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Case number:051
Age:78
Clinical presentation:Postmenopausal woman with average risk of developing breast cancer presented with pain and a lump in the left breast of duration 1 month. Examination revealed a hard lump 4 cm in diameter in the left breast.


Mammography:


Breast composition:ACR category a (the breasts are almost entirely fatty)
Mammography features:

 ‣ Location of the lesion:Left breast, upper inner quadrant at 10 o’clock, middle third
 ‣ Mass:
   • Number:1
   • Size:3.2 × 3.2 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:Skin thickening and nipple retraction

Ultrasound:


Ultrasound features: Left breast, upper inner quadrant at 10 o’clock

 ‣ Mass
   • Location:Left breast, upper inner quadrant at 10 o’clock
   • Number:1
   • Size:3.6 × 2.2 cm
   • Shape:Irregular
   • Orientation:Not parallel
   • Margins:Angular
   • Echo pattern:Heteroechoic
   • Posterior features:No posterior features
 ‣ Calcifications:None
 ‣ Associated features:Internal vascularity in mass and enlarged left axillary lymph nodes with altered morphology
 ‣ 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:Upper inner
   • Localization technique:Palpation
   • Nature of aspirate:whitish
 ‣ Cytological description:Smears are cellular with poorly cohesive sheets of malignant ductal cells. Cells show features of a low-grade malignancy
 ‣ Reporting category:Malignant
 ‣ Diagnosis:Carcinoma – low grade
 ‣ Comments:None


Histopathology:

MRM



Histopathology features:

 ‣ Specimen type:MRM
 ‣ Laterality:Left
 ‣ Macroscopy:A greyish white, irregular tumour mass (3.5 × 3.0 × 3.0 cm) in the inner quadrant. A few tiny cystic areas are seen on the cut surface of the tumour
 ‣ Histological type:Infiltrating duct carcinoma with extensive neuroendocrine differentiation. Extracellular mucin is present, at places forming lakes
 ‣ Histological grade:Grade 1 (2 + 1 + 1 = 4)
 ‣ Mitosis:2
 ‣ Maximum invasive tumour size:3.5 cm in greatest dimension
 ‣ Lymph node status:0/15
 ‣ Peritumoural lymphovascular invasion:Present
 ‣ DCIS/EIC:Cribriform and solid DCIS of low grade
 ‣ Margins:Free of tumour, 2.0 cm from the base
 ‣ Pathological stage:pT2N0
 ‣ Biomarkers:
 ‣ Comments:IHC is confirmatory for neuroendocrine differentiation. Neuron-specific enolase and chromogranin are positive

Case summary:

Postmenopausal woman presented with left breast lump. Diagnosed as left breast carcinoma, BI-RADS 5 on imaging, as breast carcinoma on cytology, and as invasive breast carcinoma with neuroendocrine differentiation, pT2N0 on histopathology.

Learning points:


  • Expression of neuron-specific enolase, chromogranin proteins, and/or synaptophysin is a characteristic feature of carcinoma with neuroendocrine differentiation.

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