Case number:	071
Age:	74
Clinical presentation:	Postmenopausal woman with a family history of breast cancer in her mother, presented with a left breast lump. On examination, she had two lumps palpable in her left breast. The larger lump was in the lower inner quadrant, 3 cm in diameter, hard, and fixed to the muscle. The other lump was 2 cm in diameter and in the upper outer quadrant.

Mammography:

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

‣ Location of the lesion:	Left breast, upper outer quadrant at 2 o’clock, posterior third
‣ Mass:
• Number:	1
• Size:	2.8 × 2.3 cm
• Shape:	Irregular
• Margins:	Spiculated
• Density:	High
‣ Calcifications:
• Typically benign:	None
• Suspicious:	Suspicious calcifications
• Distribution:	Groups of pleomorphic calcifications within the mass
‣ Architectural distortion:	None
‣ Asymmetry:	None
‣ Intramammary node:	None
‣ Skin lesion:	None
‣ Solitary dilated duct:	None
‣ Associated features:	None

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

‣ Location of the lesion:	Left breast, lower inner quadrant at 8–9 o’clock, posterior third
‣ Mass:
• Number:	1
• Size:	3.0 × 2.5 cm
• Shape:	Irregular
• Margins:	Spiculated
• Density:	High
‣ Calcifications:
• Typically benign:	None
• Suspicious:	Fine linear and pleomorphic microcalcifications
• Distribution:	Groups of pleomorphic calcifications within the mass
‣ Architectural distortion:	None
‣ Asymmetry:	Focal
‣ Intramammary node:	None
‣ Skin lesion:	None
‣ Solitary dilated duct:	None
‣ Associated features:	Fine linear pleomorphic microcalcifications within the mass

Ultrasound:

Ultrasound features: Left breast, upper outer quadrant at 2 o’clock and inner quadrant at 8–9 o’clock

‣ Mass
• Location:	Left breast, upper outer quadrant at 2 o’clock and inner quadrant at 8–9 o’clock
• Number:	2
• Size:	Lesion 1: 2.5 × 2.3 cm in upper outer quadrant at 2 o’clock position Lesion 2: 2.6 × 2.0 cm in lower inner quadrant at 9 o’clock position
• Shape:	Irregular
• Orientation:	Not parallel
• Margins:	Spiculated
• Echo pattern:	Hypoechoic
• Posterior features:	Posterior shadowing
‣ Calcifications:	Calcifications in mass at 9 o’clock
‣ 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:	Left
• Quadrant:	Upper outer
• Localization technique:	Palpation
• Nature of aspirate:	Whitish
‣ Cytological description:	Paucicellular, a few scattered single isolated malignant seen in the smears. Many fibrous tissue fragments seen
‣ Reporting category:	Malignant
‣ Diagnosis:	Carcinoma
‣ Comments:	None

Histopathology:

MRM

Histopathology features:

‣ Specimen type:	MRM
‣ Laterality:	Left
‣ Macroscopy:	On serial sectioning, a greyish white tumour (3.5 × 2.5 × 2.5 cm) was identified. Two centimetres lateral to this tumour is another tumour (2.0 × 2.0 × 1.5 cm)
‣ Histological type:	Invasive carcinoma of no special type
‣ Histological grade:	Grade 2 (3 + 2 + 2 = 7)
‣ Mitosis:	12
‣ Maximum invasive tumour size:	Largest 4.0 cm in greatest dimension (smaller one 2.0 cm)
‣ Lymph node status:	0/15
‣ Peritumoural lymphovascular invasion:	Not identified
‣ DCIS/EIC:	Comedo, cribriform – high grade
‣ Margins:	Free of tumour
‣ Pathological stage:	pT2(2)N0
‣ Biomarkers:
‣ Comments:	Stroma shows dense fibrosis and desmoplasia. Focal area of calcification present

Case summary:

Postmenopausal woman presented with two palpable lumps in the upper inner and lower outer quadrants of left breast. Diagnosed as left breast multicentric carcinoma, BI-RADS 5 on imaging, as carcinoma breast on cytology, and as invasive breast carcinoma of no special type, pT2(2)N0 on histopathology.

Learning points:

Two or more than two separate mass lesions of breast cancer, typically in different quadrants of the breast, usually in different ductal systems and > 5 cm apart from each other is called multicentric breast cancer. In patients undergoing mastectomy for breast cancer, more than one focus of cancer will be seen in up to 40% of the specimens.
In this case, two lesions are seen – one in the upper outer quadrant and another in the inner quadrant of the left breast.
Multicentric breast cancer is more common in women with family history of breast cancer, as seen in this case. The patient has history of breast cancer in her mother.