Master the board step 3

Master the Boards: USMLE Step 3
Surgical duct excision
is never the answer for
bilateral, milky nipple
discharge. These patients
should undergo workup for
prolactinoma.
Breast Mass
Fibrocystic Disease
This classically presents in a woman age 20–50 with cyclical, bilateral painful
breast lump(s). A clue to the diagnosis is that the pain will vary with the
menstrual cycle. A simple cyst will have sharp margins and posterior acoustic
enhancement on ultrasound. It will collapse on fine-needle aspiration FNA.
Treatment is oral contraceptive pills/medications (OCP). In patients with
severe pain, danazol may be used.
Fibroadenoma
This classically presents as a discrete, firm, nontender, and highly mobile
breast nodule. A clue to the diagnosis is a mass that’s highly mobile on clinical
exam. Fibroadenomas are made up of stromal and epithelial cells.
Diagnostic Testing
The steps in diagnosis of any patient (including pregnant women) with a breast
mass are as follows:
1. Clinical breast examination (CBE)
2. Imaging: Ultrasound or diagnostic mammography (if patient > 40)
3. Fine-needle aspiration (FNA) biopsy
Never diagnose a simple
cyst on clinical exam
alone. The diagnosis must
be confirmed with either
ultrasound or FNA.
Treatment
No treatment is necessary. Surgical removal can be done if the mass is growing.
A 30-year-old woman complains of bilateral breast enlargement and tenderness,
which fluctuates with her menstrual cycle. On physical examination, the breast
feels lumpy, and there is a painful, discrete 1.5-cm nodule. A fine-needle aspiration
is performed, and clear liquid is withdrawn. The cyst collapses with aspiration.
Which of the following is the next step in management?
a. Clinical breast exam in 6 weeks
b. Core needle biopsy
c. Mammography
d. Repeat FNA in 6 weeks
e. Ultrasound in 6 weeks
Answer: A. Clinical breast exam in 6 weeks is appropriate follow-up for a cystic mass
that disappears after FNA. If the mass recurs on the 6-week follow-up, FNA may be
repeated, and a core biopsy can be performed.
When do you answer the following?
··
Ultrasound:
--
First step in workup of a palpable mass that feels cystic on exam.
--
Imaging test for younger women with dense breasts.
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