Presentation
Palpated a lump in his left chest. His wife convinced him to go get checked.
Patient Data
Right mammography:
No mass seen in the soft tissue.
No pathological calcification seen.
Fibroglandular tissue - normal.
Skin and nipple - normal.
Impression: no abnormal finding.
BIRADS 1.
Left mammography:
2.5 cm mass in upper middle part, spiculated border.
No pathological calcification seen.
Skin and nipple: pacemaker projected onto tail of breast.
Impression: mass, as depicted.
BIRADS 5 - highly suspicious for malignancy.
Left breast:
Irregular, lobulated, hypoechoic mass measuring 2.0 x 3.0 cm demonstrated at 11 o'clock, approximately 3 cm from the nipple, in concordance with the mammographic finding, palpable.
BIRADS 4B: moderate suspicion for malignancy.
Left axilla:
two lymph nodes demonstrated, with preserved sonographic structure; the larger one measures 10x28 mm.
BIRADS 2: normal finding.
Impression: mass, as described.
BIRADS 5: highly suspicious for malignancy.
Recommendations: Ultrasound-guided Tru-Cut® biopsy recommended for the left breast mass.
Case Discussion
He went on to have a core needle biopsy and insertion of a tissue marker clip and underwent a sentinel lymph node scan and excision.
Pathology report:
- Left breast, 11 o'clock, trucut biopsy: Infiltrating ductal carcinoma.
- Left axilla, trucut biopsy: Lymph node fragments with no evidence of malignancy.
Immunohistochemical studies:
- Weak, incomplete membranous immunoreactivity for Her-2/Neu protein expression observed in 10% of infiltrating tumor cells (score 1, range 1- 3).
Interpretation: negative.
The study was performed with monoclonal Ab-4B5. - Estrogen receptor immunoreactivity positive.
Quantitation: 90% of tumor cells positive.
Intensity of staining: strong.
Internal control: not present.
The study was performed with monoclonal Ab-SPI. - Progesterone receptor immunoreactivity positive.
Quantitation: 50% of tumor cells positive.
Intensity of staining: weak to strong.
Internal control: not present.
The study was performed with monoclonal Ab-16. - Ki67 expressed in 30% of tumor cells. (score 3, range 1-4).
The study was performed with monoclonal Ab-Mib 1.
Positive controls show the expected staining.
Negative controls show no immunostaining.
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