When Looks Can Be Deceiving
An uncommon diagnosis turns up in a recent Case in Point™case.
The April 2017 Case in Point™ case of the month featured the diagnosis tubular adenoma of the breast and was submitted by Resident C. Eric Gullbrand, DO, and Associate Program Director of Diagnostic Radiology Kristina A. Siddall, MD, both from Christiana Health Care System in Newark, Del.
“The case does a great job helping the learner round out their differential diagnosis for benign breast masses in young women. This case illustrates what CIP does best — sharing interesting cases with great images and effective, concise teaching points,” says Case in Point Associate Editor Melissa M. Wein, MD.
For more than 10 years, Case in Point has provided the radiology community with common and uncommon presentations of unique and important diagnoses, delivered each weekday to thousands of subscribers. CME is provided free to ACR members and at a low cost for nonmembers. In fact, completing the daily cases offers up to 65 CME credits annually.
Gullbrand is a regular reader of Case in Point, despite the fact that he’s a resident, a status that doesn’t require him to earn CME. “I review CIP cases regularly to learn about interesting cases and to test my current knowledge base,”
Gullbrand says. “Case in Point is a fantastic resource for providing concise information about a variety of interesting cases. The musculoskeletal cases are usually my favorite.”
Gullbrand and Siddall chose to submit the tubular adenoma case to Case in Point because such a diagnosis is so rare. “Tubular adenomas are rare benign breast neoplasms with an overall incidence ranging from 0.13 to 1.17 percent of benign breast lesions,” notes Gullbrand. “This case is a review of the classic sonographic findings for tubular adenomas. Tubular adenomas most commonly affect young women of reproductive age and present as firm, mobile, painless breast masses. Sonographic findings can be very helpful in differentiating benign from malignant breast lesions.”
The classic ultrasound findings Gullbrand discusses are those of a well-circumscribed, hypoechoic mass. “This is usually effective in confirming the benign nature of the lesion,” he says. However, imaging is often not enough to make the diagnosis. “Histopathological evaluation of tubular adenomas is currently the gold standard for diagnosis. Clinical, radiologic, and cytological preoperative diagnosis can be unreliable,” he says.
Indeed, the case diagnosis surprised Gullbrand, and imaging can be deceiving. “Based on the imaging findings, most would expect this lesion to be a breast fibroadenoma, which is a fairly common diagnosis, encountered by breast imagers on an almost daily basis,” he says. “So we were surprised when the pathology report came back suggesting the lesion was a tubular adenoma, which is much less common. We felt that this case would be both a good opportunity to review ultrasound imaging findings for benign breast lesions and to expose others to an interesting and rare diagnosis.”
To assist Gullbrand in preparing the case, Siddall, as the more experienced radiologist, pointed him in the right direction to obtain additional information about differential considerations and imaging findings. “At Christiana, senior staff members expose residents to many unusual cases and provide helpful teaching points,” says Gullbrand.
If you’re interested in submitting your case, Case in Point staff suggests that you first check the archive to review presentations of similar cases. This ensures that a variety of presentations are published — common and uncommon cases of familiar diagnoses and the rare “zebra.” To review other awardees of Case of the Month, visit BestofCIP. We look forward to your submission!
By Raina Keefer, assistant director, member resources, ACR