Case number:	077
Age:	65
Clinical presentation:	Postmenopausal woman with average risk of developing breast cancer presented with an ulcer on the upper quadrant of the left breast. Examination revealed a hard irregular lump involving underlying breast and the overlying skin.

Mammography:

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

‣ Location of the lesion:	Left breast, upper quadrants at 12 o’clock, posterior third
‣ Mass:
• Number:	1
• Size:	3.6 × 2.5 cm
• Shape:	Irregular
• Margins:	Spiculated
• 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:	Skin retraction and skin thickening

Ultrasound:

Ultrasound features: Left breast, upper quadrants at 12 o’clock

‣ Mass
• Location:	Left breast, upper quadrants at 12 o’clock
• Number:	1
• Size:	3.5 × 3.0 cm
• Shape:	Irregular
• Orientation:	Not parallel
• Margins:	Spiculated
• Echo pattern:	Hypoechoic
• Posterior features:	Posterior shadowing
‣ Calcifications:	None
‣ Associated features:	Skin thickening, skin retraction, and vessels in rim
‣ Special cases:	None

BI-RADS:

BI-RADS Category: 5 (highly suggestive of malignancy)

Further assessment:

Further assessment advised: Referral for core biopsy

Cytology:

Cytology features:

‣ Type of sample:	FNAC (solid lesion)
‣ Site of biopsy:
• Laterality:	Left
• Quadrant:	Upper at 12 o’clock
• Localization technique:	Palpation
• Nature of aspirate:	Whitish
‣ Cytological description:	Loosely cohesive malignant cell clusters with many scattered single isolated cells
‣ Reporting category:	Malignant
‣ Diagnosis:	Carcinoma
‣ Comments:	None

Histopathology:

Breast-conserving surgery

Histopathology features:

‣ Specimen type:	Breast-conserving surgery
‣ Laterality:	Left
‣ Macroscopy:	Specimen of left breast lumpectomy 9.5 × 6.0 × 3.5 cm with an elliptical flap of skin 9.2 × 4.5 cm. Skin appears puckered in the centre. Cut surface shows a tumour 3.0 × 2.5 × 2.1 cm. The tumour is firm, greyish white with infiltrating margins. The tumour is flush with the skin, 0.2 cm from the base, 4.0 cm from the superior margin, 3.0 cm from the inferior margin, 1.8 cm from the lateral margin, and 1.3 cm from the medial margin
‣ Histological type:	Invasive carcinoma of no special type
‣ Histological grade:	Grade 3 (3 + 3 + 2 = 8)
‣ Mitosis:	15
‣ Maximum invasive tumour size:	3 cm in greatest dimension
‣ Lymph node status:	5/15
‣ Peritumoural lymphovascular invasion:	Present
‣ DCIS/EIC:	Not identified
‣ Margins:	Posterior margin is free of tumour, involving skin
‣ Pathological stage:	pT4bN2
‣ Biomarkers:
‣ Comments:	Foci of calcification seen

Case summary:

Postmenopausal woman presented with ulcerated skin in left axilla. Diagnosed as left breast carcinoma with overlying skin retraction and ulceration, BI-RADS 5 on imaging, as left breast carcinoma on cytology, and as invasive breast carcinoma of no special type, pT4bN2 on histopathology.

Learning points:

Skin retraction and ulceration with breast cancer is suggestive of locally advanced superficial breast cancer adjacent to the region of skin changes. Mass lesions deep within the breast may also show skin changes in long-standing cancer of advanced stage with involvement and tethering of the ligaments of Cooper and the retinacula cutis.