A 24-year-old woman presents to her primary care physician with concern about a right breast lump which she noticed two months ago. It is non-painful, and she denies constitutional symptoms. She has no chronic medical conditions except for generalized anxiety disorder, which is managed with escitalopram. Her family history is significant for colon cancer in her father at age 32. There is no family history of breast cancer, Lynch syndrome, or Li-Fraumeni syndrome. Physical examination is significant for a discrete 1.5 cm breast mass in the right upper quadrant of her right breast.
E) Ultrasonography of the lesion
As this woman is below the age of 30, she is likely to have dense breast tissue for which other imaging modalities will be less effective.
Answer choice A: Fine needle aspiration of the lesion, is incorrect. Although fine needle aspiration may eventually be needed to obtain a sample of the lesion, imaging is indicated prior to sample collection to better assess the lesion’s features (e.g., presence of microcalcifications, border definition, composition).
Answer choice B: Initiation of tamoxifen, is incorrect. Tamoxifen is used to treat premenopausal women with estrogen receptor-positive breast cancer. Although it is also used to decrease breast cancer risk in women at high risk, this patient does not have high risk features (early onset breast cancer in a first degree relative).
Answer choice C: Mammography, is incorrect. In women under the age of 30, breast tissue is typically too dense to adequately visualize lesions with mammography.
Answer choice D: Magnetic resonance imaging of the chest, is incorrect. MRI may be appropriate to assess breast lesions for individuals with high risk of breast cancer. This patient has no family history of breast cancer and denies syndromes associated with breast cancer (Lynch syndrome, Li-fraumeni syndrome).
Key Learning Point
Ultrasound is the preferred initial imaging modality for breast lesions in women under 30 without high-risk features.
