M.J. is a 30-year-old African American female with a past medical history of obesity. She explains that a week ago
M.J. is a 30-year-old African American female with a past medical history of obesity. She explains that a week ago
I need reply to these two post which are about the same topics
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Cavan part 1
C: Lump in breast.
M.J. is a 30-year-old African American female with a past medical history of obesity. She explains that a week ago she was showering and noticed a mass in her left breast that is non-tender. Patient describes the lump as firm and movable and states that she felt a mass like this one a year ago that went away on its own. M.J.’s last menstrual period was 2 weeks, and she denies any past pregnancies. She is currently not taking any medications and has no known allergies. The only surgery she has ever had was the removal of her tonsils at age 7. She has never smoked tobacco and denies any alcohol use. Her family history is positive for obesity and hyperlipidemia. M.J. works as a medical assistant for a doctor’s office near her home. The patient is currently 5’4 and 190lbs. BMI is 31.2.
The differential diagnosis’, their risk factors and demographics, and the differences between them:
- Fibroadenoma:
Fibroadenomas are marble-like mobile masses, with regular borders that vary in size, and are made up of both epithelial and stromal tissue of the breast (Peng et al., 2021). Breast cancers and fibroadenomas are made up of solid tissues. Breast cysts differ from fibroadenomas because they are made up of fluid, and are not mobile. Fibroadenomas are the most common type of benign breast tumor in women ages 15-35 years of age. However, 50% of women from the age of 30 will develop fibrocystic breast disease (Peng et al., 2021). They are painless and benign tumors in which hormones play a role in their development because the tissues which make them up have estrogen and progesterone receptors. Regression is seen during menopause (Stachs et al., 2019). Fibroadenomas, breast cysts, and breast cancer can all be influenced by changes in hormones.
- Breast cyst:
Breast cysts are a common diagnosis seen in young women and commonly develop between the ages of 30 to 50- years of age. Breast cysts are fluid filled terminal duct lobular units that are lined with a single layer of epithelium that can form as a result of hormonal changes (Stachs et al., 2019). Breast cysts can be either symptomatic or asymptomatic. Patients may present with pain in the region of the lump or nipple discharge (Stachs et al., 2019). Patients will either find the cyst from palpation or incidentally through imaging such as an ultrasound. Aspiration is only recommended if the lesion is large and causes symptoms (Stachs et al., 2019).
- Breast cancer:
Breast cancer is a leading cause of cancer-related morbidity, with early diagnosis and treatment giving the best prognosis. 281,550 women were projected to be diagnosed with breast cancer in 2021 (Bhushan et al., 2021). Breast cancer forms due to DNA damage and genetic mutations that can be influenced by estrogen exposure. Some but not all types of cancer have the pro-cancerous genes BRCA1 and BRCA2. There are two types of invasive and non-invasive breast cancer; lobular and ductal carcinoma in situ (Bhushan et al., 2021). Imaging such as mammograms and ultrasound play key roles in breast cancer detection. Breast cancer is different from the other two diagnoses because you need the DNA damage and genetic mutation to make tissues suspectable to carcinoma formation.
Diagnosis and evaluation of the severity of the three differentials and national guidelines:
The gold standard for diagnosing a fibroadenoma or breast cancer is through a pathology examination, which can be done by fine needle aspiration, a core needle biopsy, excision, or vacuum-assisted breast biopsy (Peng et al., 2018). An MRI can be used in patients that are at a high-risk for developing breast cancer (Bhushan et al.,2021). For the diagnosis of breast cysts, they will be found on a breast ultrasound or mammogram and will show up as well-circumscribed and oval to round with variability in size. Occasionally, fine-needle aspiration or a biopsy may be needed for breast cyst diagnosis confirmation (Stachs et al., 2019).
References
Bhushan, A., Gonsalves, A., & Menon, J. U. (2021). Current State of Breast Cancer Diagnosis, Treatment, and Theragnostic. Pharmaceutics, 13(5), 723. https://doi.org/10.3390/pharmaceutics13050723Links to an external site.
Chen, Y. Y., Fang, W. H., Wang, C. C., Kao, T. W., Chang, Y. W., Yang, H. F., Wu, C. J., Sun, Y. S., & Chen, W. L. (2018). Examining the Associations among fibrocystic breast change, total lean mass, and percent body fat. Scientific reports, 8(1), 9180. https://doi.org/10.1038/s41598-018-27546-3Links to an external site.
