Case number:	067
Age:	53
Clinical presentation:	Postmenopausal woman with average risk of developing breast cancer presented with painful right breast lump. On examination, she was found to have a freely mobile soft to firm lump in the right breast.

Mammography:

Breast composition:	ACR category b (there are scattered areas of fibroglandular density)
Mammography features:

‣ Location of the lesion:	Right breast, lower outer quadrant at 7–8 o’clock, middle third
‣ Mass:
• Number:	1
• Size:	7.0 × 6.0 × 6.7 cm
• Shape:	Oval
• Margins:	Circumscribed with perilesional halo
• Density:	High
‣ Calcifications:
• Typically benign:	None
• Suspicious:	None
• Distribution:	None
‣ Architectural distortion:	None
‣ Asymmetry:	None
‣ Intramammary node:	None
‣ Skin lesion:	None
‣ Solitary dilated duct:	None
‣ Associated features:	None

Breast composition:	ACR category b (there are scattered areas of fibroglandular density)
Mammography features:

‣ Location of the lesion:	Right breast, lower inner quadrant at 5 o’clock, middle third
‣ Mass:
• Number:	1
• Size:	1.0 × 0.6 cm
• Shape:	Oval
• 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:	None
‣ Associated features:	None

Ultrasound:

Ultrasound features: Right breast, lower outer quadrant at 7 o’clock

‣ Mass
• Location:	Right breast, lower outer quadrant at 7 o’clock
• Number:	1
• Size:	5.5 × 3.8 cm
• Shape:	Oval
• Orientation:	Parallel
• Margins:	Circumscribed
• Echo pattern:	Heteroechoic
• Posterior features:	No posterior features
‣ Calcifications:	None
‣ Associated features:	Internal vascularity
‣ Special cases:	None

BI-RADS:

BI-RADS Category: 4A (low level of suspicion for malignancy)

Further assessment:

Further assessment advised: Referral for cytology

Cytology:

Cytology features:

‣ Type of sample:	FNAC
‣ Site of biopsy:
• Laterality:	Right
• Quadrant:	Outer
• Localization technique:	Palpation
• Nature of aspirate:	Whitish fluid
‣ Cytological description:	Smears are cellular and show monolayered clusters and sheets of ductal epithelial cells. Myoepithelial cells are seen. A few clusters of apocrine cells are seen. Background shows many foamy cells, macrophages, and haemorrhage
‣ Reporting category:	Benign
‣ Diagnosis:	Benign proliferative breast lesion
‣ Comments:	None

Histopathology:

Lumpectomy

Histopathology features:

‣ Specimen type:	Lumpectomy
‣ Laterality:	Right
‣ Macroscopy:	Breast specimen (6.0 × 5.0 × 3.0 cm) with smooth external surface. Cut surface shows a large cystic area (4.0 × 4.0 × 2.0 cm) with a pedunculated papillary structure. Surrounding breast tissue contains smaller cysts with papillae
‣ Histological type:	Multiple benign papillomas. Sections from the papillary lesions reveal multiple benign papillomas with well-developed fibrovascular cores and broad club-like papillae and arborescent fronds. The broader papillae contain glands. Both the fibrovascular cores and the glandular components are lined by epithelial cells with a prominent myoepithelial layer
‣ Histological grade:
‣ Mitosis:
‣ Maximum invasive tumour size:
‣ Lymph node status:
‣ Peritumoural lymphovascular invasion:
‣ DCIS/EIC:
‣ Margins:
‣ Pathological stage:
‣ Biomarkers:
‣ Comments:	Negative for malignancy

Case summary:

Postmenopausal woman presented with painful right breast lump. Diagnosed as mass of suspicious morphology, BI-RADS 4A on imaging, as benign proliferative lesion on cytology, and as multiple benign papillomas on histopathology.

Learning points:

Intraductal papillomas can arise in small or large ducts and may be either identified grossly as a polypoid intraductal mass or found only on microscopic examination.