Case number:	073
Age:	47
Clinical presentation:	Premenopausal woman with average risk of developing breast cancer presented with a lump in her right breast. On clinical examination, she had a hard lump in the upper outer quadrant of the right breast.

Mammography:

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

‣ Location of the lesion:	Right breast, upper outer quadrant at 10 o’clock, middle third
‣ Mass:
• Number:	1
• Size:	Not measurable in the dense breast parenchyma, approximately 2.0 cm
• Shape:	Irregular
• Margins:	Indistinct
• Density:	High
‣ Calcifications:
• Typically benign:	None
• Suspicious:	Coarse
• Distribution:	In mass
‣ Architectural distortion:	Present
‣ Asymmetry:	Focal
‣ Intramammary node:	None
‣ Skin lesion:	None
‣ Solitary dilated duct:	None
‣ Associated features:	Coarse calcifications in mass

Ultrasound:

Ultrasound features: Right breast, outer quadrants at 9–10 o’clock

‣ Mass
• Location:	Right breast, outer quadrants at 9–10 o’clock
• Number:	2
• Size:	Lesion 1: 2.0 × 1.7 cm in upper outer quadrant at 10 o’clock position. Lesion 2: 1.1 × 0.7 cm in outer quadrant at 9 o’clock position
• Shape:	Irregular
• Orientation:	Not parallel
• Margins:	Spiculated
• Echo pattern:	Hypoechoic
• Posterior features:	No posterior features
‣ 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 (solid lesion)
‣ Site of biopsy:
• Laterality:	Right
• Quadrant:	Upper outer
• Localization technique:	Palpation
• Nature of aspirate:	Whitish
‣ Cytological description:	Smears are very cellular and show loosely cohesive ductal epithelial cells. Many of these cells show nuclear pleomorphism, nuclear overlapping, and occasionally prominent nucleoli
‣ Reporting category:	Malignant
‣ Diagnosis:	Carcinoma – high grade
‣ Comments:	None

Histopathology:

Breast-conserving surgery

Histopathology features:

‣ Specimen type:	Breast-conserving surgery
‣ Laterality:	Right
‣ Macroscopy:	On cut surface of the specimen, a firm, poorly circumscribed area (2 × 1.2 × 0.8 cm) is seen, which is 0.3 cm from the base. Another whitish area of fibrosis (3.0 × 3.0 × 2.0 cm ) with a few cysts is 1.0 cm from the lateral margin
‣ Histological type:	Invasive carcinoma of no special type
‣ Histological grade:	Grade 3 (3 + 2 + 3 = 8)
‣ Mitosis:	22
‣ Maximum invasive tumour size:	Largest 3.0 cm in greatest dimension (another is 2.0 cm)
‣ Lymph node status:	5/21
‣ Peritumoural lymphovascular invasion:	Present
‣ DCIS/EIC:	Solid and cribriform type – intermediate grade
‣ Margins:	Free of tumour
‣ Pathological stage:	pT2(2)N0
‣ Biomarkers:
‣ Comments:	Benign proliferative breast disease such as UDH, cyst formation, and apocrine change

Case summary:

Premenopausal woman presented with lump in the right breast. Diagnosed as right breast carcinoma (multifocal), 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:

Heterogeneously dense breasts obscure optimal visualization of the breast mass lesions. Supplementary breast ultrasound in this case clearly shows the two foci of cancer, both in the same quadrant.