NMS Q&A Family Medicine

140 NMS Q&A Family Medicinebe considered after the results of the ultrasound study,and the revelation of fluid would rule out cancer, makingthe FNA a fluid aspiration procedure, with the same limitationsalready mentioned.10. The answer is B. The CNB, done with 14- to 18-gaugeneedle, is as much as 99% sensitive in palpable lesionsand 93% sensitive in nonpalpable nodules for diagnosingbreast cancer. A minimum of four cores is required togain these statistics, which include a higher predictivevalue than found in FNA. Excisional biopsy is the goldstandard but is obviously more expensive and more traumaticthan the CNB. Lumpectomy is a therapeutic technique,designed to cure a known cancer under favorablecircumstances.11. The answer is B. Although the so-called upper-outerquadrant will contain the most breast cancers, so is thatlocation the quadrant that contains the most breast tissue;hence, residency in the superolateral quadrant in of itselfis not a particular danger sign in a nodule. Lack of anaspirant retrieval by tapping does not signal breast cancer,but appearance of fluid aspirant in that situation rulesstrongly against cancer. The durometer is a measure ofhardness; 20 durometers is comparable to a soft tomedium grape and 60 durometers approaches the hardnessof calcified bone, a sign suggestive of cancer. Irregularshape, as opposed to well-circumscribed roundness, issuggestive of cancer as well.12. The answer is E. Nearly 50% of breast cancers inwomen in the United States occur in women older than65 years of age. About one-quarter occur in the age groupof 50 to 65 years, leaving about one-quarter for the under50 age group. The latter, as was implied earlier, tend tocontract more aggressive cancers, giving rise to a changingview of screening that calls for more frequent routinemammography (i.e., yearly) in the age group of 40through 49 years. This point is not heavily emphasized inthe chapter by Bowman and Szewczyk (1997), but a tellingreport on the subject was freshly published as thatmanuscript was being processed.13. The answer is D. Needle aspiration is the first stepchoice for the 26-year-old woman with a cyclically tenderbreast lump. All other choices given in the vignette haverelevance at certain times and under certain circumstances.However, the clinical picture is that of fibrocysticdisease. If the nodule disappears as fluid is yielded in theprocedure in the given setting, cancer can virtually beruled out, assuming the fluid is clear. Disappearance isdefined as nonrecurrence of the cystic nodule after aperiod of several monthly cycles. If the fluid is bloody,cytological examination of the fluid should be routine inthat circumstance. Any other result requires, at the least,an imaging study.14. The answer is C. Observing for 3 months is acceptable,given the history of trauma, because hematomas canpersist for 6 weeks or longer before resolving. A mammogrammay be obtained, although inaccuracies are attendantto the patient’s age; thus, an ultrasound would bepreferable. On the basis of the aforementioned information,the breast biopsy can wait. Needle aspiration isacceptable but need not be done on this visit becausehematoma is a logical diagnosis.15. The answer is E. Although there was a flurry of medicolegal litigation during the early 1990s surrounding theclaim of autoimmune disease associated with breastimplants, there was never, either at the time or since, evenpurported incidence or prevalence attached to that allegedassociation; there were only patients (deluded or selfserving)and eager lawyers driving the claims throughcourts and too often succeeding, which gave birth to thatwave of economic waste. All the other complications dooccur. Capsule contraction and scarring occur in 15% to25% of cases of silicone implants; implant rupture occursin 5%.16. The answer is D. Several points are relevant here.Perhaps, the most important is that the doctor shouldexplain both the strengths and the weaknesses of any testto which the patient agrees. This is the foremost procedureso that the patient is provided with the best datathrough which the patient’s health care is in accord withthe doctors, but avoiding placing the physician in a defensivemedico legal position. Thus, the patient in this case isinformed that a negative CBE is not a guarantee againstbreast cancer in the near future. Furthermore, in the presentexample, there is an approximately 30% chance thatthe CBE may miss diagnosing a cancer (i.e., 70% sensitivity).It follows that patient and doctor must avail themselvesof other reasonable means of screening for breastcancer, such as mammography yearly beginning at the ageof 40 years, after a baseline study at the age of 35 (forwomen of average expected lifetime risk). Mammographyitself has been estimated to be only 70% sensitive. Presumably,the cancers missed are most likely to be the smallestnodules by both methods. Although sensitivity is questionable,breast self-examination appears to confer additionaladvantages only if performed monthly or moreoften, even by an initially insecure and unpracticed woman.Specificity of all three methods is obviously imperfect, andnegative breast biopsies will necessarily occur.