Case number:	117
Age:	60
Clinical presentation:	Postmenopausal woman with increased risk because of a family history of breast cancer presented with increased size of the breast with pain. Examination revealed warmth and redness over the right breast with a large hard lump 8 cm in diameter. The lump was not fixed to the skin or the chest wall but she had nipple retraction on the same side.

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 10 o’clock, middle third
‣ Mass:
• Number:	1
• Size:	4.8 × 4.4 cm
• Shape:	Irregular
• Margins:	Spiculated
• Density:	High
‣ Calcifications:
• Typically benign:	None
• Suspicious:	None
• Distribution:	None
‣ Architectural distortion:	None
‣ Asymmetry:	Focal
‣ Intramammary node:	None
‣ Skin lesion:	None
‣ Solitary dilated duct:	None
‣ Associated features:	Skin thickening, trabecular thickening, metastatic, axillary lymphadenopathy, and architectural distortion

Ultrasound:

Ultrasound features: Right breast, upper outer quadrant at 10 o’clock

‣ Mass
• Location:	Right breast, upper outer quadrant at 10 o’clock
• Number:	1
• Size:	4.0 × 3.5 cm
• Shape:	Irregular
• Orientation:	Not parallel
• Margins:	Spiculated
• Echo pattern:	Hypoechoic
• Posterior features:	Posterior shadowing
‣ Calcifications:	None
‣ Associated features:	Architectural distortion, skin thickening (5 mm), oedema, internal vascularity, and enlarged right axillary lymph nodes with thickened cortex
‣ Special cases:	None

Ultrasound features: Right axillary tail

‣ Mass
• Location:	Right axillary tail
• Number:	1
• Size:	2.4 × 1.9 cm
• Shape:	Irregular
• Orientation:	Not parallel
• Margins:	Spiculated
• Echo pattern:	Hypoechoic
• Posterior features:	Posterior shadowing
‣ Calcifications:	None
‣ Associated features:	Internal vascularity and enlarged right axillary lymph nodes
‣ Special cases:	None

BI-RADS:

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

Further assessment:

Further assessment advised: Referral for cytology

Cytology:

Cytology features:

‣ Type of sample:	FNAC
‣ Site of biopsy:
• Laterality:	Right
• Quadrant:	Upper outer
• Localization technique:	Palpation
• Nature of aspirate:	whitish
‣ Cytological description:	Smears are very cellular and have loosely cohesive clusters of malignant ductal cells. These cells have large irregular nuclei with prominent nucleoli
‣ Reporting category:	Malignant
‣ Diagnosis:	Carcinoma
‣ Comments:	None

Case summary:

Postmenopausal woman presented with a rapidly increasing painful right breast lump. Diagnosed as inflammatory right breast carcinoma with breast oedema and skin thickening, BI-RADS 5 on imaging and as breast carcinoma on cytology.

Learning points:

Inflammatory breast cancer is a more aggressive type of invasive carcinoma, which develops rapidly over a few weeks or months. Breast skin thickening and oedema limit the evaluation on mammography where focal or global asymmetry is seen. Breast ultrasound can be used to detail the morphology of the irregular malignant mass, to indicate features of breast oedema, and to monitor the extent of disease progression.
Neo-adjuvant chemotherapy with possible hormone and targeted therapy is the treatment of choice to reduce the tumour size before definitive surgical management.