PMC9238203_01
Imaging and pathologic findings of metachronous controlateral axillary lymph node metastasis from invasive ductal carcinoma in a 67-year-old female.. A. Transverse ultrasonography of the left breast shows an irregular hypoechoic mass with indistinct margins (arrows), and transverse ultrasonography of the left axilla shows an enlarged lymph node.. B. MIP image shows an oval-shaped mass with circumscribed margins and heterogeneous enhancement in the upper outer quadrant of the left breast and enlarged lymph nodes in the left axilla (dashed arrows).. C.
18F-FDG PET/CT shows multifocal avid FDG uptake in the left breast, left axilla, and left supraclavicular fossa (arrowheads).. D. Primary left breast cancer shows medullary features with tumor clusters arranged in a syncytial growth pattern, highly pleomorphic nuclear atypia, conspicuous mitotic activity, and prominent lymphoplasmacytic infiltrates (H&E stain, x 200). Prominent membranous expression of EGFR is noted in immunohistochemical staining (EGFR, x 200).. E. At 22 months after the initial breast cancer diagnosis, mediolateral oblique MG of the right breast shows enlarged lymph nodes in the right axilla. Transverse US of the right axilla shows an enlarged lymph node. MIP image shows enlarged lymph nodes at the right axilla (arrow) without any abnormally enhancing lesion in the breast.. F. The contralateral right axillary lymph node shows metastatic ductal carcinoma composed of tumor clusters of highly pleomorphic nuclear atypia (H&E stain, x 100), and diffuse strong EGFR immunohistochemistry membranous staining (EGFR, x 200).. EGFR = epidermal growth factor receptor, FDG = fluorodeoxyglucose, H&E = hematoxylin and eosin, MG = mammography, US = ultrasonography, MIP = maximal intensity projection
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Ultrasonography (US) performed at the outside hospital showed an irregular hypoechoic mass with indistinct margins (Fig. 1A) and increased vascularity on the color Doppler image. Several enlarged lymph nodes were seen in the left axilla (Fig. 1A). Dynamic contrast-enhanced MRI of the breast showed an oval- shaped mass with circumscribed margins and heterogeneous enhancement in the upper outer quadrant of the left breast and enlarged lymph nodes in the left axilla (Fig. 1B). 18F-fluorodeoxyglucose (FDG)-PET showed focal avid FDG uptake in the left breast, left axilla, and left supraclavicular fossa with a maximum standardized uptake value (SUV) of 7.1, 13.4, and 5.1, respectively (Fig. 1C). Histopathological examination confirmed a poorly differentiated invasive ductal carcinoma with medullary features (Fig. 1D), 1.8 cm x 1.5 cm in size with a clear resection margin. The tumor was negative for estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2); however, it had a diffuse strong membranous positive for epidermal growth factor receptor (EGFR) expressing the immunophenotype of triple negative basal-like type (Fig. 1D). Twenty-two months after the initial diagnosis, MG showed enlarged lymph nodes in the right axilla (Fig. 1E). US showed enlarged lymph nodes with loss of the fatty hilum in the right axilla (Fig. 1E) and an irregular hypoechoic mass with indistinct margins at the 10 o'clock direction of the right breast. Breast MRI showed enlarged lymph nodes in the right axilla without any abnormally enhancing lesion in the breast (Fig. 1E). 18F-FDG PET/CT showed focal avid FDG uptake in the right axilla with a SUV of 5.8. These metastatic lymph nodes had the same triple negative basal like immunophenotype, showing negativity of ER, PR, HER2 and diffuse strong EGFR expression (Fig. 1F).