Presentation
The patient presented to the surgery clinic complaining of a right breast lump. Negative family history of breast cancer.
Patient Data
Breast composition: Heterogeneously dense breast, which may obscure small masses, ACR C.
There is architectural distortion seen in the right mid-outer region, associated with clustered pleomorphic calcifications and mild areolar skin thickening.
Bilateral inverted nipples.
No left sided dominant spiculated lesion.
No left sided suspicious clustered microcalcification.
The right breast shows a spiculated hypoechoic lesion with a hyperechoic halo, seen at 9:00 measuring about 4.5 x 3.5 x 2.7 cm, the lesion appears to involve the nipple.
There is a right axillary lymph node with a thickened cortex however it appears oval with a preserved fatty hilum.
The left breast shows normal fibroglandular tissue without evidence of cystic or solid focal lesion apart from a small cyst in the upper outer quadrant.
Benign-looking lymph nodes in left axillae.
Case Discussion
This is a BI-RADS V lesion, highly suggestive of malignancy regarding the right breast. A biopsy was performed.
Histopathology
GROSS: Specimen fixed labeled with patient's name consists of 2 grey-white soft tissue needle core biopsies, the largest 2 x 0.2 cm. Submitted all in one cassette.
MICROSCOPIC: Sections reveal breast core biopsies infiltrated by invasive ductal carcinoma of intermediate nuclear grade with wide areas of necrosis.
DIAGNOSIS: right breast mass, trucut biopsy. Consistent with invasive ductal carcinoma, NOS.
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