A 57-year-old postmenopausal woman comes to the office for an annual health maintenance examination. The patient is feeling well and has no medical concerns. She has depression and hypertension, which are well controlled with her current regimen. Her maternal aunt died from metastatic breast cancer at age 72.
Vital signs are normal. BMI is 29 kg/m². Breast examination reveals a nontender, fixed, 3-cm mass in the upper outer quadrant of the left breast. There are no skin changes, nipple discharge, or associated axillary lymphadenopathy. A diagnostic mammogram and breast ultrasound reveal no masses or calcifications.
Which of the following is the best next step in management of this patient?

Question

Quizplus · Accepted Answer

11ec193a_97e7_7ae3_853d_cb4375417af1_MD0002_00 A palpable breast mass is a common presenting symptom of breast cancer. Breast masses that are firm, immobile, irregularly shaped, and accompanied by lymphadenopathy, nipple discharge, or skin changes are concerning for malignancy. However, history and physical examination are not sufficient to diagnose or exclude malignancy, and further evaluation with imaging is required. skin changes In women age ≥30 who have a palpable breast mass, the first step is mammography, followed by possible ultrasound, to characterize the mass and determine the need for biopsy. Patients with a palpable breast mass and benign radiographic features (eg, simple cyst on ultrasound) may not require further workup; those with other abnormal imaging findings require core needle biopsy to exclude malignancy. However, even palpable breast masses can be mammographically and sonographically occult (false negative rate as high as 30%), particularly in patients with dense breasts, and malignancy can be missed. Therefore, patients with palpable breast masses and negative imaging require percutaneous core needle biopsy. (Choice A) BRCA testing is indicated for high-risk patients, including those who have breast cancer at age ≤50, have invasive ovarian or peritoneal cancer, or have ≥1 relatives with breast cancer at age ≤50. This patient does not meet the criteria for BRCA testing. (Choice B) Palpable breast masses can be managed conservatively with a repeat breast examination and imaging after malignancy has been excluded via imaging and biopsy. (Choice D) MRI of the breast is used to evaluate for metastasis in patients with malignancy confirmed on biopsy. It can also be used for screening in high-risk patients (eg, prior chest irradiation, lifetime breast cancer risk ≥20%). (Choice E) Tamoxifen is used as adjuvant endocrine therapy in patients with nonmetastatic, estrogen receptor-positive breast cancer; in the treatment of metastatic breast cancer; and to prevent breast cancer in high-risk women (eg, atypical hyperplasia, BRCA carrier). Educational objective: Women age ≥30 with a palpable breast mass and negative breast imaging (eg, mammogram, ultrasound) require further evaluation with a core needle biopsy to exclude malignancy. __________ References: ACOG Practice Bulletin No. 164: diagnosis and management of benign breast disorders. (http://www.ncbi.nlm.nih.gov/pubmed/27214189) ACR Appropriateness Criteria® palpable breast masses. (http://www.ncbi.nlm.nih.gov/pubmed/28473077)

A 57-Year-Old Postmenopausal Woman Comes to the Office for an Annual