436) A 24 year old woman returns to your office to discuss breast biopsy results. One week ago, she was evaluated your office for a palpable lump in her left breast of one week duration. She reported significant pain associated with this lump and it was also associated with pale yellow colored nipple discharge. She is physically very active and enjoys playing soccer. She does not smoke or drink. She has no other problems except for mild ankle sprain that she sustained during an inter-collegiate match two weeks ago. Physical examination was positive for a tender left breast lump in the outer quadrant . She underwent ultrasound guided core needle biopsy . Image from pathology slides is shown below:
Which of the following is the most appropriate recommendation for this patient?
B) Genetic testing for BRCA1/BRCA2
C) Reassurance and repeat in 6 months
D) Counsel regarding increased risk of subsequent breast cancer in this condition
E) Start Tamoxifen
Filed under: USMLE Test Prep |
Archer USMLE Step 3 Blog 
Answer (C) : its a fatty changes from probably a trauma to the breast in a highly active woman…
C- fatty change
Fat necrosis of the breast is a benign condition that most commonly occurs as the result of breast trauma or surgical intervention. Fat necrosis can be confused with a malignancy on physical examination and may mimic malignancy on radiologic studies. It is sometimes necessary to biopsy these lesions to confirm the diagnosis, although experienced radiologists can usually determine that a lesion represents fat necrosis based on mammographic and ultrasound findings such as oil cysts (collections of liquefied fat) . Once the diagnosis is established, excision is not necessary and there is no increased risk of subsequent breast cancer
A
I couldn’t make out whether the lesion is benign/malignant in the slide, but in either case I would have gone for lumpectomy
Reassurance is not certainly the only thing we can give under this case. that is the reason which keeps me away from choosing option C
Fat necrosis. Treatment reassurance. But how to justify the yellow fluid discharge?
Cccc
Her age is 24, generally very healthy and active. I am thinking c. Would have considered something else if she was older, and if her nipple discharge was bloody.
C…
c
c
c
Answer E
Ans C
If the lump appeared 2 weeks previously and is painful, those alone suggest it is not malignancy in a 24 y.o. (no other hx?) Why biopsy? so invasive yet helpful to different fat necrosis from a later malignancy Why not examine the discharge and send her for an ultrasound (for a lump >5mm) or mri or mammogram? There is a slight risk of squamous metaplasia following fat necrosis – not sure of the incidence.
Reassure, follow up in 6 months.
Ps :there are macrophages around the adipocytes – they are removing necrotic tissue and lipids from the damaged area.
C . This is fat necrosis
c
C
fatty acid necrosis
c
C . Clearly this patient does not have breast Cancer nor needs further investigations or treatment for that .