Case Study: A 44-Year-Old Woman with Unilateral Breast Flattening and Intermittent Mastalgia

Case at a Glance

A 44-year-old female with a family history of breast cancer presented with a two-month history of contour change, increased density, and intermittent pain in her left breast, raising concerns about the urgency of evaluation for potential malignancy.

Patient's Story

The patient is a 44-year-old Caucasian female (BMI approx. 26.6 kg/m²) who presented for advice regarding changes in her left breast over the preceding two months. She is generally healthy with no significant medical history but noted she is overweight. Her family history is significant for a paternal grandmother with breast cancer. She takes no regular medications. The patient first noticed a subtle 'flattening' on the outer quadrant of her left breast. She subsequently experienced two episodes of focal pain in the same breast: one minor and one of greater intensity that woke her from sleep. On self-examination, she perceived the tissue in the affected area to be denser than the surrounding tissue and the contralateral breast, but could not palpate a discrete lump.

Initial Assessment

The patient's self-reported symptoms of unilateral breast shape change, increased density, and pain, combined with a positive family history, were clinically significant. The primary concern was the need to rule out an underlying pathology, particularly malignancy such as lobular carcinoma, which can present as architectural distortion or thickening rather than a distinct mass. The patient was unestablished with a primary care provider and faced a potential two-month delay for an appointment with a preferred physician, prompting her to question the safety of this wait time.

The Diagnostic Journey

Based on the concerning nature of the symptoms, the recommendation was to expedite medical evaluation. It was advised that any change in breast shape or texture warrants prompt investigation. The patient was counseled against waiting several months for an appointment and encouraged to seek an evaluation with any available primary care physician or at an urgent care clinic to obtain the necessary referrals for diagnostic imaging. The patient accepted this advice and began attempting to schedule an earlier appointment. She confirmed that a direct attempt to schedule imaging was unsuccessful, as the local diagnostic center required a physician's referral.

Final Diagnosis

A final diagnosis is pending. The constellation of symptoms—architectural distortion (flattening), increased density, and pain—requires a thorough diagnostic workup. Differential diagnoses include invasive lobular carcinoma, inflammatory breast cancer, fat necrosis, or benign fibrocystic changes.

Treatment Plan

The immediate plan is to obtain a clinical breast examination and a referral for diagnostic imaging. The standard imaging protocol would include a bilateral diagnostic mammogram with tomosynthesis and a targeted ultrasound of the left breast. If imaging identifies a suspicious lesion (BI-RADS 4 or 5), a core needle biopsy would be the next step to obtain a histological diagnosis. Further management will be dictated by the results of the imaging and any subsequent biopsy.

Outcome and Follow-up

The patient is actively seeking a more immediate medical appointment to facilitate the diagnostic process. The key takeaway from the initial consultation was the urgency of her presentation. Close follow-up is critical to ensure she successfully navigates the referral process and completes the recommended imaging studies in a timely manner. The prognosis is entirely dependent on the findings of the forthcoming evaluation.