Case Report: 31year Old Unmarried Female Patient with Left Breast Swelling
Sushila B Ladumor1* and Mehak Raja2
1Consultant Radiologist, Clinical Imaging Department, Hamad Medical Corporation, HGH, Doha, Qatar, Assistant Professor in Clinical Radiology, Weil Cornel Medical College, Qatar (WCMC-Q)
2Resident Radiologist, Clinical Imaging Department, Body Imaging, Hamad Medical Corporation, Hamad General Hospital, Qatar
Submission: October 30, 2017; Published: November 16, 2017
*Corresponding author: Sushila Ladumor B, Consultant Radiologist, Clinical Imaging Department, Hamad Medical Corporation, HGH, Doha, Qatar, Assistant Professor in Clinical Radiology, Weil Cornel Medical College, Doha, Qatar (WCMC-Q), Email: drsbladumor@yahoo.com
How to cite this article: Sushila B L, Mehak R. Case Report: 31year Old Unmarried Female Patient with Left Breast Swelling. Open Access J Surg. 2017; 7(1): 555701. DOI: 10.19080/OAJS.2017.07.555701
Abstract
A lump in the breast is reason of great concern. High frequency, high-resolution USG helps in its detection and evaluation. Breast cysts are a relatively common cause of a breast lump in perimenopausal women, and usually causing unexplained pain or discomfort and non-tender or slightly tender on palpation. They are a benign (BIRADS II) entity.
Keywords: Breast ultrasound; Doppler; Breast cyst; Acoustic enhancement; Debris; Soft tissue component; Calcification; Breast mass; ACR BIRADS-US criteria
Introduction
(Figure 1) Case Detail and Cytology Report from Cerner
a. Chief Complaint: New consultation for left breast swelling. Complain of swelling left breast for last two years. Now the size is increasing that is why she has consulted Breast Physician.No comorbidities. No other breast problems in the past. No family history of breast or ovarian cancers. Patient is Single Regular periods and her age at menarche 13years. No hormonal intake. No Known Allergies.
b. Physical Exam
Observations & Measurements
Temperature: 36.2 °C (Oral),
Respiratory Rate: 20,
Blood Pressure: 134/80,
Height: 148 cm
Weight: 55 kg
BMI: 25.11
On examination 5 x 5 cm left breast firm smooth mobile lump mostly retro areolar from 12 to 9:00 o’ clock position. No axillary lymph nodes palpable bilaterally, Right breast clear Assessment
Patient sent for Ultrasound BREAST
a. US REPORT: Large breast simple cyst.
b. Treatment plan: Bed side aspiration done.
15cc of straw colored clean cyst fluid aspirated and sent for cytology. Lump disappeared immediately.
To be seen after 2 weeks for cytology results, then for US follow up
Cytopathology Non-Gyn/FNA Request
Clinical Information
Clinical Data: Left breast large cyst.
Previous Cytology/Biopsy: No
A. Specimen Source: Aspiration of left breast cyst
B. Macroscopic Description: Specimen labeled as left breast aspirate, as indicated on both request and container, consist of a 3 mL yellow turbid fluid.
C. Slides Generated: Fixed slides: 3 Air dried slides: 1 Cell Block Slides: 0.
D. Microscopic Description: Some clusters of apocrine cells with some foamy macrophages and few ductal cells red blood cells.
E. Diagnosis: Aspiration of left breast cyst: Apocrine cyst.
Discussion
Breast cysts are the commonest cause of breast lumps in women between 35 and 50 years of age [1,2]. A cyst occurs when fluid accumulates due to obstruction of the extralobular terminal ducts, either due to fibrosis or because of intraductal epithelial proliferation. A cyst is seen on USG as a well-defined, round or oval, anechoic structure with a thin wall and smaller cyst are compressible and larger cyst are usually mildly compressible and color Doppler demonstrates no flow (shown in this case).
