Radiological Category Breast Principal Modality 1 General Radiography

Radiological Category: Breast Principal Modality (1): General Radiography Principal Modality (2): Ultrasound Case Report #0535 Submitted by: Gustav Arthur Blomquist, M. D. Faculty reviewer: Lumarie Santiago, M. D. Date accepted: 18 December 2008

Case History 70 year old female presents with two new palpable breast abnormalities felt by both the patient and the doctor.

Mammogram from 2003 RCC RMLO

Taking The Case Today’s mammogram is unchanged from 2003. What is the next step? a) Tell her to come back in a year for screening mammogram. b) Assign her a BIRADS 0 and request an ultrasound without further mammographic imaging. c) Continue your mammographic imaging. Obtain magnification views of the palpable area. d) Continue your mammographic imaging. Obtain compression views of the palpable area. Think about why you request each of the above studies. Pick an answer before proceeding to the next slide.

Compression View from Diagnostic Mammogram

Taking The Case Both B and D could have been correct answers because the compression views help further characterize the area. Sometimes glandular tissue will overlap to form a pseudolesion. The pseudolesion will compress out on the compression views. Ultrasound is the next step for these two new palpable lesions because you see only the one lesion on mammogram. Now describe the findings on the mammogram. Describe the lesion if you see it. Ask yourself, “What does the compression view add to your workup? ”

Case History There are scattered fibroglandular densities that could obscure a lesion on mammography. Two palpable area markers are on the right breast at 10 o'clock. A scar marker is present on the right breast in the upper outer quadrant, which has been there since 1995. a) “There is not a thing wrong with that breast. ” – Dr. P. H. b) Spiculated lesion with associated pleomorphic calcifications. The area does not compress out. c) Regional punctate calcifications. I don’t need no magnification views. d) An anterior palpable area 3 cm from the nipple correlates with a 2 x 1. 6 cm stable well circumscribed oval, fat and soft tissue density mass with a thin radiopaque pseudocapsule. The area does not compress out. Pick an answer and assign a BIRADS to the lesion before proceeding to the next slide. What is the next step?

Case History The correct answer is D. This palpable mass is a BIRADS 0 because we want further imaging by ultrasound. The patient was taken to ultrasound where these next images were obtained of the right breast.

Ultrasound

Ultrasound

Test Your Diagnosis Which one of the following is your choice for the appropriate diagnosis? After your selection, go to next page. • Ductal Carcinoma In Situ. It is the most common, so it is my best bet. • Lobular Carcinoma. I want an MRI to make sure there are no other lesions. • Phylloides Tumor. Looks leafy to me. • Lymphoma… or, maybe TB… They can act like anything. • Fibroadenolipoma. a. k. a. “Hamartoma”

Findings and Differentials Findings: Ultrasound: The anterior palpable area 3 cm from the nipple correlates with a sharply defined heterogenously mixed hyper- and isoechoic oval mass. There are no other ultrasound findings. Mammogram: The anterior palpable area 3 cm from the nipple correlates with a 2. 2 x 2. 1 x 1. 6 cm stable fat containing mass. The findings are consistent with a hamartoma. No underlying mammographic abnormality is noted in the region of the second reported palpable area at 10 o'clock, 4 cm from the nipple. Answer: Fibroadenolipoma. a. k. a. “Hamartoma”. Birads 2. Screening mammogram in one year. – An Aunt Minnie.

Discussion • • • At mammography, fibroadenolipomas are typically well-circumscribed, round to oval masses containing both fat and soft-tissue density with a thin, radiopaque pseudocapsule. At US, a sharply defined, heterogeneous oval mass is seen, or the lesion may manifest as normal glandular tissue. Fibroadenolipoma or hamartoma of the breast consists of benign proliferation of fibrous, glandular, and fatty tissue surrounded by a thin capsule of connective tissue. Malignancy may arise within the glandular elements of a hamartoma. "BREAST WITHIN A BREAST"

Diagnosis Fibroadenolipoma. a. k. a. “Hamartoma”. BIRADS 2. Screening mammogram in one year.

References 1) Feder JM, et al. Unusual Breast Lesions: Radiologic-Pathologic Correlation. Radio. Graphics 1999 19: 11 -26. 2) Tse GMK, et al. Hamartoma of the breast: a clinicopathological review. J Clin Pathol. 2002; 55(12): 951– 954. 3) Ruiz-Tovar J, et al. Infiltrating Ductal Carcinoma and Ductal Carcinoma in Situ Associated With Mammary Hamartoma. The Breast Journal. Vol 12, Issue 4, 368 - 370.