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Case number:	106
Age:	49
Clinical presentation:	Premenopausal woman presented with increased risk of developing breast cancer because of family history of endometrial and breast cancer. She presented for follow-up screening. Examination did not reveal any lumps in the breasts or axillae.

Mammography:

Breast composition:	ACR category a (the breasts are almost entirely fatty)
Mammography features:
‣ Location of the lesion:	2013: Right breast, central portion of the breast, central zone, anterior third
‣ Mass:
• Number:	1
• Size:	None
• Shape:	Irregular
• Margins:	Indistinct
• Density:	Equal
‣ Calcifications:
• Typically benign:	None
• Suspicious:	None
• Distribution:	None
‣ Architectural distortion:	None
‣ Asymmetry:	None
‣ Intramammary node:	None
‣ Skin lesion:	None
‣ Solitary dilated duct:	Present
‣ Associated features:	None

Breast composition:	ACR category b (there are scattered areas of fibroglandular density)
Mammography features:
‣ Location of the lesion:	2017: Right breast, central portion of the breast, central zone, anterior third
‣ Mass:
• Number:	1
• Size:	0.6 cm
• Shape:	Round
• Margins:	Circumscribed
• Density:	Equal
‣ Calcifications:
• Typically benign:	None
• Suspicious:	None
• Distribution:	None
‣ Architectural distortion:	None
‣ Asymmetry:	None
‣ Intramammary node:	None
‣ Skin lesion:	None
‣ Solitary dilated duct:	Present
‣ Associated features:	None

Breast composition:	ACR category b (there are scattered areas of fibroglandular density)
Mammography features:
‣ Location of the lesion:	2018: Right breast, central portion of the breast, central zone, anterior third
‣ Mass:
• Number:	0
• Size:	None
• Shape:	None
• Margins:	None
• Density:	None
‣ Calcifications:
• Typically benign:	None
• Suspicious:	None
• Distribution:	None
‣ Architectural distortion:	None
‣ Asymmetry:	None
‣ Intramammary node:	None
‣ Skin lesion:	None
‣ Solitary dilated duct:	Present
‣ Associated features:	None

Ultrasound:

Ultrasound features: 2013: Right breast, upper outer quadrant at 10 o'clock
‣ Mass
• Location:	2013: Right breast, upper outer quadrant at 10 o'clock
• Number:	1
• Size:	None
• Shape:	None
• Orientation:	Parallel
• Margins:	Circumscribed
• Echo pattern:	Hypoechoic
• Posterior features:	No posterior features
‣ Calcifications:	None
‣ Associated features:	Solitary dilated duct with bulbous terminal end and internal echoes
‣ Special cases:	Solitary dilated duct

Ultrasound features: 2016: Right breast, upper outer quadrant at 10 o'clock
‣ Mass
• Location:	2016: Right breast, upper outer quadrant at 10 o'clock
• Number:	1
• Size:	None
• Shape:	None
• Orientation:	Parallel
• Margins:	Circumscribed
• Echo pattern:	Hypoechoic
• Posterior features:	No posterior features
‣ Calcifications:	None
‣ Associated features:	Stable solitary dilated duct with bulbous terminal end and internal echoes
‣ Special cases:	Solitary dilated duct

Ultrasound features: 2017: Right breast, outer quadrants at 9 o'clock
‣ Mass
• Location:	2017: Right breast, outer quadrants at 9 o'clock
• Number:	1
• Size:	None
• Shape:	None
• Orientation:	Parallel
• Margins:	Circumscribed
• Echo pattern:	Hypoechoic
• Posterior features:	No posterior features
‣ Calcifications:	None
‣ Associated features:	Stable solitary dilated duct with bulbous terminal end and internal echoes
‣ Special cases:	Solitary dilated duct

BI-RADS:

BI-RADS Category (2013): 3 (probably benign)
BI-RADS Category (MRI 2014): 3 (probably benign)
BI-RADS Category (MRI 2017 and Mammography 2018): 2 (benign)

Further assessment:

Further assessment advised: Further imaging with breast MRI

MRI:

MRI features:
‣ MRI features:		MRI 2014: Amount of fibroglandular tissue: ACR category a (the breasts are almost entirely fatty). Background parenchymal enhancement: Minimal (< 25%), symmetrical
‣ Location:		Right breast, upper quadrant
‣ Focus:		No
‣ Mass:
• Shape:	Irregular
• Margin:	Indistinct
• Internal enhancement:	Heterogeneous
• Kinetic curve:	No
‣ Non-mass enhancement:
• Distribution:	No
• Internal enhancement:	No
‣ Non-enhancing findings:		No
‣ Associated features:		No
‣ Axillary nodes:		No

Cytology:

Cytology features:
‣ Type of sample:	FNAC
‣ Site of biopsy:
• Laterality:	Right
• Quadrant:	Non-palpable lesion seen on ultrasound at 9 o’clock
• Localization technique:	Ultrasound-guided
• Nature of aspirate:	Fatty material
‣ Cytological description:	Smear reveals blood, a single cluster of benign ductal cells, and a few fragments of adipose tissue
‣ Reporting category:	Insufficient material
‣ Diagnosis:	Insufficient. Core biopsy advised
‣ Comments:	None

Case summary:

Premenopausal woman with increased risk of developing breast cancer presented for routine screening, diagnosed as solitary dilated duct in right breast of suspicious morphology on initial assessment, BI-RADS category 3 on imaging. Regular follow-up for more than 5 years in view of family risk in many relatives, diagnosed as stable unchanged solitary dilated duct in right breast, BI-RADS category 2 on imaging.

Learning points:

If uncomplicated and in the absence of nipple discharge, solitary dilated duct is categorized as BI-RADS 2 (benign) or BI-RADS 3 (probably benign). In this case, with a high family risk and more than one relative with carcinoma of the breast and uterus, BI-RADS 3 assessment protocol was followed. Short interval follow-up ultrasound at 6 months showed stability; after another 6 months (i.e. annual follow-up), mammogram also revealed no interval change. The finding has further remained stable on 5 years follow-up. The assessment category is BI-RADS 2. Breast MRI has been performed for high-risk screening. BI-RADS 2 assessment category.