nipples are most commonly seen just inferior to a
normal breast or above the groins.
Chest wall/
rib cage
Pectoralis
major
muscle
Fat
Lobules
Ducts
Dilated section
of duct to
hold milk
Nipple
Normal duct cells
Tail of Spence
Upper outer
Upper inner
Lower outer
Lower inner
Fig. 11.1 Adult right breast.
Basement membrane
Lumen (centre of duct)
Fig. 11.3 Cross-section of the female breast.
The breast is composed of mammary glands, which are modified
sweat glands surrounded by connective tissue stroma
(Fig. 11.3). The mammary glands consist of 15–20 duct and
lobular units that open individually onto the nipple-areolar complex. The connective tissue stroma has a fibrous and a fatty
component. The fibrous bands, called the suspensory ligaments
of Cooper, anchor the breast tissue to the dermis and underlying
pectoral fascia and separate the secretory lobules of the breast.
The fibrous stroma maintains the shape of the breast, while the
fatty component contributes to the breast volume. Advancing
age, body weight fluctuations and hormonal changes during
puberty, menstruation, pregnancy and lactation can alter the
consistency and density of the breast, resulting in changes to
breast shape and volume.
Four groups of lymph nodes drain each breast: supraclavicular, infraclavicular, internal mammary and axillary. More
than 75% of the lymphatic drainage of the breast is to the ipsilateral axillary lymph nodes.
The history
Fig. 11.2 Accessory breast tissue in the axilla.
Breast symptoms affect all ages. Most patients present with a
single breast complaint, but it is not uncommon for patients to
have multiple breast concerns. The most common presenting
symptoms are breast lumps, breast pain and changes to the skin
and nipples. Malignancy is more common as patients get older.
An older patient who presents with a painless breast lump with
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skin dimpling and nipple inversion would raise suspicion of malignancy. On the other hand, a red, painful, swollen breast lump in
a patient who is breastfeeding would suggest lactational mastitis.
For each presenting symptom, it is important to establish the
duration and progression of the symptom and any association
with the menstrual cycle.
In addition, ask about previous breast investigations, breast
surgeries, breast cancer diagnoses and treatments. Document
any exposure to exogenous oestrogen, especially the use of
hormonal replacement therapy. Previous mantle field radiation for
the treatment of lymphoma is also relevant.
Family history of cancer, especially breast and ovarian cancer,
should be established. Be specific about the degree of relatives
affected and their age at diagnosis.
The history • 241
Common presenting symptom s
Breast pain (mastalgia)
Ask if the pain varies during the menstrual cycle (if relevant) and
establish the site, duration, severity and characteristics of the pain.
Breast pain associated with the menstrual cycle (cyclical
mastalgia) is commonest among young women. Non-cyclical
mastalgia may suggest a non-breast origin, for example, the
chest wall. Ask about the association of pain with arm movements and the presence of underlying shoulder pathologies to
distinguish a non-breast cause.
Breast lump
A breast lump is the commonest reason for referral to a breast
clinic. Many patients describe lumpiness or nodularity rather than
a discrete mass. Patients may also present with an axillary lump.
The general approach to history taking is the same for all these
scenarios.
Ask:
• Is it a single lump or multiple lumps?
• When was it first noticed?
• Has it changed in size?
• Is there any relation to the menstrual cycle?
Establish:
• Any association with other symptoms, such as skin dimpling
or nipple retraction?
• Any recent trauma to the breast?
In addition, for an axillary lump, establish:
• Any recent systemic illness?
• Any previous history of skin malignancy?
The commonest causes of an axillary lump are lymph nodes,
skin lesions such as cysts, and accessory breast tissue.
Breast volume and shape changes
Patients may report a change in the size or shape of their
breasts. To quantify breast volume changes, it is best to ask the
Fig. 11.4 Breast volume and shape changes to right breast following
lumpectomy (scar at upper outer quadrant) and radiotherapy (tattoo indicated
by arrow). Radiotherapy has also resulted in right breast skin thickening and
hyperpigmentation
patient if they have recently changed their bra size. In addition,
ask if the changes are:
• unilateral or bilateral,
• recent or longstanding
Breast cancer surgery or treatment, especially radiotherapy,
are likely to cause scarring that results in breast skin colour,
texture, shape and volume changes (Fig. 11.4).
