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Case number:	007
Age:	63
Clinical presentation:	Postmenopausal woman with average risk of breast cancer presented with pain and lump in the left breast. Examination revealed a lump in the left retroareolar region.

Mammography:

Breast composition:	ACR category b (there are scattered areas of fibroglandular density)
Mammography features:
‣ Location of the lesion:	Left breast, lower inner quadrant at 6–7 o’clock, anterior third
‣ Mass:
• Number:	Multiple
• Size:	Largest 3.7 × 3.4 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 b (there are scattered areas of fibroglandular density)
Mammography features:
‣ Location of the lesion:	Right breast, upper outer quadrant at 10 o’clock, posterior third
‣ Mass:
• Number:	1
• Size:	2.3 × 2.2 cm
• Shape:	Round
• Margins:	Circumscribed
• Density:	Equal
‣ 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:	Calcifications

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:	1.5 × 1.0 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 b (there are scattered areas of fibroglandular density)
Mammography features:
‣ Location of the lesion:	Bilateral breasts, diffuse fat necrosis calcifications
‣ Mass:
• Number:	Multiple
• Size:	None
• Shape:	None
• Margins:	None
• Density:	None
‣ Calcifications:
• Typically benign:	Round
• Suspicious:	None
• Distribution:	Diffuse
‣ 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 6 o’clock
‣ Mass
• Location:	Left breast, central portion of the breast at 6 o’clock
• Number:	Multiple
• Size:	Largest 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 outer quadrant at 10 o’clock
‣ Mass
• Location:	Right breast, upper outer quadrant at 10 o’clock
• Number:	1
• Size:	1.8 × 1.3 cm
• Shape:	Oval
• Orientation:	Parallel
• Margins:	Circumscribed
• Echo pattern:	Hypoechoic
• Posterior features:	Posterior shadowing
‣ Calcifications:	Coarse macrocalcifications in mass
‣ Associated features:	None
‣ 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:	Left
• Quadrant:	Lower inner
• Localization technique:	Palpation
• Nature of aspirate:	11 mL of straw-coloured fluid. Nodule was not palpable after the aspiration
‣ Cytological description:	Smears show plenty of foamy histiocytes on a proteinaceous background. Ductal epithelial cells not seen
‣ Reporting category:	Benign
‣ Diagnosis:	Non-proliferative fibrocystic change
‣ Comments:	None

Case summary:

Postmenopausal woman presented with painful left breast lump. Diagnosed as multiple simple cysts in the left breast, BI-RADS 2 on imaging and as non-proliferative fibrocystic change on cytology. Also noted were right breast involuting fibroadenoma and simple cyst, BI-RADS 2 on imaging.

Learning points:

A lump in the breast is a cause of great concern. High-frequency, high-resolution ultrasound helps in its evaluation. Diagnosis of a simple cyst (BI-RADS 2) is made because the following criteria are seen: sharply defined wall, enhanced through transmission of sound, no internal echoes, and lesions solitary or in groups. Microscopically, the epithelial lining of many cysts, especially the larger ones, is flattened or absent, the cyst having only a thick fibrous wall. Frequently the cyst ruptures and elicits an inflammatory response in the stroma with abundant foamy macrophages and cholesterol clefts.