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Case number:113
Age:51
Clinical presentation:Postmenopausal woman with increased risk of developing breast cancer presents for a follow-up because she feels pain in her right breast. She has a strong family history of breast carcinoma. Clinical examination reveals different para-areolar consistencies on the right and left breasts. Comparison was made with a previous mammogram dated May 2015 (BI-RADS 2).


Mammography:


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

 ‣ Location of the lesion:May 2015: Right breast, upper outer quadrant at 10 o’clock, posterior third
 ‣ Mass:
   • Number:1
   • Size:1.2 cm in greatest dimension
   • 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 b (there are scattered areas of fibroglandular density)
Mammography features:

 ‣ Location of the lesion:2016: Right breast, upper outer quadrant at 10 o’clock, posterior third
 ‣ Mass:
   • Number:1
   • Size:1.2 cm in greatest dimension
   • Shape:Oval (stable lesion since 2015)
   • 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 b (there are scattered areas of fibroglandular density)
Mammography features:

 ‣ Location of the lesion:2016: Right breast, lower inner quadrant at 5 o’clock, middle third
 ‣ Mass:
   • Number:1 (this is a new finding, developing asymmetry)
   • Size:0.9 cm in greatest dimension
   • Shape:Irregular
   • 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

Ultrasound:


Ultrasound features: May 2015: Right breast, upper outer quadrant at 10 o‘clock

 ‣ Mass
   • Location:May 2015: Right breast, upper outer quadrant at 10 o‘clock
   • Number:1
   • Size:1.0 × 0.5 cm
   • Shape:Oval
   • Orientation:Parallel
   • Margins:Circumscribed
   • Echo pattern:Hypoechoic
   • Posterior features:No posterior features
 ‣ Calcifications:None
 ‣ Associated features:None
 ‣ Special cases:None


Ultrasound features: November 2015: Right breast, lower inner quadrant at 5 o‘clock

 ‣ Mass
   • Location:November 2015: Right breast, lower inner quadrant at 5 o‘clock
   • Number:1 (suspicious interval change)
   • Size:0.6 cm in greatest dimension
   • Shape:Irregular
   • Orientation:Parallel
   • Margins:Angular
   • Echo pattern:Hypoechoic
   • Posterior features:No posterior features
 ‣ Calcifications:None
 ‣ Associated features:None
 ‣ Special cases:None


Ultrasound features: March 2016: Right breast, lower inner quadrant at 5 o’clock

 ‣ Mass
   • Location:March 2016: Right breast, lower inner quadrant at 5 o’clock
   • Number:1
   • Size:0.9 cm in greatest dimension
   • Shape:Irregular
   • Orientation:Parallel
   • Margins:Angular and spiculated
   • Echo pattern:Hypoechoic
   • Posterior features:No posterior features
 ‣ Calcifications:None
 ‣ Associated features:Dilated duct
 ‣ Special cases:Developing asymmetry – interval cancer

BI-RADS:

BI-RADS Category (2015): 2 (benign)
BI-RADS Category (2016): 4C (high suspicion for malignancy)

Further assessment:

Further assessment advised: Referral for cytology

Cytology:

Cytology features:

 ‣ Type of sample:Ultrasound-guided FNAC
 ‣ Site of biopsy:
   • Laterality:Right
   • Quadrant:5 o’clock
   • Localization technique:1.5
   • Nature of aspirate:Whitish
 ‣ Cytological description:Smears reveal many dyscohesive clusters and many singly scattered large malignant cells with marked nuclear polymorphism, hyperchromasia, and abundant cytoplasm
 ‣ Reporting category:Malignant
 ‣ Diagnosis:Ductal carcinoma – high grade
 ‣ Comments:None


Histopathology:

Breast-conserving surgery



Histopathology features:

 ‣ Specimen type:Breast-conserving surgery
 ‣ Laterality:
 ‣ Macroscopy:
 ‣ Histological type:Invasive breast carcinoma of no special type
 ‣ Histological grade:Grade 3
 ‣ Mitosis:
 ‣ Maximum invasive tumour size:3
 ‣ Lymph node status:1/15
 ‣ Peritumoural lymphovascular invasion:Present
 ‣ DCIS/EIC:EIC present – high grade with necrosis
 ‣ Margins:Free of tumour
 ‣ Pathological stage:pT2N1
 ‣ Biomarkers:
 ‣ Comments:

Case summary:

Postmenopausal woman with increased risk of developing breast cancer presented for a follow-up because of pain in her right breast. Clinical examination reveals different para-areolar consistencies in the right and left breasts. Mammography and breast ultrasound dated 2016 reveal a new irregular lesion in right breast. Compared with a previous mammogram dated 2015, follow-up reveals developing asymmetry in the right breast. Interval change is seen. Diagnosed as highly suspicious for malignancy, BI-RADS 4C on imaging, as carcinoma on cytology, and as invasive breast carcinoma of no special type, pT2N1 on histopathology.

Learning points:


  • Family history in first-degree relatives (parents, siblings, and children) and second-degree relatives (such as aunts and cousins) on both sides of the family is an indication for the woman to follow high-risk screening guidelines.

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