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Case number:140
Age:43
Clinical presentation:Premenopausal woman with average risk of breast cancer presented with a lump in the left breast of recent onset. Examination revealed a left upper quadrant lump. She has had a stable right breast lump for many years, which is proven fibroadenoma on tissue diagnosis.


Mammography:


Breast composition:ACR category d (the breasts are extremely dense, which lowers the sensitivity of mammography)
Mammography features:

 ‣ Location of the lesion:Left breast, upper inner quadrant at 10–11 o’clock, middle third
 ‣ Mass:
   • Number:1
   • Size:4.2 × 4.0 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


Breast composition:ACR category d (the breasts are extremely dense, which lowers the sensitivity of mammography)
Mammography features:

 ‣ Location of the lesion:Right breast, upper inner quadrant at 1 o’clock, middle third
 ‣ Mass:
   • Number:1
   • Size:No
   • Shape:None
   • Margins:None
   • Density:None
 ‣ Calcifications:
   • Typically benign:Coarse, popcorn-like
   • 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, upper inner quadrant at 11 o’clock

 ‣ Mass
   • Location:Left breast, upper inner quadrant at 11 o’clock
   • Number:1
   • Size:3.5 × 2.5 cm
   • Shape:Oval
   • Orientation:Parallel
   • Margins:Circumscribed
   • Echo pattern:Anechoic
   • Posterior features:Posterior shadowing
 ‣ Calcifications:None
 ‣ Associated features:None
 ‣ Special cases:Simple cyst


Ultrasound features: Right breast, upper inner quadrant at 1 o’clock

 ‣ Mass
   • Location:Right breast, upper inner quadrant at 1 o’clock
   • Number:1
   • Size:1.4 × 1.2 cm
   • Shape:Oval
   • Orientation:Parallel
   • Margins:Circumscribed
   • Echo pattern:Hypoechoic
   • Posterior features:No posterior features
 ‣ Calcifications:Macrocalcifications in mass
 ‣ Associated features:Poor vascularity
 ‣ Special cases:None

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:Right
   • Quadrant:Lower outer
   • Localization technique:Palpation
   • Nature of aspirate:Whitish
 ‣ Cytological description:Highly cellular aspirate, showing many cohesive groups of ductal cells with sharply demarcated borders with branching glove-like or “antler-horn” shapes. Many stripped or bare nuclei are seen in the background
 ‣ Reporting category:Benign
 ‣ Diagnosis:Fibroadenoma
 ‣ Comments:None


Cytology features:

 ‣ Type of sample:FNAC
 ‣ Site of biopsy:
   • Laterality:Left
   • Quadrant:Upper inner
   • Localization technique:Palpation
   • Nature of aspirate:0.5 mL of brownish fluid
 ‣ Cytological description:Smears show foamy histiocytes on a thick proteinaceous background. Very a few ductal cells are seen
 ‣ Reporting category:Benign
 ‣ Diagnosis:Fibrocystic change, non-proliferative
 ‣ Comments:None


Case summary:

Premenopausal woman presented with left breast lump. Diagnosed as simple cyst, BI-RADS 2 on imaging and as non-proliferative fibrocystic change on cytology. Incidentally noted right breast involuting fibroadenoma, BI-RADS 2 on imaging.

Learning points:


  • Cyst is the most common type of breast mass with peak incidence in women aged 30–50 years. A circumscribed mass of low or equal density on mammography and anechoic on ultrasound is diagnosed as simple cyst on imaging, BI-RADS category 2. Its natural history is to develop and regress, but occasionally it may increase in size.

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