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.