Master the board step 3

Gynecology
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Mammography (> 50 years old) and biopsy (or biopsy alone if < 40 years old):
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Cyst recurs > twice within 4 to 6 weeks.
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There is bloody fluid on aspiration.
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Mass does not disappear completely upon FNA.
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There is bloody nipple discharge (excisional biopsy).
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There are skin edema and erythema suggestive of inflammatory breast
carcinoma (excisional biopsy).
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Fine-needle aspiration or core biopsy is needed for a palpable mass. May
be done after ultrasound or instead of ultrasound.
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Cytology:
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Any aspirate that is grossly bloody must be sent for cytology.
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Observation with repeat exam in 6–8 weeks:
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Cyst disappears on aspiration, and the fluid is clear.
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Needle biopsy and imaging studies are negative.
Mammogram should be
done before biopsy. Biopsy
distorts radiography.
Core biopsy is superior to
FNA.
A 47-year-old woman completes her yearly mammogram and is told to return for
evaluation. The mammogram reveals a “cluster” of microcalcifications in the left
breast. What is the most appropriate next step in management?
a. Excision biopsy
b. Core needle biopsy
c. Repeat screening mammogram in 6 months
d. Repeat screening mammogram in 12 months
e. Ultrasound
Answer: B. A cluster of microcalcifications are mostly benign; however, approximately
15–20 percent represent early cancer. The next step in workup is core needle biopsy
under mammographic guidance.
Breast Cancer
Preinvasive Diseases
Both ductal carcinoma in situ (DCIS) and lobular carcinoma in situ (LCIS)
increase the risk of invasive disease. If biopsy reveals
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DCIS, then schedule surgical resection with clear margins (lumpectomy;
i.e., breast conserving surgical resection) and give radiation therapy (RT)
and tamoxifen for 5 years to prevent the development of invasive disease.
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LCIS, then tamoxifen alone given for 5 years to reduce risk of development
of breast cancer. It is not necessary to perform surgery.
Risks associated with
tamoxifen use:
• Endometrial carcinoma
• Thromboembolism
Contraindications:
• Patient is active smoker
• Previous
thromboembolism
• High risk for
thromboembolism
Note that LCIS is classically seen in premenopausal women.
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