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Case number:067
Age:53
Clinical presentation:Postmenopausal woman with average risk of developing breast cancer presented with painful right breast lump. On examination, she was found to have a freely mobile soft to firm 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, lower outer quadrant at 7–8 o’clock, middle third
 ‣ Mass:
   • Number:1
   • Size:7.0 × 6.0 × 6.7 cm
   • Shape:Oval
   • Margins:Circumscribed with perilesional halo
   • Density:High
 ‣ 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, lower inner quadrant at 5 o’clock, middle third
 ‣ Mass:
   • Number:1
   • Size:1.0 × 0.6 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, lower outer quadrant at 7 o’clock

 ‣ Mass
   • Location:Right breast, lower outer quadrant at 7 o’clock
   • Number:1
   • Size:5.5 × 3.8 cm
   • Shape:Oval
   • Orientation:Parallel
   • Margins:Circumscribed
   • Echo pattern:Heteroechoic
   • Posterior features:No posterior features
 ‣ Calcifications:None
 ‣ Associated features:Internal vascularity
 ‣ Special cases:None

BI-RADS:

BI-RADS Category: 4A (low level of suspicion for malignancy)

Further assessment:

Further assessment advised: Referral for cytology

Cytology:

Cytology features:

 ‣ Type of sample:FNAC
 ‣ Site of biopsy:
   • Laterality:Right
   • Quadrant:Outer
   • Localization technique:Palpation
   • Nature of aspirate:Whitish fluid
 ‣ Cytological description:Smears are cellular and show monolayered clusters and sheets of ductal epithelial cells. Myoepithelial cells are seen. A few clusters of apocrine cells are seen. Background shows many foamy cells, macrophages, and haemorrhage
 ‣ Reporting category:Benign
 ‣ Diagnosis:Benign proliferative breast lesion
 ‣ Comments:None


Histopathology:

Lumpectomy



Histopathology features:

 ‣ Specimen type:Lumpectomy
 ‣ Laterality:Right
 ‣ Macroscopy:Breast specimen (6.0 × 5.0 × 3.0 cm) with smooth external surface. Cut surface shows a large cystic area (4.0 × 4.0 × 2.0 cm) with a pedunculated papillary structure. Surrounding breast tissue contains smaller cysts with papillae
 ‣ Histological type:Multiple benign papillomas. Sections from the papillary lesions reveal multiple benign papillomas with well-developed fibrovascular cores and broad club-like papillae and arborescent fronds. The broader papillae contain glands. Both the fibrovascular cores and the glandular components are lined by epithelial cells with a prominent myoepithelial layer
 ‣ Histological grade:
 ‣ Mitosis:
 ‣ Maximum invasive tumour size:
 ‣ Lymph node status:
 ‣ Peritumoural lymphovascular invasion:
 ‣ DCIS/EIC:
 ‣ Margins:
 ‣ Pathological stage:
 ‣ Biomarkers:
 ‣ Comments:Negative for malignancy

Case summary:

Postmenopausal woman presented with painful right breast lump. Diagnosed as mass of suspicious morphology, BI-RADS 4A on imaging, as benign proliferative lesion on cytology, and as multiple benign papillomas on histopathology.

Learning points:


  • Intraductal papillomas can arise in small or large ducts and may be either identified grossly as a polypoid intraductal mass or found only on microscopic examination.

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