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.