drk1980
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35 yr old comes with a 10 yr h/o tenderness in both her breasts related with the menstrual cycle. She has multiple lumps on both breasts which seem to come and go at different times in the cycle. She now noticed a firm round 2cm mass which hasnt gone away for 6weeks. After physical exam which confirms the mass, whats ur next step?
1) Mammogram
2) Ultrasound
3) Aspirate the palpable lump
4) FNA and cytology
5) Excisional biopsy
this Q is made from a vignette in kaplan. wud like to know ur answer wth an expln. thanks in advance.
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| msyamp
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4 FNAC any firm palpable mass go for FNAC first
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| juanma0
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Lot of controversy here! Let me Start by saying that 4 is the most logical answer. Hereīs why, you basically do a FNA on any palpable mass, be it thyroid, breast or other, basically because itīs right there, you have good sensitivity, its cheap, low complications. The other answer could be mammogram, and it is a good answer, because the rationale is look for contralateral masses or ipsilateral (usually nonpalpable for both). I think you have to use your common sense here and say well i have a patient whom I`m suspecting breast cancer, do I wait for the results of mammogram to do a FNA, which I will do anyway? I dont think so. Save time and anguish for the patient and do FNA first is my opinion. Kaplan says mammogram, Dr. Goljan says FNA. What does everyone else think?
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| achilles
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how about 2-ultrasound and if the mass is cystic then we can aspirate the mass. if the mass does not completely disappear or if it recurs then we can go for FNAC. this lady is relatively younger and a mammogram will not be the best choice because of dense breast tissue.
i choose ultrasound because the question asked the next best step...the diagnostic test would always be FNAC.
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| juanma0
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Even though this is a bad description of the mass, we can gather that this mass is firm not fluctuant, soft or cystic making ultrasound useless if it truly is a firm solid mass. Besides if you`re gonna aspirate it anyway why not just FNA from the beginning and save time? I dont remember the algorythm for these masses but, iīm pretty sure ultrasound isnt indicated here.
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| nadiabarati
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4
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| som
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why not an excisioanl biopsy..firm..not mobile..2cm..jus thinking loud here.
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| juanma0
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I think an excisional biopsy would be inapropriate given we do not have a a tissue diagnosis, much less staging. What if she were to need a lymph node dissection? Tough q!
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| yasmeen
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no consider her age and symptoms ultrasound should b done first to ifferentiate bw solid and cystic masses
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| drk1980
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Like i mentioned, i made this Q from a vignette in kaplan. the discussion thr goes like this...
This lump is a palpable cyst (diagnosed from her presenting symptoms, i guess) Start with a mammogram to see if thr are any other nonpalpable lesions. Once we can zero in on this one, tissue diagnosis (biopsy) becomes impractical when thr are lumps every month. Aspiration of the cyst is the asnwer here (this is NOT FNA). Aspiration of the fluid will empty the cyst and if the lump goes away...thts all. If its bloody, send to cytology. If the mass remains or recurs...biopsy.
so to clarify, wud the next step be send for mammogram or aspiration in the office?
i was wondering, if this same woman had a positive family history......wud the next step be different or wud it follow the same protocol?
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| achilles
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just trying to know, what wud be an age where yu can say that a mammogram will be a good choice as the first step and not be worried of dense breast tissue ?
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| study_ing
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35 i think
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| achilles
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just checked in my UW notes....it says 40 and found this chart in aafp site...it says 40 as well.
Attached Files:
evaluation of breast mass.gif (22 KB, 133 downloads)
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" it's not whether you get knocked down, it's whether you get up"
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| achilles
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just thought this might be helpful. pls do correct this if wrong. but i had a reason to believe this info after reviewing UW notes and the aafp site. so i guess ultrasound seems like a good way to start for this patient although i do agree that the question says that the mass is firm.
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| ed222
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ultrasound, they asking about next step, best dx will be fna
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| keller
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3
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| damngood
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i think we first need to do an ultrasound rule out if its cystic or a solid mass if cystic then apirate nadobserve if solid the go for a mamogram
correct me if i am wrong
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| ram3
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I the patient is thirty five or older the mass is firm has positive family history axillary adenopathy skin changes first step is mammography
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