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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.

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