Question

A 9 year old African-American female is brought to the physician by her mother, who is concerned about a ""lump"" in the patient's left breast. She noted this lump two weeks ago, and is concerned because the patient's grandmother was recently diagnosed with breast cancer. The child is otherwise well, and has not yet had onset of menses. On physical examination, the left breast and areola are enlarged and are Tanner stage 3. There is a small tender mass beneath the areola on the left. The right breast is flat and prepubertal. There is no axillary adenopathy. The external genitalia are grossly normal, and are covered with fine velus hair. Which of the following is the most appropriate next step in the management of this patient?

A. Reassurance and anticipatory guidance
B. Transdermal ethinyl estradiol
C. Measurement of serum luteinizing hormone (LH) level
D. Mammography
E. Open biopsy of breast

Answer 1

Reassurance and anticipatory guidance is the most appropriate next step for a 9-year-old with asymmetric breast development and a breast mass consistent with benign pubertal changes.

Step-by-step explanation:

The most appropriate next step in the management of a 9-year-old female with a breast mass and Tanner stage 3 development is A. Reassurance and anticipatory guidance. Given the patient's age and lack of other concerning signs such as axillary adenopathy, the described symptoms most likely represent benign breast development, which can sometimes occur asymmetrically during puberty. In addition, mammography is not typically indicated for this age group due to the high density of breast tissue in younger individuals, and the risks of ionizing radiation. A biopsy would be considered invasive, especially given the low likelihood of breast cancer in this age group and the presentation's consistency with normal development. It's important for young individuals to become familiar with what is normal for their bodies through practices like monthly breast self-exam, but in this clinical scenario, simple reassurance and monitoring of development is recommended. Hormone measurement and hormone treatment are not indicated based on the information provided.