Go back to the list of case studies
                                                                                                                         Click on the pictures to magnify and display the legends

Case number:	076
Age:	40
Clinical presentation:	Premenopausal woman presented to surgical unit with pain in abdomen. Ultrasound of the abdomen revealed focal hepatic lesions of indeterminate aetiology, suspicious of metastatic foci. Clinical examination to look for primary revealed bilateral breast lumps.

Mammography:

Breast composition:	ACR category c (the breasts are heterogeneously dense, which may obscure small masses)
Mammography features:
‣ Location of the lesion:	Right breast, upper outer quadrant at 10 o’clock, middle third
‣ Mass:
• Number:	1
• Size:	1.8 × 0.8 cm
• Shape:	Oval
• Margins:	Indistinct
• Density:	Equal
‣ 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

Breast composition:	ACR category c (the breasts are heterogeneously dense, which may obscure small masses)
Mammography features:
‣ Location of the lesion:	Right breast, upper inner quadrant at 1 o’clock, posterior third
‣ Mass:
• Number:	1
• Size:	2.2 × 1.4 cm
• Shape:	Oval
• Margins:	Circumscribed
• Density:	Fat-containing
‣ 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

Breast composition:	ACR category c (the breasts are heterogeneously dense, which may obscure small masses)
Mammography features:
‣ Location of the lesion:	Right breast, inner quadrants at 3 o’clock, middle third
‣ Mass:
• Number:	1
• Size:	2.0 × 1.0 cm
• Shape:	Oval
• Margins:	Circumscribed
• Density:	Equal
‣ 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

Breast composition:	ACR category c (the breasts are heterogeneously dense, which may obscure small masses)
Mammography features:
‣ Location of the lesion:	Left breast, inner quadrants at 9 o’clock, middle and posterior thirds
‣ Mass:
• Number:	1
• Size:	4.5 × 2.0 cm
• Shape:	Irregular
• Margins:	Spiculated
• Density:	High
‣ Calcifications:
• Typically benign:	None
• Suspicious:	Fine linear and pleomorphic microcalcifications
• Distribution:	None
‣ Architectural distortion:	None
‣ Asymmetry:	None
‣ Intramammary node:	None
‣ Skin lesion:	None
‣ Solitary dilated duct:	None
‣ Associated features:	Left axillary adenopathy and round enlarged node in left axilla with loss of fatty hilum

Ultrasound:

Ultrasound features: Right breast, upper and lower quadrants at 4-12 o'clock
‣ Mass
• Location:	Right breast, upper and lower quadrants at 4-12 o'clock
• Number:	Multiple
• Size:	Lesion 1: 1.5 × 0.8 cm at 10 o’clock Lesion 2: 2.0 × 1.0 cm at 5 o’clock Lesion 3: 2.2 × 1.4 cm and 1.8 × 0.8 cm at 12 o’clock Lesion 4: 0.5 cm in greatest dimension at 8 o’clock Lesion 5: 0.7 cm in greatest dimension at 4 o’clock
• Shape:	Oval
• Orientation:	Parallel
• Margins:	Lesion 1: Indistinct, lesions 2–5: Circumscribed
• Echo pattern:	Hypoechoic
• Posterior features:	No posterior features
‣ Calcifications:	None
‣ Associated features:	None
‣ Special cases:	None

Ultrasound features: Left breast, inner quadrants
‣ Mass
• Location:	Left breast, inner quadrants
• Number:	1
• Size:	4.5 × 2.0 cm
• Shape:	Irregular
• Orientation:	Parallel
• Margins:	Angular
• Echo pattern:	Heteroechoic
• Posterior features:	No posterior features
‣ Calcifications:	Present in mass
‣ Associated features:	Internal vascularity and calcifications
‣ Special cases:	None

BI-RADS:

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

Further assessment:

Further assessment advised: Referral for cytology

Cytology:

Cytology features:
‣ Type of sample:	FNAC
‣ Site of biopsy:
• Laterality:	Right
• Quadrant:
• Localization technique:	Palpation
• Nature of aspirate:	Whitish
‣ Cytological description:	Smears from right breast lump reveal many loosely cohesive clusters and singly scattered atypical cells with large hyperchromatic and pleomorphic nuclei and moderate cytoplasm. Many large multinucleate cells seen
‣ Reporting category:	Malignant
‣ Diagnosis:	Carcinoma
‣ Comments:	None

Cytology features:
‣ Type of sample:	FNAC
‣ Site of biopsy:
• Laterality:	Left
• Quadrant:	Inner
• Localization technique:	Palpation
• Nature of aspirate:	Whitish
‣ Cytological description:	Smears reveal many loosely cohesive clusters and single scattered malignant cells with moderate cytoplasm and hyperchromatic pleomorphic nuclei. Nucleoli are seen in many cells. A few tightly cohesive benign clusters are also noted
‣ Reporting category:	Malignant
‣ Diagnosis:	Carcinoma
‣ Comments:	None

Systemic metastatic workup:

Case summary:

Premenopausal woman presented with pain in abdomen. Ultrasound of the abdomen revealed focal hepatic lesions of indeterminate aetiology, suspicious of metastatic foci. Further clinical examination revealed bilateral breast lumps. Patient was diagnosed as left breast suspicious mass with enlarged left axillary node, likely metastatic node, and right breast mass with features suspicious for malignancy, BI-RADS 4C – bilateral – synchronous on imaging and as bilateral breast carcinoma on cytology.

Learning points:

Patients with evidence of local, regional, or distant metastasis, as seen in this case, are at a higher risk of having metastatic disease in the contralateral breast than of having a primary cancer. Here the patient presented with abdominal pain, which showed hepatic lesions, suspicious of metastasis on imaging. Detailed investigations for primary lesions revealed bilateral breast cancer. Bilateral synchronous breast carcinomas of advanced stage at time of presentation and diagnosis with distant metastasis to liver and bony skeleton need extensive workup. Emphasis is on the role of careful survey of the breast in patients with metastatic disease incidentally picked up on imaging and with clinical suspicion of breast cancer. Ultrasound delineates morphology in mammographically dense breasts.