Case number:	183
Age:	71
Clinical presentation:	Postmenopausal woman with average risk of developing breast cancer presented with a left breast lump noticed 6 months ago. On examination, abnormal unilateral reduction in the size of the left breast was noted. A hard lump was palpable in the lower inner quadrant of the left breast with skin retraction seen. The left nipple was retracted.

Mammography:

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

‣ Location of the lesion:	Left breast, central portion of the breast at 8-10 o'clock, anterior, middle, and posterior thirds
‣ Mass:
• Number:	1
• Size:	2.6 × 2.0 cm
• Shape:	Irregular
• Margins:	Spiculated
• Density:	High
‣ Calcifications:
• Typically benign:	Vascular calcification in both breasts
• Suspicious:	None
• Distribution:	None
‣ Architectural distortion:	Present
‣ Asymmetry:	None
‣ Intramammary node:	Present
‣ Skin lesion:	None
‣ Solitary dilated duct:	None
‣ Associated features:	Left nipple retraction, skin thickening, skin retraction, and axillary lymphadenopathy

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

‣ Location of the lesion:	Right breast, upper outer quadrant at 10 o’clock, middle third
‣ Mass:
• Number:	1
• Size:	1 cm
• Shape:	Round
• Margins:	Circumscribed
• Density:	Equal
‣ Calcifications:
• Typically benign:	Vascular calcification in both breasts
• 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: Left breast, lower inner quadrant at 8 o’clock

‣ Mass
• Location:	Left breast, lower inner quadrant at 8 o’clock
• Number:	1
• Size:	2.8 × 2.5 cm
• Shape:	Irregular
• Orientation:	Not parallel
• Margins:	Spiculated
• Echo pattern:	Hypoechoic
• Posterior features:	Strong posterior shadowing
‣ Calcifications:	None
‣ Associated features:	Skin thickening and enlarged left axillary node
‣ Special cases:	None

Ultrasound features: Right breast, upper outer quadrant at 10 o’clock

‣ Mass
• Location:	Right breast, upper outer quadrant at 10 o’clock
• Number:	1
• Size:	0.8 cm
• Shape:	Round
• Orientation:	Parallel
• Margins:	Circumscribed
• Echo pattern:	Hypoechoic
• Posterior features:	No posterior features
‣ Calcifications:	None
‣ Associated features:	None
‣ Special cases:	None

BI-RADS:

BI-RADS Category (left breast): 5 (highly suggestive of malignancy)
BI-RADS Category (right breast): 2 (benign)

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:	Inner lower
• Localization technique:	Palpation
• Nature of aspirate:	Whitish
‣ Cytological description:	Smears are very cellular. They show loosely cohesive clusters and single isolated pleomorphic malignant ductal epithelial cells
‣ Reporting category:	Malignant
‣ Diagnosis:	Malignant
‣ Comments:	None

Histopathology:

Core needle biopsy

Histopathology features:

‣ Specimen type:	Core needle biopsy
‣ Laterality:	Right
‣ Macroscopy:	Three whitish cores (1.5 cm, 1.5 cm, and 1 cm long)
‣ Histological type:	Invasive breast carcinoma of no special type
‣ Histological grade:	Grade 3 (3 + 3 + 2 = 8)
‣ Mitosis:	6
‣ Maximum invasive tumour size:
‣ Lymph node status:
‣ Peritumoural lymphovascular invasion:
‣ DCIS/EIC:
‣ Margins:
‣ Pathological stage:
‣ Biomarkers:
‣ Comments:

Case summary:

Postmenopausal woman presented with left breast lump. On examination, abnormal unilateral reduction in the size of the left breast was noted, with a hard lump in the left breast, skin retraction, and left nipple retraction. Diagnosed as left breast carcinoma with skin thickening and retraction, and left nipple retraction, BI-RADS 5 on imaging and as invasive breast carcinoma of no special type on histopathology.

Learning points:

Patients with locally advanced breast cancer, as in this case, whatever the subtype, are ideal candidates for neo-adjuvant therapy because their risk of distant recurrence warrants systemic treatment.