Case number:	099
Age:	77
Clinical presentation:	Woman was diagnosed with right breast carcinoma and underwent MRM in 2000. She noticed a left breast lump 6–8 months ago. On clinical examination, a hard lump was palpable in the upper quadrant of the left breast.

Mammography:

Breast composition:	ACR category b (there are scattered areas of fibroglandular density)
Mammography features:

‣ Location of the lesion:	Left breast, upper inner quadrant at 10–11 o’clock, posterior third
‣ Mass:
• Number:	1
• Size:	4.5 × 3.4 cm
• Shape:	Irregular
• Margins:	Indistinct
• Density:	High
‣ Calcifications:
• Typically benign:	None
• Suspicious:	Fine pleomorphic
• Distribution:	Regional
‣ Architectural distortion:	Present
‣ Asymmetry:	Focal
‣ Intramammary node:	None
‣ Skin lesion:	None
‣ Solitary dilated duct:	None
‣ Associated features:	Trabecular thickening, architectural distortion, pleomorphic microcalcifications, skin thickening, and axillary adenopathy – nodes with thickened cortex and loss of fatty hilum

Ultrasound:

Ultrasound features: Left breast, upper inner quadrant at 10–11 o’clock position

‣ Mass
• Location:	Left breast, upper inner quadrant at 10–11 o’clock position
• Number:	2–3, grouped together
• Size:	Largest 4.5 × 2.5 cm
• Shape:	Irregular
• Orientation:	Not parallel
• Margins:	Angular
• Echo pattern:	Hypoechoic
• Posterior features:	No posterior features
‣ Calcifications:	Present in mass
‣ Associated features:	Architectural distortion, skin thickening, internal vascularity, oedema, and axillary lymphadenopathy
‣ Special cases:	None

BI-RADS:

BI-RADS Category (Right MRM): 5 (highly suggestive of malignancy)

Further assessment:

Further assessment advised: Referral for cytology and for core biopsy

Cytology:

Cytology features:

‣ Type of sample:	FNAC
‣ Site of biopsy:
• Laterality:	Left
• Quadrant:	Upper inner
• Localization technique:	Palpation
• Nature of aspirate:	Whitish
‣ Cytological description:	Loosely cohesive sheets of large malignant cells with marked nuclear pleomorphism
‣ Reporting category:	Malignant
‣ Diagnosis:	Carcinoma – high grade
‣ Comments:	None

Histopathology:

Core needle biopsy

Histopathology features:

‣ Specimen type:	Core needle biopsy
‣ Laterality:	Left
‣ Macroscopy:	5 cores
‣ Histological type:	Invasive carcinoma of no special type
‣ Histological grade:	Grade 3 (3 + 3 + 2 = 8)
‣ Mitosis:	18
‣ Maximum invasive tumour size:
‣ Lymph node status:
‣ Peritumoural lymphovascular invasion:
‣ DCIS/EIC:
‣ Margins:
‣ Pathological stage:
‣ Biomarkers:
‣ Comments:

MRM

Histopathology features:

‣ Specimen type:	MRM
‣ Laterality:	Left
‣ Macroscopy:	On serial sectioning, a firm greyish white tumour (6.8 × 4.5 × 2.8 cm) is identified. It is located 1.4 cm below the skin and 0.2 cm from the base
‣ Histological type:	Invasive carcinoma of no special type
‣ Histological grade:	Grade 3 (3 + 3 + 3 = 9)
‣ Mitosis:	22
‣ Maximum invasive tumour size:	6.8 cm
‣ Lymph node status:	3/19
‣ Peritumoural lymphovascular invasion:	Present
‣ DCIS/EIC:	Comedo DCIS – high grade
‣ Margins:	Free of tumour
‣ Pathological stage:	pT3N3
‣ Biomarkers:
‣ Comments:	The remaining breast tissue shows extensive areas of fibrosis

Case summary:

Postmenopausal woman, operated 15 years ago for right breast carcinoma, presented with a large, hard left breast lump. Diagnosed as left breast carcinoma with clustered pleomorphic microcalcifications, BI-RADS 5 on imaging, as carcinoma on cytology, and as invasive breast carcinoma of no special type, pT3N3 on histopathology.

Learning points:

Women with breast cancer treated with MRM should follow surveillance guidelines for the normal breast. A contralateral synchronous tumour detected 17 years after treatment of the primary tumour represents a new cancer.
The diameter of the primary tumour shows a good correlation with the incidence of nodal metastases and with the survival rate (with the notable exception of triple-negative, basal-like carcinomas, which do not follow the “size node rule”).