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Atlas of breast cancer early detection

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Case number:063
Clinical presentation:Premenopausal woman with average risk of developing breast cancer presented with a rapidly growing left breast lump. On examination, she was found to have a large firm to hard lump in her left breast.


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

 ‣ Location of the lesion:Left breast, lower outer quadrant at 5 o’clock, anterior, middle, and posterior thirds
 ‣ Mass:
   • Number:1
   • Size:5.5 × 4.0 cm
   • Shape:Oval
   • Margins:Circumscribed
   • 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 features: Left breast, lower outer quadrant at 5 o’clock

 ‣ Mass
   • Location:Left breast, lower outer quadrant at 5 o’clock
   • Number:1
   • Size:5.2 × 4.0 cm
   • Shape:Irregular
   • Orientation:Parallel
   • Margins:Indistinct
   • Echo pattern:Heterogeneous with areas of breakdown
   • Posterior features:No posterior features
 ‣ Calcifications:None
 ‣ Associated features:Internal vascularity in mass. Enlarged lymph nodes (2.0 × 1.3 cm and 2.0 × 0.7 cm) with loss of central fatty hilum
 ‣ Special cases:None


BI-RADS Category: 4C (high suspicion for malignancy)

Further assessment:

Further assessment advised: Referral for cytology


Cytology features:

 ‣ Type of sample:FNAC (solid lesion)
 ‣ Site of biopsy:
   • Laterality:Left
   • Quadrant:Lower outer
   • Localization technique:Palpation
   • Nature of aspirate:Whitish
 ‣ Cytological description:Highly pleomorphic malignant cells seen with lymphocytes in the background
 ‣ Reporting category:Malignant
 ‣ Diagnosis:Carcinoma – high grade
 ‣ Comments:None


Breast-conserving surgery

Histopathology features:

 ‣ Specimen type:Breast-conserving surgery
 ‣ Laterality:Left
 ‣ Macroscopy:Cut surface shows a large, greyish white, well-circumscribed tumour (5.5 × 5.0 × 4.0 cm) (T3) with a soft central necrotic area
 ‣ Histological type:Invasive breast carcinoma of no special type with medullary pattern
 ‣ Histological grade:Grade 3 (3 + 2 + 2 = 7)
 ‣ Mitosis:15
 ‣ Maximum invasive tumour size:5.5 cm in greatest dimension
 ‣ Lymph node status:1/24
 ‣ Peritumoural lymphovascular invasion:Not identified
 ‣ DCIS/EIC:Not identified
 ‣ Margins:Free of tumour
 ‣ Pathological stage:pT3N1
 ‣ Biomarkers:
 ‣ Comments:Extensive areas of tumour necrosis seen

Case summary:

Premenopausal woman presented with lump in the left breast. Diagnosed as circumscribed high-density mass with perilesional halo, with left axillary enlarged node of altered morphology, BI-RADS 4C on imaging, as breast carcinoma on cytology, and as invasive breast carcinoma of no specific type with medullary pattern, pT3N1 on histopathology.

Learning points:

  • “Medullary” carcinoma is a subtype of breast carcinoma and is so-called because the tumour is a soft, fleshy mass that resembles the medulla of the brain. The large tumour with extensive necrosis is seen to displace the adjacent breast parenchyma with perilesional halo, thus forming a clear boundary between the tumour and the normal breast tissue.

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