Case number:	087
Age:	42
Clinical presentation:	Premenopausal woman with average risk of developing breast cancer presented with a lump in the left breast noticed 1 month ago. On clinical examination, a single left upper quadrant lump 3 cm in diameter was found.

Mammography:

Breast composition:	ACR category c (the breasts are heterogeneously dense, which may obscure small masses)
Mammography features:

‣ Location of the lesion:	Left breast, upper outer quadrant at 12–1 o’clock, middle third
‣ Mass:
• Number:	1
• Size:	Not measurable in the dense breast parenchyma
• Shape:	Irregular
• Margins:	Indistinct
• Density:	High
‣ Calcifications:
• Typically benign:	None
• Suspicious:	None
• Distribution:	None
‣ Architectural distortion:	Present
‣ Asymmetry:	Focal
‣ Intramammary node:	None
‣ Skin lesion:	None
‣ Solitary dilated duct:	None
‣ Associated features:	Architectural distortion and axillary lymphadenopathy

Ultrasound:

Ultrasound features: Left breast, central portion of the breast, central quadrant at 12–1 o’clock

‣ Mass
• Location:	Left breast, central portion of the breast, central quadrant at 12–1 o’clock
• Number:	3
• Size:	Largest 2.2 × 1.7 cm
• Shape:	Irregular
• Orientation:	Not parallel
• Margins:	Indistinct
• Echo pattern:	Hypoechoic
• Posterior features:	No posterior features
‣ Calcifications:	None
‣ Associated features:	Internal vascularity
‣ Special cases:	None

BI-RADS:

BI-RADS Category: 4C (high suspicion for malignancy)

Further assessment:

Further assessment advised: Referral for core biopsy

Cytology:

Cytology features:

‣ Type of sample:	FNAC (solid lesion)
‣ Site of biopsy:
• Laterality:	Left
• Quadrant:	Upper outer
• Localization technique:	Ultrasound-guided
• Nature of aspirate:	Whitish
‣ Cytological description:	Smears show dyscohesive clusters of pleomorphic malignant cells
‣ Reporting category:	Malignant
‣ Diagnosis:	Carcinoma – high grade
‣ Comments:	None

Histopathology:

Core needle biopsy

Histopathology features:

‣ Specimen type:	Core needle biopsy
‣ Laterality:	Left
‣ Macroscopy:	3 cores
‣ Histological type:	Invasive carcinoma of no special type
‣ Histological grade:	Grade 3 (3 + 2 + 2 = 7)
‣ Mitosis:	11
‣ Maximum invasive tumour size:
‣ Lymph node status:
‣ Peritumoural lymphovascular invasion:
‣ DCIS/EIC:
‣ Margins:
‣ Pathological stage:
‣ Biomarkers:	Triple negative: ER negative (internal control positive), PR negative (internal control positive), and HER2/neu negative (score 0)
‣ Comments:

Case summary:

Premenopausal woman presented with left breast lump. Diagnosed as retroareolar high-density focal asymmetry in left breast, BI-RADS 4C on imaging, as left breast carcinoma, high grade on cytology, and as invasive carcinoma of no special type, triple negative on histopathology.

Learning points:

Supplementary ultrasound helps to provide detailed characterization of the morphological features of the clinically palpable lump as highly suspicious for malignancy. Biopsy recommended for confirmation.
Mammography with supplementary breast ultrasound reveals a mass with microlobulated or indistinct margins, no posterior features, and some vascularity on colour flow mapping. There is usually no calcification in triple-negative breast cancer.