The answer is b) primary ductal carcinoma (breast cancer)

The mammogram images (Figures 1a & 1b) reveal a small-to-moderate amount of background dense breast tissue, along with a discrete irregular speculated dense 2 cm mass lesion in the inferior left breast. The mammographic features are highly suspicious for primary breast cancer. An enhanced breast MRI was also performed, considering the patient’s young age, to assess for multifocal and/or bilateral carcinoma. Thankfully, only the solitary left breast lesion was discovered. The patient was referred for subsequent surgical and oncological treatment.

The current recommendations for breast cancer (BC) screening that we support at our institution, as endorsed by the American Medical Association, American College of Radiologists, American Cancer Society and the American College of Obstetricians and Gynecologists, is annual mammographic screening, combined with self breast exam, commencing at age 40. This combination has been shown by numerous large clinical trials around the world to reduce breast cancer mortality. Essentially, the earlier you find the cancer and the smaller the size of the lesion at diagnosis, the better the prognosis. In addition, breast cancers that develop in women aged 40-49 are often more aggressive than those developing in older women, making the annual screening interval all the more important in that early age group. A recent article in the Annals of Internal Medicine from the U.S. Preventative Services Task Force revealed their change in the recommendations, now supporting screening commencement at age 50. This was quickly countered by results from a large trial out of Portland which again concluded that annual mammographic screening reduces BC mortality for women aged 39-69, and found that both clinical and self-breast examination had no effect on mortality.

For women with very dense breasts and high risk factors (BC in first-degree relatives, BRCA 1 & 2 mutations, history of chest radiation treatment between ages 10-30 years), annual enhanced breast MRI should be considered as a complement to the usual mammographic study. Recommendations for women with 1st-degree relatives with early onset BC age (45-49 years or earlier) is commencement of annual screening mammography 10 years earlier than the age at BC diagnosis in the 1st-degree relative, along with consideration for annual breast MRI. Screening of those high-risk women should only start before age 30 for those with known or suspected BRCA 1 or BRCA 2 genetic mutation, and those with a personal history of breast carcinoma, lobular carcinoma in situ, and atypical ductal or lobular hyperplasia. In women of intermediate risk with dense breasts, or high risk who can’t tolerate MRI (or have absolute contraindications for MRI), breast ultrasound should complement annual mammography.

Simple breast cysts are benign fluid collections within the breast and are very common in women of almost all ages. On mammography they are typically seen as discrete circular or oval nodules with sharp margins. They do not enhance on MRI. The lesion shown should not be considered a cyst. Breast hematomas can simulate cancer and can be irregular on mammography and may even exhibit some degree of enhancement on MRI. However, the lack of any breast trauma history would make this diagnosis less likely than BC. Breast abscesses not uncommonly develop in lactating women and typically present as extremely tender focal mass lesions, often with associated overlying dermal erythema and increased local heat to palpation. They may appear somewhat irregular on mammography and can exhibit peripheral enhancement on MRI. The clinical presentation is atypical for abscess in this case. Intramammary lymph nodes are a very common finding in women of all ages. They are incidental and benign. They appear as discrete oval nodules on mammography, typically with a lucent centre (representing the fatty node hilum). They do enhance on MRI. The appearance in this case is not typical for intramammary lymph node.

Although controversy will likely always percolate through the medical community on this topic, again I would reiterate that annual screening mammograms should be performed on all women starting at age 40 and continuing for as long as the woman is in good health. There’s no upper age at which mammo screening should be discontinued. Rather, the decision to stop annual mammographic screening should be made on an individual basis, based on the potential benefits and risks of screening within the context of the patient’s personal health and life expectancy.

References

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