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Case number:015
Age:42
Clinical presentation:Premenopausal woman with average risk of breast cancer presented with a right breast lump. Examination revealed a 5 cm lump in the right breast.


Mammography:


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, anterior and middle thirds
 ‣ Mass:
   • Number:1
   • Size:9.0 × 8.5 × 5.5 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

Ultrasound:


Ultrasound features: Right breast upper outer quadrant at 10 o’clock position

 ‣ Mass
   • Location:Right breast upper outer quadrant at 10 o’clock position
   • Number:1
   • Size:8.0 × 2.5 cm
   • Shape:Oval
   • Orientation:Parallel
   • Margins:Circumscribed
   • Echo pattern:Heteroechoic
   • Posterior features:No posterior features
 ‣ Calcifications:None
 ‣ Associated features:Minimum internal 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:Upper outer
   • Localization technique:Palpation, rubbery consistency felt through the needle
   • Nature of aspirate:Whitish material
 ‣ Cytological description:Cell-rich smear of elongated, branching fragments of ductal epithelium and numerous single bipolar nuclei in the background. Fragments of fibromyxoid stroma were seen in the background
 ‣ Reporting category:Benign
 ‣ Diagnosis:Fibroadenoma
 ‣ Comments:None


Histopathology:

Lumpectomy



Histopathology features:

 ‣ Specimen type:Lumpectomy
 ‣ Laterality:Right
 ‣ Macroscopy:Single whitish tissue piece (7.5 × 5.5 × 3.5 cm). On cut section shows firm whitish areas and mucoid areas
 ‣ Histological type:Histological features of fibroadenoma with extensive sclerosis of stromal tissue. Some of the ducts are cystically dilated
 ‣ Histological grade:
 ‣ Mitosis:
 ‣ Maximum invasive tumour size:
 ‣ Lymph node status:
 ‣ Peritumoural lymphovascular invasion:
 ‣ DCIS/EIC:
 ‣ Margins:
 ‣ Pathological stage:
 ‣ Biomarkers:
 ‣ Comments:

Case summary:

Premenopausal woman presented with right breast lump. Diagnosed as fibroadenoma, BI-RADS 2 on imaging and as fibroadenoma on cytology and histopathology.

Learning points:



  • Fibroadenoma is the most common benign tumour of the breast, typically occurring in women aged 20–35 years. It increases in size during pregnancy and tends to regress with age.


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