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Case number:	012
Age:	65
Clinical presentation:	Postmenopausal woman with average risk of developing breast cancer presented with a left breast lump that she first noticed more than 4 months ago. Now presented with overlying skin changes and pain.

Mammography:

Breast composition:	ACR category b (there are scattered areas of fibroglandular density)
Mammography features:
‣ Location of the lesion:	Left breast, central portion of the breast, central zone, anterior and middle thirds
‣ Mass:
• Number:	Multiple
• Size:	Left retroareolar: Largest 5.5 × 3.0 cm, multiple satellite lesions (largest 2.5 × 1.0 cm) in outer quadrant at 4 o’clock
• Shape:	Irregular
• Margins:	Spiculated
• 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:	Skin thickening, nipple retraction

Ultrasound:

Ultrasound features: Left breast, lower quadrants at 6 o'clock
‣ Mass
• Location:	Left breast, lower quadrants at 6 o'clock
• Number:	Multiple
• Size:	Largest 3.8 × 1.8 cm
• Shape:	Irregular
• Orientation:	Not parallel
• Margins:	Spiculated
• Echo pattern:	Heteroechoic
• Posterior features:	No posterior features
‣ Calcifications:	None
‣ Associated features:	Skin thickening, vascularity in mass, axillary lymphadenopathy
‣ Special cases:	None

BI-RADS:

BI-RADS Category: 5 (highly suggestive of malignancy)

Further assessment:

Further assessment advised: Referral for core biopsy

Histopathology:

Core needle biopsy

Histopathology features:
‣ Specimen type:	Core needle biopsy
‣ Laterality:	Left
‣ Macroscopy:	Seven linear cores: longest is 20 mm in length and smallest is 7 mm in length
‣ Histological type:	Invasive breast carcinoma of no special type
‣ Histological grade:	Grade 2 (3 + 2 + 1 = 6)
‣ Mitosis:	4
‣ Maximum invasive tumour size:
‣ Lymph node status:
‣ Peritumoural lymphovascular invasion:
‣ DCIS/EIC:
‣ Margins:
‣ Pathological stage:
‣ Biomarkers:
‣ Comments:

Case summary:

Postmenopausal woman presented with palpable left breast lump with skin changes. Diagnosed as large irregular high-density mass with spiculated margins in left breast with associated features of left breast areolar skin thickening, left nipple retraction, and left axillary lymphadenopathy, BI-RADS 5 on imaging and as invasive breast carcinoma of no special type on needle core biopsy histopathology.

Learning points:

Breast skin thickening on mammography and breast ultrasound is defined as skin > 2 mm thick. Focal breast skin thickening in the presence of an underlying breast mass indicates locally invasive breast cancer.