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Case number:078
Age:65
Clinical presentation:Postmenopausal woman with average risk of developing breast cancer presented with right nipple–areolar ulceration and itching. On clinical examination, a hard lump was felt in the right breast in the retroareolar region.



Mammography:


Breast composition:ACR category b (there are scattered areas of fibroglandular density)
Mammography features:

 ‣ Location of the lesion:Right breast, lower inner quadrant at 5 o’clock, anterior third
 ‣ Mass:
   • Number:1
   • Size:1.9 × 1.8 cm
   • Shape:Round
   • Margins:Indistinct
   • Density:High
 ‣ Calcifications:
   • Typically benign:None
   • Suspicious:None
   • Distribution:None
 ‣ Architectural distortion:Present
 ‣ Asymmetry:Focal, central quadrant
 ‣ Intramammary node:None
 ‣ Skin lesion:None
 ‣ Solitary dilated duct:None
 ‣ Associated features:Skin thickening, axillary adenopathy, and architectural distortion


Breast composition:ACR category b (there are scattered areas of fibroglandular density)
Mammography features:

 ‣ Location of the lesion:Right breast, lower inner quadrant at 4 o’clock, middle third
 ‣ Mass:
   • Number:2
   • Size:0.5 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: Right breast, lower inner quadrant at 5 o’clock

 ‣ Mass
   • Location:Right breast, lower inner quadrant at 5 o’clock
   • Number:1
   • Size:1.7 × 1.3 cm
   • Shape:Irregular
   • Orientation:Not parallel
   • Margins:Spiculated
   • Echo pattern:Hypoechoic
   • Posterior features:No posterior features
 ‣ Calcifications:None
 ‣ Associated features:Skin thickening, architectural distortion, and internal vascularity
 ‣ Special cases:None


Ultrasound features: Right breast, lower inner quadrant at 4 o’clock

 ‣ Mass
   • Location:Right breast, lower inner quadrant at 4 o’clock
   • Number:1
   • Size:0.5 cm in greatest dimension
   • Shape:Irregular
   • Orientation:Not parallel
   • Margins:Spiculated
   • Echo pattern:Hypoechoic
   • Posterior features:No posterior features
 ‣ Calcifications:None
 ‣ Associated features:Internal vascularity
 ‣ Special cases:None

BI-RADS:

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

Further assessment:

Further assessment advised: Referral for cytology

Cytology:

Cytology features:

 ‣ Type of sample:FNAC (solid lesion)
 ‣ Site of biopsy:
   • Laterality:Right
   • Quadrant:
   • Localization technique:Palpation
   • Nature of aspirate:
 ‣ Cytological description:Cellular smears with many single isolated malignant cells and dyscohesive malignant cell clusters
 ‣ Reporting category:Malignant
 ‣ Diagnosis:Carcinoma
 ‣ Comments:None


Histopathology:

MRM



Histopathology features:

 ‣ Specimen type:MRM
 ‣ Laterality:Right
 ‣ Macroscopy:The nipple and areola are flattened and this area is seen as an indurated firm whitish area (3.0 × 2.5 cm). On serial sectioning, a greyish white tumour (2.3 × 2.0 × 2.0 cm) is identified, located below the areola. It is 1.0 cm from the skin and 2.5 cm from the base
 ‣ Histological type:Invasive carcinoma of no special type
 ‣ Histological grade:Grade 3 (3 + 3 + 3 = 9)
 ‣ Mitosis:22
 ‣ Maximum invasive tumour size:2.3 cm in greatest dimension
 ‣ Lymph node status:24/24
 ‣ Peritumoural lymphovascular invasion:Present
 ‣ DCIS/EIC:Comedo – high grade
 ‣ Margins:Posterior margin is free of tumour and areolar skin is ulcerated
 ‣ Pathological stage:pT4bN3
 ‣ Biomarkers:
 ‣ Comments:

Case summary:

Postmenopausal woman presented with right breast lump, nipple–areolar ulceration, and itching. Diagnosed as right breast carcinoma with right areolar skin thickening and right nipple excoriation, BI-RADS 5 on imaging, as right breast carcinoma on cytology, and as invasive breast carcinoma of no special type, pT4bN3 on histopathology.

Learning points:


  • Patient presented with a lump and ulceration of the nipple. Paget disease of the nipple has different clinical appearances; here it corresponds to late-stage disease with a scaly, erythematous lesion with ulcerations and nipple flattening.

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