ROJoson’s MAR: Breast mass in an 81-year-old Filipino female

Medical Anecdotal Report

Date of Medical Observation: July 25, 2017

NARRATION:

An 81-year-old Filipino female, a close family friend, called me up by phone on July 24, 2017, arranging for an medical appointment on July 25, 2017.  Over the phone, she told me, that last month, while undergoing a medical examination for visa purpose, the examining physician palpated a mass on her left breast. No diagnostic tests were done.

I told her to see me as soon as possible on July 25, 2017.  She asked whether she needed to do diagnostic tests like ultrasound and mammography before coming to see me.  I said, not yet.  I would see her first.  She agreed.

At home, on July 24, 2017, I was telling my wife  I hope there is no actual mass.  If there is, I hope it is not breast cancer for our close family friend.  The incidence of breast cancer is high at this age 80 (actually the incidence of breast cancer increases with age).

July 25, 2017, after I did a physical examination, I found a 3-4 cm dominant breast mass at 2 o;clock.  It was a little tender.  It felt “cystic” (depressible).  There were no axillary nodes.

I told my close family friend (my patient) my primary clinical diagnosis was macrocyst.  I recommended a needle evaluation and aspiration with possible biopsy.  She agreed.

Lo and behold, it was really a macrocyst as the mass was really cystic and yielded 20 cc of yellow-brown fluid on needle aspiration followed by complete disappearance of the mass.  My close family friend was very happy on the findings and very thankful for my service.

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INSIGHTS:

  1. Although the incidence of breast cancer is high at age 80, the clinical diagnosis is still based primarily on the physical examination finding.  I have observed the common pitfall among medical students, residents, and even consultants who would use AGE out-rightly to give out a primary clinical diagnosis of breast cancer. This is not the way to do it.  Use first the physical examination findings to arrive to a clinical diagnosis.  If the physical examination findings point to a benign condition, the clinical diagnosis should be a benign condition.  If the physical examination findings point to a malignant condition, the clinical diagnosis should be a malignant condition.  If there are equivocal findings on physical examination, then use the prevalence or incidence data (high incidence of breast cancer at this age group of 80) to suspect a malignant condition.
  2. There is a common tendency for physicians (particularly non-breast specialists) and patients to order for diagnostic tests like ultrasound of the breast and mammography before physical examination.  In this particular patient, I asked the patient to see me first without going through diagnostic tests. With my physical examination findings, I was already quite certain of my clinical diagnosis that I did not need to have an ultrasound and mammography anymore.  Here, I saved the patient from having unnecessary tests.  I saved the patients from the inconvenience, pain and expenses of unnecessary tests.  My advice: do clinical examination (inclusive of physical examination) first. After the clinical diagnosis, decide whether a diagnostic test is needed or not.  As a rule, if one is not certain of the clinical diagnosis, one goes for a diagnostic test.  If one is already certain of the clinical diagnosis, one does not need a diagnostic test anymore.
  3. Not all breast masses in an elderly patient are breast cancers. They can still be benign breast conditions.  In this case, it turned out to be a macrocyst, a condition associated with fibrocystic changes of the breasts.  Macrocysts are probably the most common benign breast conditions in elderly patients  In this age group, fibroadenoma is rare.  Fibroadenoma is the most common benign breast condition in younger patients, say less than 25 years old.

ROJ@17jul25

 

 

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