NYACP Board Review Question of the Week
Every other Tuesday, NYACP members are sent a Board Review Question from ACP's MKSAP 18 to test professional knowledge and help prepare for the exam. Participant totals and answer percentages are distributed on the first Thursday of the month in IM Connected, the Chapter's eNewsletter, and are also published on this page.
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April 9, 2024
MKSAP 18 Booster Pack B General Internal Medicine Question 14
Stem:
A 62-year-old woman is evaluated for a 3-month history of a palpable nonpainful breast mass. She has no nipple discharge. She underwent menarche at age 14 years and menopause at age 55 years. She has no history of previous breast biopsies and no family history of breast, ovarian, or colorectal cancer. She took hormone replacement therapy for 1 year after menopause because of vasomotor symptoms.
On physical examination, temperature is 37.4 °C (99.3 °F), blood pressure is 135/80 mm Hg, pulse rate is 80/min, and respiration rate is 16/min. There is a firm, nontender mass in the upper outer quadrant of the right breast, approximately 2 cm at its largest dimension. There is no nipple discharge or change in or fixation to the overlying skin. There is no axillary lymphadenopathy. A diagnostic mammogram obtained 2 days before the visit revealed no masses or calcifications.
Which of the following is the most appropriate management of this patient?
A. Breast MRI
B. Breast ultrasonography
C. Core-needle biopsy
D. Reassurance
Responses Received from Members (894 Responses):
The Correct Answer is: C. Core-needle biopsy
Educational Objective
Evaluate a breast mass in a postmenopausal woman.
Critique
This patient should undergo core-needle biopsy of the mass. She presents with a normal mammogram but findings on physical examination that are suspicious for breast cancer. The palpable mass is nonpainful, persistent, and firm. Although her normal mammogram could be interpreted as reassuring, approximately 10% to 20% of palpable breast cancers can be missed by ultrasonography or screening mammography. She requires further evaluation to definitively rule in or rule out malignancy. Core-needle biopsy, with or without ultrasonographic or stereotactic guidance, provides excellent tissue sampling for pathology and receptor status. It is the test of choice for most solid lesions.
Breast MRI would likely better define the breast lesion, which was not visualized on mammography, but would not replace the need for a tissue diagnosis in this patient.
Breast ultrasonography is particularly useful in defining possible cystic lesions identified on examination or mammography. However, given the highly suspicious nature of this patient's breast mass, ultrasonography would not be indicated.
Reassurance is inappropriate because definitive diagnosis of the mass via tissue sampling is imperative in this postmenopausal woman.
Key Points
Core-needle biopsy is the test of choice for most solid breast masses.
Bibliography
Albisinni S, Biaou I, Marcelis Q, Aoun F, De Nunzio C, Roumeguère T. New medical treatments for lower urinary tract symptoms due to benign prostatic hyperplasia and future perspectives. BMC Urol. 2016;16:58. PMID: 27629059 doi:10.1186/s12894-016-0176-0
Copyright 2018, American College of Physicians.
March 26, 2024
MKSAP 18 Rheumatology Question 3
Stem:
A 78-year-old woman is evaluated for a 2-year history of gout with progressively more frequent and severe attacks. She currently has pain and swelling in the right second finger. History is also significant for hypertension, chronic kidney disease, nephrolithiasis, and type 2 diabetes mellitus. Medications are lisinopril, furosemide, metformin, and the maximal dose of febuxostat; she is allergic to allopurinol.
On physical examination, vital signs are normal. The joint findings are shown.
Laboratory studies show an erythrocyte sedimentation rate of 76 mm/h, a serum creatinine level of 1.5 mg/dL (132.6 µmol/L), and a serum urate level of 6.3 mg/dL (0.37 mmol/L).
Which of the following is the most appropriate treatment?
A. Add probenecid
B. Stop febuxostat; begin pegloticase infusions
C. Stop lisinopril; begin losartan
D. Continue current treatment
Responses Received from Members (923 Responses):
The Correct Answer is: B. Stop febuxostat; begin pegloticase infusions
Educational Objective
Treat severe tophaceous gout.
Critique
In addition to stopping febuxostat, the most appropriate treatment is pegloticase infusions. This patient has severe recurrent and tophaceous gout that has been resistant to standard therapies, including febuxostat. Pegloticase is an intravenously administered porcine-derived uricase (infused every 2 weeks), which reduces serum urate to nearly zero within hours of administration. If anti-drug antibodies do not form, tophi may resolve over the course of months. Other urate-lowering therapies should be discontinued with initiation of pegloticase because they can mask the development of antibodies that manifest as rising serum urate levels. Patients starting pegloticase should be placed on prophylaxis to prevent acute gout attacks; colchicine, prednisone, or NSAIDs are appropriate. In this case, glucocorticoids and NSAIDs should be avoided because of the concomitant type 2 diabetes mellitus and chronic kidney disease; therefore, low-dose colchicine is the appropriate prophylactic agent. In February 2019, the FDA mandated a boxed warning for febuxostat regarding the increased risk for cardiovascular death and all-cause mortality with the drug. The FDA has also limited the approved use of febuxostat for patients who are unresponsive to or cannot tolerate allopurinol.
It is important to note that two recently published guidelines differ regarding the role of pharmacologic urate- lowering therapy in patients with gout. The 2016 American College of Physicians guideline notes a lack of evidence supporting a specific target level for urate lowering; this guideline stresses discussing the risks and benefits of urate-lowering therapy with patients and suggests a “treat to avoid symptoms” approach without specifically considering the serum urate levels. The 2020 American College of Rheumatology (ACR) guideline for the management of gout strongly recommends continuing urate-lowering therapy with xanthine oxidase inhibitors (allopurinol, febuxostat) to achieve and maintain a serum urate target less than 6 mg/dL (0.37 mmol/L). The guideline also strongly recommends switching from xanthine oxidase inhibitors to pegloticase in patients with gout who have not achieved the serum urate target and who have frequent gout flares or nonresolving tophi. The patient's serum urate level is 6.3 mg/dL (0.37 mmol/L) on febuxostat therapy, and she continues to have symptoms and tophi; therefore, escalation of treatment is appropriate according to both the ACP and ACR guidelines.
Probenecid is not appropriate for those with an estimated glomerular filtration rate of less than 60 mL/min/1.73 m2 or with a history of kidney stones; this patient has both.
Losartan has a modest uricosuric effect, but not significant enough that it would be recommended in a patient with severe tophaceous gout, especially one who remains symptomatic with an elevated serum urate level despite febuxostat therapy.
Key Points
Pegloticase is strongly recommended for patients with severe recurrent and/or tophaceous gout that is intolerant or resistant to standard therapies.
Copyright 2018, American College of Physicians.