Peng, Y., Xie, F., Zhao, Y., Wang, S., & Chinese Society of Breast Surgery (2021). Clinical practice guideline for breast fibroadenoma: Chinese Society of Breast Surgery (CSBrS) practice guideline 2021. Chinese medical journal, 134(9), 1014–1016. https://doi.org/10.1097/CM9.0000000000001462Links to an external site.
Stachs, A., Stubert, J., Reimer, T., & Hartmann, S. (2019). Benign breast disease in women. Deutsches Arzteblatt international, 116(33-34), 565–574. https://doi.org/10.3238/arztebl.2019.0565
Caban part 2
Treatment plan with diagnostic tests and results:
The plan for M.J. is going to include ordering a bilateral mammogram with ultrasound of the breasts. If multiple lesions were found and diagnosis could not be made from mammography, then a breast MRI would be ordered. M.J. has a fibroadenoma, which are marble-like mobile mass or masses, with regular borders, and made up of both epithelial and stromal breast tissue (Peng et al., 2021). These are the most common type of painless benign breast tumor in women ages 15-35 years of age. These benign tumors are made up of tissues which contain estrogen and progesterone receptors. For this reason, hormones play a role in their development, and regression is seen during menopause (Stachs et al., 2019).
The gold standard for diagnosing a fibroadenoma is through a pathology examination, which can be done by fine needle aspiration, a core needle biopsy, excision, or vacuum-assisted breast biopsy (Peng et al., 2018). Despite biopsy being the gold standard in diagnosis, I would not order a biopsy on this patient at this time. Once I saw that there was only the single fibroadenoma, because M.J. is younger than 40 and doesn’t have a family history of breast cancer, I would choose to monitor it.
Follow-ups & client education:
I would have M.J. follow-up every 6-months for breast exams and mammography. Additionally, I would want her to be performing regular self-breast exams and to report any new lesions or changes in the one that she has. If the lesion or lesions remained stable and didn’t grow after 2-years of regular exams and mammography I would then have her come in annually (Peng et al.,2021).
Medications and non-pharmacologic treatments:
If M.J. was experiencing mastalgia and/or had multiple fibroadenomas that were found on imaging, Ormeloxifene, a selective estrogen receptor modulator can be prescribed. As I mentioned above, fibroadenomas are made up of breast tissue that contain estrogen and progesterone receptors so medications that have anti-estrogen effects have been shown to be beneficial (Brahmachari et al., 2021). Another medication that has been shown to have anti-estrogenic and anti-proliferative properties is Metformin. Some studies have found with 1000mg of Metformin daily has had a favorable effect in women with multiple fibroadenomas (Alipour et al., 2021). At this time there are no non-pharmacologic treatments that M.J. would benefit from however, if she developed mastalgia then warm compresses might be helpful.
Suggested consults/referrals: If I didn’t feel comfortable with the mammography report I would refer M.J. to breast specialist, a breast surgeon to better assess and decide if a biopsy was warranted.
References
Alipour, S., Abedi, M., Saberi, A., Maleki-Hajiagha, A., Faiz, F., Shahsavari, S., & Eslami, B. (2021). Metformin as a new option in the medical management of breast fibroadenoma; a randomized clinical trial. BMC endocrine disorders, 21(1), 169. https://doi.org/10.1186/s12902-021-00824-4Links to an external site.
Brahmachari, S., Bhagat, V., Patil, P., & Vasuniya, V. (2021). Evaluating the Effect of Ormeloxifene on Multiple Fibroadenomas and Mastalgia. Journal of pharmacy & bioallied sciences, 13(Suppl 2), S1386–S1389. https://doi.org/10.4103/jpbs.jpbs_222_21Links to an external site.
Peng, Y., Xie, F., Zhao, Y., Wang, S., & Chinese Society of Breast Surgery (2021). Clinical practice guideline for breast fibroadenoma: Chinese Society of Breast Surgery (CSBrS) practice guideline 2021. Chinese medical journal, 134(9), 1014–1016. https://doi.org/10.1097/CM9.0000000000001462Links to an external site.
Stachs, A., Stubert, J., Reimer, T., & Hartmann, S. (2019). Benign breast disease in women. Deutsches Rothblatt international, 116(33-34), 565–574. https://doi.org/10.3238/arztebl.2019.0565
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