27 year old Female with Palpable Right Breast Mass • Xray of the Week 2016 • Week #30
A 27-year-old, African American female presented with a right breast mass, palpable for one year. Given the patient’s age, an ultrasound was performed. The findings prompted a mammogram. What is the diagnosis?
Left: Medial lateral oblique (MLO) mammogram of right breast. Mammogram revealed two irregular, spiculated masses with pleomorphic calcifications involving the entire upper, outer quadrant of the right breast, corresponding to this patient’s region of palpable lesion.
Right: Breast ultrasound showing an irregular, hypoechoic mass with posterior shadowing. There are also bright internal echoes consistent with microcalcifications. Mild increased flow is present with color Doppler sonography.
Fig.2 Spot magnification views of right breast demonstrate pleomorphic calcifications and irregular, spiculated masses
Fig.3 Ultrasound demonstrating dilated ducts with internal echos in the periareolar breast adjacent to the mass.
An ultrasound core biopsy was performed. Pathology was invasive ductal (IDC), grade 2 and ductal carcinoma in situ (DCIS), comedo type with high nuclear grade, Estrogen and Progesterone Receptor Positivity (ER/PR +), and HER2/neu 2+ (equivocal).
In younger women, palpable masses are often benign and related to hormonal influences, commonly fibroadenomas, and cysts, or galactoceles in pregnant or breastfeeding females. Fibroadenomas are the most common benign breast tumor, especially in African American women and women under the age of 30. However, ultrasound imaging of a fibroadenoma will typically reveal a circumscribed, hypoechoic mass which often has posterior acoustic enhancement. A cyst would demonstrate circumscribed margins, be anechoic, and have posterior acoustic enhancement. This patient’s mass did not demonstrate benign characteristics, thus prompting mammographic evaluation.
The features of this patient’s mass, including the irregular margins, suspicious calcifications, hyperemia and associated dilated ducts with internal echos are all common appearances for IDC and DCIS on mammogram and ultrasound. The incidence of breast cancer is very low in young females. For women under the age of 40, the risk of developing breast cancer within 10 years is less than 2%. However, African American women have higher rates of premenopausal breast cancer in comparison to other groups. It is important to closely evaluate the ultrasound appearance of masses in women under the age of 30. Characteristics associated with malignancy include: spiculation, taller than wide, microlobulations, angular margins, markedly hypoechoic nodule, posterior acoustic shadowing, punctate calcifications, or duct extension. If there are any of these suspicious findings, further imaging with mammography is required.
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4. Kaur, K. (2014, July 2). Breast Lumps in Young Women: Diagnostic Approaches. Retrieved July 9, 2016, from http://reference.medscape.com/features/slideshow/breastlumps#9
Dr. Anjali Malik received her B.A. in Public Health from The Johns Hopkins University and her MD from Tulane University. She completed her residency in Diagnostic Radiology at the University of Texas - Southwestern with Dr. Neil Rofsky. In 2013, Dr. Malik commenced a Breast Imaging Fellowship with Dr. Rachel Brem at George Washington University. Currently, she is a Breast Imaging and Intervention Specialist at Eastern Radiologists, Inc in Greenville, NC. She is passionate about breast imaging, women’s health issues, and preventive medicine.
Follow Dr. Malik on Twitter @AnjaliMalikMD
Shannon Maree Osborne is in the Class of 2019 at The Brody School of Medicine at East Carolina University
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