Case number:	049
Age:	49
Clinical presentation:	Premenopausal woman with average risk of developing breast cancer presented with a left breast lump. Examination revealed a hard 2 cm lump in the lower inner quadrant of the left breast.

Mammography:

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

‣ Location of the lesion:	Left breast, lower inner quadrant at 7–8 o’clock, middle third
‣ Mass:
• Number:	1
• Size:	3.0 × 2.0 cm
• Shape:	Oval
• Margins:	Partly circumscribed and partly obscured
• 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: Left breast, lower inner quadrant at 8 o’clock

‣ Mass
• Location:	Left breast, lower inner quadrant at 8 o’clock
• Number:	1
• Size:	1.9 cm
• Shape:	Round
• Orientation:	Parallel
• Margins:	indistinct
• Echo pattern:	Heteroechoic
• Posterior features:	No posterior features
‣ Calcifications:	None
‣ Associated features:	None
‣ 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:	Left
• Quadrant:	Lower inner
• Localization technique:	Palpation
• Nature of aspirate:	Whitish
‣ Cytological description:	Smear reveals loosely cohesive sheets and isolated malignant cells showing hyperchromatic pleomorphic nuclei with coarse chromatin. N:C ratio is high and there is a moderate amount of cytoplasm. Necrotic debris is seen in the background
‣ Reporting category:	Malignant
‣ Diagnosis:	Carcinoma
‣ Comments:	None

Histopathology:

Breast-conserving surgery

Histopathology features:

‣ Specimen type:	Breast-conserving surgery
‣ Laterality:	Left
‣ Macroscopy:	Lumpectomy specimen (9.0 × 6.0 × 4.0 cm) oriented with long suture laterally and short suture superiorly. Skin flap (8.0 × 4.0 cm). Part of areola noted (2.0 × 1.0 cm). On serial sectioning, a greyish white tumour (3.0 × 2.3 × 2.2 cm) is identified. Areas of fibrosis noted. Tumour is located 0.6 cm from the skin, 1.8 cm from the posterior margin, 1.4 cm from the superior margin, 3.0 cm from the inferior margin, 1.3 cm from the medial margins, and 3.3 cm from the lateral margin. The remaining breast parenchyma is unremarkable
‣ Histological type:	Invasive breast carcinoma
‣ Histological grade:	Grade 2 (3 + 2 + 1 = 6)
‣ Mitosis:	6
‣ Maximum invasive tumour size:	3 cm in greatest dimension
‣ Lymph node status:	0/13
‣ Peritumoural lymphovascular invasion:	Present
‣ DCIS/EIC:	Clinging type DCIS of high nuclear grade; no necrosis
‣ Margins:	Free of tumour
‣ Pathological stage:	pT2N0
‣ Biomarkers:
‣ Comments:	The centre of the tumour shows extensive tumour necrosis. The adjacent breast parenchyma show extensive stromal fibrosis with hyalinization

Case summary:

Premenopausal woman presented with left breast lump. Diagnosed as left breast carcinoma, BI-RADS 5 on imaging, as left breast carcinoma on cytology, and as invasive breast carcinoma of no special type, pT2N0 on histopathology.

Learning points:

Mammography in this case revealed a solitary non-calcified mass with partly circumscribed and partly obscured margins, which is a feature suspicious for malignancy.
Supplementary ultrasound showed a mass with spiculated margins and thick echogenic rim, which are classical morphological features of malignancy. Histopathology showed extensive necrosis in the centre with a narrow rim of tumour tissue.