Review Question - QID 212729

The patient is presenting with nipple discharge, a breast lump, lymphadenopathy, and a mammogram revealing microcalcifications. This presentation is suspicious for infiltrating ductal carcinoma, and the patient should undergo a core biopsy of the breast nodule.

Invasive ductal carcinoma may present with a firm, immobile, painless lump associated with axillary lymphadenopathy and pathologic nipple discharge. A mammography may show a mass with irregular, fibrotically stranded borders. Microcalcifications are another common feature and can also be seen with ductal carcinoma in situ, which is a true premalignancy. Patients should undergo a core or excisional biopsy and staging. Treatment is dependent on results, and further diagnostic testing for certain genetic features.

Figure A is a mammogram showing microcalcifications that can be associated with ductal carcinoma in situ.

Incorrect Answers:
Answer 2: Lumpectomy and post-operative radiation is a treatment option for invasive ductal carcinoma. A biopsy confirming diagnosis should be completed prior to treatment.

Answer 3: Modified radical mastectomy is a treatment option for invasive ductal carcinoma. A biopsy confirming diagnosis should be completed prior to treatment.

Answer 4: Repeating a mammography in 1 year would be inappropriate. Although breast calcifications can routinely appear on mammograms and may be benign, further evaluation with a core biopsy is needed. Additionally, this patient has other worrying symptoms such as pathologic nipple discharge and axillary lymphadenopathy.

Answer 5: Trastuzumab can be used for breast cancer that is HER2-neu positive. This patient does not have confirmed breast cancer yet and needs a biopsy of the breast nodule.

Bullet Summary:
Microcalcifications on mammography could represent ductal carcinoma in situ or invasive ductal carcinoma and necessitate a core biopsy for further initial evaluation.