Case number:	078
Age:	65
Clinical presentation:	Postmenopausal woman with average risk of developing breast cancer presented with right nipple–areolar ulceration and itching. On clinical examination, a hard lump was felt in the right breast in the retroareolar region.

Mammography:

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

‣ Location of the lesion:	Right breast, lower inner quadrant at 5 o’clock, anterior third
‣ Mass:
• Number:	1
• Size:	1.9 × 1.8 cm
• Shape:	Round
• Margins:	Indistinct
• Density:	High
‣ Calcifications:
• Typically benign:	None
• Suspicious:	None
• Distribution:	None
‣ Architectural distortion:	Present
‣ Asymmetry:	Focal, central quadrant
‣ Intramammary node:	None
‣ Skin lesion:	None
‣ Solitary dilated duct:	None
‣ Associated features:	Skin thickening, axillary adenopathy, and architectural distortion

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

‣ Location of the lesion:	Right breast, lower inner quadrant at 4 o’clock, middle third
‣ Mass:
• Number:	2
• Size:	0.5 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: Right breast, lower inner quadrant at 5 o’clock

‣ Mass
• Location:	Right breast, lower inner quadrant at 5 o’clock
• Number:	1
• Size:	1.7 × 1.3 cm
• Shape:	Irregular
• Orientation:	Not parallel
• Margins:	Spiculated
• Echo pattern:	Hypoechoic
• Posterior features:	No posterior features
‣ Calcifications:	None
‣ Associated features:	Skin thickening, architectural distortion, and internal vascularity
‣ Special cases:	None

Ultrasound features: Right breast, lower inner quadrant at 4 o’clock

‣ Mass
• Location:	Right breast, lower inner quadrant at 4 o’clock
• Number:	1
• Size:	0.5 cm in greatest dimension
• Shape:	Irregular
• Orientation:	Not parallel
• Margins:	Spiculated
• Echo pattern:	Hypoechoic
• Posterior features:	No posterior features
‣ Calcifications:	None
‣ Associated features:	Internal vascularity
‣ 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 (solid lesion)
‣ Site of biopsy:
• Laterality:	Right
• Quadrant:
• Localization technique:	Palpation
• Nature of aspirate:
‣ Cytological description:	Cellular smears with many single isolated malignant cells and dyscohesive malignant cell clusters
‣ Reporting category:	Malignant
‣ Diagnosis:	Carcinoma
‣ Comments:	None

Histopathology:

MRM

Histopathology features:

‣ Specimen type:	MRM
‣ Laterality:	Right
‣ Macroscopy:	The nipple and areola are flattened and this area is seen as an indurated firm whitish area (3.0 × 2.5 cm). On serial sectioning, a greyish white tumour (2.3 × 2.0 × 2.0 cm) is identified, located below the areola. It is 1.0 cm from the skin and 2.5 cm from the base
‣ Histological type:	Invasive carcinoma of no special type
‣ Histological grade:	Grade 3 (3 + 3 + 3 = 9)
‣ Mitosis:	22
‣ Maximum invasive tumour size:	2.3 cm in greatest dimension
‣ Lymph node status:	24/24
‣ Peritumoural lymphovascular invasion:	Present
‣ DCIS/EIC:	Comedo – high grade
‣ Margins:	Posterior margin is free of tumour and areolar skin is ulcerated
‣ Pathological stage:	pT4bN3
‣ Biomarkers:
‣ Comments:

Case summary:

Postmenopausal woman presented with right breast lump, nipple–areolar ulceration, and itching. Diagnosed as right breast carcinoma with right areolar skin thickening and right nipple excoriation, BI-RADS 5 on imaging, as right breast carcinoma on cytology, and as invasive breast carcinoma of no special type, pT4bN3 on histopathology.

Learning points:

Patient presented with a lump and ulceration of the nipple. Paget disease of the nipple has different clinical appearances; here it corresponds to late-stage disease with a scaly, erythematous lesion with ulcerations and nipple flattening.