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Case number:162
Age:43
Clinical presentation:Premenopausal woman with high risk of breast carcinoma because of family history (first-degree relative with bilateral breast carcinoma) presented with a right breast lump. CBE revealed a firm lump in the upper outer quadrant of the right breast.


Mammography:


Breast composition:ACR category b (there are scattered areas of fibroglandular density)
Mammography features:

 ‣ Location of the lesion:2011: Right breast, upper outer quadrant at 11 o’clock, anterior third
 ‣ Mass:
   • Number:1
   • Size:1.9 × 1.5 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


Mammography features:

 ‣ Location of the lesion:2011: Left breast, upper inner quadrant at 11 o’clock, anterior third
 ‣ Mass:
   • Number:1
   • Size:1.0 cm in greatest dimension
   • 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:2012: Right breast, upper outer quadrant at 11 o’clock, anterior third
 ‣ Mass:
   • Number:1
   • Size:1.9 × 1.5 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


Mammography features:

 ‣ Location of the lesion:2012: Left breast, upper inner quadrant at 11 o’clock, anterior third
 ‣ Mass:
   • Number:1
   • Size:1.0 cm in greatest dimension
   • 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:2017: Right breast, upper outer quadrant at 11 o’clock, anterior third
 ‣ Mass:
   • Number:1
   • Size:1.9 × 1.5 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


Mammography features:

 ‣ Location of the lesion:2017: Left breast, upper inner quadrant at 11 o’clock, anterior third
 ‣ Mass:
   • Number:1
   • Size:1.0 cm in greatest dimension
   • 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: 2011: Right breast, outer quadrants at 9 o’clock

 ‣ Mass
   • Location:2011: Right breast, outer quadrants at 9 o’clock
   • Number:1
   • Size:1.7 × 1.5 cm
   • Shape:Oval
   • Orientation:Parallel
   • Margins:Circumscribed, 2–3 lobulations present
   • Echo pattern:Heterogeneous
   • Posterior features:No posterior features
 ‣ Calcifications:None
 ‣ Associated features:None
 ‣ Special cases:None


Ultrasound features: 2011: Left breast, upper inner quadrant at 11 o’clock

 ‣ Mass
   • Location:2011: Left breast, upper inner quadrant at 11 o’clock
   • Number:1
   • Size:1.0 × 10.5 cm
   • Shape:Irregular
   • Orientation:Parallel
   • Margins:Angular
   • Echo pattern:Hypoechoic
   • Posterior features:No posterior features
 ‣ Calcifications:None
 ‣ Associated features:None
 ‣ Special cases:None


Ultrasound features: 2017: Right breast, outer quadrants at 9 o’clock

 ‣ Mass
   • Location:2017: Right breast, outer quadrants at 9 o’clock
   • Number:1
   • Size:1.7 × 1.5 cm
   • Shape:Oval
   • Orientation:Parallel
   • Margins:Circumscribed, 2–3 lobulations present
   • Echo pattern:Heterogeneous
   • Posterior features:No posterior features
 ‣ Calcifications:None
 ‣ Associated features:None
 ‣ Special cases:None


Ultrasound features: 2017: Left breast, upper inner quadrant at 11 o’clock

 ‣ Mass
   • Location:2017: Left breast, upper inner quadrant at 11 o’clock
   • Number:1
   • Size:1.0 × 10.5 cm
   • Shape:Irregular
   • Orientation:Parallel
   • Margins:Angular
   • Echo pattern:Hypoechoic
   • Posterior features:No posterior features
 ‣ Calcifications:None
 ‣ Associated features:None
 ‣ Special cases:None

BI-RADS:

BI-RADS Category (2011): 3 (probably benign)
BI-RADS Category (2012): 2 (benign)
BI-RADS Category (2017): 2 (benign)

MRI:


MRI features:
 ‣ MRI features:Amount of fibroglandular tissue: ACR category a (predominantly fatty with small proportion of glandular density). Background parenchymal enhancement: Mild (25–50%), symmetrical

 ‣ Location:Right breast at 11 o’clock
 ‣ Focus:No
 ‣ Mass:
   • Shape:Round
   • Margin:Circumscribed
   • Internal enhancement:Homogeneous
   • Kinetic curve:Type I
 ‣ Non-mass enhancement:
   • Distribution:No
   • Internal enhancement:No
 ‣ Non-enhancing findings:T2 hypointense
 ‣ Associated features:A few smaller lesions of similar morphology
 ‣ Axillary nodes:None


Case summary:

Premenopausal woman with increased risk of developing breast cancer presented with right breast lump diagnosed as involuting (partially calcified) fibroadenoma in right breast, BI-RADS category 2 on imaging. Left breast reveals probably benign lesion, BI-RADS category 3 on initial assessment. Regular annual follow-up done for 5 years and diagnosed as sclerotic fibroadenoma in left breast, BI-RADS category 2 on imaging.

Learning points:


  • The patient presented with a right breast lump and imaging revealed a clinically non-palpable left breast lesion. Initial assessment category is BI-RADS 3 (probably benign).
  • Short-interval follow-up confirmed the lesions in both breasts to be stable.
  • MRI breast was performed in view of the high-risk status at first annual follow-up. This revealed right breast fibroadenoma and left breast lesion probably sclerotic fibroadenoma.
  • At 5 years follow-up the lesions are stable with features of involuting fibroadenoma. Final assessment category was BI-RADS 2 (benign) finding.

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