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Case number:183
Age:71
Clinical presentation:Postmenopausal woman with average risk of developing breast cancer presented with a left breast lump noticed 6 months ago. On examination, abnormal unilateral reduction in the size of the left breast was noted. A hard lump was palpable in the lower inner quadrant of the left breast with skin retraction seen. The left nipple was retracted.



Mammography:


Breast composition:ACR category a (the breasts are almost entirely fatty)
Mammography features:

 ‣ Location of the lesion:Left breast, central portion of the breast at 8-10 o'clock, anterior, middle, and posterior thirds
 ‣ Mass:
   • Number:1
   • Size:2.6 × 2.0 cm
   • Shape:Irregular
   • Margins:Spiculated
   • Density:High
 ‣ Calcifications:
   • Typically benign:Vascular calcification in both breasts
   • Suspicious:None
   • Distribution:None
 ‣ Architectural distortion:Present
 ‣ Asymmetry:None
 ‣ Intramammary node:Present
 ‣ Skin lesion:None
 ‣ Solitary dilated duct:None
 ‣ Associated features:Left nipple retraction, skin thickening, skin retraction, and axillary lymphadenopathy


Breast composition:ACR category a (the breasts are almost entirely fatty)
Mammography features:

 ‣ Location of the lesion:Right breast, upper outer quadrant at 10 o’clock, middle third
 ‣ Mass:
   • Number:1
   • Size:1 cm
   • Shape:Round
   • Margins:Circumscribed
   • Density:Equal
 ‣ Calcifications:
   • Typically benign:Vascular calcification in both breasts
   • 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 8 o’clock

 ‣ Mass
   • Location:Left breast, lower inner quadrant at 8 o’clock
   • Number:1
   • Size:2.8 × 2.5 cm
   • Shape:Irregular
   • Orientation:Not parallel
   • Margins:Spiculated
   • Echo pattern:Hypoechoic
   • Posterior features:Strong posterior shadowing
 ‣ Calcifications:None
 ‣ Associated features:Skin thickening and enlarged left axillary node
 ‣ Special cases:None


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:0.8 cm
   • Shape:Round
   • 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 (left breast): 5 (highly suggestive of malignancy)
BI-RADS Category (right breast): 2 (benign)

Further assessment:

Further assessment advised: Referral for cytology and for core biopsy

Cytology:

Cytology features:

 ‣ Type of sample:FNAC
 ‣ Site of biopsy:
   • Laterality:Left
   • Quadrant:Inner lower
   • Localization technique:Palpation
   • Nature of aspirate:Whitish
 ‣ Cytological description:Smears are very cellular. They show loosely cohesive clusters and single isolated pleomorphic malignant ductal epithelial cells
 ‣ Reporting category:Malignant
 ‣ Diagnosis:Malignant
 ‣ Comments:None


Histopathology:

Core needle biopsy



Histopathology features:

 ‣ Specimen type:Core needle biopsy
 ‣ Laterality:Right
 ‣ Macroscopy:Three whitish cores (1.5 cm, 1.5 cm, and 1 cm long)
 ‣ Histological type:Invasive breast carcinoma of no special type
 ‣ Histological grade:Grade 3 (3 + 3 + 2 = 8)
 ‣ Mitosis:6
 ‣ Maximum invasive tumour size:
 ‣ Lymph node status:
 ‣ Peritumoural lymphovascular invasion:
 ‣ DCIS/EIC:
 ‣ Margins:
 ‣ Pathological stage:
 ‣ Biomarkers:
 ‣ Comments:

Case summary:

Postmenopausal woman presented with left breast lump. On examination, abnormal unilateral reduction in the size of the left breast was noted, with a hard lump in the left breast, skin retraction, and left nipple retraction. Diagnosed as left breast carcinoma with skin thickening and retraction, and left nipple retraction, BI-RADS 5 on imaging and as invasive breast carcinoma of no special type on histopathology.

Learning points:


  • Patients with locally advanced breast cancer, as in this case, whatever the subtype, are ideal candidates for neo-adjuvant therapy because their risk of distant recurrence warrants systemic treatment.
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