repro. Mehl other breast disorders 12-22 (1)

Question 1

Benign cystic alteration in breast tissue in women 20s-50s.?

Answer 1

Fibrocystic change

Question 2

Fibrocystic change. 3 ways show up in nbme

Answer 2

1) Highly buzzy/classic presentation is a woman 20s-30s who has bilateral, waxing/waning breast tenderness over the course of her menstrual cycle;

2) Unilateral tenderness or sharp pain in one breast (students are often surprised that it’s not always bilateral).

3) Painless, unilateral breast cyst in woman in her 40s that drains brown/greenish fluid -> answer = fibrocystic change straight-up on the NBME. Call it weird all you want. Take it up with NBME, not me.

Question 3

1) Highly buzzy/classic presentation is a woman 20s-30s who has bilateral, waxing/waning breast tenderness over the course of her menstrual cycle;?

Answer 3

Fibrocystic change

Question 4

2) Unilateral tenderness or sharp pain in one breast (students are often surprised that it’s not always bilateral).

Answer 4

Fibrocystic change

Question 5

3) Painless, unilateral breast cyst in woman in her 40s that drains brown/greenish fluid -> answer = fibrocystic change straight-up on the NBME. Call it weird all you want. Take it up with NBME, not me.

Answer 5

Fibrocystic change

Question 6

how to Dx Fibrocystic change?

Answer 6

You do not need to biopsy or do ultrasound. It is a clinical diagnosis and Tx is symptomatic only (i.e., warm showers, evening primrose oil).

Question 7

Fibrocystic change. what in theory histo whould show?

Answer 7

In theory, biopsy of fibrocystic change will show some buzzy findings: “sclerosing adenosis,” apocrine metaplasia,” and/or “blue dome cysts.”

Question 8

Simple breast cyst. on UG?

Answer 8

“Simple” means hypoechoic, or black on ultrasound. It reflects a fluid-filled cyst.

Question 9

Simple breast cyst. What means complex? UG

Answer 9

“Complex” means at least in some part hyperechoic, or white on ultrasound. It
reflects a solid component to the cyst.

Question 10

Simple breast cyst. Dx/Mx?

Answer 10

Simple cysts are observed and do not require FNA drainage unless they cause discomfort to the patient (e.g., large cysts). There is no specific size that requires drainage on USMLE.

Question 11

Simple breast cyst.
There is an NBME Q where they say a woman was started on HRT three months ago and now has a simple cyst –> answer = next step?

Answer 11

“biopsy of the lesion.” So you should be aware that sudden growth in size can be indication for biopsy.

Question 12

Simple breast cyst. Complex cyst. next step?

Answer 12

All complex cysts require FNA biopsy, similar to fibroadenoma.

Question 13

Mastitis. CP?

Answer 13

Classically presents as red, cracked, fissured nipple in breastfeeding woman.

Question 14

Mastitis. mos?

Answer 14

Usually caused by S. aureus, but Group A Strep also possible.

Question 15

Mastitis. Mx on usmle?

Answer 15

USMLE wants oral dicloxacillin (not doxycycline) + continue breastfeeding through the affected breast as treatment. There is no risk of harm to the neonate.

Methicillin-class beta-lactams (e.g., dicloxacillin) and first-generation cephalosporins (e.g., cephalexin) are equivalent on USMLE for all intents and purposes. They both treat S. aureus skin infections.

Question 16

Mastitis. HY CP?

Answer 16

High-yield point is that mastitis need not affect the nipple and can present as a red, warm, tender, non-fluctuant mass of the breast. When we talk about infection of the breast, non-fluctuant = mastitis; fluctuant = abscess. This is asked insidiously
on a 2CK form and students get it wrong all the time thinking it’s abscess – i.e., “They say it’s a warm, red, tender mass of the breast though!” Yeah, but they say non-fluctuant, not fluctuant. Not my issue if you get emotional over dumb shit.

Question 17

Abscess. CP?

Answer 17

Warm, red, tender fluctuant mass of the breast.

Question 18

Abscess. next best step?

Answer 18

Drain

Question 19

Galactocele. definition?

Answer 19

Aka milk retention cyst; usually seen in recently breastfeeding women.

Question 20

Galactocele. confused with what?

Answer 20

breast abscess

Question 21

Galactocele. CP?

Answer 21

Can present as painless or tender fluctuant mass of the breast that is peri-areolar.

USMLE will say the patient is afebrile and that the lesion is not warm or red.

Question 22

Galactocele. Tx?

Answer 22

Tx is warm compresses followed by drainage.

Question 23

Ductal ectasia. definition? how to make Dx?

Answer 23

As the name implies, this is dilation of lactiferous ducts.

Dx of exclusion

Question 24

Ductal ectasia.
- Presents 2/3 Qs as an inverted nipple.
- Presents 1/3 Qs as some random breast lesion where they say biopsy shows “dilation of the ducts,” which is what the name means.

Answer 24

.

Question 25

Virginal breast hypertrophy. Definition?

Answer 25

benign asymmetric growth of the breasts that can occur in young women. USMLE will try to trick you into thinking it’s sinister by saying a first-degree relative had breast cancer.

Question 26

Virginal breast hypertrophy.
They will say 16-year-old girl has large breast lump under the nipple on one side. next step?

Answer 26

Answer is just follow-up / observe.

Question 27

Gynecomastia. Physiologic gynecomastia can occur in teenage boys on USMLE, where there can
be ­ breast tissue, either tender or not, occurring uni- or bilaterally. next step?

Answer 27

Just observe.

Question 28

Gynecomastia. can occur in what pathology/drugs?

Answer 28

Can occur as a result of ­ estrogen in liver failure, or due to certain drugs like cimetidine, spironolactone, ketoconazole, or even marijuana.

Question 29

Gynecomastia. mechanism that causes it?

Answer 29

Caused by direct estrogen effect on breast. It is not caused by prolactin.

Question 30

Gynecomastia. an NBME Q gives gynecomastia in a male patient taking hCG. They ask for the mechanism -> answer?

Answer 30

“testis producing estrogen.”

They can also have as answer “estrogen; direct effect on breast.” The reason this makes sense is because, since hCG shares the same alpha-subunit with LH and FSH (and TSH), giving hCG is as though we are giving LH and FSH at the same time. So LH
effect -> androgen production; FSH effect -> aromatase production -> therefore androgens are converted to estrogens in the testis -> mechanism via which we could get gynecomastia.

Question 31

Necrosis. definition?

Answer 31

Non-enzymatic fat necrosis of breast due to trauma; can calcify.

Question 32

Necrosis. Don’t confuse with enzymatic fat necrosis, which is acute pancreatitis.

Answer 32

.

Question 33

Necrosis. can occur in what setting?

Answer 33

Can occur due to overt trauma (e.g., getting hit by softball) or sometimes by tight-fitting sports bras.