Case number:	059
Age:	43
Clinical presentation:	Premenopausal woman with average risk of developing breast cancer presented with pain and a lump in the left breast of duration 4–5 days. Examination revealed a large (6 cm) tender lump with redness of the overlying skin in the upper half of the left breast.

Mammography:

Breast composition:	ACR category c (the breasts are heterogeneously dense, which may obscure small masses)
Mammography features:

‣ Location of the lesion:	Left breast, upper outer quadrant at 2–4 o’clock, middle third
‣ Mass:
• Number:	Obscured by the dense parenchyma
• Size:	Not measurable
• Shape:	None
• Margins:	None
• Density:	None
‣ Calcifications:
• Typically benign:	None
• Suspicious:	None
• Distribution:	None
‣ Architectural distortion:	Present
‣ Asymmetry:	Present with unilateral breast enlargement
‣ Intramammary node:	None
‣ Skin lesion:	None
‣ Solitary dilated duct:	None
‣ Associated features:	Skin thickening, trabecular thickening, axillary lymphadenopathy, architectural distortion, and nipple retraction

Ultrasound:

Ultrasound features: Left breast, outer quadrants at 2–4 o’clock

‣ Mass
• Location:	Left breast, outer quadrants at 2–4 o’clock
• Number:	1
• Size:	5.8 × 4.6 cm
• Shape:	Irregular
• Orientation:	Not parallel
• Margins:	Spiculated
• Echo pattern:	Hypoechoic
• Posterior features:	Strong posterior shadowing
‣ Calcifications:	None
‣ Associated features:	Architectural distortion, skin thickening, oedema, internal vascularity, multiple enlarged axillary lymph nodes with loss of central fatty sinus, and nipple retraction
‣ Special cases:	None

BI-RADS:

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

Further assessment:

Further assessment advised: Referral for cytology and for core biopsy

Cytology:

Cytology features:

‣ Type of sample:	FNAC
‣ Site of biopsy:
• Laterality:	Left
• Quadrant:
• Localization technique:	Palpation
• Nature of aspirate:	whitish
‣ Cytological description:	Smears show loosely dispersed malignant cells with mild anisonucleosis. Many single isolated malignant cells are also seen
‣ Reporting category:	Malignant
‣ Diagnosis:	Carcinoma – low grade
‣ Comments:	None

Histopathology:

Core needle biopsy

Histopathology features:

‣ Specimen type:	Core needle biopsy
‣ Laterality:	Left
‣ Macroscopy:	Three firm whitish core tissue bits, each 20 mm in length
‣ Histological type:	Sections shows features of breast carcinoma with a lobular pattern of infiltration in the biopsy specimen. Malignancy is present in 30% of the core biopsy tissue. Normal ducts are also seen in the section
‣ Histological grade:
‣ Mitosis:
‣ Maximum invasive tumour size:
‣ Lymph node status:
‣ Peritumoural lymphovascular invasion:
‣ DCIS/EIC:
‣ Margins:
‣ Pathological stage:
‣ Biomarkers:
‣ Comments:

Case summary:

Premenopausal woman presented with painful left breast lump. Diagnosed as inflammatory left breast carcinoma with breast oedema, skin thickening, and left nipple retraction, BI-RADS 5 on imaging, as breast carcinoma on cytology, and as invasive lobular carcinoma on histopathology of needle core biopsy.

Learning points:

Inflammatory carcinoma of the breast is defined as locally advanced breast cancer with inflammatory skin changes. Clinical presentation is breast enlargement, warmth, pain, induration, and oedema involving more than one third of the breast with no relief with antibiotics. The clinical inflammatory symptoms are caused by numerous dermal lymphatic emboli.
Here, the mass is mammographically occult with global asymmetry and features of breast oedema. Breast ultrasound was diagnostic and revealed a large spiculated mass with strong posterior shadowing obscuring the cancer.