AMSER Case of the Month: November 2018
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1 AMSER Case of the Month: November year old with right breast mass Rina Kiyota Petek Lake Erie College of Osteopathic Medicine, OMS-III Kossivi Dantey, MD Bibianna Klepchick, MD Matthew Hartman, MD Allegheny General Hospital
2 Patient Presentation HPI: Patient is a 42 yo female that presented with a palpable right breast mass for 2 months. Patient last had mammography 2 years prior. Patient denies breast pain, tenderness, skin changes, or discharge from nipples. PMHx: LMP 3.5 mo ago, chlamydia, female infertility PSHx: No pertinent surgical hx Family Hx: DM, HTN, paternal aunt had breast cancer, maternal great aunt had breast cancer Medications: none
3 Physical Exam General Appearance: No apparent distress Neck: Thyroid normal, no masses Skin: No rashes, lesions, or ulcers C/V: Normal heart sounds, no murmurs or external edema Lungs: Respiratory effort normal. Lungs clear bilaterally GI: No masses, tenderness, heme, hernias, or liver enlargement. Spleen not palpable Abdomen: Benign, soft, non-tender, no hernia, masses, or lymphadenopathy Breast Exam: Moderate fibrocystic condition of both breasts, A rounded lump noted in the left breast at 2 o clock location approximately 8cm from the nipple, measures 3 cm in diameter and approximately 1 cm in depth. It is quite well circumscribed, movable, rubbery, nontender. No axillary lymphadenopathy. No galactorrhea.
4 Mammography CC MLO Extremely dense breast tissue. There is a spiculated mass in the posterior upper inner quadrant of the right breast with overlying BB marker indicating site of palpable abnormality. There are no suspicious calcifications.
5 Ultrasound Focused sonography of the right breast over palpable abnormality demonstrates an irregular hypoechoic mass with posterior shadowing without increased internal vascularity. BIRADS 5- Highly suggestive of malignancy
6 Differential diagnosis based on imaging Malignancy Fibrocystic change Fibroadenoma Intraductal papilloma Foreign body reaction/granuloma Idiopathic Granulomatous Lobular Mastitis Sclerosing adenosis Radial scar
7 Ultrasound-guided needle biopsy Invasive ductal carcinoma nuclear grade 2 E-Cadherin (+) Smooth muscle myosin heavy chain/p63 (-) BIRADS 6- Known biopsyproven malignancy
8 Needle Localization Yellow arrows: needle advanced through mass
9 Gross pathology from lumpectomy and confirmation
10 Pathology- H&E Low Mag Malignant ductal cells invading surrounding stroma and invading into normal fatty tissue of the breast
11 Pathology- H&E High Mag Cellular pleomorphism with large cells and large nucleoli. Mitotic figures present
12 Pathology Invasive ductal carcinoma, nuclear grade 3: Estrogen receptor (+), Progesterone receptor (+), HER2/Neu (-) Ductal carcinoma in situ, nuclear grade 2, solid, micropapillary and cribriform types, with comedonecrosis and calcifications Margins free of invasive and in situ carcinoma; lymphovascular invasion not identified Pathologic stage: pt2 N0(sn) MX
13 Final Dx: Invasive Ductal Carcinoma with Ductal Carcinoma in Situ
14 Invasive Ductal Carcinoma:Discussion Ductal carcinoma in situ accounts for almost 1/5 th of all breast cancers detected by screening in North America Risk factors: older age, benign breast disease, family history of breast cancer, nulliparity, older age of first pregnancy Due to screening mammograms, almost 90% of ductal carcinomas in situ are diagnosed while clinically occult due to detection of microcalcifications, soft-tissue densities, or both, which trigger investigation via stereotactic core needle biopsy.
15 Invasive Ductal Carcinoma:Discussion Pathobiologic events associated with ductal carcinoma in situ and invasive ductal carcinoma Abnormal response to growth factors-i.e. estrogen receptor, progesterone receptor Loss of tumor-suppressor function- i.e. p53 Abnormal oncogene expression- i.e. HER2/neu Genetic instability Tissue invasion, stromal changes, clinical phenotype of tumor determined
16 Radiographic features of malignant breast lesions Mammogram: Greater density, spiculated or irregular mass, asymmetry from other breast tissue, pointed irregular calcifications that are heterogeneous in size or fine and branching calcifications Ultrasound: Hypoechoic lesions with irregular or ill-defined borders, can be taller than broader, posterior acoustic shadowing, and microcalcifications.
17 Pathologic features of ductal carcinoma Pathologic classification of ductal carcinoma in situ and ductal carcinoma: Nuclear grade of tumor cells- low, intermediate, high Architectural pattern of tumor growth- solid, papillary, micropapillary, or cribriform Presence or absence of comedonecrosis High grade lesions and lesions associated with comedonecrosis are associated with greatest risk of recurrence after breast conserving procedures. Immunohistochemistry: Hormone status: Estrogen receptor, Progesterone receptor Used to predict potential treatment response to tamoxifen Oncogenes: HER-2/Neu Used as a marker for sensitivity for trastuzumab and resistance to tamoxifen Myoepithelial markers: smooth muscle actinin, calponin, p63, SMMHC Ductal Carcinoma/DCIS Lobular Carcinoma Benign lesion (-) (-) (+) E-Cadherin (+) (-) (+/-) CK8 (-) (+) (+/-)
18 References: Kim YR, Kim HS, Kim H-W. Are Irregular Hypoechoic Breast Masses on Ultrasound Always Malignancies?: A Pictorial Essay. Korean Journal of Radiology. 2015;16(6): doi: /kjr Franquet, T., C. D. Miguel, R. Cozcolluela, and L. Donoso. Spiculated lesions of the breast: mammographic-pathologic correlation. RadioGraphics 13: , Burstein HJ, Polyak K, Wong JS, Lester SC, Kaelin CM. Ductal carcinoma in situof the breast. N Engl J Med Apr 1;350(14): Review. PubMed PMID: McKenna RJ Sr. The abnormal mammogram radiographic findings, diagnostic options, pathology, and stage of cancer diagnosis. Cancer Jul 1;74(1Suppl): PubMed PMID: Gokhale S. Ultrasound characterization of breast masses. The Indian Journal of Radiology&Imaging. 2009;19(3): doi: / Zaha DC. Significance of immunohistochemistry in breast cancer. World Journal of Clinical Oncology. 2014;5(3): doi: /wjco.v5.i3.382.
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