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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”).

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