A 35-year-old woman, gravida 3 para 3, comes to the office due to a lump in her right breast. She noticed the mass last week and it has not grown. There is no associated nipple discharge, breast pain, or skin rash. The patient has no chronic medical conditions. She has had 3 full-term deliveries, 1 cesarean and 2 vaginal. She finished breastfeeding her youngest child 12 months ago. Menstrual periods are now regular, occurring every 28 days with 5 days of moderate bleeding. The patient is sexually active and had a bilateral tubal ligation with her last delivery. She takes ibuprofen occasionally and has no known allergies. The patient does not use tobacco, alcohol, or illicit drugs. Her maternal grandmother died of breast cancer at age 62; family history is otherwise unremarkable. Vital signs are normal. BMI is 28 kg/m². Examination reveals a firm, ill-defined, 2-cm density in the upper outer quadrant of the right breast. Bilateral breasts have no nipple retraction or expressed discharge. No axillary or supraclavicular lymphadenopathy is present. Which of the following is the most appropriate next step in management of this patient?

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Explanation: 11ec2b69_c141_5f86_8f63_359f60eee452_MD0005_00 A firm, palpable breast mass with ill-defined borders is concerning for malignancy. Additional clinical features suggestive of malignancy include an immobile mass with associated lymphadenopathy, expressed nipple discharge, skin changes, or new-onset nipple inversion. However, history and physical examination are not sufficient for diagnosing or excluding malignancy in patients with breast masses, so diagnosis requires further evaluation with imaging. In patients age >30, first-line imaging is with mammography due to its ability to further characterize the mass and determine the need for biopsy. On mammography, cancer typically appears as a spiculated soft tissue mass with calcifications. Additional mammographic findings concerning for malignancy include architectural distortion and linear branching calcifications. If mammography shows the lesion but has no features suggestive of malignancy, an ultrasound can be performed (eg, targeted ultrasound) to further characterize the lesion (eg, solid, cystic). If imaging indicates possible malignancy, a core needle biopsy is performed to obtain tissue for histologic diagnosis, which will guide further management if malignancy is identified (Choice D). (Choice A) Ultrasound alone is used to evaluate breast masses in women age <30 as the increased breast density in these patients reduces the sensitivity of mammography. (Choice C) A breast MRI is associated with a high false-positive rate and unnecessary biopsies; therefore, it is not used as initial imaging in the evaluation of palpable breast masses. Instead, an MRI is indicated in the evaluation of cancer metastasis. It can be also used for breast cancer screening in high-risk patients (eg, BRCA mutation, chest irradiation). (Choice E) Conservative management of a breast mass with observation and repeat physical examination is appropriate after malignancy has been excluded. Educational objective: The initial imaging in women age >30 with a palpable breast mass is mammography. A targeted breast ultrasound and/or biopsy may be indicated if mammographic findings are concerning for malignancy. References: ACR appropriateness criteria palpable breast masses. (http://www.ncbi.nlm.nih.gov/pubmed/27814822) Practice Bulletin No. 164: diagnosis and management of benign breast disorders. (http://www.ncbi.nlm.nih.gov/pubmed/27214189)

A 35-Year-Old Woman, Gravida 3 Para 3, Comes to the Office