Breast implant surgery is increasingly common, and changes
to breast volume and shape may be a consequence of implant
changes, such as capsular contracture or implant rupture.
Skin changes
• Ask about skin colour and textural changes and their site,
duration and progression. Common descriptions of skin
changes used by patients include rash, dimpling, puckering and
thickening. It is essential to understand what they are referring to
and establish any association with other symptoms.
• Rash can be a sign of infection. It is important to establish
if the patient has been treated with antibiotics and if the
rash has responded to them. If not, further investigation is
necessary, as it may be a sign of inflammatory breast
cancer (Fig. 11.5).
• ‘Orange peel appearance’ or ‘peau d’orange’ describes
thickened and dimpled breast skin (Fig. 11.6). It is a sign
of breast lymphoedema and may be a consequence of
infection or malignancy.
Nipple changes
Patients may report changes to the nipple, or these may be
noted on examination. Common nipple complaints are: pain,
discharge, inversion and nipple and/or areola skin changes.
• Nipple pain: establish the duration, severity and characteristics of the pain.
11
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Fig. 11.7 Single duct, blood-stained nipple discharge.
Fig. 11.5 Inflammatory breast cancer: patchy erythema, flattened nipple,
peau d’orange of right breast.
Fig. 11.6 Peau d’orange of the breast.
• Nipple discharge: establish if unilateral or bilateral and if spontaneous or provoked by massage. Ascertain the frequency,
quantity (from single or multiple ducts) and the colour (white,
yellow, green or blood-stained) of the discharge. Nipple
discharge can be part of the ageing process (e.g. duct ectasia).
Galactorrhoea, which is bilateral milky discharge not associated
with pregnancy or breastfeeding, can be drug-induced or
secondary to hyperprolactinaemia. A persistent, blood-stained
(Fig.11.7), spontaneous, single duct nipple discharge should
be investigated in order to exclude malignancy.
• Nipple and areola skin changes: may be skin colour changes,
irritation or ulceration. Dermatitis of the nipple-areola complex
can be part of a generalised skin condition; however, if it fails
to respond to conservative treatments, Paget’s disease of the
nipple and skin malignancy should be excluded.
• Nipple inversion: retraction of the nipple is common. Establish its
duration, whether it is correctible or not, and any associated
symptoms. Malignant nipple retraction is unlikely to be
correctable and often presents with other signs of malignancy.
Gynaecomastia
Gynaecomastia is the enlargement of the male breast and is
usually, but not always, bilateral. It can be due to physiological,
pharmacological or pathological causes, often when there is
relative oestrogen excess or testosterone insufficiency (Box 11.1).
11.1 Causes of gynaecomastia
Physiological
Pharmacological
Pathological
• Neonatal, puberty and old age
• Prescription: cimetidine, digoxin, diazepam,
spironolactone, Angiotension Converting
Enzyme (ACE) inhibitor
• Recreational: cannabis, marijuana, alcohol,
anabolic steroids
• Cirrhosis, thyrotoxicosis, hypogonadism,
Klinefelter’s syndrome, testicular and adrenal
tumours
The physical examination
Breast examination should be conducted in a well-illuminated
room, on an examination bed, in the presence of a chaperone,
whose name should be recorded. Ask your patient to undress to
the waist and explain that you will be examining them sitting up
as well as lying down.
Examination sequence
• Ask the patient to sit with hands relaxed by their side
(Fig.11.8A).
• Look for:
• breast asymmetry: shape/contour and volume differences
The physical examination • 243
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AB CD
Fig. 11.8 Positions for inspecting the breasts. A Hands resting on the thighs. B Hands pressed on to the hips. C Arms above the head. D Leaning
forward with the breasts pendulous.
• breast skin colour and textural variation
• nipple-areola complex changes: spontaneous discharge,
skin ulceration, nipple retraction.
