Case number:	096
Age:	60
Clinical presentation:	Postmenopausal woman with average risk of developing breast cancer presented with nipple discharge from the right nipple of duration 10 days. Examination revealed a lump 4 cm in diameter in the right retroareolar region.

Mammography:

Breast composition:	ACR category a (the breasts are almost entirely fatty)
Mammography features:

‣ Location of the lesion:	Right breast, central portion of the breast, central zone, anterior third
‣ Mass:
• Number:	1
• Size:	3.0 × 2.5 cm
• Shape:	Irregular
• Margins:	Circumscribed
• 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:	Trabecular thickening

Ultrasound:

Ultrasound features: Right breast, central portion of the breast

‣ Mass
• Location:	Right breast, central portion of the breast
• Number:	1
• Size:	2.1 × 2.0 cm
• Shape:	Irregular
• Orientation:	Parallel
• Margins:	Indistinct
• Echo pattern:	Complex cystic and solid
• Posterior features:	Posterior shadowing
‣ Calcifications:	None
‣ Associated features:	Internal vascularity
‣ Special cases:	None

BI-RADS:

BI-RADS Category: 4C (high suspicion for malignancy)

Further assessment:

Further assessment advised: Referral for cytology

Cytology:

Cytology features:

‣ Type of sample:	FNAC (cystic lesion)
‣ Site of biopsy:
• Laterality:	Right
• Quadrant:	Inner, retroareolar region
• Localization technique:	Palpation
• Nature of aspirate:	0.5 mL of brownish yellow fluid
‣ Cytological description:	Smear shows thick proteinaceous debris in the background with scattered small clusters of benign ductal epithelial cells
‣ Reporting category:	Benign
‣ Diagnosis:	Fibrocystic change, benign
‣ Comments:	None

Histopathology:

Breast lumpectomy specimen

Histopathology features:

‣ Specimen type:	Breast lumpectomy specimen
‣ Laterality:	Right
‣ Macroscopy:	Specimen 4.0 × 3.0 × 1.5 cm. Cut surface shows two cystic areas (2.0 × 1.0 × 0.5 cm and 0.5 × 0.6 × 0.3 cm)
‣ Histological type:	Multiple sections taken from the entire lumpectomy specimen show changes of epithelial hyperplasia, sclerosing adenosis, and intraductal papillomas. Some areas show densely fibrotic stroma with entrapped small tubules and varying degrees of cyst formation and hyperplasia. A few of the epithelial cells show apocrine metaplasia
‣ Histological grade:
‣ Mitosis:
‣ Maximum invasive tumour size:
‣ Lymph node status:
‣ Peritumoural lymphovascular invasion:
‣ DCIS/EIC:	Not identified
‣ Margins:
‣ Pathological stage:
‣ Biomarkers:
‣ Comments:	Negative for malignancy

Case summary:

Postmenopausal woman presented with right breast lump. Diagnosed as a complex cystic and solid mass in the subareolar region of the right breast, BI-RADS 4C on imaging, as benign fibrocystic change on cytology, and as epithelial hyperplasia, sclerosing adenosis, and intraductal papillomas, negative for malignancy on histopathology.

Learning points:

Complex cystic and solid mass showing a solid papillary vascular stalk within a papillary lesion. Tissue histology confirms a benign papilloma.
Because this patient had spinal tuberculosis and had undergone dorsolumbar spine fixation surgery, she was unable to stand or sit for the mammogram. This means that positioning is suboptimal.