Go back to the list of case studies
                                                                                                                         Click on the pictures to magnify and display the legends

Case number:	113
Age:	51
Clinical presentation:	Postmenopausal woman with increased risk of developing breast cancer presents for a follow-up because she feels pain in her right breast. She has a strong family history of breast carcinoma. Clinical examination reveals different para-areolar consistencies on the right and left breasts. Comparison was made with a previous mammogram dated May 2015 (BI-RADS 2).

Mammography:

Breast composition:	ACR category b (there are scattered areas of fibroglandular density)
Mammography features:
‣ Location of the lesion:	May 2015: Right breast, upper outer quadrant at 10 o’clock, posterior third
‣ Mass:
• Number:	1
• Size:	1.2 cm in greatest dimension
• Shape:	Oval
• 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:	None

Breast composition:	ACR category b (there are scattered areas of fibroglandular density)
Mammography features:
‣ Location of the lesion:	2016: Right breast, upper outer quadrant at 10 o’clock, posterior third
‣ Mass:
• Number:	1
• Size:	1.2 cm in greatest dimension
• Shape:	Oval (stable lesion since 2015)
• 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:	None

Breast composition:	ACR category b (there are scattered areas of fibroglandular density)
Mammography features:
‣ Location of the lesion:	2016: Right breast, lower inner quadrant at 5 o’clock, middle third
‣ Mass:
• Number:	1 (this is a new finding, developing asymmetry)
• Size:	0.9 cm in greatest dimension
• Shape:	Irregular
• Margins:	Indistinct
• 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:	None

Ultrasound:

Ultrasound features: May 2015: Right breast, upper outer quadrant at 10 o‘clock
‣ Mass
• Location:	May 2015: Right breast, upper outer quadrant at 10 o‘clock
• Number:	1
• Size:	1.0 × 0.5 cm
• Shape:	Oval
• Orientation:	Parallel
• Margins:	Circumscribed
• Echo pattern:	Hypoechoic
• Posterior features:	No posterior features
‣ Calcifications:	None
‣ Associated features:	None
‣ Special cases:	None

Ultrasound features: November 2015: Right breast, lower inner quadrant at 5 o‘clock
‣ Mass
• Location:	November 2015: Right breast, lower inner quadrant at 5 o‘clock
• Number:	1 (suspicious interval change)
• Size:	0.6 cm in greatest dimension
• Shape:	Irregular
• Orientation:	Parallel
• Margins:	Angular
• Echo pattern:	Hypoechoic
• Posterior features:	No posterior features
‣ Calcifications:	None
‣ Associated features:	None
‣ Special cases:	None

Ultrasound features: March 2016: Right breast, lower inner quadrant at 5 o’clock
‣ Mass
• Location:	March 2016: Right breast, lower inner quadrant at 5 o’clock
• Number:	1
• Size:	0.9 cm in greatest dimension
• Shape:	Irregular
• Orientation:	Parallel
• Margins:	Angular and spiculated
• Echo pattern:	Hypoechoic
• Posterior features:	No posterior features
‣ Calcifications:	None
‣ Associated features:	Dilated duct
‣ Special cases:	Developing asymmetry – interval cancer

BI-RADS:

BI-RADS Category (2015): 2 (benign)
BI-RADS Category (2016): 4C (high suspicion for malignancy)

Further assessment:

Further assessment advised: Referral for cytology

Cytology:

Cytology features:
‣ Type of sample:	Ultrasound-guided FNAC
‣ Site of biopsy:
• Laterality:	Right
• Quadrant:	5 o’clock
• Localization technique:	1.5
• Nature of aspirate:	Whitish
‣ Cytological description:	Smears reveal many dyscohesive clusters and many singly scattered large malignant cells with marked nuclear polymorphism, hyperchromasia, and abundant cytoplasm
‣ Reporting category:	Malignant
‣ Diagnosis:	Ductal carcinoma – high grade
‣ Comments:	None

Histopathology:

Breast-conserving surgery

Histopathology features:
‣ Specimen type:	Breast-conserving surgery
‣ Laterality:
‣ Macroscopy:
‣ Histological type:	Invasive breast carcinoma of no special type
‣ Histological grade:	Grade 3
‣ Mitosis:
‣ Maximum invasive tumour size:	3
‣ Lymph node status:	1/15
‣ Peritumoural lymphovascular invasion:	Present
‣ DCIS/EIC:	EIC present – high grade with necrosis
‣ Margins:	Free of tumour
‣ Pathological stage:	pT2N1
‣ Biomarkers:
‣ Comments:

Case summary:

Postmenopausal woman with increased risk of developing breast cancer presented for a follow-up because of pain in her right breast. Clinical examination reveals different para-areolar consistencies in the right and left breasts. Mammography and breast ultrasound dated 2016 reveal a new irregular lesion in right breast. Compared with a previous mammogram dated 2015, follow-up reveals developing asymmetry in the right breast. Interval change is seen. Diagnosed as highly suspicious for malignancy, BI-RADS 4C on imaging, as carcinoma on cytology, and as invasive breast carcinoma of no special type, pT2N1 on histopathology.

Learning points:

Family history in first-degree relatives (parents, siblings, and children) and second-degree relatives (such as aunts and cousins) on both sides of the family is an indication for the woman to follow high-risk screening guidelines.