A 37-year-old woman comes to the office for evaluation of a left breast mass. The patient has had left breast discomfort before menses for the past year, with continuous pain over the past 3 months. She noticed the mass last week and reports no associated trauma or skin changes. At age 29, the patient underwent an excisional biopsy for a benign fibroadenoma in the right breast. She has type 2 diabetes mellitus that is well controlled with oral medications. The patient also has polycystic ovary syndrome and takes a combined estrogen progestin oral contraceptive for menstrual regulation. There is no family history of breast or ovarian cancer. She has no known allergies. The patient drinks 2 glasses of wine with dinner every night but does not use tobacco or illicit drugs. Blood pressure is 128/70 mm Hg and pulse is 73/min. BMI is 31 kg/m². A 2-cm, smooth, tender, mobile mass is palpated in the upper outer quadrant of the left breast, 10 cm from the nipple. Both breasts are diffusely nodular, and a small biopsy scar is noted on the right breast. There is no nipple discharge or lymphadenopathy. Mammogram shows no calcifications. Ultrasound of the breast reveals a 2-cm, cystic mass with smooth borders, thin walls, and no internal septations. Fine-needle aspiration shows a thin, green fluid; after the procedure, the mass resolves completely and the patient's pain is gone. Which of the following is the best next step in management of this patient?

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Quizplus · Accepted Answer

Explanation: 11ec2b69_bee0_da7e_8f63_b9c1672d4b05_MD0005_00 This patient has a breast cyst, a fluid-filled mass resulting from breast duct obstruction. Breast cysts typically present as a palpable breast mass in women age 30-50. Depending on their size (ie, mass effect on surrounding breast tissue), breast cysts can be asymptomatic or cause breast pain. Examination typically reveals a smooth, mobile, well circumscribed mass without malignant features (eg, lymphadenopathy, nipple discharge). However, because history and physical examination alone are insufficient to exclude breast cancer, patients with a new breast mass require breast imaging (mammography and/or ultrasonography depending on patient age). Breast ultrasound can help assess the risk of cancer based on the composition and characteristics of the mass. Complex-appearing masses (eg, thick-walled, septated, solid and cystic components) are suspicious for cancer and require core needle biopsy. In contrast, simple breast cysts, which have smooth borders, thin walls, and no septations or solid components, are typically benign. simple breast cysts Simple cysts in asymptomatic patients may be observed. Symptomatic patients, such as this one with 3 months of continuous breast pain, can undergo cyst drainage via percutaneous fine-needle aspiration for pain relief. Further management then depends on aspiration results: cyst drainage If the fluid is bloody and/or the mass persists, patients may be at increased risk for breast cancer. These patients require core needle biopsy for a histologic diagnosis (Choice A). In contrast, if the aspirated fluid is nonbloody (eg, clear, green, straw-colored) and both the mass and symptoms resolve, patients are at low risk for cancer and require no additional management. (Choice B) Antibiotics are indicated for the treatment of a breast cellulitis or abscess. A breast abscess can present as a painful mass; however, patients typically have fever, erythema, induration, and fluctuance, none of which are seen in this patient. (Choice C) Simple breast cysts that disappear with aspiration are benign and do not require repeat imaging unless the mass or symptoms recur. (Choice E) Serum prolactin and TSH levels are indicated for evaluation of galactorrhea (ie, physiologic, bilateral nipple discharge); this patient has no associated nipple discharge. Educational objective: Simple breast cysts are benign and managed with observation (in asymptomatic patients) or fine-needle aspiration (in symptomatic patients). Nonbloody, simple breast cysts that resolve with fine-needle aspiration require no further management. References: Cystic breast masses and the ACRIN 6666 experience. (http://www.ncbi.nlm.nih.gov/pubmed/20868895) ACR Appropriateness Criteria palpable breast masses. (http://www.ncbi.nlm.nih.gov/pubmed/28473077)

A 37-Year-Old Woman Comes to the Office for Evaluation of a Left