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Case number:111
Age:69
Clinical presentation:Postmenopausal woman with average risk of developing breast cancer presented with a painful lump in her right breast. On clinical examination, she was found to have a large hard lump in the upper quadrant of her right breast with ulceration of the overlying skin.



Mammography:


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

 ‣ Location of the lesion:Right breast, upper outer quadrant at 11 o’clock, anterior, middle, and posterior thirds
 ‣ Mass:
   • Number:1
   • Size:7.2 × 4.7 × 5.3 cm
   • Shape:Irregular
   • Margins:Microlobulated
   • Density:High
 ‣ Calcifications:
   • Typically benign:Coarse heterogeneous
   • Suspicious:None
   • Distribution:None
 ‣ Architectural distortion:None
 ‣ Asymmetry:None
 ‣ Intramammary node:Reactive
 ‣ Skin lesion:None
 ‣ Solitary dilated duct:None
 ‣ Associated features:Skin retraction, coarse calcification, and axillary adenopathy

Ultrasound:


Ultrasound features: Right breast, upper outer quadrant at 11 o‘clock

 ‣ Mass
   • Location:Right breast, upper outer quadrant at 11 o‘clock
   • Number:1
   • Size:> 5.0 cm in greatest dimension
   • Shape:Irregular
   • Orientation:Not parallel
   • Margins:Angular
   • Echo pattern:Hypoechoic
   • Posterior features:Posterior shadowing
 ‣ Calcifications:Coarse calcifications in mass
 ‣ Associated features:Skin retraction and thickening, and metastatic axillary lymphadenopathy
 ‣ Special cases:None

BI-RADS:

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

Further assessment:

Further assessment advised: Referral for core biopsy

Histopathology:

MRM



Histopathology features:

 ‣ Specimen type:MRM
 ‣ Laterality:Right
 ‣ Macroscopy:On serial sectioning, a firm to hard, greyish white, well-circumscribed tumour is identified (4.5 × 4.0 × 3.5 cm) in the upper outer quadrant. Overlying skin shows an ulcerated indurated area (4.0 × 3.0 cm). The remaining breast tissue is unremarkable
 ‣ Histological type:Invasive carcinoma of no special type
 ‣ Histological grade:Grade 2 (2 + 2 + 1 = 5)
 ‣ Mitosis:8
 ‣ Maximum invasive tumour size:4.5 cm in greatest dimension
 ‣ Lymph node status:1/23
 ‣ Peritumoural lymphovascular invasion:Not identified
 ‣ DCIS/EIC:Not identified
 ‣ Margins:Skin ulceration and oedema
 ‣ Pathological stage:pT4bN1
 ‣ Biomarkers:
 ‣ Comments:Areas of calcification and ossification seen within the tumour

Case summary:

Postmenopausal woman presented with right breast lump with ulcerated skin. Diagnosed as right breast carcinoma with coarse calcifications within and overlying skin ulceration and thickening, BI-RADS 5 on imaging, as right breast carcinoma on cytology, and as invasive breast carcinoma of no special type, pT4bN1 on histopathology.

Learning points:


  • Tumour of any size with direct extension to the chest wall and/or to the skin (ulceration or skin nodules) is pT4 and will be in stage group IIIB, irrespective of nodal metastases (i.e. whether N0, N1, or N2).

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