A. Radiographic features
a. Ultrasound: Ultrasound evaluation of breast cysts is the modality of choice. Obstruction of the ducts, often appearing as the result of epithelial hyperplastic processes or the stromal fibrosis, or both processes lead to the formation of cysts, impair the drainage of the terminal ducts of the lobules. Sonographic features of a simple cyst include:
i. Typical cyst:
I. Anechoic signal (no internal echoes)
II. smooth walls
III. well-circumscribed shape
IV. enhanced through transmission: posterior acoustic enhancement
V. sharp anterior and posterior borders
VI. reverberation artifact
ii. Atypical cyst:
I. with all the features of typical cysts with
II. More or less subtle echoes within the anechoic cyst
III. Proliferations
IV. Calcifications
In almost 70% of all fibrocystic change, the cysts represent the predominant finding.
According to size, the cysts are divided into two categories:
a. Macro cysts: ranging from 1-6 cm in diameter that could be simple cysts or lobulated multilocular lesions
b. Microcysts: <3 mm in diameter
I. Cysts can be:
a. Single lesion
b. Multiple lesions
Cyst should not increase in size in post-menopausal women. When a cyst contains internal low level echoes and absence of some of the typical features of a simple cyst, it is named as complicated breast cyst. Cysts are usually transonic with posterior acoustic enhancement in all cases. Irregular internal margins or lesions that are not smoothly circumscribed or defined are not simple cysts.
Treatment and prognosis
Imaging findings of typical simple breast cyst, then no further workup is necessary. Symptomatic large cysts may require aspiration [3]. If such a cyst is aspirated cytological analysis is usually not required unless it contains bloody material. Simple cyst aspiration showing straw colored fluid, which can be discarded. Follow-up post aspiration ultrasound confirms the complete non-visualization of cyst with no residual cyst/ mass will indicate hemostasis. Complications from aspiration are virtually unknown but include bleeding and theoretically infection. Aspiration of cysts can be safely performed without stopping aspirin therapy. BIRADS classification is proposed by American College of Radiology, last updated in November 2015, and is widely used classification system at the time of writing this article (July 2016) [4,5].
Classification
The latest version classifies lesions into six categories:
A. BIRADS 0:
a) + Incomplete, further imaging or information is required, e.g. compression, magnification, special mammographic views, ultrasound
b) + This is also used when requesting previous images not available at the time of reading
c) BIRADS I: negative, symmetrical and no masses, architectural disturbances or suspicious calcifications present
B. BIRADS II: benign findings, interpreter may wish to describe a benign-appearing finding
a) + calcified fibroadenomas
b) + multiple secretory calcifications
c) + fat-containing lesions such as:
d) + oil cysts
e) + breast lipomas
f) + fibroadenolipoma or mixed density hamartomas
g) + galactoceles
h) + simple breast cysts
i) + these all should have characteristic appearances, and may be labeled with confidence; the interpreter might wish to describe intra-mammary lymph nodes, implants, etc. while still concluding that there is no mammographic evidence suggesting malignancy
C. BIRADS III: probably benign, short interval follow-up suggested
D. BIRADS IV: suspicious abnormality
a) + there is a mammographic appearance which is suspicious for malignancy
b) + biopsy should be considered for such a lesion
c) + these can be further divided as
i. BIRADS IVa: low level of suspicion for malignancy
ii. BIRADS IVb: intermediate suspicion for malignancy
iii. BIRADS IVc: moderate suspicion for malignancy
iv. BIRADS V: there is a mammographic appearance which is highly suggestive of malignancy, action should be taken
v. BIRADS VI: known biopsy proven malignancy
The vast majority of screening mammograms fall into BIRADS I or II.
References
- BergWA, Campassi CI, Ioffe OB (2003) Cystic lesions of the breast: sonographic-pathologic correlation. Radiology 227(1): 183-191.
- (2009) Gokhale’s Sonography clinic, Indore, India, Ultrasound characterization of breast masses, Indian J Radiol Imaging 19(3): 242- 247.
- Heisey RE, McCready (2010) Office management of a palpable breast lump with aspiration. CMAJ 182 (7): 693-696.
- Mirjan M Nadrljanski (2015) Fibrocystic change (breast).
- Yuranga Weerakkody (2015) Breast imaging-reporting and data system (BIRADS).