A 39-year-old woman comes to the office for evaluation of breast pain. The patient has had persistent right-sided breast pain for the past 2 months. She has had no breast trauma or changes in activity. The patient has no chronic medical conditions, and her only medication is an oral contraceptive. Her last menstrual period was 2 weeks ago. Family history is significant for a female paternal cousin with breast cancer at age 58. Temperature is 98.8 F (37.1 C), blood pressure is 106/64 mm Hg, and pulse is 88/min. There is dense breast tissue bilaterally. The right breast has localized tenderness immediately lateral to the areola, at the 9 o'clock position. There are no skin changes or axillary lymphadenopathy. The remainder of the physical examination is unremarkable. Urine pregnancy test is negative. Which of the following is the best next step in management of this patient?

Question

A 39-year-old woman comes to the office for evaluation of breast pain.  The patient has had persistent right-sided breast pain for the past 2 months.  She has had no breast trauma or changes in activity.  The patient has no chronic medical conditions, and her only medication is an oral contraceptive.  Her last menstrual period was 2 weeks ago.  Family history is significant for a female paternal cousin with breast cancer at age 58.  Temperature is 98.8 F (37.1 C), blood pressure is 106/64 mm Hg, and pulse is 88/min.  There is dense breast tissue bilaterally.  The right breast has localized tenderness immediately lateral to the areola, at the 9 o'clock position.  There are no skin changes or axillary lymphadenopathy.  The remainder of the physical examination is unremarkable.  Urine pregnancy test is negative.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d899_60c6_bc81_195082a320b4_MD0003_00 Mastalgia (breast pain) is a common symptom in women and is usually caused by normal estrogen and progesterone fluctuations associated with the menstrual cycle. This type of physiologic breast pain is typically bilateral, diffuse, and cyclic (ie, onset 1-2 weeks prior to menses and resolution with menses). In the absence of a palpable breast mass, skin changes, or lymphadenopathy, these patients may undergo repeat examination and observation because there is low risk for malignancy (Choice E). In contrast, patients with any of the following concerning features for malignancy require further evaluation: Unilateral breast pain Persistent, noncyclic breast pain Focal pain and tenderness, which may indicate tumor compression or local invasion of surrounding benign breast tissue, even if there is no palpable mass on clinical breast examination Therefore, this patient with unilateral, focal, and noncyclic breast pain requires further evaluation with breast imaging due to an increased risk of malignancy. Breast ultrasound with or without mammography is indicated in this patient with dense breast tissue. Abnormal imaging requires tissue biopsy (eg, core needle biopsy). (Choice A) BRCA testing is indicated for family history of breast cancer in ≥2 first-degree relatives (1 of whom is diagnosed at age ≤50). A single second-degree relative (eg, paternal cousin) with breast cancer diagnosed at age >50 is not an indication because BRCA mutation is unlikely. (Choice C) Although oral contraceptives can cause breast pain and tenderness, these symptoms are typically bilateral and usually occur at the time of initiation rather than with regular use. Therefore, discontinuing this patient's oral contraceptive and changing to a nonhormonal contraceptive method is not indicated. (Choice D) Core needle biopsy is performed in patients with focal breast pain who have either an abnormal breast examination (eg, palpable mass) or imaging findings suggestive of malignancy. Focal breast pain without a palpable mass requires imaging prior to decision to biopsy. Educational objective: Patients with bilateral, diffuse, and cyclic breast pain typically have physiologic mastalgia and do not require imaging. In contrast, patients with unilateral, focal, and noncyclic breast pain require breast imaging to evaluate for cancer. References: ACR Appropriateness Criteria ® breast pain. (http://www.ncbi.nlm.nih.gov/pubmed/28473081) Common breast problems. (http://www.ncbi.nlm.nih.gov/pubmed/22963023)

A 39-Year-Old Woman Comes to the Office for Evaluation of Breast