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Case number:108
Age:52
Clinical presentation:Premenopausal woman presented for mammography screening. She had an increased risk of breast cancer because of family history, and was scheduled for mammographic surveillance.


Mammography:


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

 ‣ Location of the lesion:Right breast, upper outer quadrant at 10 o’clock, middle third
 ‣ Mass:
   • Number:1
   • Size:0.7 cm in greatest dimension
   • Shape:Irregular
   • Margins:Indistinct
   • Density:Equal
 ‣ 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:None

Ultrasound:


Ultrasound features: Right breast, upper outer quadrant at 10 o’clock

 ‣ Mass
   • Location:Right breast, upper outer quadrant at 10 o’clock
   • Number:1
   • Size:0.7 cm in greatest dimension
   • Shape:Irregular
   • Orientation:Not parallel
   • Margins:Spiculated
   • Echo pattern:Hypoechoic
   • Posterior features:Posterior shadowing
 ‣ Calcifications:None
 ‣ Associated features:None
 ‣ Special cases:None

BI-RADS:

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

Further assessment:

Further assessment advised: Further imaging with breast MRI

MRI:


MRI features:
 ‣ MRI features:Amount of fibroglandular tissue: category b (there are scattered areas of fibroglandular density). Background parenchymal enhancement: Mild (25–50%), symmetrical

 ‣ Location:Right breast, upper outer quadrant
 ‣ Focus:No
 ‣ Mass:
   • Shape:Round
   • Margin:Spiculated
   • Internal enhancement:Intense homogeneous
   • Kinetic curve:Type 3
 ‣ Non-mass enhancement:
   • Distribution:No
   • Internal enhancement:No
 ‣ Non-enhancing findings:No
 ‣ Associated features:No
 ‣ Axillary nodes:No


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 reveal many sheets of tightly cohesive, benign ductal epithelial cells and bare nuclei. A few sheets of ductal epithelial cells show anisonucleosis, enlarged, mildly hyperchromatic nuclei and moderate amounts of cytoplasm
 ‣ Reporting category:Suspicious, probably in situ or invasive carcinoma
 ‣ Diagnosis:Predominantly benign cells with a few cells suspicious for malignancy
 ‣ Comments:None


Histopathology:

Breast-conserving surgery



Histopathology features:

 ‣ Specimen type:Breast-conserving surgery
 ‣ Laterality:Right
 ‣ Macroscopy:On serial sectioning, a small firm greyish white area (0.6 × 0.5 × 0.5 cm) is seen. The closest cut margin is the superior margin, which is 1.5 cm from the tumour
 ‣ Histological type:Invasive carcinoma of no special type, a few with tubular carcinoma morphology
 ‣ Histological grade:Grade 1 (2 + 1 + 1 = 4)
 ‣ Mitosis:3
 ‣ Maximum invasive tumour size:0.6 cm in greatest dimension
 ‣ Lymph node status:0/14
 ‣ Peritumoural lymphovascular invasion:Not identified
 ‣ DCIS/EIC:Small foci of cribriform type – low grade
 ‣ Margins:Free of tumour
 ‣ Pathological stage:pT1N0
 ‣ Biomarkers:
 ‣ Comments:Amount of fibroglandular tissue: category b (scattered fibroglandular tissue). Background: parenchymal enhancement: Mild (25–50%), symmetrical.

Case summary:

Premenopausal woman with increased risk of developing breast cancer presented for screening. Mammography, breast ultrasound, and breast MRI reveal right breast irregular subcentimeter-size lesion of suspicious morphology, diagnosed as BI-RADS category 4C on imaging, suspicious for malignancy on cytology, and invasive breast carcinoma of no special type, pT1N0 on histopathology.

Learning points:



  • Screen-detected suspicious findings were further evaluated on supplementary ultrasound and MRI in view of the patient’s high-risk family status. Tissue sampling confirmed the presence of malignancy.

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