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Breast Lump Case Study

The case involves a 37-year-old woman, gravida 2 para 2, who presents to the clinic with a chief complaint of a lump in her left breast. Her family is positive for breast cancer. Both children, aged 9 and 7, are alive and delivered without complications. She has a healthy weight (BMI 22), and does not smoke, but drink a glass of wine most evening with supper. She has regular physicals and is up to date with smears. A physical examination revealed a firm lump near the surface with no masses. The lump was aspirated, removing an opaque liquid. The aspiration vanished the lump. 

The most probable diagnosis is a breast cyst. Cysts are formed by the accumulation of fluid inside the breast glands. A majority of cystic lesions are benign while the majority of solid lesions are malignant. Most breast cysts are small (5 mm to 20 mm) and painless. They are strongly influenced by hormones and are common in women of childbearing age. While a breast cyst is palpable, it can be confused with a solid mass. Therefore, one of the fundamental approaches is a fine-needle aspiration biopsy. The aspirated fluid does not contain blood or other cystic components. However, if it contained blood, it would have been critical to send the fluid for cytology and consultation from a surgeon. 

Further evaluation of the breast lump or mass is guided by findings on history, physical examination, imaging, and biopsy. In this case, a triple test of clinical breast exam, ultrasonography, and needle biopsy may be necessary to find a definitive diagnosis. Based on the extent of clinical suspicion, the practitioner should order mammography before a pathologic diagnosis. Mammography is essential in the evaluation of palpable lesions. However, if the lump is suggestive of a fibroadenoma by ultrasound and mammography, short-term follow-up and re-imaging are essential. Fibrocystic changes present on a mammogram as round or oval, well-defined masses. A biopsy is also necessary to identify whether the cysts are malign. Complex cysts with both fluid and solid matter necessitate biopsy (Brown, Phillips, Slanetz, Fein-Zachary, Venkataraman, Dialani & Mehta, 2017). The fine needle aspiration provides sufficient cellular material to facilitate adequate cytologic evaluation. However, core biopsy is recommended because it uses a large cutting needle that allows the collection of tissues suitable for histologic analysis that is familiar to most pathologists. 

Breast cysts do not increase the risk of breast cancer. According to Lin, Peng, and He (2018), cysts, including complex cysts have a low risk of breast cancer. However, benign breast diseases (BBD) are not life-threatening, some may increase the risk of breast cancer. Cysts are classified as non-proliferative disorder and their absolute risk of causing cancer is estimated to be 2% (Stachs, Stubert, Reimer & Hartmann, 2019). Etiologically, cysts are associated with fibrocystic changes. More than 50% of women develop symptomatic fibrocystic changes in their lifetime. Fibrocystic changes are caused by hormonal changes and are common in women between 20 and 59 years. Breast cancer risk factors are numerous and diverse, including age (65 years and above), atypical hyperplasia, history of early-onset breast cancer, high postmenopausal endogenous estrogen, and high-dose radiation to the chest. 

However, it is important to consider her family history of breast cancer. A hereditary predisposition to breast cancer increases the risk of developing breast cancer at a younger age. Therefore, early identification of patients with a hereditary predisposition is vital to exploit the numerous opportunities provided by enhanced surveillance, chemoprevention, and risk-reducing surgery. Patient can be counseled on breast self-examination and a follow-up schedule established. Follow-up is critical in detecting missed cancer. During the follow-up, it is fundamental to evaluate recurrent masses or fluid.

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