A 35-year-old woman is being evaluated for a breast mass first noticed during a routine physical examination last week. The patient had bilateral reduction mammoplasty for mammary hyperplasia 2 years ago. She takes no medications and has no allergies; her paternal grandmother died at age 65 of breast cancer. Breast examination shows a fixed mass palpated in the upper outer quadrant of the right breast. Mammography shows a 3 x 3-cm spiculated mass with coarse calcifications in the upper outer quadrant of the right breast. Ultrasonography of the breast shows a hyperechoic mass. Core biopsy shows foamy macrophages and fat globules, and the mass is excised with concordant pathologic findings. Which of the following is the most appropriate course of action in management of this patient?

Question

A 35-year-old woman is being evaluated for a breast mass first noticed during a routine physical examination last week.  The patient had bilateral reduction mammoplasty for mammary hyperplasia 2 years ago.  She takes no medications and has no allergies; her paternal grandmother died at age 65 of breast cancer.  Breast examination shows a fixed mass palpated in the upper outer quadrant of the right breast.  Mammography shows a 3 x 3-cm spiculated mass with coarse calcifications in the upper outer quadrant of the right breast.  Ultrasonography of the breast shows a hyperechoic mass.  Core biopsy shows foamy macrophages and fat globules, and the mass is excised with concordant pathologic findings.  Which of the following is the most appropriate course of action in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d8d1_d635_bc81_fbad0c79d060_MD0003_00 This patient most likely has fat necrosis of the breast. This benign condition is associated with breast surgery (eg, breast reduction/reconstruction) and trauma (eg, seatbelt injury). Fat necrosis can mimic breast cancer in its clinical and radiographic presentation because it commonly presents as a fixed mass with skin or nipple retraction and gives the appearance of calcifications on mammography. Ultrasonography can demonstrate a hyperechoic mass, which often correlates with a benign etiology. Biopsy is diagnostic and typically shows fat globules and foamy histiocytes. Despite benign biopsy results, the entire mass is often excised due to concerning findings of calcifications on mammography and a fixed irregular mass on clinical examination. Once the diagnosis is confirmed with pathologic analysis, routine annual screening is sufficient as the risk of breast cancer is not increased. (Choices A, C, and E) Radiation and surgery are not indicated for this nonmalignant condition. Prophylactic mastectomy can be considered in patients with a strong family history of breast cancer, such as a patient with >1 first-degree relatives with breast cancer before age 50, or a hereditary oncogenic mutation. > (Choice B) MRI of the breast is used for the screening of high-risk patients (eg, BRCA carrier, first-degree relative of known BRCA carrier) and the evaluation of disease extent and chemotherapy response in breast cancer patients. Further imaging is not necessary with this patient as excisional biopsy confirmed a benign condition. Educational objective: Fat necrosis of the breast is a benign condition with clinical and radiographic findings similar to breast cancer, including skin or nipple retraction and calcifications on mammography. Biopsy will reveal fat globules and foamy histiocytes in fat necrosis. No further workup is indicated for excised lesions. References: Mimickers of breast malignancy on breast sonography. (http://www.ncbi.nlm.nih.gov/pubmed/24154908) Fat necrosis of the breast--a review. (http://www.ncbi.nlm.nih.gov/pubmed/16198567) Hyperechoic lesions of the breast: radiologic-histopathologic correlation. (http://www.ncbi.nlm.nih.gov/pubmed/23617519)

A 35-Year-Old Woman Is Being Evaluated for a Breast Mass