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Case number:006
Age:48
Clinical presentation:Premenopausal woman with average risk of breast cancer presented with a recent-onset left breast lump in the upper quadrant. Examination revealed a firm 8 cm lump in the upper half of the left breast.


Mammography:


Breast composition:ACR category c (the breasts are heterogeneously dense, which may obscure small masses)
Mammography features:

 ‣ Location of the lesion:Left breast, upper quadrants at 12 o’clock, anterior and middle thirds
 ‣ Mass:
   • Number:Multiple
   • Size:Largest 4.5 × 3.0 cm
   • Shape:Oval
   • Margins:Obscured
   • 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


Breast composition:ACR category c (the breasts are heterogeneously dense, which may obscure small masses)
Mammography features:

 ‣ Location of the lesion:Right breast, all quadrants, entire breast, anterior and middle thirds
 ‣ Mass:
   • Number:Multiple
   • Size:Largest 1.8 × 1.5 cm
   • Shape:Oval
   • Margins:Obscured
   • 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: Left breast, central portion of the breast at 12 o’clock

 ‣ Mass
   • Location:Left breast, central portion of the breast at 12 o’clock
   • Number:Multiple
   • Size:Largest 4.5 × 3.0 cm
   • Shape:Oval
   • Orientation:Parallel
   • Margins:Circumscribed
   • Echo pattern:Anechoic with internal echoes
   • Posterior features:Posterior Enhancement
 ‣ Calcifications:None
 ‣ Associated features:None
 ‣ Special cases:Simple cyst and complicated cyst


Ultrasound features: Right breast, central portion of the breast at 12 o’clock

 ‣ Mass
   • Location:Right breast, central portion of the breast at 12 o’clock
   • Number:Multiple
   • Size:Largest 1.8 × 1.0 cm
   • Shape:Oval
   • Orientation:Parallel
   • Margins:Circumscribed
   • Echo pattern:Anechoic
   • Posterior features:Posterior Enhancement
 ‣ Calcifications:None
 ‣ Associated features:None
 ‣ Special cases:Simple cyst

BI-RADS:

BI-RADS Category: 2 (benign)

Further assessment:

Further assessment advised: Referral for cytology

Cytology:

Cytology features:

 ‣ Type of sample:FNAC
 ‣ Site of biopsy:
   • Laterality:Left
   • Quadrant:12 o’clock
   • Localization technique:Palpation
   • Nature of aspirate:0.2 mL of yellowish fluid
 ‣ Cytological description:Smear shows a few monolayered sheets of benign ductal epithelial cells with a few macrophages
 ‣ Reporting category:Benign
 ‣ Diagnosis:Proliferative fibrocystic change
 ‣ Comments:None


Case summary:

Premenopausal woman presented with recent-onset left breast lump. Diagnosed as complicated cyst, BI-RADS 2 on imaging and as proliferative fibrocystic change on cytology. Multiple simple cysts were also noted in both breasts on imaging.

Learning points:



  • Breast ultrasound has 95–100% accuracy to detect a cystic lesion.


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