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Difficulty: Very hardBreast Disorders

Match each clinical scenario describing a patient with a breast disorder to the most appropriate next step in management.

  • A 42-year-old woman undergoes a core needle biopsy of an indeterminate mammographic density. Pathology reveals lobular carcinoma in situ (LCIS).Surgical excisional biopsy
  • A 50-year-old woman undergoes an excisional biopsy of a palpable breast mass with clear margins. Pathology confirms lobular carcinoma in situ (LCIS).Surveillance and discussion of chemoprevention
  • A 35-year-old woman presents with spontaneous, unilateral, bloody nipple discharge. Physical examination, mammography, and ultrasound are completely normal.Subareolar duct excision
  • A 28-year-old lactating woman presents with a 4-cm, tender, fluctuant breast mass and fever despite 3 days of appropriate oral antibiotic therapy.Ultrasound-guided needle aspiration
  • A 54-year-old asymptomatic woman is found to have newly clustered pleomorphic microcalcifications in the right breast on a routine screening mammogram.Stereotactic core needle biopsy

Answer

The correct matches accurately pair specific clinical and histological presentations of breast pathology with their guideline-directed next steps in management.
Each presentation requires a highly specific intervention: LCIS on core biopsy requires excision to prevent understaging, while fully excised LCIS only needs surveillance. Pathologic discharge without imaging correlates requires duct excision. Abscesses are first managed by aspiration, and microcalcifications are sampled using stereotactic guidance.

Step-by-Step Solution

1
Evaluate the management of LCIS diagnosed via core needle biopsy.
Identify that surgical excisional biopsy is required.
Core needle biopsy may miss adjacent DCIS or invasive cancer; excisional biopsy is needed to rule out upstaging.
2
Evaluate the management of LCIS fully excised with clear margins.
Identify that surveillance and discussion of chemoprevention is the appropriate next step.
Completely excised LCIS is a risk marker, not a true malignancy, and does not require further surgery or radiation.
3
Evaluate the workup for pathologic nipple discharge with negative imaging.
Identify subareolar duct excision as the necessary intervention.
A physical sample is needed to diagnose underlying pathology (e.g., intraductal papilloma) when imaging cannot locate a target.
4
Evaluate the treatment for a lactational breast abscess.
Identify ultrasound-guided needle aspiration as first-line therapy.
Needle aspiration is preferred over incision and drainage for breast abscesses due to reduced morbidity and continued ability to breastfeed.
5
Evaluate the workup for suspicious mammographic microcalcifications.
Identify stereotactic core needle biopsy as the correct step.
Stereotactic guidance utilizes mammography to successfully target calcifications that are typically invisible on ultrasound.

Key Concept

Management of breast disorders requires differentiating the diagnostic algorithms for non-palpable imaging abnormalities, pathologic nipple discharge, breast infections, and the specific surgical implications of LCIS based on the biopsy method.
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Topics

Breast Disorders

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