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Case number:103
Age:82
Clinical presentation:Postmenopausal woman had undergone microdochectomy for right nipple discharge. Histopathology of the excised duct showed benign papilloma. On follow-up a year later, she presented with a left breast lump. Mammography and breast ultrasound dated 2015 reveal a new lesion in the left breast. Compared with a previous mammogram dated 2014, follow-up reveals developing asymmetry in the left breast. Interval change is seen. Diagnosed as highly suspicious for malignancy, BI-RADS 4C on imaging, as mucinous carcinoma on cytology, and as mucinous carcinoma, pT2N0 on histopathology.


Mammography:


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

 ‣ Location of the lesion:September 2014: Left breast, upper outer quadrant at 1–3 o’clock, middle third
 ‣ Mass:
   • Number:Multiple
   • Size:Largest 0.4 cm
   • Shape:Round
   • Margins:Circumscribed
   • Density:Equal
 ‣ 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:Multiple simple cysts


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

 ‣ Location of the lesion:July 2015: Left breast, upper outer quadrant at 2 o’clock, posterior third
 ‣ Mass:
   • Number:Multiple
   • Size:Largest 1.7 × 1.0 cm (this is the developing asymmetry)
   • Shape:Oval
   • Margins:Indistinct posterior margin
   • Density:High
 ‣ 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

Ultrasound:


Ultrasound features: July 2015: Left breast, upper outer quadrant at 2 o’clock

 ‣ Mass
   • Location:July 2015: Left breast, upper outer quadrant at 2 o’clock
   • Number:1
   • Size:2.0 × 1.0 cm (this is the developing asymmetry)
   • Shape:Irregular
   • Orientation:Not parallel
   • Margins:Partly circumscribed and partly indistinct margins
   • Echo pattern:Heteroechoic
   • Posterior features:No posterior features
 ‣ Calcifications:None
 ‣ Associated features:None
 ‣ Special cases:None

BI-RADS:

BI-RADS Category (2014): 2 (benign)
BI-RADS Category (2015): 4C (high suspicion for malignancy)

Further assessment:

Further assessment advised: Referral for cytology

Cytology:

Cytology features:

 ‣ Type of sample:FNAC
 ‣ Site of biopsy:
   • Laterality:Left
   • Quadrant:Upper outer
   • Localization technique:Palpation
   • Nature of aspirate:0.2 mL of mucoid material
 ‣ Cytological description:Numerous moderately cohesive clusters and balls of malignant cells dispersed in a mucinous background
 ‣ Reporting category:Malignant
 ‣ Diagnosis:Mucinous carcinoma
 ‣ Comments:None


Histopathology:

MRM



Histopathology features:

 ‣ Specimen type:MRM
 ‣ Laterality:Left
 ‣ Macroscopy:Specimen (28.0 × 13.0 × 6.0 cm) with an overlying skin flap (11.0 × 5.0 cm). The nipple and areola are unremarkable. On serial sectioning, a small well-circumscribed area (2.1 × 1.3 × 1.0 cm) is identified in the upper outer quadrant, 5.0 cm from the skin and 1.5 cm from the base. Cut surface shows mucoid areas. The remaining breast tissue is unremarkable
 ‣ Histological type:Mucinous carcinoma
 ‣ Histological grade:Grade 2 (2 + 2 + 1 = 5)
 ‣ Mitosis:4
 ‣ Maximum invasive tumour size:2.1 cm in greatest dimension
 ‣ Lymph node status:0/22
 ‣ Peritumoural lymphovascular invasion:Absent
 ‣ DCIS/EIC:Absent
 ‣ Margins:Free of tumour
 ‣ Pathological stage:pT2N0
 ‣ Biomarkers:
 ‣ Comments:

Case summary:

Postmenopausal woman had undergone microdochectomy for right nipple discharge, histopathology of the excised duct showed benign papilloma. On follow up a year later, she presented with left breast lump. Mammography and breast ultrasound dated 2015 reveal new lesion in left breast. Compared to previous mammogram dated 2014, follow-up reveals developing asymmetry in left breast. Interval change is seen, diagnosed as highly suspicious of malignancy, BI-RADS category 4C on imaging, mucinous carcinoma on cytology and Mucinous carcinoma, pT2N0 on histopathology.

Learning points:


  • Mucinous carcinoma incidence is higher in women older than 75 years (7%), compared with women younger than 35 years of age (1%). Grossly, it is well-circumscribed, fluctuant to palpation, and formed by a gelatinous mass held together by delicate septa. Mucinous carcinomas are divided into type A (a paucicellular type without neuroendocrine differentiation) and type B (a hypercellular type with neuroendocrine differentiation). There appears to be no influence of this separation on survival.

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