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Case number:	036
Age:	52
Clinical presentation:	Perimenopausal woman presented with left nipple discharge. She had an increased risk of developing breast cancer because of a family history of breast cancer. Examination did not reveal any lump or palpable lesion.

Mammography:

Breast composition:	ACR category b (there are scattered areas of fibroglandular density)
Mammography features:
‣ Location of the lesion:	Left breast, central portion of the breast, central zone, anterior third
‣ Mass:
• Number:	Multiple
• Size:	Largest 1.5 cm in greatest dimension
• Shape:	Irregular
• Margins:	Indistinct
• Density:	Equal
‣ Calcifications:
• Typically benign:	None
• Suspicious:	Fine pleomorphic
• Distribution:	In mass
‣ Architectural distortion:	None
‣ Asymmetry:	None
‣ Intramammary node:	None
‣ Skin lesion:	None
‣ Solitary dilated duct:	Present
‣ Associated features:	Fine pleomorphic microcalcifications in mass

Ultrasound:

Ultrasound features: Left breast, central portion of the breast, intraductal multiple lesions
‣ Mass
• Location:	Left breast, central portion of the breast, intraductal multiple lesions
• Number:	Multiple intraductal
• Size:	Largest 1.8 cm in greatest dimension
• Shape:	Irregular
• Orientation:	Not parallel
• Margins:	Indistinct
• Echo pattern:	Heterogeneous
• Posterior features:	No posterior features
‣ Calcifications:	None
‣ Associated features:	Internal vascularity, dilated duct
‣ Special cases:	None

BI-RADS:

BI-RADS Category: 4B (moderate suspicion of malignancy)

Further assessment:

Further assessment advised: Referral for cytology

Cytology:

Cytology features:
‣ Type of sample:	FNAC
‣ Site of biopsy:
• Laterality:	Left
• Quadrant:
• Localization technique:	Palpation
• Nature of aspirate:
‣ Cytological description:	Smears reveal a haemorrhagic background with sheets of tightly cohesive ductal epithelial cells suggestive of a proliferative breast lesion. A few cells show a very mild nuclear atypia with karyomegaly and hyperchromasia
‣ Reporting category:	Atypical, probably benign
‣ Diagnosis:	Mild atypia, likely benign
‣ Comments:	A histological evaluation may be more informative

Case summary:

Perimenopausal woman presented with left breast nipple discharge. Diagnosed as left breast subareolar solitary dilated duct with intraductal lesions, BI-RADS 4B on imaging, as mild nuclear atypia on cytology, and reported at higher centre as ADH on histopathology.

Learning points:

ADH is considered a high-risk lesion and when seen on core biopsy, it warrants excision.