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Case number:102
Age:58
Clinical presentation:Postmenopausal woman with increased risk of developing breast cancer in view of family history of breast cancer in paternal aunt and maternal grandmother. She presented with a lump in the right breast. Examination revealed a 2.5 cm right breast lump at the 12 o’clock position.


Mammography:


Breast composition:ACR category a (the breasts are almost entirely fatty)
Mammography features:

 ‣ Location of the lesion:November 2010: No mass
 ‣ Mass:
   • Number:0
   • Size:None
   • Shape:None
   • Margins:None
   • Density:None
 ‣ Calcifications:
   • Typically benign:None
   • Suspicious:None
   • Distribution:None
 ‣ Architectural distortion:None
 ‣ Asymmetry:None
 ‣ Intramammary node:None
 ‣ Skin lesion:None
 ‣ Solitary dilated duct:None
 ‣ Associated features:None


Breast composition:ACR category a (the breasts are almost entirely fatty)
Mammography features:

 ‣ Location of the lesion:October 2012: Right breast, central portion of the breast, upper inner quadrant at 12–1 o’clock, anterior third
 ‣ Mass:
   • Number:1 (this is the developing asymmetry)
   • Size:2.2 × 1.7 cm
   • Shape:Irregular
   • Margins:Spiculated
   • Density:High
 ‣ Calcifications:
   • Typically benign:None
   • Suspicious:None
   • Distribution:None
 ‣ Architectural distortion:Perilesional
 ‣ Asymmetry:Focal
 ‣ Intramammary node:None
 ‣ Skin lesion:None
 ‣ Solitary dilated duct:None
 ‣ Associated features:Architectural distortion

Ultrasound:


Ultrasound features: October 2012: Right breast, central portion of the breast at 12 o‘clock

 ‣ Mass
   • Location:October 2012: Right breast, central portion of the breast at 12 o‘clock
   • Number:1, developing asymmetry
   • Size:2.6 × 1.6 cm
   • Shape:Irregular
   • Orientation:Not parallel
   • Margins:Indistinct
   • Echo pattern:Heteroechoic
   • Posterior features:Posterior shadowing
 ‣ Calcifications:None
 ‣ Associated features:Internal vascularity
 ‣ Special cases:None

BI-RADS:

BI-RADS Category (2010): 1 (negative)
BI-RADS Category (2012): 5 (highly suggestive of malignancy)

Further assessment:

Further assessment advised: Referral for cytology

Cytology:

Cytology features:

 ‣ Type of sample:FNAC
 ‣ Site of biopsy:
   • Laterality:Right
   • Quadrant:12 o’clock, superior areolar margin
   • Localization technique:Palpation
   • Nature of aspirate:Whitish
 ‣ Cytological description:Cellular smears with pleomorphic malignant cells with prominent nucleoli within many stromal fibrous fragments
 ‣ Reporting category:Malignant
 ‣ Diagnosis:Carcinoma
 ‣ Comments:None


Histopathology:

Breast-conserving surgery



Histopathology features:

 ‣ Specimen type:Breast-conserving surgery
 ‣ Laterality:Right
 ‣ Macroscopy:Cut surface shows a fairly well-circumscribed tumour (2.5 × 1.5 × 2.5 cm)
 ‣ Histological type:Invasive carcinoma of no special type
 ‣ Histological grade:Grade 3 (3 + 3 + 2 = 8)
 ‣ Mitosis:15
 ‣ Maximum invasive tumour size:2.5 cm in greatest dimension
 ‣ Lymph node status:5/20
 ‣ Peritumoural lymphovascular invasion:Present
 ‣ DCIS/EIC:Solid and comedo DCIS – high grade
 ‣ Margins:Free of tumour
 ‣ Pathological stage:pT2N2
 ‣ Biomarkers:
 ‣ Comments:

Case summary:

Postmenopausal woman with increased risk of developing breast cancer presented with right breast lump. Mammography and breast ultrasound dated 2012 reveals a new irregular lesion in the right breast. Compared with an earlier mammogram dated 2010, follow-up reveals developing asymmetry in the right breast. Interval change is seen. Diagnosed as highly suggestive of malignancy, BI-RADS 5 on imaging, as carcinoma on cytology, and as invasive breast carcinoma of no special type, pT2N2 on histopathology.

Learning points:


  • Because of family history of breast cancer in two first-degree relatives (mother and sister), the woman requires regular surveillance with mammography. The developing asymmetry seen on comparison with a previous mammogram confirms the presence of a suspicious mass, probably a cancer. The presence of lymphatic tumour emboli on histology is considered an important prognostic factor and is associated with increased risk of distant recurrence.

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