CCS Interactive Case 10

Question 1

40 y/o F presents to the office w/ a mobile painless mass in the upper outer quadrant of her left breast discovered 2 months ago on self-exam. Does not vary with menses, no nipple discharge, systemic symptoms, family history of breast cancer. 10 pack-year smoking history.

Exam?

Answer 1

Focused, including breast and lymph node

Question 2

Exam reveals a 2-cm firm, mobile, non-tender mass w/distinct margins, no palpable LAD

Features of history and physical that raise concern for alignancy?

Answer 2

Age >40, family history of breast cancer, early menarche, late pregnancy, nulliparity, late menopause

Solitary, hard, immobile lumps, irregular borders, size >2cm, LAD

Question 3

DDx for benign breast disease?

Answer 3

Fibroadenoma, fibrocystic changes, intraductal papilloma, fat necrosis, duct ectasia

Question 4

First steps in evaluation of solitary breast mass?

Answer 4

Ultrasound

If simple cyst, nothing further

If complex cyst or solid mass, proceed to FNA

Question 5

What happens next after FNA based on results?

Answer 5

If cystic and bloody, evaluate cytology of fluid and excise of cytology is +

If cystic and non-bloody or bloody but cytology negative, then reassure and repeat exam in 4-6 weeks to see if lump has returned. If recurrence, refer for surgery.

If solid and appears malignant or suspicious, then excision/definitive therapy

If solid and appears benign, then mammography for women >35

Question 6

Next steps based on mammography?

Answer 6

If negative, repeat exam in 3-6 months (does not detect 102-0% of breast masses, thus negative should not preclude diagnosis)

If positive, additional imaging or excision/definitive treatment

Question 7

Sequence?

Answer 7

Exam: focused
Order: mammography, FNAB
Location: change to home
Clock: appt in 1 week, results of mammography and FNAB return and are consistet with diagnosis of simple fibroadenoma. Patient arrives
Exam: interval follow-up
Order: Reassurance, counseling, Pap smear
Location: home
Clock: schedule appointment in 4 months
Case ends
Final orders: None
Dx: fibroadenoma of the left breast

Question 8

Do not use mammography in women less than age ___.

Answer 8

35 (inaccurate due to breast density)