Case number:	044
Age:	65
Clinical presentation:	Postmenopausal woman with average risk of developing breast cancer presented with a left breast lump. Examination revealed a hard lump, 6 cm in diameter, in the upper quadrant of the left breast.

Mammography:

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

‣ Location of the lesion:	Left breast, central portion of the breast at 12 o’clock, anterior and middle thirds
‣ Mass:
• Number:	1
• Size:	6.4 × 3.3 cm
• Shape:	Irregular
• Margins:	Spiculated
• Density:	High
‣ Calcifications:
• Typically benign:	None
• Suspicious:	Fine pleomorphic
• Distribution:	Grouped and fine-linear branching
‣ Architectural distortion:	None
‣ Asymmetry:	None
‣ Intramammary node:	None
‣ Skin lesion:	None
‣ Solitary dilated duct:	None
‣ Associated features:	Skin retraction and grouped and fine-linear branching calcifications

Ultrasound:

Ultrasound features: Left breast, upper quadrants at 12 o’clock

‣ Mass
• Location:	Left breast, upper quadrants at 12 o’clock
• Number:	1
• Size:	5.0 × 2.0 cm
• Shape:	Irregular
• Orientation:	Not parallel
• Margins:	Angular and spiculated
• Echo pattern:	Heterogeneous
• Posterior features:	Posterior shadowing
‣ Calcifications:	Present in mass
‣ Associated features:	Internal vascularity, skin thickening, and microcalcifications
‣ Special cases:	None

BI-RADS:

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

Further assessment:

Further assessment advised: Referral for cytology and for core biopsy

Cytology:

Cytology features:

‣ Type of sample:	FNAC
‣ Site of biopsy:
• Laterality:	Left
• Quadrant:
• Localization technique:	Palpation
• Nature of aspirate:	0.5 mL of thick whitish material
‣ Cytological description:	Smears show many dyscohesive clusters and a few dissociated cells with a high N:C ratio and hyperchromatic, pleomorphic nucleoli with coarse chromatin. Background shows many RBCs and proteinaceous material
‣ Reporting category:	Malignant
‣ Diagnosis:	Carcinoma
‣ Comments:	None

Histopathology:

Core needle biopsy

Histopathology features:

‣ Specimen type:	Core needle biopsy
‣ Laterality:	Left
‣ Macroscopy:	Three whitish tissue cores, each 12 mm in length
‣ Histological type:	Invasive breast carcinoma of no special type
‣ Histological grade:	Grade 2 (3 + 2 + 2 = 7)
‣ Mitosis:	14
‣ Maximum invasive tumour size:
‣ Lymph node status:
‣ Peritumoural lymphovascular invasion:
‣ DCIS/EIC:
‣ Margins:
‣ Pathological stage:
‣ Biomarkers:
‣ Comments:

Case summary:

Postmenopausal woman presented with left breast lump. Diagnosed as left breast carcinoma with fine pleomorphic, grouped and fine-linear branching calcifications within, and overlying skin thickening and retraction, BI-RADS 5 on imaging, as carcinoma of the left breast on cytology, and as invasive breast carcinoma of no special type on core biopsy histopathology.

Learning points:

Locally advanced breast carcinoma, as seen in this case, shows all the features of local extent of the disease, seen as an irregular mass with skin thickening and skin retraction. Retracted skin is caused by shortening and thickening of the ligaments of Cooper as a result of infiltration by malignant disease. Extensive comedo necrosis is seen adjacent to the mass as fine-linear branching calcifications.