Case number:	102
Age:	58
Clinical presentation:	Postmenopausal woman with increased risk of developing breast cancer in view of family history of breast cancer in paternal aunt and maternal grandmother. She presented with a lump in the right breast. Examination revealed a 2.5 cm right breast lump at the 12 o’clock position.

Mammography:

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

‣ Location of the lesion:	November 2010: No mass
‣ Mass:
• Number:	0
• Size:	None
• Shape:	None
• Margins:	None
• Density:	None
‣ 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 a (the breasts are almost entirely fatty)
Mammography features:

‣ Location of the lesion:	October 2012: Right breast, central portion of the breast, upper inner quadrant at 12–1 o’clock, anterior third
‣ Mass:
• Number:	1 (this is the developing asymmetry)
• Size:	2.2 × 1.7 cm
• Shape:	Irregular
• Margins:	Spiculated
• Density:	High
‣ Calcifications:
• Typically benign:	None
• Suspicious:	None
• Distribution:	None
‣ Architectural distortion:	Perilesional
‣ Asymmetry:	Focal
‣ Intramammary node:	None
‣ Skin lesion:	None
‣ Solitary dilated duct:	None
‣ Associated features:	Architectural distortion

Ultrasound:

Ultrasound features: October 2012: Right breast, central portion of the breast at 12 o‘clock

‣ Mass
• Location:	October 2012: Right breast, central portion of the breast at 12 o‘clock
• Number:	1, developing asymmetry
• Size:	2.6 × 1.6 cm
• Shape:	Irregular
• Orientation:	Not parallel
• Margins:	Indistinct
• Echo pattern:	Heteroechoic
• Posterior features:	Posterior shadowing
‣ Calcifications:	None
‣ Associated features:	Internal vascularity
‣ Special cases:	None

BI-RADS:

BI-RADS Category (2010): 1 (negative)
BI-RADS Category (2012): 5 (highly suggestive of malignancy)

Further assessment:

Further assessment advised: Referral for cytology

Cytology:

Cytology features:

‣ Type of sample:	FNAC
‣ Site of biopsy:
• Laterality:	Right
• Quadrant:	12 o’clock, superior areolar margin
• Localization technique:	Palpation
• Nature of aspirate:	Whitish
‣ Cytological description:	Cellular smears with pleomorphic malignant cells with prominent nucleoli within many stromal fibrous fragments
‣ Reporting category:	Malignant
‣ Diagnosis:	Carcinoma
‣ Comments:	None

Histopathology:

Breast-conserving surgery

Histopathology features:

‣ Specimen type:	Breast-conserving surgery
‣ Laterality:	Right
‣ Macroscopy:	Cut surface shows a fairly well-circumscribed tumour (2.5 × 1.5 × 2.5 cm)
‣ Histological type:	Invasive carcinoma of no special type
‣ Histological grade:	Grade 3 (3 + 3 + 2 = 8)
‣ Mitosis:	15
‣ Maximum invasive tumour size:	2.5 cm in greatest dimension
‣ Lymph node status:	5/20
‣ Peritumoural lymphovascular invasion:	Present
‣ DCIS/EIC:	Solid and comedo DCIS – high grade
‣ Margins:	Free of tumour
‣ Pathological stage:	pT2N2
‣ Biomarkers:
‣ Comments:

Case summary:

Postmenopausal woman with increased risk of developing breast cancer presented with right breast lump. Mammography and breast ultrasound dated 2012 reveals a new irregular lesion in the right breast. Compared with an earlier mammogram dated 2010, follow-up reveals developing asymmetry in the right breast. Interval change is seen. Diagnosed as highly suggestive of malignancy, BI-RADS 5 on imaging, as carcinoma on cytology, and as invasive breast carcinoma of no special type, pT2N2 on histopathology.

Learning points:

Because of family history of breast cancer in two first-degree relatives (mother and sister), the woman requires regular surveillance with mammography. The developing asymmetry seen on comparison with a previous mammogram confirms the presence of a suspicious mass, probably a cancer. The presence of lymphatic tumour emboli on histology is considered an important prognostic factor and is associated with increased risk of distant recurrence.