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Case number:062
Age:63
Clinical presentation:Postmenopausal woman with average risk of developing breast cancer presented with a lump in the left breast. On examination, she was found to have a hard 3 cm lump in her left breast. Axillary nodes were not palpable.


Mammography:


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

 ‣ Location of the lesion:Left breast, lower quadrants at 6 o’clock, posterior third
 ‣ Mass:
   • Number:1
   • Size:2.8 × 2.5 cm
   • 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

Ultrasound:


Ultrasound features: Left breast, lower quadrants at 6 o’clock

 ‣ Mass
   • Location:Left breast, lower quadrants at 6 o’clock
   • Number:1
   • Size:2.5 × 1.6 cm
   • Shape:Oval
   • Orientation:Parallel
   • Margins:Spiculated
   • Echo pattern:Heteroechoic
   • Posterior features:No posterior features
 ‣ Calcifications:None
 ‣ Associated features:Minimal internal vascularity
 ‣ 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 at 6 o’clock
   • Localization technique:Palpation, soft feel to the needling
   • Nature of aspirate:Whitish
 ‣ Cytological description:Highly cellular smears show poorly cohesive clusters and dispersed malignant cells. These cells are large and pleomorphic with prominent nucleoli. Many lymphocytes are seen in the background
 ‣ Reporting category:Malignant
 ‣ Diagnosis:Carcinoma – high grade. Medullary carcinoma to be considered in view of the lymphocytes
 ‣ Comments:None


Histopathology:

Breast-conserving surgery



Histopathology features:

 ‣ Specimen type:Breast-conserving surgery
 ‣ Laterality:Left
 ‣ Macroscopy:Lumpectomy specimen (7.5 × 6.0 × 3.5 cm) oriented with long suture laterally and short suture superiorly. Skin flap is 7.0 × 2.5 cm. On serial sectioning a firm greyish white tumour (2.5 × 2.1 × 2.5 cm) is identified with an intact cystic cavity (1.6 × 1.2 cm) filled with blood
 ‣ Histological type:Invasive breast carcinoma of no special type with medullary pattern
 ‣ Histological grade:Grade 3 (3 + 2 + 3 = 8)
 ‣ Mitosis:28
 ‣ Maximum invasive tumour size:2.5 cm in greatest dimension
 ‣ Lymph node status:0/29
 ‣ Peritumoural lymphovascular invasion:Present
 ‣ DCIS/EIC:Absent
 ‣ Margins:Free of tumour
 ‣ Pathological stage:pT2N0
 ‣ Biomarkers:
 ‣ Comments:

Case summary:

Postmenopausal woman presented with lump in the left breast. Diagnosed as left breast carcinoma, BI-RADS 5 on imaging, as breast carcinoma on cytology, and as invasive breast carcinoma of no specific type with medullary pattern, pT2N0 on histopathology.

Learning points:


  • Invasive breast cancers of no special type with medullary pattern are well-circumscribed breast cancers with high histological grade, pushing margins, syncytial architecture with no glandular structures, regions of necrosis, and a prominent infiltrate of tumour-infiltrating lymphocytes. They are often negative for hormone receptors (ER and PR) and HER2 (triple negative).

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