Case number:	045
Age:	67
Clinical presentation:	Postmenopausal woman with average risk of developing breast cancer presented with a lump in the right breast. Examination revealed a 4 × 3 cm lump in the upper inner quadrant of the right breast. It was freely mobile and not fixed to the skin or chest wall.

Mammography:

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

‣ Location of the lesion:	Right breast, inner quadrant at 12–1 o’clock, middle third
‣ Mass:
• Number:	1
• Size:	3.4 × 3.2 × 2.2 cm
• Shape:	Irregular
• Margins:	Angular
• Density:	High
‣ Calcifications:
• Typically benign:	Vascular calcification
• Suspicious:	Fine pleomorphic
• Distribution:	In mass
‣ Architectural distortion:	None
‣ Asymmetry:	None
‣ Intramammary node:	None
‣ Skin lesion:	None
‣ Solitary dilated duct:	None
‣ Associated features:	Calcifications and axillary lymphadenopathy

Ultrasound:

Ultrasound features: Right breast, upper inner quadrant at 12–1 o’clock

‣ Mass
• Location:	Right breast, upper inner quadrant at 12–1 o’clock
• Number:	1
• Size:	3.2 × 2.0 cm
• Shape:	Irregular
• Orientation:	Not parallel
• Margins:	Angular
• Echo pattern:	Hypoechoic
• Posterior features:	Posterior shadowing
‣ Calcifications:	Macrocalcifications in mass
‣ Associated features:	Vessels in rim and axillary lymphadenopathy
‣ 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
‣ Site of biopsy:
• Laterality:	Right
• Quadrant:
• Localization technique:	Palpation
• Nature of aspirate:	0.5 mL of thick whitish material
‣ Cytological description:	Smear shows tumour cells with overt malignant characteristics, such as dissociated cells (arrow), marked nuclear enlargement, nuclear hyperchromasia, and loosely cohesive cell clusters. (Pap; 400×)
‣ Reporting category:	Malignant
‣ Diagnosis:	Carcinoma
‣ Comments:	None

Histopathology:

BCS

Histopathology features:

‣ Specimen type:	BCS
‣ Laterality:	Right
‣ Macroscopy:	Right breast lumpectomy specimen (11.0 × 5.0 × 4.5 cm) with an elliptical flap of skin (5.0 × 1.5 cm). Cut surface shows a greyish white tumour (3.4 × 2.3 × 2.5 cm). The tumour is 2.5 cm below the skin, 3.0 cm from the base; 3.0 cm from the lateral margin, 2.3 cm from the medial margin, 2.0 cm from the superior margin, and 1.5 cm from the inferior margin. There is a smooth-walled cyst (2.5 cm in diameter) located inferior to the tumour
‣ Histological type:	Invasive breast carcinoma of no special type
‣ Histological grade:	Grade 3 (3 + 3 + 2 = 8)
‣ Mitosis:	15
‣ Maximum invasive tumour size:	3.4 cm in greatest dimension
‣ Lymph node status:	2/14
‣ Peritumoural lymphovascular invasion:	Absent
‣ DCIS/EIC:	Comedo type DCIS of high grade; EIC absent
‣ Margins:	Free of tumour
‣ Pathological stage:	pT2N1
‣ Biomarkers:
‣ Comments:	Sections from the cyst inferior to the tumour show changes of fibrocystic change

Case summary:

Postmenopausal woman presented with right breast lump. Diagnosed as right breast carcinoma with coarse heterogeneous and fine microcalcifications within and nipple and skin retraction, BI-RADS 5 on imaging, as breast carcinoma on cytology, and as invasive breast carcinoma of no special type, pT2N1 on histopathology.

Learning points:

Fine pleomorphic microcalcifications seen in the centre of the malignant mass represent casting-type calcification in the necrotic tumour debris within the ducts. Nipple retraction is secondary to desmoplastic reaction adjacent to the mass seen as linear shadows extending from the mass to the subareolar region.