Case
A 46-year-old premenopausal, diabetic lady with two living children presented to the outpatient clinic in September 2020 with a left-sided breast lump.
On clinical examination, the lump measured 5x6 cm, occupying the upper half of the left breast. It extended to the nipple-areolar complex (NAC) with no fixity to the skin or underlying tissue. There were no skin changes. Axillary palpation showed multiple left-sided matted lymph nodes.
Elaboration of a risk factor history revealed a 5-year history of oral contraceptive pills (OCPs) usage 20 years previously.
An Ultrasonogram of the breasts showed a large hypoechoic space-occupying lesion, measuring about 6.5x4.6cm, with irregular, mildly lobulated margins on the left upper breast at 12 o’clock position. The lesion showed no calcification or necrosis. Two oval lymph nodes measuring 1.2cm and 1.4cm in the largest diameter with noted in the left axilla. The scan was classified as BIRADS-4.
A trucut biopsy was done shortly after the presentation. The histopathology of the sample was suggestive of invasive BC. Immunohistochemistry (IHC) revealed hormone receptors (oestrogen and progesterone) and HER2-neu negative- triple negative breast cancer (TNBC).
Oncological work-up including a chest X-ray (CXR) and USS of her abdomen revealed no abnormalities. A Tc99 m bone scan was advised, but the patient was unable to get it done due to economic constraints.
The tumour was staged at T3N2aM0 and the patient was discussed in a multidisciplinary team meeting. She was planned for surgical clip (marker) placement to delineate the tumour margins followed by neoadjuvant chemotherapy (NACT), re-imaging and definitive surgery. A further plan was to be made following the histopathological examination of the surgical specimen.
She underwent 6 cycles of NACT with intravenous Docetaxol (75mg/m2), Doxorubicin (50mg/m2) and Cyclophosphamide (500mg/m2) at 3 weekly intervals. Chemotherapy was tolerated well.
An interval ultrasonogram of both breasts was done post-chemotherapy, which showed an interval increase in the size of the lesion- 9.4x6.4x5.9cm. There were internal echoes noted, likely necrotic foci within the lesion, with no significant axillary adenopathy. The right breast remained normal. The scan was classed BIRADS-6.
Following this, the option of surgery was discussed with the patient. She was keen on breast conservation. Due to a high breast: tumour ratio, she underwent a left-sided extreme oncoplasty- where the tumour and left axillary nodal tissue were removed en-mass and reconstruction was performed with a latisimus dorsi musculocutaneous flap. The nipple-areola complex was spared. The post-operative period was uneventful.
Histopathological sections of the 18x13x6cm surgical specimen showed a tumour measuring 7x6x4 cm. The tumour was composed of tubules, clusters, solid nests, and syncytial cell infiltrate. (Fig 2) A large necrotic focus was also identified. There were areas of mesenchymal differentiation with pleomorphic cells and intervening occasional spindle cells. The cells had a variegated appearance and showed pleomorphism, prominent nucleoli and brisk mitosis. There was no evidence of lymphovascular or perineural invasion and no component of ductal carcinoma in situ. All resection margins and deep margins were clear. All resected axillary lymph nodes were negative. The tumour was classified as Grade 3, staged pT3N0Mx.
She was rediscussed in the multidisciplinary team meeting. The meeting outcome was to treat her with adjuvant radiotherapy (RT) utilizing external beam RT (EBRT) with a Telecobalt-60 machine (42.6 Gray in 16 fractions) with photon boost to the surgical bed, marked by the initial clips placed (10 Gray in 5 fractions) using right and left tangential fields. In June 2021, she completed EBRT uneventfully. Since then, she has been on 3 monthly follow-up visits with USS of bilateral breast and axillae, serum CA15-3 level and clinical breast examination alongside CT scan of thorax done 6 monthly. None of the aforesaid modalities have shown evidence of residual or recurrent disease and she has had no fresh complaints.