Presentation
Screening for primary malignancy. Chest pain with bilateral breast hardness.
Patient Data
An irregular, hyperdense, retro areolar mass with spiculated margins is seen in the lower inner quadrant of the right breast.
The left breast shows an area of increased density with architectural distortion extending to the nipple.
No apparent nipple retraction, skin thickening or retraction.
Benign calcification in the left breast.
Right axillary lymphadenopathy.
Lung window shows : bilateral diffuse faint ground glass opacities, interlobular septal thickening along with nodular appearance of the fissures and a few sub centimetric nodules.
Mediastinal window shows: enlarged right axillary lymph node measuring (1.1 cm in short axis) with axillary fat plane's stranding.
Bone window shows: diffuse scattered innumerable mixed lytic and sclerotic lesions involving the visualized skeleton.
Case Discussion
This patient had CT chest angiography to rule out PE, no evidence of PE encountered, however, the lung and bone findings are suggestive of metastatic process ( diffuse mixed bone mets and bilateral lymphangitis carcinomatosis).
Mammogram was requested to rule out primary breast cancer.
On mammogram images, both breasts show suspicious findings. Complementary ultrasound was done (images not shown), and showed a large ill defined hypoechoic mass at 4 o'clock in the right breast extending to the nipple associated with pathological right axillary lymph node ,and an ill defined heterogenous area between 2 and 5 o'clock in the left breast.
These findings are compatible with (BIRADS V); high suspicion of malignancy.
On pathology reports , sections of both right and left breast true cut biopsies revealed similar findings of breast tissue infiltrated by invasive mammary carcinoma, of low to intermediate nuclear grade, forming small tubules with Indian-file pattern and targetoid spread, suggesting lobular component confirmed by negative E- cadherin immune stain.
(Immunohistochemical stains for hormone receptors HER2 neu and E- cadherin (performed on both sides) reveal the tumor cells are: Estrogen receptors: positive, Progesterone receptors: positive, Her 2 neu: negative, E- cadherin: negative).
Diagnosis: Invasive mammary carcinoma, with features of lobular component.
The imaging findings and pathology reports confirm the diagnosis of bilateral invasive lobular breast cancer with metastasis.