A 28-year-old woman comes to the office due to a painful breast mass. She first noticed the mass during her last menstrual period, and its size has not changed since. The patient has no chronic medical conditions, and her only medication is a daily combined oral contraceptive. On breast examination, there are no skin changes or nipple discharge. A palpable, 3-cm mass is present in the right breast at the 5-o'clock position. The mass is soft, mobile, and tender to palpation. Breast ultrasound shows a single, thin-walled, fluid-filled cyst. Fine-needle aspiration is performed and evacuates all the cystic fluid, which is clear and light yellow. However, after aspiration, the mass is still visible on ultrasound and palpable on examination. Which of the following is the best next step in management of this patient?

Question

A 28-year-old woman comes to the office due to a painful breast mass.  She first noticed the mass during her last menstrual period, and its size has not changed since.  The patient has no chronic medical conditions, and her only medication is a daily combined oral contraceptive.  On breast examination, there are no skin changes or nipple discharge.  A palpable, 3-cm mass is present in the right breast at the 5-o'clock position.  The mass is soft, mobile, and tender to palpation.  Breast ultrasound shows a single, thin-walled, fluid-filled cyst.  Fine-needle aspiration is performed and evacuates all the cystic fluid, which is clear and light yellow.  However, after aspiration, the mass is still visible on ultrasound and palpable on examination.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d894_098c_bc81_2dd2c32a7c8b_MD0003_00 This patient has a painful, palpable breast mass. Because history and physical examination alone are insufficient for breast cancer evaluation, imaging is required. Ultrasonography is the preferred imaging modality in women age <30 and can help assess the risk of cancer by evaluating the composition and characteristics of the mass. On ultrasound, this patient's mass resembles a simple cyst (thin-walled, fluid-filled) rather than a complex cyst (thick-walled, solid components). Complex cysts automatically require core needle biopsy due to the increased risk of underlying cancer. In contrast, asymptomatic simple cysts can be observed. However, patients with symptomatic (ie, painful) cysts can undergo fine-needle aspiration for pain relief, and further management then depends on the results of the aspiration: If the fluid is bloody and/or the mass persists (ie, remains palpable and/or visible on ultrasound, as in this patient) despite aspiration, patients may be at increased risk for breast cancer and should undergo core needle biopsy. Biopsy provides a histologic diagnosis to guide further management, which may include surveillance (eg, repeat examinations), excisional biopsy, or tumor-directed treatment (Choice D). In contrast, if the aspirated fluid is nonbloody (eg, clear, green, grey) and both the breast mass and symptoms resolve completely, patients are at low risk for cancer and require no additional management. Repeat examination and imaging are not required unless the mass or symptoms recur. (Choice A) Breast MRI is sometimes used for cancer screening in high-risk patients (eg, BRCA carrier). It is not used to evaluate a new breast mass because breast MRI has high sensitivity but low specificity for cancer (ie, both benign and malignant masses appear enhanced). (Choice C) Combined oral contraceptives can cause breast pain, particularly during the first few months after initiation, but they typically do not cause breast cysts. Therefore, discontinuation of contraceptives is unnecessary in this patient. (Choice E) Thermography is the measurement of skin temperature to detect underlying cancer (ie, increased temperature may suggest higher metabolic activity and increased risk of cancer). However, thermography has not been proven to identify breast cancer and is not recommended. Educational objective: Symptomatic simple breast cysts can be managed with fine-needle aspiration. Breast cysts that contain bloody fluid or that do not resolve with aspiration require core needle biopsy to evaluate for breast cancer. 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 28-Year-Old Woman Comes to the Office Due to a Painful