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Case number:071
Age:74
Clinical presentation:Postmenopausal woman with a family history of breast cancer in her mother, presented with a left breast lump. On examination, she had two lumps palpable in her left breast. The larger lump was in the lower inner quadrant, 3 cm in diameter, hard, and fixed to the muscle. The other lump was 2 cm in diameter and in the upper outer quadrant.


Mammography:


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

 ‣ Location of the lesion:Left breast, upper outer quadrant at 2 o’clock, posterior third
 ‣ Mass:
   • Number:1
   • Size:2.8 × 2.3 cm
   • Shape:Irregular
   • Margins:Spiculated
   • Density:High
 ‣ Calcifications:
   • Typically benign:None
   • Suspicious:Suspicious calcifications
   • Distribution:Groups of pleomorphic calcifications within the mass
 ‣ Architectural distortion:None
 ‣ Asymmetry:None
 ‣ Intramammary node:None
 ‣ Skin lesion:None
 ‣ Solitary dilated duct:None
 ‣ Associated features:None


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

 ‣ Location of the lesion:Left breast, lower inner quadrant at 8–9 o’clock, posterior third
 ‣ Mass:
   • Number:1
   • Size:3.0 × 2.5 cm
   • Shape:Irregular
   • Margins:Spiculated
   • Density:High
 ‣ Calcifications:
   • Typically benign:None
   • Suspicious:Fine linear and pleomorphic microcalcifications
   • Distribution:Groups of pleomorphic calcifications within the mass
 ‣ Architectural distortion:None
 ‣ Asymmetry:Focal
 ‣ Intramammary node:None
 ‣ Skin lesion:None
 ‣ Solitary dilated duct:None
 ‣ Associated features:Fine linear pleomorphic microcalcifications within the mass

Ultrasound:


Ultrasound features: Left breast, upper outer quadrant at 2 o’clock and inner quadrant at 8–9 o’clock

 ‣ Mass
   • Location:Left breast, upper outer quadrant at 2 o’clock and inner quadrant at 8–9 o’clock
   • Number:2
   • Size:
  • Lesion 1: 2.5 × 2.3 cm in upper outer quadrant at 2 o’clock position
  • Lesion 2: 2.6 × 2.0 cm in lower inner quadrant at 9 o’clock position
   • Shape:Irregular
   • Orientation:Not parallel
   • Margins:Spiculated
   • Echo pattern:Hypoechoic
   • Posterior features:Posterior shadowing
 ‣ Calcifications:Calcifications in mass at 9 o’clock
 ‣ Associated features: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 (solid lesion)
 ‣ Site of biopsy:
   • Laterality:Left
   • Quadrant:Upper outer
   • Localization technique:Palpation
   • Nature of aspirate:Whitish
 ‣ Cytological description:Paucicellular, a few scattered single isolated malignant seen in the smears. Many fibrous tissue fragments seen
 ‣ Reporting category:Malignant
 ‣ Diagnosis:Carcinoma
 ‣ Comments:None


Histopathology:

MRM



Histopathology features:

 ‣ Specimen type:MRM
 ‣ Laterality:Left
 ‣ Macroscopy:On serial sectioning, a greyish white tumour (3.5 × 2.5 × 2.5 cm) was identified. Two centimetres lateral to this tumour is another tumour (2.0 × 2.0 × 1.5 cm)
 ‣ Histological type:Invasive carcinoma of no special type
 ‣ Histological grade:Grade 2 (3 + 2 + 2 = 7)
 ‣ Mitosis:12
 ‣ Maximum invasive tumour size:Largest 4.0 cm in greatest dimension (smaller one 2.0 cm)
 ‣ Lymph node status:0/15
 ‣ Peritumoural lymphovascular invasion:Not identified
 ‣ DCIS/EIC:Comedo, cribriform – high grade
 ‣ Margins:Free of tumour
 ‣ Pathological stage:pT2(2)N0
 ‣ Biomarkers:
 ‣ Comments:Stroma shows dense fibrosis and desmoplasia. Focal area of calcification present

Case summary:

Postmenopausal woman presented with two palpable lumps in the upper inner and lower outer quadrants of left breast. Diagnosed as left breast multicentric carcinoma, BI-RADS 5 on imaging, as carcinoma breast on cytology, and as invasive breast carcinoma of no special type, pT2(2)N0 on histopathology.

Learning points:



  • Two or more than two separate mass lesions of breast cancer, typically in different quadrants of the breast, usually in different ductal systems and > 5 cm apart from each other is called multicentric breast cancer. In patients undergoing mastectomy for breast cancer, more than one focus of cancer will be seen in up to 40% of the specimens.
  • In this case, two lesions are seen – one in the upper outer quadrant and another in the inner quadrant of the left breast.
  • Multicentric breast cancer is more common in women with family history of breast cancer, as seen in this case. The patient has history of breast cancer in her mother.

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