Case number:	028
Age:	62
Clinical presentation:	Postmenopausal woman with average risk of developing breast cancer presented with a left breast lump noticed 4–5 months ago.

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, central zone, anterior third
‣ Mass:
• Number:	1
• Size:	None
• Shape:	Irregular
• Margins:	Spiculated
• Density:	High
‣ Calcifications:
• Typically benign:	None
• Suspicious:	None
• Distribution:	None
‣ Architectural distortion:	Area of architectural distortion, 4.5 × 3.0 cm, with radiating linear shadows
‣ Asymmetry:	Focal
‣ Intramammary node:	None
‣ Skin lesion:	None
‣ Solitary dilated duct:	None
‣ Associated features:	Axillary lymphadenopathy

Ultrasound:

Ultrasound features: Left breast, central portion of the breast

‣ Mass
• Location:	Left breast, central portion of the breast
• Number:	1
• Size:	4.0 × 3.2 cm
• Shape:	Irregular
• Orientation:	Not parallel
• Margins:	Spiculated
• Echo pattern:	Hypoechoic
• Posterior features:	Strong posterior shadowing
‣ Calcifications:	None
‣ Associated features:	Axillary lymphadenopathy with thickened cortex
‣ 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:	Multiple whitish fragmented cores. Two long cores were 13 mm in length and 10 mm in length; the remaining multiple fragmented cores ranged in length from 2 to 3 mm
‣ Histological type:	Invasive breast carcinoma of no special type
‣ Histological grade:	Grade 2 (3 + 2 + 2 = 7)
‣ Mitosis:	12
‣ Maximum invasive tumour size:
‣ Lymph node status:
‣ Peritumoural lymphovascular invasion:
‣ DCIS/EIC:
‣ Margins:
‣ Pathological stage:
‣ Biomarkers:
‣ Comments:

MRM left (after chemotherapy)

Histopathology features:

‣ Specimen type:	MRM left (after chemotherapy)
‣ Laterality:	Left
‣ Macroscopy:	Left MRM specimen (25.0 × 25.0 × 7.0 cm) with overlying skin flap (20.0 × 7.0 cm). The nipple and areola are unremarkable. On serial sectioning a firm, greyish white area (4.5 × 4.0 × 3.0 cm) is identified, located in the upper inner quadrant. It is located 3.5 cm from the skin and 6.0 cm from the base. The remaining breast tissue is unremarkable
‣ Histological type:	Invasive breast carcinoma of no special type
‣ Histological grade:	Grade 2 (3 + 3 + 1 = 7)
‣ Mitosis:	5
‣ Maximum invasive tumour size:	4.5 cm
‣ Lymph node status:	1/16 without extranodal extension
‣ Peritumoural lymphovascular invasion:
‣ DCIS/EIC:	Very few DCIS. Solid, low nuclear grade without necrosis. EIC absent
‣ Margins:	Free of tumour
‣ Pathological stage:	yT2yN1
‣ Biomarkers:
‣ Comments:	Extensive fibrosis seen in the tumour bed and surrounding breast tissue

Case summary:

Postmenopausal woman presented with left breast lump. Diagnosed as architectural distortion with radiating linear shadows in the retroareolar region of the left breast with left axillary lymphadenopathy, BI-RADS 5 on imaging, as invasive breast carcinoma of no special type on needle core biopsy, and post neo-adjuvant therapy, MRM specimen showed residual invasive breast carcinoma of no special type, and yT2yN1 on histopathology.

Learning points:

Breast malignancy is commonly associated with architectural distortion with extensive fibrosis and linear radiating strands. There is no obvious mass or suspicious calcifications. Additional imaging on breast ultrasound reveals a malignant mass with strong posterior shadowing, likely scirrhous nature of the mass.