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Case number:002
Age:49
Clinical presentation:Premenopausal woman with average risk of developing breast cancer presented with painful breast lumps in both breasts. On examination, she had multiple lumps with firm consistency in both breasts and a well-defined mobile lump, 5 × 3 cm.


Mammography:


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

 ‣ Location of the lesion:Right breast, all quadrants, entire breast, all zones
 ‣ Mass:
   • Number:Multiple
   • Size:Largest 5.2 × 3.6 cm
   • Shape:Oval
   • Margins:Circumscribed with perilesional halo
   • Density:Equal
 ‣ Calcifications:
   • Typically benign:None
   • Suspicious:None
   • Distribution:None
 ‣ Architectural distortion:None
 ‣ Asymmetry:Global
 ‣ 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:Left breast, all quadrants, entire breast, all zones
 ‣ Mass:
   • Number:Multiple
   • Size:Largest 6.2 × 5.3 cm
   • Shape:Oval
   • Margins:Circumscribed with perilesional halo
   • Density:Equal
 ‣ Calcifications:
   • Typically benign:Coarse
   • Suspicious:None
   • Distribution:None
 ‣ Architectural distortion:None
 ‣ Asymmetry:Global
 ‣ Intramammary node:None
 ‣ Skin lesion:None
 ‣ Solitary dilated duct:None
 ‣ Associated features:Calcification

Ultrasound:


Ultrasound features: Right breast, all quadrants

 ‣ Mass
   • Location:Right breast, all quadrants
   • Number:Multiple
   • Size:Largest 4.5 × 3.0 cm
   • Shape:Round to oval
   • Orientation:Parallel
   • Margins:Circumscribed
   • Echo pattern:Anechoic
   • Posterior features:Posterior shadowing
 ‣ Calcifications:None
 ‣ Associated features:None
 ‣ Special cases:Simple cyst


Ultrasound features: Left breast, all quadrants

 ‣ Mass
   • Location:Left breast, all quadrants
   • Number:Multiple
   • Size:Largest 5.2 × 4.2 cm
   • Shape:Round to oval
   • Orientation:Parallel
   • Margins:Circumscribed
   • Echo pattern:Anechoic
   • Posterior features:Posterior shadowing
 ‣ 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 (cystic lesion)
 ‣ Site of biopsy:Bilateral breast lumps
   • Laterality:
   • Quadrant:Subareolar nodules in both breasts
   • Localization technique:Palpation
   • Nature of aspirate:15 mL of thick yellowish fluid aspirated on multiple passes through the nodule in right breast; 12 mL of yellowish brown fluid aspirated on multiple passes through the nodule in left breast
 ‣ Cytological description:Smears from both sides show tight clusters of benign ductal epithelial cells without significant nuclear atypia; a few apocrine cells noted. A thick proteinaceous fluid with foamy histiocytes seen in the background
 ‣ Reporting category:Benign
 ‣ Diagnosis:Proliferative fibrocystic change
 ‣ Comments:None


Case summary:

Premenopausal woman presented with painful bilateral breast lumps. Diagnosed as multiple cysts, BI-RADS 2 on imaging and as proliferative fibrocystic change on cytology.

Learning points:



  • Breast cysts can be solitary but are often multiple, seen in either or both breasts, and may be associated with pain and discomfort. They are BI-RADS 2 (benign).
  • Fibrocystic change is characterized microscopically by any combination of small or large cysts, apocrine metaplasia, focal fibrosis, adenosis, and intraductal hyperplasia. Fibrocystic change is usually categorized as non-proliferative or proliferative, depending on whether significant intraductal hyperplasia is present.


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