CLINICAL CASE
Unit 3: Gynecology
Section A: General Gynecology
Section B: Breasts
Objective 40: Disorders of the Breast
A 56-year-old woman G0P0 made an appointment to see her gynecologist because she
was concerned about a small lump in her right breast that she has been able to feel for
2 months. She has not had breast problems in the past and does not have a family
history of breast cancer.
Physical examination
No apparent skin changes, asymmetry or skin dimpling. Axillary or subclavian lymph
nodes are not palpable. Breasts are symmetric, diffusely cystic and non-tender. There
is an area of firmness approximately 1 cm in diameter with indiscreet boarders at 9:00
on her right breast. The area is slightly different in consistency than the rest of the
surrounding tissue.
Diagnosis
Breast cancer vs. Fibrocystic changes
LABS
The patient was sent for a mammogram that revealed dense breast tissue, but no
discrete mammographic abnormalities.
Diagnosis/management plan
The patient was informed that the mammogram was negative, and routine follow up
was appropriate. The patient was initially relieved, but became more anxious because
over the course of the next 6 months she thought that the palpable area in question
had grown in size. She consulted another physician who referred her for a surgical
biopsy. The 1.5 cm mass was found to be infiltrating ductal carcinoma. The patient
filed suit against the first physician alleging negligence regarding the failed diagnosis
of breast cancer in a palpable breast lesion.
Teaching points
1. The commonly quoted projection of the risk of breast cancer (1 in 8
women) represents a cumulative lifetime risk. For a woman aged 50-59
years, the lifetime risk of having a breast cancer diagnosis is 1in 36, while
for a woman-aged 70-79 years the risk increases to 1 in 24.
2. A persistent palpable breast mass requires evaluation. Mammography
alone is not sufficient to rule out malignant pathology in a patient with a
palpable breast mass. Ultrasonography or magnified mammographic
imaging of the breast containing the mass may provide additional
information and may identify cystic structures or variations in normal
breast architecture that account for the palpable abnormality. When cyst
aspiration is performed, the fluid may be discarded if it is clear
(transparent and not bloody) and the mass disappears. Otherwise, the
patient should be considered a candidate for a breast biopsy.
3. Solid masses require a histologic diagnosis in most cases. Fine-needle
aspiration or sterotactic needle biopsy may be an alternative to open breast
biopsy in certain cases. If breast cancer or specific benign condition is not
detected by fine-needle aspiration or needle core biopsy, open biopsy is
necessary.
4. The failure to provide a timely diagnosis of breast cancer is one of the most
rapidly expanding areas of medical malpractice. A common scenario
involves a patient who complains of a breast lump that the physician
cannot palpate or document on radiologic imaging. Another common
scenario involves the failure to follow-up an abnormal mammogram report.
This may lead to a “defensive” medical approach involving the liberal use
of mammography and referral. On the other hand, the aggressive
investigation of a suspected breast lump more likely represents good
medical practice, especially in a patient in an age group at risk for the
disease. The consequences of “missing” a breast cancer are devastating.