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Atlas of breast cancer early detection

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Case number:087
Clinical presentation:Premenopausal woman with average risk of developing breast cancer presented with a lump in the left breast noticed 1 month ago. On clinical examination, a single left upper quadrant lump 3 cm in diameter was found.


Breast composition:ACR category c (the breasts are heterogeneously dense, which may obscure small masses)
Mammography features:

 ‣ Location of the lesion:Left breast, upper outer quadrant at 12–1 o’clock, middle third
 ‣ Mass:
   • Number:1
   • Size:Not measurable in the dense breast parenchyma
   • Shape:Irregular
   • Margins:Indistinct
   • Density:High
 ‣ Calcifications:
   • Typically benign:None
   • Suspicious:None
   • Distribution:None
 ‣ Architectural distortion:Present
 ‣ Asymmetry:Focal
 ‣ Intramammary node:None
 ‣ Skin lesion:None
 ‣ Solitary dilated duct:None
 ‣ Associated features:Architectural distortion and axillary lymphadenopathy


Ultrasound features: Left breast, central portion of the breast, central quadrant at 12–1 o’clock

 ‣ Mass
   • Location:Left breast, central portion of the breast, central quadrant at 12–1 o’clock
   • Number:3
   • Size:Largest 2.2 × 1.7 cm
   • Shape:Irregular
   • Orientation:Not parallel
   • Margins:Indistinct
   • Echo pattern:Hypoechoic
   • Posterior features:No posterior features
 ‣ Calcifications:None
 ‣ Associated features:Internal vascularity
 ‣ Special cases:None


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

Further assessment:

Further assessment advised: Referral for core biopsy


Cytology features:

 ‣ Type of sample:FNAC (solid lesion)
 ‣ Site of biopsy:
   • Laterality:Left
   • Quadrant:Upper outer
   • Localization technique:Ultrasound-guided
   • Nature of aspirate:Whitish
 ‣ Cytological description:Smears show dyscohesive clusters of pleomorphic malignant cells
 ‣ Reporting category:Malignant
 ‣ Diagnosis:Carcinoma – high grade
 ‣ Comments:None


Core needle biopsy

Histopathology features:

 ‣ Specimen type:Core needle biopsy
 ‣ Laterality:Left
 ‣ Macroscopy:3 cores
 ‣ Histological type:Invasive carcinoma of no special type
 ‣ Histological grade:Grade 3 (3 + 2 + 2 = 7)
 ‣ Mitosis:11
 ‣ Maximum invasive tumour size:
 ‣ Lymph node status:
 ‣ Peritumoural lymphovascular invasion:
 ‣ Margins:
 ‣ Pathological stage:
 ‣ Biomarkers:Triple negative: ER negative (internal control positive), PR negative (internal control positive), and HER2/neu negative (score 0)
 ‣ Comments:

Case summary:

Premenopausal woman presented with left breast lump. Diagnosed as retroareolar high-density focal asymmetry in left breast, BI-RADS 4C on imaging, as left breast carcinoma, high grade on cytology, and as invasive carcinoma of no special type, triple negative on histopathology.

Learning points:

  • Supplementary ultrasound helps to provide detailed characterization of the morphological features of the clinically palpable lump as highly suspicious for malignancy. Biopsy recommended for confirmation.
  • Mammography with supplementary breast ultrasound reveals a mass with microlobulated or indistinct margins, no posterior features, and some vascularity on colour flow mapping. There is usually no calcification in triple-negative breast cancer.

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