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Case number:177
Clinical presentation:Premenopausal woman with average risk of developing breast cancer presented with a left breast areolar nodule. On examination, there was expressible serous discharge from the left nipple.


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, anterior third
 ‣ Mass:
   • Number:1
   • Size:No mass
   • Shape:None
   • Margins:None
   • Density:None
 ‣ Calcifications:
   • Typically benign:None
   • Suspicious:None
   • Distribution:None
 ‣ Architectural distortion:None
 ‣ Asymmetry:Focal
 ‣ Intramammary node:None
 ‣ Skin lesion:None
 ‣ Solitary dilated duct:None
 ‣ Associated features:Solitary dilated duct


Ultrasound features: Intraductal lesion in solitary dilated duct in left subareolar region, lower outer quadrant at 5 o’clock

 ‣ Mass
   • Location:Intraductal lesion in solitary dilated duct in left subareolar region, lower outer quadrant at 5 o’clock
   • Number:1
   • Size:1.0 × 4.0 cm
   • Shape:Oval
   • Orientation:Parallel
   • Margins:Circumscribed
   • Echo pattern:Hypoechoic
   • Posterior features:No posterior features
 ‣ Calcifications:None
 ‣ Associated features:Solitary dilated duct
 ‣ Special cases:None


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

Further assessment:

Further assessment advised: Referral for cytology


Cytology features:

 ‣ Type of sample:FNAC
 ‣ Site of biopsy:
   • Laterality:Left
   • Quadrant:Retroareolar lump
   • Localization technique:Ultrasound-guided FNAC of intraductal lesion
   • Nature of aspirate:Whitish
 ‣ Cytological description:Smears are moderately cellular. Three-dimensional papillary groups with fibrovascular cores are seen. Flat sheets of ductal cells with myoepithelial cells are also present. Background shows foamy macrophages, apocrine metaplasia, and some inflammatory cells
 ‣ Reporting category:Atypical, probably benign
 ‣ Diagnosis:Papillary neoplasm, favour benign
 ‣ Comments:None



Histopathology features:

 ‣ Specimen type:Microdochectomy
 ‣ Laterality:Left
 ‣ Macroscopy:Microdochectomy specimen (2.0 × 2.0 ×1.5 cm) with apex marked with suture. On opening, a dilated duct with a small polypoid nodule (0.8 × 0.7 × 0.4 cm) was seen
 ‣ Histological type:Intraductal papilloma
 ‣ Histological grade:
 ‣ Mitosis:
 ‣ Maximum invasive tumour size:
 ‣ Lymph node status:
 ‣ Peritumoural lymphovascular invasion:
 ‣ Margins:
 ‣ Pathological stage:
 ‣ Biomarkers:
 ‣ Comments:

Case summary:

Premenopausal woman presented with left breast, expressible serous nipple discharge. Diagnosed as left breast subareolar solitary dilated duct with intraductal lesion, BI-RADS 4A on imaging, as benign proliferative change on cytology, and as papilloma on histopathology.

Learning points:

  • Solitary intraductal papilloma in a large duct in the retroareolar region presents as a palpable areolar lump as seen in this patient. Spontaneous or expressible nipple discharge, which may be serous or bloody, is also a common clinical presentation.
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