A 28-year-old nulligravid woman comes to the office after noticing a lump in her left breast last week. The size of the mass has not changed. The patient has no associated nipple discharge or skin discoloration. She has no chronic medical conditions or previous surgery. Her last menstrual period was 5 days ago. The patient's maternal aunt was diagnosed with breast cancer at age 56 and is doing well after surgery and chemotherapy. The patient uses a progestin-containing subdermal implant for contraception. She smokes half a pack of cigarettes a day and drinks alcohol socially but does not use illicit drugs. The patient has no known drug allergies. Blood pressure is 110/70 mm Hg and pulse is 70/min. BMI is 25 kg/m². Physical examination reveals a 1.5-cm, round, mobile, tender mass in the lateral superior quadrant of the left breast, 4 cm from the nipple. There is no fluctuance or erythema. No nipple discharge is expressed. Supraclavicular and axillary lymph nodes are not palpable. Which of the following is the best next step in management of this patient?

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Quizplus · Accepted Answer

Explanation: 11ec2b69_bee0_3e3d_8f63_af9a01beae43_MD0005_00 In patients age <30, palpable breast masses (eg, fibroadenoma, fibrocystic change, cyst) are typically benign; however, malignancy must be excluded. Malignant breast masses are typically firm, immobile, and irregularly shaped, with associated skin changes or lymphadenopathy. In contrast, mobile breast masses are more consistent with benign disease. However, history and physical examination alone cannot reliably diagnose or exclude cancer, so further evaluation with breast imaging is required. In women age <30, ultrasound is the first-line imaging modality for the evaluation of a palpable breast mass. In this age group, ultrasound is better able to distinguish between cystic (typically benign) and solid (potentially malignant) masses. Solid- or complex-appearing masses on ultrasound require further evaluation, typically via mammography and/or biopsy. Cysts can be observed in asymptomatic patients and can be aspirated via fine-needle aspiration in symptomatic patients. (Choice B) Women age <30 typically have dense breast tissue; mammography in this age group has a high false-positive rate, leading to unnecessary breast biopsies. Therefore, mammography is not used in the initial evaluation of a palpable breast mass in women age <30; however, it may be indicated if a solid mass is visualized on ultrasound. (Choice C) Fine-needle aspiration or core needle biopsy is indicated when imaging is suggestive of malignancy. core needle biopsy (Choice D) After malignancy has been excluded with imaging and/or biopsy, breast masses can be managed conservatively and reevaluated in a few months. (Choice E) Estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2 (HER2) status is assessed after breast cancer is diagnosed. These receptor markers determine the benefit of adjuvant endocrine and/or anti-HER2 (eg, trastuzumab) therapy. Educational objective: Palpable breast masses in women age <30 are initially evaluated with ultrasound. Complex- or solid-appearing masses on ultrasound require additional imaging (eg, mammography) or biopsy to exclude malignancy. References: 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/27814822)

A 28-Year-Old Nulligravid Woman Comes to the Office After Noticing