NMS Q&A Family Medicine

Diseases of the Female Breast 139Examination Answers1. The answer is B. Eighty-five percent lifetime risk ofbreast cancer is conveyed by carriage of the BRCA1 orBRCA2. However, only 2.2% of breast cancers are associatedwith BRCA.2. The answer is C. Sixty percent lifetime risk of ovariancancer resides with carriage of the BRCA1 marker. However,BRCA2 that also confers an 85% lifetime risk ofbreast has a 20% risk of ovarian cancer.3. The answer is D. Annual MRI survey should not bedone in an asymptomatic woman with breast cancer.Computed tomography (CT) and MRI are indicatedwhen symptoms or signs arise suspicious for recurrenceor metastases.4. The answer is C. Biopsy. Infections are generally quitepainful in the breast. If it had been painful and the antibiotichad resulted in significant improvement, it wouldhave likely been an infection. The big danger here is thepossibility of inflammatory carcinoma, which may bepainful, in which case, failure of response to antibioticswould have justified investigation for cancer. Inflammatorycarcinoma of the breast is the most malignant typeand conveys a poor prognosis.5. The answer is E. Unilateral sanguineous discharge warrantsthe closest and most persistent evaluation becauseit is most likely to be a sign of cancer, most types of whichbegin as intraductal carcinomas. The chances that bloodynipple discharge is caused by cancer are 1:3. Bilateral nippledischarge, milky in appearance, is galactorrhea, associatedwith various causes, including pregnancy, mechanicalstimulation, pituitary adenoma (prolactinoma), hypothyroidism,and Cushing disease, as well as chronic renal failure.Bilateral tenderness with irregular palpable masses,cyclic in course, is caused by fibrocystic disease and is seencommonly in primary care practice. Purulent dischargewith tenderness represents infection, often in a lactatingwoman.6. The answer is D. Drugs are the most common pathologiccause of galactorrhea. Galactorrhea may be normalfor a brief time in newborns, postpartum women, andpregnant women. The most common drugs associatedwith galactorrhea are categorized as follows, with certainexamples given. First, there are dopamine receptor blockingagents: butyrophenones, metoclopramide, phenothiazines,selective serotonin reuptake inhibitors, tricyclicantidepressants, and thioxanthenes. Second, there aredopamine-depleting agents, such as methyldopa andreserpine. Third, there are inhibitors of dopamine release:codeine, heroin, and morphine. Fourth, there are histaminereceptor blocking agents. Fifth, there are lactotrophstimulatingagents: oral contraceptives and verapamil.Each of the other options may be associated with galactorrhea,but all are unusual except for prolactinoma.7. The answer is D. MRI with contrast. Prolactin levelsabove 200 ng/mL should be considered to be caused byprolactinoma until proven otherwise. However, the size ofthis slowly growing benign tumor and the patient’s totalsymptomatology and attitude toward fertility togetherdetermine the therapeutic approach. The best modalityfor confirming the tumor’s size and presence is the MRI,preferably enhanced by gadolinium. Microadenomas maybe treated with dopaminergic agents such as bromocriptine.Cabergoline is a longer acting and thus more convenientdrug, but it is more expensive. Macroadenomas,especially if suprasellar, may warrant surgical removal,particularly if fertility is a critical issue.8. The answer is E. Performing aspiration before otherwiselegitimate options makes sense in this woman, whois over the age of 40 and not with epidemiologic evidenceof high risk. Fluid-filled cysts are most likely to occur inwomen over the age of 40. If aspiration results in fluidwith the disappearance of most of the nodule, the likelihoodof cancer as a basis for the mass is very low. To besure, the patient should be followed for several weeksafterward and a mammogram should be done early, ifonly as a recommended routine for all women over theage of 40. Nodules in women younger than 40 years of ageare more likely to be fibroadenomas and other benignsolid tumors. Breast biopsy need not be rushed into inthis circumstance, although it should never be withheldunnecessarily. Prolactin levels are reserved for nipple discharge.Calcium and alkaline phosphatase are indicatedwhen metastatic disease is suspected.9. The answer is E. An ultrasonic study of the breast tissueis appropriate in a young woman, even with a seconddegreefamily history of breast cancer. Sonography is 89%sensitive for breast abnormalities in symptomatic women.Women younger than the mid-30s are likely to have densebreast tissue that renders mammography less accurate(less sensitive and less specific). Aspiration is less likely tobe fruitful, as fluid-filled cysts are more common inwomen who are older than 40 years. Prolactin levels areindicated in galactorrhea or other bilateral nipple discharge.Excisional biopsy should be delayed, pending theresults of the noninvasive studies. Fine-needle biopsy may