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Case number:184
Clinical presentation:Postmenopausal woman with average risk of developing breast cancer presented with a left breast lump. Examination revealed a hard lump in the outer quadrant of the left breast.


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

 ‣ Location of the lesion:Left breast, upper outer quadrant at 12–2 o’clock, anterior and middle thirds
 ‣ Mass:
   • Number:None
   • Size:None
   • Shape:None
   • Margins:None
   • Density:None
 ‣ Calcifications:
   • Typically benign:None
   • Suspicious:Fine pleomorphic microcalcifications in segmental distribution and in clusters and in linear branching pattern
   • Distribution:None
 ‣ Architectural distortion:None
 ‣ Asymmetry:Present
 ‣ Intramammary node:None
 ‣ Skin lesion:None
 ‣ Solitary dilated duct:None
 ‣ Associated features:Skin thickening


Ultrasound features: Left breast, upper outer quadrant at 12–2 o’clock

 ‣ Mass
   • Location:Left breast, upper outer quadrant at 12–2 o’clock
   • Number:Multiple small
   • Size:< 1 cm
   • Shape:Irregular
   • Orientation:Not parallel
   • Margins:Indistinct and angular
   • Echo pattern:Heteroechoic
   • Posterior features:No posterior features
 ‣ Calcifications:Intraductal microcalcifications
 ‣ Associated features:Axillary lymphadenopathy
 ‣ Special cases:Solitary dilated duct


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

Further assessment:

Further assessment advised: Referral for cytology


Cytology features:

 ‣ Type of sample:FNAC
 ‣ Site of biopsy:
   • Laterality:Left
   • Quadrant:Upper outer quadrant
   • Localization technique:Palpation
   • Nature of aspirate:Whitish, blood tinged
 ‣ Cytological description:Smears are very cellular and show dyscohesive clusters of pleomorphic malignant cells
 ‣ Reporting category:Malignant
 ‣ Diagnosis:Carcinoma breast
 ‣ Comments:None



Histopathology features:

 ‣ Specimen type:MRM
 ‣ Laterality:Left
 ‣ Macroscopy:Left MRM specimen (24.0 × 16.0 × 7.5 cm) with skin flap (11.0 × 6.5 cm). On serial sectioning, a firm greyish white area (6.0 × 3.0 × 3.0 cm) is seen in the upper outer quadrant and extending to the lower outer quadrant. A second firm area (1.5 × 1.0 × 1.0 cm) is seen 3 cm medial to the first firm area in the upper inner quadrant. The intervening breast parenchyma shows interspersed whitish calcified areas
 ‣ Histological type:Microinvasive breast carcinoma
 ‣ Histological grade:Grade 2 (3 + 2 + 2 = 7)
 ‣ Mitosis:12
 ‣ Maximum invasive tumour size:Six foci of microinvasive breast carcinoma; all < 0.1 cm in greatest dimension
 ‣ Lymph node status:0/10
 ‣ Peritumoural lymphovascular invasion:Absent
 ‣ DCIS/EIC:DCIS of cribriform, comedocarcinoma, and solid type, high grade with necrosis in both the firm areas seen grossly. EIC present. Multiple foci of DCIS extending over 6 cm in greatest dimension
 ‣ Margins:Free of tumour
 ‣ Pathological stage:pT1miNo
 ‣ Biomarkers:ER positive, PR positive, and HER2 negative
 ‣ Comments:The adjacent breast also shows lobular mastitis with a chronic inflammatory infiltrate

Case summary:

Postmenopausal woman presented with a left breast lump. Diagnosed as solitary dilated duct with fine pleomorphic microcalcifications in segmental distribution and in clusters and in linear branching pattern, BI-RADS 5 on imaging, as breast carcinoma on cytology, and as microinvasive breast carcinoma pT1miN0 with EIC on histopathology.

Learning points:

EIC is defined by the following criteria:
  • > 25% of the area within the invasive carcinoma is DCIS and DCIS is also present outside the area of invasive carcinoma in the surrounding breast parenchyma.
  • There is extensive DCIS associated with a small (1 cm or less) invasive carcinoma. This case fulfils this second criterion.

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