• Operative scars and tattoos from previous chest wall
radiotherapy
• chest asymmetry (see Chapter 5)
• Ask the patient to press their hands firmly on their hips to
contract the pectoral muscles (see Fig. 11.8B), raise their
arms above their head (see Fig. 11.8C) and then lean forward
(see Fig. 11.8D).
• Look for any breast abnormality that becomes more visible
with arm movements and note its association with the overlying skin, adjacent nipple-areola complex and underlying
pectoral muscles.
• Ask the patient to lie supine, head on one pillow with their
hand under their head on the side to be examined (Fig.11.9).
• Use both hands to palpate the breast and feel for abnormality
under your fingertips. Avoid pressing too firmly as breasts can
be very tender.
• Examine each quadrant of the breast from the outside to-
wards the nipple, including under the nipple (Fig. 11.10).
• Examine the axillary tail between your finger and thumb.
• Gently squeeze the nipple between your index finger and
thumb to determine if a discharge is present, either from a
single or multiple ducts, and whether blood is present (either
frankly or on urine dipstick testing).
• Palpate any breast abnormality. Assess its site, size, contour,
texture and any fixation to the overlying skin, nipple-areolar
complex or underlying muscle (Fig 11.11). Compare examination findings between the two breasts (Box 11.2).
Fig. 11.9 Position for palpation of the right breast.
11
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ABC
Fig. 11.10 Clinical examination of the breast. Examine each quadrant of the breast systematically, from the outside towards the nipple, including under the nipple.
• Palpate the regional lymph nodes. The axilla and supra-
clavicular fossa are best examined with the patient in a sitting
position.
• Support the full weight of the patient’s arm at the wrist
with your ipsilateral arm, place your contralateral hand
high into the axilla and move it upwards over the chest to
the apex. Compress the contents of the axilla against the
chest wall. Define the characteristics of any mass (see
Box 3.8 in the 14th edition).
• Palpate the neck for the supraclavicular lymph nodes from
behind (see Chapter 9).
Fig. 11.11 Malignancy in the upper outer quadrant of left breast: painless,
solid, irregular mass, fixed to the overlying skin.
11.2 Summary of examination findings in commonly
presented breast conditions
Commonly
Conditions Examination findings
Fibroadenoma
Breast cyst
Lactational
mastitis
Nonlactational
mastitis
Malignancy
• Extremely mobile, discrete,
rubbery lump
• Solitary or multiples in one or
both breasts
• Firm, discrete, smooth lump
• Solitary or in clusters
• Pain, localised erythema and
swollen breast
• Usually a history of cracked nipple
• Peri-areolar infection: peri-areolar
erythema and a mass or abscess
• Peri-areolar fistula
• Painless, solid, irregular mass,
which can be fixed to
surrounding tissues, leading to
other skin and nipple changes
(see Fig. 11.11)
affect
• Young
women
<35 years
• Perimeno-
pausal women
• Breastfeeding
women
• Young female
smokers
• Women
>50 years
Investigations
Any breast abnormality, especially a breast lump, should be
assessed by triple assessment: a combination of clinical, radiological and pathological examination.
Radiological examination options include mammography
(Fig. 11.12) and ultrasonography (Fig. 11.13). Digital breast
tomosynthesis (Fig.11.14) is sometimes used as an adjunct to
standard mammography. Mammography is offered to women
aged 40 or over, often in conjunction with ultrasonography, to
detect malignancy. For women under 40, ultrasound is often the
only imaging required. High breast density in younger women
decreases the sensitivity of mammography for the detection of
cancer. However, if there is a strong clinical and ultrasonographic
suspicion of malignancy, then mammography is performed.
Digital breast tomosynthesis increases cancer detection by
increasing visibility between overlapped dense breast tissue.
Breast MRI is the most sensitive technique for the detection of
breast cancer; in selected cases, it can be used to evaluate the
extent of cancer and for screening. It is also useful in assessing
breast implant integrity.
The pathological examination involves a biopsy (Box 11.3).
Image-guided biopsy improves diagnostic accuracy.
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