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Case number:	039
Age:	77
Clinical presentation:	Postmenopausal and post hysterectomy, nulliparous woman with increased risk for developing breast cancer presented with a lump in the left breast of 6 months duration. Examination revealed hard, mobile lump in the lower inner quadrant of the left breast.

Mammography:

Breast composition:	ACR category b (there are scattered areas of fibroglandular density)
Mammography features:
‣ Location of the lesion:	Lesion 1: Left breast, lower inner quadrant at 7 o’clock, middle third
‣ Mass:
• Number:	1
• Size:	2.0 × 1.5 cm
• Shape:	Irregular
• Margins:	Indistinct
• Density:	High
‣ Calcifications:
• Typically benign:	Vascular calcification
• Suspicious:	None
• Distribution:	None
‣ Architectural distortion:	None
‣ Asymmetry:	None
‣ Intramammary node:	None
‣ Skin lesion:	None
‣ Solitary dilated duct:	None
‣ Associated features:	None

Breast composition:	ACR category b (there are scattered areas of fibroglandular density)
Mammography features:
‣ Location of the lesion:	Lesion 2: Left breast, central portion of the breast, lower outer quadrant at 5 o’clock, anterior third
‣ Mass:
• Number:	1
• Size:	0.7 cm in greatest dimension
• Shape:	Irregular
• Margins:	Indistinct
• 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:	None

Breast composition:	ACR category b (there are scattered areas of fibroglandular density)
Mammography features:
‣ Location of the lesion:	Right breast, lower inner quadrant at 5 o’clock, middle third
‣ Mass:
• Number:	1
• Size:	1.2 cm in greatest dimension
• Shape:	Oval
• Margins:	Circumscribed
• Density:	Equal
‣ Calcifications:
• Typically benign:	Coarse, popcorn-like
• Suspicious:	None
• Distribution:	None
‣ Architectural distortion:	None
‣ Asymmetry:	None
‣ Intramammary node:	None
‣ Skin lesion:	None
‣ Solitary dilated duct:	None
‣ Associated features:	Coarse, popcorn-like calcification

Ultrasound:

Ultrasound features: Left breast, lower inner quadrant at 7 o’clock
‣ Mass
• Location:	Left breast, lower inner quadrant at 7 o’clock
• Number:	1
• Size:	2.0 × 1.3 cm
• Shape:	Irregular
• Orientation:	Not parallel
• Margins:	Angular
• Echo pattern:	Hypoechoic
• Posterior features:	Posterior shadowing
‣ Calcifications:	None
‣ Associated features:	Internal vascularity
‣ Special cases:	None

Ultrasound features: Left breast, lower outer quadrant at 4 o’clock
‣ Mass
• Location:	Left breast, lower outer quadrant at 4 o’clock
• Number:	1
• Size:	0.8 × 0.6 cm
• Shape:	Irregular
• Orientation:	Not parallel
• Margins:	Spiculated
• Echo pattern:	Hypoechoic
• Posterior features:	No posterior features
‣ Calcifications:	None
‣ Associated features:	None
‣ Special cases:	None

Ultrasound features: Right breast, lower inner quadrant at 3 o’clock
‣ Mass
• Location:	Right breast, lower inner quadrant at 3 o’clock
• Number:	1
• Size:	1.3 × 0.8 cm
• Shape:	Oval
• Orientation:	Parallel
• Margins:	Circumscribed
• Echo pattern:	Hypoechoic
• Posterior features:	Posterior shadowing
‣ Calcifications:	Macrocalcifications in mass
‣ Associated features:	None
‣ Special cases:	None

BI-RADS:

BI-RADS Category (Left breast, 2 nodules): 5 (highly suggestive of malignancy)
BI-RADS Category (Right breast): 2 (benign)

Further assessment:

Further assessment advised: Referral for cytology

Cytology:

Cytology features:
‣ Type of sample:	FNAC
‣ Site of biopsy:
• Laterality:	Left
• Quadrant:	Lower inner
• Localization technique:	Palpation
• Nature of aspirate:	Whitish
‣ Cytological description:	Cellular smears are from the lower inner quadrant breast lump. Many clusters and sheets of atypical ductal cells are seen. Many scattered solitary cells are also present. These cells have large, pleomorphic, and hyperchromatic nuclei with prominent nucleoli. Background shows abundant lymphocytes
‣ Reporting category:	Malignant
‣ Diagnosis:	Carcinoma
‣ Comments:	None

Cytology features:
‣ Type of sample:	FNAC
‣ Site of biopsy:
• Laterality:	Left
• Quadrant:	Upper outer
• Localization technique:	Palpation
• Nature of aspirate:	Fatty material
‣ Cytological description:	Smears show a few fibroadipose tissue fragments against a background of RBCs
‣ Reporting category:	Insufficient material
‣ Diagnosis:	Insufficient
‣ Comments:	None

Histopathology:

MRM

Histopathology features:
‣ Specimen type:	MRM
‣ Laterality:	Left
‣ Macroscopy:	Specimen (25.0 × 20.0 × 60.0 cm), with overlying skin flap (20.0 × 6.0 cm). The nipple appears flattened. On serial sectioning an irregular greyish white tumour (2.2 × 1.7 × 1.7 cm) with a haemorrhagic area is identified in the lower inner quadrant. It is located 1.5 cm from the skin and 2.0 cm from the base. Closest inferior margin is 1.0 cm away. There is another small firm whitish nodule (0.5 cm) in the lateral half of the specimen, 2.5 cm from the base and 12.0 cm from the first tumour
‣ Histological type:	Invasive breast carcinoma
‣ Histological grade:	Grade 2 (3 + 2 + 2 = 7)
‣ Mitosis:	12
‣ Maximum invasive tumour size:	2.2 cm
‣ Lymph node status:	0/15
‣ Peritumoural lymphovascular invasion:	Present
‣ DCIS/EIC:	Absent
‣ Margins:	Free of tumour
‣ Pathological stage:	pT2N0
‣ Biomarkers:
‣ Comments:	The other small nodule shows areas with ductal epithelial hyperplasia. DCIS and malignancy is not present in this nodule

Case summary:

Postmenopausal woman presented with lump in the left breast. Diagnosed as left breast carcinoma with another suspicious smaller nodule, BI-RADS 5 (multicentric) on imaging, as breast carcinoma on cytology, and as invasive breast carcinoma of no special type, pT2N0 on histopathology in the nodule seen in the lower inner quadrant of the left breast. The other small nodule shows areas with ductal epithelial hyperplasia.

Learning points:

In this case, two lesions were seen in the left breast on imaging, one in the inner quadrant and another in the subareolar region. Although both the lesions showed morphological imaging features suspicious of malignancy, the second nodule in the left subareolar region showed features of UDH on histology. Intraductal proliferative lesions of the breast are divided into three categories: UDH, ADH, and DCIS.