Invasive ductal carcinoma with intramammary and axillary lymph node metastases

Case contributed by Alexandra Stanislavsky
Diagnosis almost certain


Screening mammogram, round 6. Asymptomatic.

Patient Data

Age: 65
Gender: Female

There is a lobulated, circumscribed, dense mass in the upper outer quadrant of the right breast (M1).

Just medial and superior to it, there is a subtle, smaller spiculate lesion (M2).

There is also a newly enlarge lymphnode in the right axilla (M3).

The stated lesion designations (M1, M2 and M3) correspond to ultrasound annotations below.

Comparison with multiple prior mammograms shows that the larger or the two lesions was in fact present on multiple prior mammograms but was of smaller and of lower density, never previously suspicious in appearance.

Mammographic workup views better demonstrate the presence of two RUOQ lesions: the larger, circumscribed mass with irregular margin (M1), and a smaller but persistent spiculated mass just medial and superior to it (M2).

The larger breast mass at 10 o'clock 9 cm FN is rounded, markedly hypoechoic with posterior acoustic enhancement and markedly hypervascular with a large feeding vessel (M1).

The smaller lesion at 11 o'c 9 cm FN is taller than wide, hypoechoic with spiculated margins and much less vascular (M2).  

Thickened and hypervascular right axillary lymph node is also seen corresponding to the mammographic M3 lesion. 

An ultrasound guided core biopsy of the two intramammary lesions and an FNA of the axillary lymph node were peformed.  Note the markedly reduced vascularity around the M1 lesion following the infiltration of local anesthetic with epinephrine. This was very helpful in this case in reducing the risk of significant procedural hematoma.

Histology demonstrated the smaller lesion M2 as a high grade invasive ductal carcinoma.

The larger M1 was in fact a metastatic intramammary lymph node. 

M3 metastatic axillary lymph node.

Case Discussion

Key teaching points:

High-grade breast cancer may present as nodal (or other!) metastases that are more conspicuous than the primary. Indeed in some cases, the primary lesion may remain occult in the presence of advanced metastatic disease.

New change in a longstanding circumscribed lesion may herald lymph node metastasis.  It would be highly unusual for a primary circumscribed tumor to remain unchanged over such a long period of time.

Note the change in density, as well as in size and shape of the infiltrated lymph node from prior studies to current.

Procedural tip: use of local anesthetic with epinephrine prior to biopsy of a hypervascular lesion to reduce the risk of hematoma.

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