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Case number:	074
Age:	59
Clinical presentation:	Postmenopausal woman with average risk of developing breast cancer presented with a left breast lump. Examination revealed a lump 3 cm in diameter in the lower inner quadrant of the left breast.

Mammography:

Breast composition:	ACR category a (the breasts are almost entirely fatty)
Mammography features:
‣ Location of the lesion:	Lesion 1: Left breast, lower inner quadrant at 8 o’clock, posterior third, at 6.4 cm from the nipple just beneath the dermis
‣ Mass:
• Number:	1
• Size:	2.6 × 1.7 cm
• Shape:	Irregular
• Margins:	Indistinct
• Density:	High
‣ 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:	Left enlarged lymph node (1.2 × 1.0 cm) with thickened cortex 4.2 mm

Breast composition:	ACR category a (the breasts are almost entirely fatty)
Mammography features:
‣ Location of the lesion:	Lesion 2: Left breast, central portion of the breast, central zone at 6 o’clock, posterior third, approximately 7.0 cm superolateral to the primary mass lesion
‣ Mass:
• Number:	1
• Size:	1.1 × 0.6 cm
• Shape:	Irregular
• Margins:	Indistinct
• Density:	High
‣ 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:	Left enlarged lymph node (1.2 × 1.0 cm) with thickened cortex 4.2 mm

Breast composition:	ACR category a (the breasts are almost entirely fatty)
Mammography features:
‣ Location of the lesion:	Lesion 3: Left breast, upper inner quadrant at 9–10 o’clock, middle third
‣ Mass:
• Number:	1
• Size:	0.9 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:	Left enlarged lymph node (1.2 × 1.0 cm) with thickened cortex 4.2 mm

Breast composition:	ACR category a (the breasts are almost entirely fatty)
Mammography features:
‣ Location of the lesion:	Right breast, central portion of the breast at 12 o’clock, posterior third
‣ Mass:
• Number:	1
• Size:	1.5 × 1.2 cm
• 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

Ultrasound:

Ultrasound features: Left breast, lower inner quadrant at 7–8 o’clock
‣ Mass
• Location:	Left breast, lower inner quadrant at 7–8 o’clock
• Number:	1
• Size:	2.7 × 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

Ultrasound features: Left breast, lower quadrants at 6 o’clock
‣ Mass
• Location:	Left breast, lower quadrants at 6 o’clock
• Number:	1
• Size:	0.8 × 0.6 cm
• Shape:	Irregular
• Orientation:	Not parallel
• Margins:	Spiculated
• Echo pattern:	Hypoechoic
• Posterior features:	No posterior features
‣ Calcifications:	None
‣ Associated features:	None
‣ Special cases:	None

Ultrasound features: Left breast, outer quadrants at 9 o’clock
‣ Mass
• Location:	Left breast, outer quadrants at 9 o’clock
• Number:	1
• Size:	0.9 cm in greatest dimension
• Shape:	Oval
• Orientation:	Parallel
• Margins:	Circumscribed
• Echo pattern:	Hypoechoic
• Posterior features:	No posterior features
‣ Calcifications:	None
‣ Associated features:	None
‣ Special cases:	None

Ultrasound features: Right breast, upper quadrants at 12 o’clock
‣ Mass
• Location:	Right breast, upper quadrants at 12 o’clock
• Number:	1
• Size:	1.0 × 0.6 cm
• Shape:	Oval
• Orientation:	Parallel
• Margins:	Circumscribed
• Echo pattern:	Hypoechoic
• Posterior features:	No posterior features
‣ Calcifications:	None
‣ Associated features:	None
‣ 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:	Left
• Quadrant:	Lower inner
• Localization technique:	Palpation
• Nature of aspirate:	Whitish
‣ Cytological description:	Smears are very cellular with loose clusters of highly pleomorphic malignant cells
‣ Reporting category:	Malignant
‣ Diagnosis:	Carcinoma – high grade
‣ Comments:	None

Histopathology:

MRM

Histopathology features:
‣ Specimen type:	MRM
‣ Laterality:	Left
‣ Macroscopy:	On serial sectioning three tumours are identified: Lesion 1: A nodular greyish white tumour (3.0 × 2.9 × 2.4 cm) located in the inferior half of the specimen. It is 0.2 cm from the skin and 1.3 cm from the base Lesion 2: Another firm greyish area (2.0 × 2.0 × 1.8 cm) 1.4 cm away from lesion 1. This is 1.5 cm from overlying skin and 0.3 cm from the base Lesion 3: A firm white area (1.1 × 1.0 × 1.0 cm) 2.0 cm from lesion 2 and 5.0 cm from lesion 1. It is 1.2 cm from the base and 2.0 cm from the skin
‣ Histological type:	Invasive carcinoma of no special type
‣ Histological grade:	Grade 2 (3 + 2 + 2 = 7)
‣ Mitosis:	12
‣ Maximum invasive tumour size:	Largest 3.0 cm (others 2.0 cm and 1.1 cm)
‣ Lymph node status:	2/21
‣ Peritumoural lymphovascular invasion:	Present
‣ DCIS/EIC:	Solid, cribriform, and comedo type – intermediate nuclear grade
‣ Margins:	Free of tumour
‣ Pathological stage:	pT2(3)N1
‣ Biomarkers:
‣ Comments:

Case summary:

Postmenopausal woman presented with lump in the left breast, diagnosed as left breast multicentric carcinoma, BI-RADS category 5 on imaging, as breast carcinoma on cytology, and as invasive breast carcinoma of no special type, pT2(3)N1 on histopathology.

Learning points:

Up to 10% of women have occult multicentric or multifocal foci on imaging or histology. Clinical presentation in this case was of a single, left, parasternal, far medial, palpable mass lesion. Imaging was done for preoperative workup, where additional foci of suspicion were seen on mammography. On additional views or spot compression magnification views, these suspicious foci showed features of malignancy.