A 15-year-old girl comes to the office due to a self-palpated breast mass. The patient discovered the breast lump 2 days ago while taking a shower and noted that it is mildly tender. Breast development began at age 9 and menses at age 11. The patient's menstrual cycles were irregular for the first year after menarche, but now they occur monthly. Her last menstrual period was a week ago. She has no chronic medical conditions and takes no medications. The patient's mother has a history of breast cancer diagnosed at age 38. BMI is at the 75th percentile. Vital signs are normal. Physical examination reveals a firm, smooth, mobile mass in the superior outer quadrant of the right breast. There is no palpable lymphadenopathy. The remainder of the physical examination is unremarkable. Which of the following is the best next step in management of this patient?

Question

A 15-year-old girl comes to the office due to a self-palpated breast mass.  The patient discovered the breast lump 2 days ago while taking a shower and noted that it is mildly tender.  Breast development began at age 9 and menses at age 11.  The patient's menstrual cycles were irregular for the first year after menarche, but now they occur monthly.  Her last menstrual period was a week ago.  She has no chronic medical conditions and takes no medications.  The patient's mother has a history of breast cancer diagnosed at age 38.  BMI is at the 75th percentile.  Vital signs are normal.  Physical examination reveals a firm, smooth, mobile mass in the superior outer quadrant of the right breast.  There is no palpable lymphadenopathy.  The remainder of the physical examination is unremarkable.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d9ab_bad6_bc81_dd9fbf912bb3_MD0003_00 The most common cause of breast masses in adolescents are fibroadenomas, which typically present as unilateral, firm, well-circumscribed, mobile masses in the upper outer quadrant. Although fibroadenomas are typically benign and self-limited, they can cause anxiety; adolescents, in particular, may be sensitive to a perceived abnormality. Unlike adults, who have a higher baseline risk of malignancy, adolescents with a suspected fibroadenoma and no suspicious findings (eg, lymphadenopathy) do not require immediate breast imaging. However, these patients do require observation and repeat examination after completion of a full menstrual cycle (eg, in 6 weeks) because fibroadenomas are estrogen-sensitive and their size and tenderness can change with menses (Choice F). If reexamination reveals a decrease in size or tenderness, then the mass is most likely a benign fibroadenoma. No additional evaluation is indicated and spontaneous regression may occur in up to 10%-40% of adolescents. In contrast, enlarging masses require evaluation with breast ultrasound. (Choices A and B) Excisional biopsies (ie, lumpectomies) are reserved for large, persistently symptomatic masses or lesions highly suspicious for malignancy (eg, increasing size, skin/nipple changes, lymphadenopathy). Fine-needle aspiration may be performed for symptomatic relief of a persistent (eg, weeks to months), tender breast cyst, which can also present as a smooth, mobile breast mass but usually occurs in women age 35-50. In contrast, this adolescent's mass has benign features (eg, well-circumscribed, mobile) with mild tenderness. (Choice C) FSH, LH, and estradiol levels may be indicated in girls with no breast development by age 13 (ie, delayed puberty). Adequate estradiol levels are required for normal ductal development, and FSH and LH abnormalities may indicate primary (eg, Turner syndrome) or secondary (eg, excessive exercise) hypogonadism. (Choice D) MRI of the breast can be used for screening in high-risk adults (eg, BRCA carrier). Although this patient may be at higher risk for breast cancer due to her family history, an MRI is not recommended for diagnosis of a new breast mass due to high sensitivity but low specificity (ie, both benign and malignant masses appear enhanced). Educational objective: In adolescents, there is a high prevalence of benign fibroadenomas and low prevalence of breast malignancy. Therefore, adolescent girls with a new breast mass with clinical features consistent with a fibroadenoma can undergo observation and reexamination after completion of a full menstrual cycle. References: Diagnosis and management of fibroadenomas in the adolescent breast. (http://www.ncbi.nlm.nih.gov/pubmed/24872735) Breast fibroadenomas in adolescents: current perspectives. (http://www.ncbi.nlm.nih.gov/pubmed/26366109)

A 15-Year-Old Girl Comes to the Office Due to a Self-Palpated