Case number:	072
Age:	58
Clinical presentation:	Postmenopausal woman with average risk of developing breast cancer presented with a lump in her right breast. On clinical examination, she had a hard lump in the upper quadrant of the right breast.

Mammography:

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

‣ Location of the lesion:	Right breast, upper inner quadrant at 12-1 o’clock, posterior third
‣ Mass:
• Number:	2
• Size:	2.0 × 1.4 cm and 0.8 × 0.5 cm
• Shape:	Irregular
• Margins:	Microlobulated
• 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: Right breast, upper quadrants at 12 o’clock

‣ Mass
• Location:	Right breast, upper quadrants at 12 o’clock
• Number:	1
• Size:	2.2 × 1.6 cm
• Shape:	Irregular
• Orientation:	Not parallel
• Margins:	Angular
• Echo pattern:	Hypoechoic
• Posterior features:	No posterior features
‣ Calcifications:	None
‣ Associated features:	Internal vascularity
‣ Special cases:	None

Ultrasound features: Right breast, upper inner quadrant at 1 o’clock

‣ Mass
• Location:	Right breast, upper inner quadrant at 1 o’clock
• Number:	1
• Size:	1.0 × 0.6 cm
• Shape:	Irregular
• Orientation:	Not parallel
• Margins:	Angular
• Echo pattern:	Hypoechoic
• Posterior features:	No posterior features
‣ Calcifications:	None
‣ 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:	Right
• Quadrant:	Upper inner
• Localization technique:	Palpation
• Nature of aspirate:	Whitish
‣ Cytological description:	Smears are very cellular and show loosely cohesive sheets of larger ductal epithelial cells with high N:C ratio, pleomorphism, and hyperchromatic nuclei
‣ Reporting category:	Malignant
‣ Diagnosis:	Carcinoma
‣ Comments:	None

Histopathology:

MRM

Histopathology features:

‣ Specimen type:	MRM
‣ Laterality:	Right
‣ Macroscopy:	On serial sectioning, two nodules 2.2 × 1.6 × 1.0 cm and 1.0 × 0.8 × 0.4 cm were seen 4.0 cm apart. Both were well circumscribed and firm in consistency
‣ Histological type:	Invasive breast carcinoma of no special type
‣ Histological grade:	Grade 3 (3 + 3 + 2 = 8)
‣ Mitosis:	14
‣ Maximum invasive tumour size:	Largest 2.2 cm (another smaller at 1.0 cm)
‣ Lymph node status:	0/26
‣ Peritumoural lymphovascular invasion:	Not identified
‣ DCIS/EIC:	Solid and cribriform – intermediate grade
‣ Margins:	Free of tumour
‣ Pathological stage:	pT2(2)N0
‣ Biomarkers:
‣ Comments:

Case summary:

Postmenopausal woman presented with lump in the right breast. Diagnosed as right breast carcinoma (multifocal), BI-RADS 5 on imaging, as breast carcinoma on cytology, and as invasive breast carcinoma of no special type, pT2(2)N0 on histopathology.

Learning points:

When there are two distinct breast tumours, the T category should be determined by the characteristics of the larger or higher T category cancer.