25 years old lady with palpable mass: Breast ultrasound is the best initial test based on the

patient's age. A follow-up mammogram may be helpful but should only be pursued after an US
scan.

Poland syndrome is a rare, sporadic, congenital anomaly characterized by

unilateral partial or total absence of the pectoral muscle and ipsilateral
symbrachydactyly. No definite etiology has been identified, but a leading
hypothesis suggests that it stems from the interruption of the early embryonic
blood supply in the subclavian arteries, the vertebral arteries, and their
branches. This "subclavian artery supply disruption sequence" may represent a
possible basis for Poland syndrome, as well as for other birth defects such as
Klippel-Feil syndrome, Moebius syndrome, and Sprengel anomalies. Functional
problems due to the muscle disorder are not common. Additional anatomic
findings include absent sternocostal head of pectoralis major, absent pectoralis
minor, and hypoplasia of latissimus dorsi, serratus anterior, external oblique and
intercostal muscles, infra- and supraspinatus, deltoid, nipple, or breast, as well
as dextrocardia, diaphragmatic hernia, and scoliosis. Mammography in the
mediolateral oblique (MLO) view and cross-sectional imaging demonstrate
unilateral hypoplasia of the breast or the pectoralis major muscle. Chest
radiograph demonstrates unilateral hyperlucent hemithorax.

The pectoralis major on the left is absent, compatible with Poland disease. Poland disease is a
congenital condition characterized by underdevelopment of the chest wall. It is also associated with
abnormalities of the hand on the side ipsilateral to the chest wall abnormality. It is more common on
the right and is thought to be due to a vascular insult during development. Amastia is the absence
of the breast tissue and nipple. Moebius syndrome is a rare disorder that has associated chest wall
abnormalities but is also associated with facial paralysis

There is a circumscribed hypoechoic intraductal mass with a stalk, which

is most compatible with an intraductal papilloma. Fibroadenoma is not an
intraductal mass. Ductal carcinoma in situ most commonly presents with
calcifications. Invasive ductal carcinoma is less likely given the
circumscribed margins. Papillary carcinoma may have a similar
appearance but is less common than a papilloma

Intraductal papillomas with atypia on biopsy should undergo excision due to a high risk of
associated invasive cancer or ductal carcinoma in situ (DCIS). Bloody discharge associated with a
papilloma is thought to occur when the papilloma twists on its vascular pedicle and undergoes
infarction. There is a higher risk of malignancy of papillomas when there are multiple lesions and
when lesions are in peripheral rather than central ducts. While papillomas are rare in males, they
have been reported.

There is a circumscribed, oval, isoechoic mass in the right breast

without suspicious features. The mass most likely represents a
fibroadenoma or lactating adenoma. An abscess is more likely to
appear as a hypoechoic fluid collection with posterior acoustic
enhancement and increased vascularity surrounding the collection.
There is no fluid level to suggest galactocele. The mass is not
intraductal to suggest the diagnosis of papilloma. Invasive ductal carcinoma would be more likely if
the mass had spiculated margins and an irregular shape.

Classic ultrasound findings of an abscess: an avascular, hypoechoic fluid collection with internal
echogenic debris and peripheral hyperechoic, vascular rim.

There is increased fibroglandular tissue in the subareolar right breast. The borders of the tissue are
not convex, and the lesion is not centrally dense. Therefore, the lesion does not meet the criteria for
a mass. The two-view finding has increased since the prior mammogram, which makes it a
developing asymmetry rather than a focal asymmetry.

Pseudoangiomatous stromal hyperplasia (PASH) is an uncommon benign stromal proliferation. It

may be related to a hormonal response. PASH may present as a mass or asymmetry, which makes
the pathology and imaging findings concordant in this case. PASH is not premalignant and does not
require excision. When PASH presents as a mass, the mammographic and ultrasound appearance
may be similar to that of a fibroadenoma

The breasts are heterogeneously dense. There are multiple bilateral, well-circumscribed masses
with a surrounding rim of air density in keeping with the superficial location (cutaneous). On the
tomosynthesis views, the masses are more conspicuous on the first and last images, consistent
with superficial location. Tangential views could aim in demonstrating the superficial location.
Bilateral, multiple, well-circumscribed masses are benign in etiology, corresponding to BI-RADS 2.
 BI-RADS 3 corresponds to a risk of cancer of 2%.
 BI-RADS 4 corresponds to a risk of cancer of 2% to 94%.
 BI-RADS 5 corresponds to a risk of cancer greater than 95%.

