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.