Obgyn · Year 3 · from Obgyn
Case 2: Breast Mass Evaluation
Patient Demographics
- Age: 45 years
- Sex: Female
- Occupation: High school principal
Chief Complaint
"I found a lump in my left breast about 3 weeks ago."
History of Present Illness
The patient noticed a firm lump in her left breast while showering. It has not changed in size over 3 weeks. She denies breast pain, nipple discharge, skin changes, or weight loss. She has never noticed a breast lump before. She is concerned because her mother was diagnosed with breast cancer at age 58.
Breast History
- Last mammogram: 1 year ago, reported as BI-RADS 2 (benign finding - bilateral cysts)
- No prior breast biopsies
- No nipple discharge
- No breast surgeries
Menstrual History
- Menarche: Age 11
- Currently perimenopausal with irregular cycles
- Last menstrual period: 6 weeks ago
Family History
- Mother: Breast cancer at age 58 (deceased age 65)
- Maternal aunt: Ovarian cancer at age 62
- No known BRCA testing in family
Risk Factors
- Early menarche (age 11)
- First pregnancy at age 32
- Family history of breast cancer (mother)
- Family history of ovarian cancer (maternal aunt)
- Dense breast tissue on prior mammogram
Physical Examination
Inspection:
- No skin dimpling, retraction, or erythema
- Nipples symmetric, no inversion or discharge
- No peau d'orange appearance
Palpation (Patient Supine, Arm Raised):
- Left breast: 2 cm firm, fixed mass at 2 o'clock position, 4 cm from nipple
- Mass is irregular, non-tender, poorly mobile
- Right breast: No masses, mild nodularity consistent with fibrocystic changes
- Axillae: No palpable lymphadenopathy bilaterally
Assessment
Concerning left breast mass requiring urgent workup
Red flags present:
- Fixed, irregular mass
- Poor mobility
- Family history of breast and ovarian cancer
Diagnostic Workup
Diagnostic Mammogram:
- Left breast: Irregular, spiculated mass at 2 o'clock position
- Associated microcalcifications
- Right breast: Unchanged bilateral cysts
- BI-RADS 5: Highly suggestive of malignancy
Breast Ultrasound:
- Left breast: 2.1 cm irregular hypoechoic mass with angular margins
- Posterior acoustic shadowing
- No cystic component (solid mass)
- Left axilla: One lymph node with thickened cortex (suspicious)
Tissue Diagnosis
Ultrasound-Guided Core Needle Biopsy:
- Left breast mass: 4 cores obtained
- Left axillary lymph node: Fine needle aspiration
Pathology Results:
- Left breast: Invasive ductal carcinoma, grade 2
- Estrogen receptor: Positive (90%)
- Progesterone receptor: Positive (70%)
- HER2/neu: Negative
- Ki-67: 15%
- Axillary lymph node: Positive for metastatic carcinoma
Diagnosis
Left Breast Invasive Ductal Carcinoma, ER+/PR+/HER2-, Clinical Stage IIA (T2N1)
Multidisciplinary Management
- Referred to breast surgeon and medical oncology
- Discussed surgical options (lumpectomy with radiation vs. mastectomy)
- Genetic counseling recommended given family history
- BRCA testing performed: BRCA1 mutation detected
Treatment Plan
- Given BRCA1+ status: Patient elected bilateral mastectomy with reconstruction
- Sentinel lymph node biopsy (converted to axillary dissection for positive nodes)
- Adjuvant chemotherapy followed by hormonal therapy
- Discussion of risk-reducing salpingo-oophorectomy
Teaching Points
- Any new, fixed, or hard breast mass requires urgent evaluation
- BI-RADS 4 and 5 require tissue diagnosis
- Core needle biopsy is preferred over excisional biopsy for diagnosis
- Family history of breast and ovarian cancer should prompt genetic testing consideration
- Triple assessment: Clinical exam + Imaging + Tissue diagnosis
Clinical Image
Image Description: Mammographic image demonstrating an irregular, spiculated mass in the upper outer quadrant of the left breast with associated pleomorphic microcalcifications, classified as BI-RADS 5 (highly suggestive of malignancy).
Attribution: Image from Radiopaedia. Case courtesy of Dr. Henry Knipe. Licensed under CC BY-NC-SA 3.0. Source: https://radiopaedia.org/cases/breast-carcinoma