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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.


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