In this case, these masses correspond to breast neurofibromas in a patient with neurofibromatosis
type 1 (NF1).

There is a diffuse increase in breast density and interstitial

markings with associated skin thickening and asymmetric
enlargement of the left breast. There is focal asymmetry in the
left outer upper quadrant with associated coarse calcifications.
There is suspicious asymmetric enlargement of the left axillary
lymph nodes. The clinical history and this constellation of
findings are suspicious for inflammatory breast cancer.

Inflammatory breast cancer is usually poorly differentiated

invasive intraductal carcinoma with associated dermal lymphatic tumor emboli/obstruction and
lymphovascular invasion. It is an invasive aggressive cancer, classified as T4d stage by TNM
classification with 20% to 30% of distant metastasis at the time of diagnosis. Patients may present
with rapid onset of breast erythema, edema involving at least one-third of the breast, “orange
peel” skin, and nipple retraction with or without a palpable breast lump

Flare artifact: The nonhomogeneous fat suppression in the lower outer breast is from the patient's
breast being too close to the coil element. This can be diminished by repositioning.

Other answer options:

 Motion artifact is typically in the phase encoding direction, which for most breast protocols is
from top to bottom.
 Chemical shift artifact occurs at the fat-water interfaces.
  Susceptibility artifact would be signal void. In the breast, this is most frequently seen with
metallic biopsy markers or surgical clips.

There is a dense, irregular mass with spiculated margins and associated calcifications. This is in the
BI-RADS 5 category (highly suggestive of malignancy), with a greater than 95% likelihood of
cancer. If biopsy yielded a benign pathology, the pathology would be considered discordant.

There is a large, dense mass in the subareolar left breast, which is compatible with invasive ductal
carcinoma.
Gynecomastia presents with flame-shaped fibroglandular tissue. Lipomas
demonstrate fat-density. Papillomas are uncommon in males but typically present
as small subareolar masses with nipple discharge. Ductal carcinoma in situ most
commonly presents with calcifications. Invasive papillary carcinoma may be similar
in appearance to invasive ductal carcinoma but is far less common.

Klinefelter syndrome is a risk factor for male breast cancer. Invasive ductal carcinoma is the most
common subtype of male breast cancer, representing 80% of breast cancer in males. It is bilateral
in less than 1% of cases. Up to 50% of males present with axillary nodal involvement due to a delay
in presentation. Men develop breast cancer later than women, with a mean age of presentation
around 67 years

Complementary:

 Magnification views are helpful for characterizing calcifications.

 Breast MRI is helpful for staging known cancer and may be helpful later if biopsy confirms
cancer.
 Mediolateral (ML) view mammogram can be helpful for localization of small and nonpalpable
lesions seen on craniocaudal (CC) and/or mediolateral oblique (MLO) views.

There is a dense, irregular mass with spiculated margins and associated calcifications. This is in the
BI-RADS 5 category (highly suggestive of malignancy), with a greater than 95% likelihood of
cancer. If biopsy yielded a benign pathology, the pathology would be considered discordant.

Invasive lobular carcinoma, papillary carcinoma, medullary carcinoma, mucinous carcinoma. Of the
lesions listed, invasive carcinoma of no special type, or invasive ductal carcinoma, is the most
common and most commonly presents as a mass with spiculated margins. Invasive lobular
carcinoma accounts for 10% to 15% of invasive breast cancer. It most
commonly presents as a spiculated mass, but it may also present as
architectural distortion or asymmetry. Papillary carcinoma is a rare
malignancy that may demonstrate circumscribed margins. Medullary and
mucinous carcinomas are rare forms of invasive ductal carcinomas, which
may also present as circumscribed masses.

Grayscale ultrasound image demonstrates a cyst with a fluid-fluid level and

increased through transmission. There is no internal vascularity and minimal
peripheral vascularity. These findings are most consistent with galactocele,
which was confirmed on aspiration. An abscess may have a similar appearance but typically
presents with pain and erythema. Fever also may be present but is less common. Fibroadenomas
and lactating adenomas typically present as solid, circumscribed lesions. The cyst does not have a
solid component with vascularity, which would be concerning for invasive carcinoma.