Presentation
Abdominal pain and abdominal distension for 1 year. No fever, change in the bowel habits or weight loss.
Patient Data
Selected images (lower chest & upper abdomen) from the CT abdomen.
Findings: Two non-enhancing hypodense lesions measuring 12 x 12 and 6 x 8 mm, are seen in segment 2 of the liver, which are likely hepatic cysts. Incidental finding of a small lobulated soft tissue density lesion in the partially visualized left breast and mild skin thickening in the upper inner quadrant of the left breast; these findings need further evaluation with dedicated breast imaging (mammogram and breast ultrasound).
Findings: Predominantly fatty breast parenchymal density. A lobulated mass of increased density, measuring about 4.5 x 3.8 cm, is seen at 12 o'clock in the left breast. Mild bilateral nipple retraction is seen (nipples imaged with a marker). No pleomorphic microcalcification clusters, abnormal skin thickening or significant axillary lymphadenopathy is seen.
Impression: Well-defined lobulated left breast mass lesion (BI-RADS 4). For further evaluation with breast ultrasound examination and biopsy.
Findings: A well-defined lobulated mildly heterogeneous hypoechoic mass measuring about 3.3 x 2.1 cm is seen at 12 o'clock position. The lesion is wider than taller and is partially outlined by the fluid at its medial and lateral edges. It has mild internal vascularity on the Doppler ultrasound examination and shows hard consistency on elastography.
Impression: Lobulated heterogeneous left breast mass.
Specimen source: Left breast biopsy. Diagnosis: Papillary epithelial lesion with ductal ectasia and apocrine metaplasia. The immunostain with the antibody anti-p63 highlights the continuous myoepithelial cells in this papillary epithelial structure, dilated ducts and lobules. The immunostain with Ki67 showed very low (<5%) index. These morphological and immunohistochemical findings are in favor of intraductal benign papillary lesion (intraductal papilloma); however, surgical resection of the lesion is indicated.
Procedure: Left breast lumpectomy/excisional biopsy. Diagnosis: Intraductal papilloma with cystic and apocrine changes. Margins are free. The immunostain showed low Ki67 labeling index (< 5%). The immunostain with the antibody anti-p63 highlights the myoepithelial layer.
Case Discussion
Intraductal papillomas are the commonest benign intraductal tumors. According to the literature, the patients with an intraductal papilloma are at an increased risk of suffering from a breast malignancy, as compared to the general public and this risk is particularly higher in the patients having multiple papillomas and based on this risk of breast malignancy, these lesions are usually surgically excised after a tissue diagnosis on needle biopsy 1,2. Features suggestive of atypia or malignancy {ductal carcinoma in situ (DCIS) or invasive ductal carcinoma (IDC)} are: lesion more than 1 cm in size, lesion sited greater than 3 cm away from the nipple, and the patient’s age more than the 50 years 2.
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