Presentation and diagnosisWe present the case of a 53-year-old patient complaining of a left-sided breast lump, which she had first noticed 2 years back following trauma to the breast caused by a fall. She had consulted a doctor about the lump 3 days prior to attending our department. The patient denied any further symptoms or signs.Clinically, she presented with the following findings ( Fig. 1): a red, fist-sized, non-ulcerating exophytic lump protruding from the upper quadrant of the left breast. The remaining breast tissue consisted of what felt like a tumor conglomerate. The right breast was characterized by very suspicious, irregular thickened tissue extending for several centimeters. There were pathological lymph nodes palpable in both axillae.Ultrasound examination revealed in the left breast next to the 8-9 cm clinically exophytic tumor, a second suspicious area measuring 8 mm at in the area between the left upper and lower inner quadrants approximately at 8 cm distance from the nipple. On the right side, ultrasound revealed a suspicious, inhomogenous area. There were bilateral enlarged supra-clavicular lymph nodes (Fig. 2), which were clinically metastatic. The patient refused mammography.Stance biopsy revealed a right-sided invasive receptor-positive lobular carcinoma (her2 negative) and a left-sided invasive receptor negative ductal carcinoma (her2 negative).
Treatment and outcomeThe patient requested a primary bilateral mastectomy. During the operation, multiple hard, enlarged lymph nodes were noted in both breasts.The final histological classification was a multicentered right-sided carcinoma (4 cm) (pT2 (m) pN0 (0/15) L0, V0, G2, R0). On the left side was an 8 cm carcinoma (pT4b, pN0 (0/14), L0, V0, G2, R0). The excision was histologically complete. The regional lymph nodes (15 on the right, 14 on the left) were negative on histological examination. As they were clinically highly suspicious, the tissue was sent for a second opinion at a histology reference center, where immune histochemistry was used to confirm the nodal negativity for any form of invasion. Follicular lymphatic hyperplasia of non-specific origin (Fig. 3) was reported. To exclude distant metastases, a chest X-ray, CT neck and thoracic inlet, Figure 1. Lump protruding from the upper quadrant of the left breast.
