Case number:	035
Age:	68
Clinical presentation:	Postmenopausal woman with family history of colon cancer presented with a lump in the right breast. Examination revealed a hard, mobile, 3 cm lump in the upper outer quadrant of the right breast.

Mammography:

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

‣ Location of the lesion:	Right breast, upper outer quadrant at 11 o’clock, middle third
‣ Mass:
• Number:	2
• Size:	2.5 × 2.0 cm and 0.7 cm in greatest dimension
• Shape:	Irregular
• Margins:	Spiculated
• Density:	High
‣ 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:	Axillary lymph node

Ultrasound:

Ultrasound features: Right breast, upper outer quadrant at 11 o’clock

‣ Mass
• Location:	Right breast, upper outer quadrant at 11 o’clock
• Number:	2
• Size:	2.2 × 1.4 cm and 0.8 × 0.6 cm
• Shape:	Irregular
• Orientation:	Not parallel
• Margins:	Angular
• Echo pattern:	Hypoechoic
• Posterior features:	Posterior shadowing
‣ 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
‣ Site of biopsy:
• Laterality:	Right
• Quadrant:	Upper outer
• Localization technique:	Palpation
• Nature of aspirate:	Whitish
‣ Cytological description:	Smears are cellular and reveal many loosely cohesive clusters and sheets of large atypical cells with large, pleomorphic and hyperchromatic nuclei and moderate amount of cytoplasm. Nucleoli are seen in a few cells. There are many stromal fragments
‣ Reporting category:	Malignant
‣ Diagnosis:	Carcinoma breast
‣ Comments:	None

Histopathology:

MRM

Histopathology features:

‣ Specimen type:	MRM
‣ Laterality:	Right
‣ Macroscopy:	Specimen (24.0 × 18.0 × 7.0 cm), with overlying skin flap (19.0 × 8.0 cm). The nipple and areola are unremarkable. On serial sectioning, a firm, gritty, greyish white tumour (2.5 × 2.0 × 2.0 cm) is identified located in the upper outer quadrant. It is located 2.5 cm from the skin and 1.5 cm from the base. Another firm, gritty, greyish white, nodular tumour (1.0 × 0.8 × 0.6 cm) is located 1.5 cm from the primary tumour and lower and lateral to it. It is 4.0 cm from the base and 1.0 cm below the overlying skin
‣ Histological type:	Invasive breast carcinoma
‣ Histological grade:	Grade 2 (3 + 2 + 2 = 7)
‣ Mitosis:	16
‣ Maximum invasive tumour size:	2.5 cm
‣ Lymph node status:	1/22
‣ Peritumoural lymphovascular invasion:	Absent
‣ DCIS/EIC:	DCIS of solid and comedo type – high grade
‣ Margins:	Free of tumour
‣ Pathological stage:	pT2(2)N1
‣ Biomarkers:
‣ Comments:

Case summary:

Postmenopausal woman presented with a lump in the right breast. Diagnosed as right breast carcinoma (multifocal) with right axillary metastatic node, BI-RADS 5 on imaging, as breast carcinoma on cytology, and as invasive breast carcinoma of no special type, pT2(2)N1 on histopathology.

Learning points:

Two or more than two separate mass lesions of breast cancer in the same quadrant of the breast, usually along the same ductal system or within 5 cm from each other, is called multifocal breast cancer.