Ms. Smith is a 28 yo G0P0 with no significant past medical or surgical history. She presents to Ob/Gyn Clinic today for the first time because she recently noticed a firm, painful mass in the upper outer quadrant of her right breast that she reports is about the size of a quarter and is certain that the mass was not present 1 month ago. She does not think the mass changes with her menstrual cycle. Her last menstrual period started 6 days ago. She does not think the mass is movable, but it has been too painful to try to move it. Her grandmother has a h/o DCIS at age 61 and is currently doing well s/p lumpectomy, XRT, and tamoxifen therapy. As you begin the clinical breast exam, you notice dried blood covering her right nipple.
You quickly remind yourself the differential diagnosis for a breast mass: fibrocystic disease, fibroadenoma, mastitis/abscess, fat necrosis, and breast cancer.
After completing the clinical breast exam, click on the study you would like to complete next:
A-breast US
B-mammography
set up each as a link with answer A correct
B-mammography-
The mammogram shows extremely dense breast tissue that would obscure almost any concerning finding. Choosing mammography over US would only be appropriate if her mass was concerning (if she were post-menopausal, had 1st degree relative with early breast cancer, rigid/fixed mass, axillary adenopathy, or skin changes). She did have evidence of bloody nipple discharge, but the most common causes of bloody nipple discharge are intraductal papilloma and duct ectasia (both benign). Ultrasound is nearly always the best first step in evaluating breast masses in women under age 30.
Since the mammogram was extremely painful for Ms. Smith, she has already left your office before you could speak with her. She finally returns to clinic 9 months later with the same complaints. You remember that ultrasound is the best first step in evaluating her mass...
A-breast ultrasound:
Ultrasound images are obtained from her right breast and a 0.3cm round, circumscribed, uniformly anechoic nontender mass consistent with a simple cyst is incidentally found 4cm away from the palpable mass (top image to right). At the area of the palpable mass, a 1.4 x 1.5 x 1cm, wider-than-tall, ovoid, solid mass with 2 soft lobulatations along an otherwise sharply circumscribed margin. The mass has a thin echogenic pseudocapsule, and no posterior acoustic shadowing - consistent with a fibroadenoma (bottom image). When she is informed of the findings, she starts crying because a family friend recently passed away from breast cancer. She just wants this situation to be "over with" and is in a hurry to leave the radiology suite.
Which of the following would you do NEXT?
OB GYN CASE 1