Clinical presentation

A 36-year-old female attended review with her GP after self-detecting a right breast mass.  She denied any other breast concerns. On examination, she looked well and had a BMI of 27. Her clinical examination identified a 1cm right retroareolar mass without any palpable right axillary lymphadenopathy.

Medical history

• Biopsy confirmed left breast fibroadenoma 
• Burkitt lymphoma at age 5 (Note that there is no association with Burkitt lymphoma or its management and the development of breast cancer.) 
• Estrogen exposure: nulliparous, denies use of oral contraceptive pill or fertility medications, menarche 12 years of age 

Family history

Breast cancer (paternal grandmother, age unknown). 

Initial

A right breast ultrasound was arranged. In the patient’s area of concern, a 13mm lobulated hypoechoic lesion was seen at the right retroareolar position. Additionally, there was an incidentally detected 4mm spiculated, hypoechoic lesion at the right breast at 2 o’clock 2cm from the nipple. This had indistinct outlines, acoustic shadowing and associated vascularity.

Radiologist’s impression

The presenting area of concern had benign imaging characteristics and was consistent with a fibroadenoma. The 2 o’clock lesion however was reported to have BI-RADS 4c imaging characteristics, and the radiologist discussed their concerns with the referring GP.

Breast specialist surgeon review

The patient was reassured of the benign pathophysiology of fibroadenomata, and that these could be monitored with progress imaging. However, further investigation of the 2 o’clock lesion was recommended to complete their breast assessment. This included considerations for bilateral breast imaging for a thorough assessment, and supplementing her mammogram with contrast to improve the sensitivity of the mammogram given the anticipated breast density in a young woman.

Further investigations

• Contrast-enhanced mammogram (CEM): The breasts were extremely dense. The right breast 2 o’clock ultrasound lesion corresponded to a 20mm area of distortion and enhancement in the mid-thirds of the right upper inner quadrant of breast.
• Ultrasound-guided biopsy: The right breast 2 o’clock lesion was biopsied. As the right retroareolar lesion had benign imaging characteristics consistent with a fibroadenoma, this was not biopsied.
• Histology: Sclerosing adenosis without atypia, no evidence of in-situ or invasive malignancy.

Outcome (breast specialist surgeon review)

As the benign histology result was not concordant with the imaging findings, further assessment options were discussed. This included vacuum-assisted biopsy, breast MRI or diagnostic breast surgery. As per her preference, the patient proceeded to a diagnostic excisional biopsy of the lesion. Surgical histology confirmed the lesion as a radial scar with no evidence of malignancy.

Given the lesion was benign, no further treatment was recommended for the 2 o’clock lesion. The patient was advised to repeat ultrasound imaging in 12 months to assess stability of the lesion, and to undergo slightly-above population risk breast cancer screening with biennial mammography when she is 50 years of age. 

Learning points

• The Breast triple test: A thorough breast assessment includes a clinical examination, breast imaging and biopsy. A negative triple test suggests that the likelihood of cancer is unlikely¹. However, further investigations are required if there is discordance.
• Contrast enhanced mammography: CEM is more sensitive and specific than standard mammography², particularly in women with dense breasts (BIRADS C or D), with high sensitivity approaching that of MRI, supporting its use as a cost-effective diagnostic and screening tool³. It has been demonstrated to help improve diagnostic accuracy in women with abnormal screening findings or symptoms of breast cancer⁴. Although the radiation exposure is slightly increased when compared to conventional mammography, it facilitates improved assessment of complex lesions that may not fulfil eligibility criteria for a Medicare-rebatable breast MRI.
• Multidisciplinary breast clinics: One-stop rapid assessment clinics have been shown to reduce patient anxiety owing to the integrated radiology and breast specialist assessment⁵. A multidisciplinary team approach that involves prompt discussions between the referring doctor, radiologist and breast specialist surgeon facilitates a comprehensive assessment. This may be particularly useful for patients who benefit from personalised recommendations, and those residing in regional areas with limited access to radiological and surgical services*.

*Model of Care at Breast Imaging Victoria:  A multidisciplinary team is on-site to provide comprehensive, holistic and personalised breast care to all patients.

Conclusion

The choice and benefits of different breast imaging modalities may be nuanced and benefit from discussion with a dedicated breast radiologist. A patient-centred, multidisciplinary approach will provide personalised and improved patient care.

Case study provided by Breast Imaging Victoria. Reviewed by Dr Eugenia Ip (specialist breast surgeon) and Dr Charuta Dagia (breast radiologist.)

References

1. Cancer Australia. Investigation of new breast symptom: a guide for General Practitioners (canceraustralia.gov.au/inbsguide)
2. Suter M, Pesapane F, Agazzi G et al. Diagnostic accuracy of contrast-enhanced spectral mammography for breast lesions: a systematic review and meta-analysis. Breast 2020; 53:8-17
3. Coffey K, Jochelson M. Contrast-enhanced mammography in breast cancer screening. Eur J Radiol. 2022 Nov:156:110513.
4. Jochelson M, Lobbes M et al. Contrast-enhanced Mammography: State of the Art. Radiology 2021. doi.org/10.1148/radiol.2021201948
5. Singh M, Maheu C, Brady T et al. Can Oncol Nurs J 2017; 27(4): 348-55