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Case number:056
Clinical presentation:Postmenopausal woman with average risk of developing breast cancer presented with blood-stained nipple discharge from the left nipple. Examination did not reveal significant lumps in either breasts or axillae.


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

 ‣ Location of the lesion:Left breast, lower outer quadrant at 5–6 o’clock, middle third
 ‣ Mass:
   • Number:Multiple small intraductal
   • Size:Not measurable
   • Shape:Indistinct
   • Margins:Obscured
   • Density:Equal
 ‣ Calcifications:
   • Typically benign:None
   • Suspicious:None
   • Distribution:None
 ‣ Architectural distortion:Present
 ‣ Asymmetry:Focal
 ‣ Intramammary node:None
 ‣ Skin lesion:None
 ‣ Solitary dilated duct:Multiple dilated ducts
 ‣ Associated features:Architectural distortion with linear opacities


Ultrasound features: Left breast, lower outer quadrant at 4 o’clock

 ‣ Mass
   • Location:Left breast, lower outer quadrant at 4 o’clock
   • Number:Ultrasound transverse scan left breast shows multiple dilated ducts with intraductal lesions along the walls of the ducts
   • Size:Largest 0.4 cm in greatest dimension
   • Shape:Irregular
   • Orientation:Not parallel
   • Margins:Indistinct
   • Echo pattern:Hypoechoic
   • Posterior features:No posterior features
 ‣ Calcifications:None
 ‣ Associated features:Duct changes: ectatic duct with intraductal lesion along the walls
 ‣ Special cases:None


BI-RADS Category: 4B (moderate suspicion of malignancy)

Further assessment:

Further assessment advised: Further imaging with breast MRI


MRI features:
 ‣ MRI features:Amount of fibroglandular tissue: ACR category a (the breasts are almost entirely fatty). Background parenchymal enhancement: Minimal (< 25%), symmetrical

 ‣ Location:Left breast, lower quadrant
 ‣ Focus:No
 ‣ Mass:
   • Shape:No
   • Margin:No
   • Internal enhancement:No
   • Kinetic curve:No
 ‣ Non-mass enhancement:
   • Distribution:Intraductal and periductal non-mass-like enhancement in the inferior half at 5–8 o’clock
   • Internal enhancement:Heterogeneous
 ‣ Non-enhancing findings:No
 ‣ Associated features:Architectural distortion
 ‣ Axillary nodes:No


Cytology features:

 ‣ Type of sample:Nipple discharge
 ‣ Site of biopsy:
   • Laterality:Left
   • Quadrant:
   • Localization technique:
   • Nature of aspirate:Brownish yellow discharge
 ‣ Cytological description:Smear from nipple discharge shows predominantly foamy macrophages and a few haemosiderin-laden macrophages. Occasional clusters of ductal epithelial cells are seen showing nuclear atypia
 ‣ Reporting category:Atypical, probably benign
 ‣ Diagnosis:Atypical, probably benign. Category 3 of IAC Yokohama System is atypical, probably benign
 ‣ Comments:None

Cytology features:

 ‣ Type of sample:FNAC
 ‣ Site of biopsy:
   • Laterality:Left
   • Quadrant:Lower half
   • Localization technique:Palpation
   • Nature of aspirate:whitish
 ‣ Cytological description:Smear shows many dyscohesive clusters and scattered solitary plasmacytoid cells with large pleomorphic nuclei and moderate cytoplasm. Background shows presence of RBCs and many macrophages; a few are haemosiderin laden. Many fibroadipose tissue fragments are also seen
 ‣ Reporting category:Suspicious, probably in situ or invasive carcinoma
 ‣ Diagnosis:Suspicious, probably in situ or invasive carcinoma
 ‣ Comments:None



Histopathology features:

 ‣ Specimen type:MRM
 ‣ Laterality:Left
 ‣ Macroscopy:On serial sectioning, a firm grey white area (7.8 × 3.0 × 2.5 cm) is seen in the central and lower quadrants. It is 3.0 cm from the skin and 1.5 cm from the base. The remaining breast tissue appears unremarkable
 ‣ Histological type:Intraductal papillary carcinoma with invasive carcinoma
 ‣ Histological grade:Grade 2 (3 + 2 + 1 = 6)
 ‣ Mitosis:3
 ‣ Maximum invasive tumour size:0.7 cm in greatest dimension
 ‣ Lymph node status:0/15
 ‣ Peritumoural lymphovascular invasion:Absent
 ‣ DCIS/EIC:DCIS of solid, micropapillary, papillary, and flat-type intermediate grade; EIC present with multiple foci of microinvasion
 ‣ Margins:Free of tumour, distance from nearest margin (i.e. base) 0.7 cm
 ‣ Pathological stage:pT1N0
 ‣ Biomarkers:
 ‣ Comments:The intraductal papillary carcinoma involves several large ducts, a few of which are cystically dilated with papillary carcinoma within the duct. Multiple foci of microinvasion are seen

Case summary:

Postmenopausal woman presented with left breast blood-stained nipple discharge, diagnosed as multiple dilated ducts with intraductal solid lesions in the left breast, BI-RADS category 4B on imaging, as suspicious, probably in situ or invasive carcinoma, left breast on cytology, and as intraductal papillary carcinoma with invasive carcinoma on histopathology.

Learning points:

  • Intraductal papillary carcinoma (papillary DCIS) is defined as a malignant non-invasive neoplastic proliferation with papillary architectural features occurring in the lumen of the ductal lobular system. The invasive component in this case was very small compared with the DCIS component.

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