Case Description
A 71-year-old African American/ black male presented with a self-palpated left retroareolar breast mass. This was evaluated with a bilateral diagnostic mammogram and left breast ultrasound demonstrating a complex cystic and solid mass. Biopsy of the solid component of the mass was performed along with cytologic evaluation of the fluid showing benign fibroadipose tissue, without malignant cells identified. After the procedure the mass reduces in size and the patient is lost to follow-up until five years later when he again complains of an enlarging left breast mass.
Subsequent repeat bilateral diagnostic mammogram demonstrated an oval circumscribed hyperdense 4.5 cm mass with an associated U-shaped biopsy clip (from prior biopsy with benign pathology) at the lateral margin of the palpable mass. Ultrasound demonstrated a cystic structure containing dependent and mobile debris measuring 5.1 x 2.9 x 4.5 cm [Figure 1 and 2]. A core needle biopsy was again performed showing atypical ductal hyperplasia involving a cystically dilated duct [Figure 3 and 4].
He was referred for surgical consultation where on exam there was a ~5cm well circumscribed, mobile, retroareolar mass without associated skin changes. He was recommended to have a left breast excision which was performed through an inframammary incision, the lesion was excised intact. Pathology revealed intermediate grade DCIS pattern [Figure 5]. The surgical margin was negative, but with multiple close margins (<1 mm). Biomarker studies showed the DCIS was positive for estrogen receptor (95%, strong intensity), and progesterone receptor (95%, strong intensity). Given the close margins the patient was recommended to have a re-excision which he declined. He was referred for radiation and completed whole breast external beam irradiation. Endocrine therapy was also discussed and recommended which he also declined.
The patient was last seen for 6 clinical follow-up and remains without evidence of clinical or radiographic disease benign one year after treatment.