diff --git "a/Me-EXCL_evaluation_cancer_dataset.csv" "b/Me-EXCL_evaluation_cancer_dataset.csv" new file mode 100644--- /dev/null +++ "b/Me-EXCL_evaluation_cancer_dataset.csv" @@ -0,0 +1,869 @@ +,section,subsection,label,text +1,Case 1,Courses of Treatment,Benign and Proliferative,"Courses of Treatment. → 2022-02-11 Excision, Lt. (8H and 5H).. C. W. Lee · B. H. Choi (*). Department of Radiology, National Cancer Center,. Goyang, Republic of Korea. e-mail: cwlee@ncc.re.kr; iawy82@ncc.re.kr. Y. Kwon. Department of Radiology, Center for Breast Cancer, National. Cancer Center, Goyang, Gyeonggi, Republic of Korea. e-mail: ymk@ncc.re.kr. Y. Kim. Department of Pathology, National Cancer Center,. Goyang, Gyeonggi, Republic of Korea. e-mail: radkyj@ncc.re.kr. . 20. . ­. . 1.3.1. . Pathology Report. • Breast, left 8 o’clock, excision:. –. – Intraductal papilloma with usual ductal. hyperplasia.. • Breast, left 5 o’clock, excision:. –. – Sclerosing adenosis.. 2. " +9,Case 1,Important Radiologic,Benign and Proliferative,Important Radiologic. Findings. 1. 2. 1.3.  +15,Case 1,Patient History,Benign and Proliferative,"Patient History and Progress. Female/37 years old, pre-menopause.. Screen detected mass lesion on left breast. 8 o’clock and 5 o’clock direction.. Outside result of biopsy: Papillary neoplasm.. No family history.. No comorbidities.. 1.2. " +2,Case 1,Courses of Treatment,Carcinoma In Situ,"Carcinoma In Situ. Eun Sook Lee, Chan Wha Lee, Youngmi Kwon,. Yunju Kim, and Bo Hwa Choi. 1. . 1.1. . Courses of Treatment. Operation + Postoperative radiation therapy +. Tamoxifen 20 mg/day for 5 years.. 1.3.1. . Operation. 5. 6. 1.3.2. . Pathology Report. Ductal carcinoma in situ, pathological TN cat­. egory (AJCC 2017): pTisN0(sn). . 1. Size of tumor: 5.2 cm (pTis).. . 2. Nuclear grade: high.. E. S. Lee et al.. 53. . . Carcinoma In Situ. 54. . 3. Necrosis: present.. . 4. Architectural pattern: papillary/cribriform/. solid/comedo.. . 5. Surgical margins:. . (a) deep margin: 6 mm,. . (b) superficial margin: subareolar margin:. (see Note 1).. . 6. Lymph nodes: no metastasis in one axillary. lymph node (pN0(sn)) (sentinel LN: 0/1).. . 7. Microcalcification: present, tumoral.. Note: 1. The subareolar margin of the mastec­. tomy specimen (slide 11) is close to ductal carci­. noma in situ (<1 mm), but this margin submitted. for frozen diagnosis (Fro 2) is free of tumor.. Result. Intensity Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Equivocal (2+). Ki-67. Positive in. 16% of tumor. cells. 2. " +10,Case 1,Important Radiologic,Carcinoma In Situ,"Important Radiologic. Findings. 1 2 3. 4. E. S. Lee. Center for Breast Cancer, National Cancer Center,. Goyang, Kyonggi-do, Republic of Korea. e-mail: eslee@ncc.re.kr. C. W. Lee (*) · B. H. Choi. Division of Diagnostic Radiology, Center for Breast. Cancer, National Cancer Center,. Goyang, Republic of Korea. e-mail: cwlee@ncc.re.kr; iawy82@ncc.re.kr. Y. Kwon. Department of Radiology, Center for Breast Cancer,. National Cancer Center, Goyang, Gyeonggi,. Republic of Korea. e-mail: ymk@ncc.re.kr. Y. Kim. Department of Pathology, National Cancer Center,. Goyang, Gyeonggi, Republic of Korea. e-mail: radkyj@ncc.re.kr. " +16,Case 1,Patient History,Carcinoma In Situ,"Patient History and Progress. Female/47 years old, pre-menopause.. Screen detected a mass lesion on left breast in. 10 o’clock direction.. No family history of breast cancer or other. cancers.. S/P Uterine myomectomy.. 1.2. " +3,Case 1,Courses of Treatment,HR(+) HER2(+) Breast Cancer,". 1.1. . Courses of Treatment. Neoadjuvant chemotherapy (#6 cycles of. docetaxel and carboplatin and trastuzumab. and pertuzumab)  +  Operation  +  Post-­. operative radiation therapy  +  Tamoxifen. 20 mg/day.. 7. 1.3.1. . Pathology Report. Invasive Ductal Carcinoma. 1. Post-chemotherapy status.. 2. Size of invasive component: 0.2 cm (pT1a).. 3. Size of intraductal component: 1.0 cm.. 4. Histologic grade:1/3 (tubule formation: 2/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 4/10 HPF).. 5. Intraductal component: present, extratumoral. (99%) (nuclear grade: high, necrosis: pres­. ent, architectural pattern: cribriform/solid/. comedo, extensive intraductal component:. present).. 6. Surgical margins:. S. Park. Department of Surgery, Wonkwang University. Sanbon Hospital, Gunpo, Republic of Korea. R. Song · E.-G. Lee (*). Division of Surgery, Center for Breast Cancer,. National Cancer Center, Goyang, Republic of Korea. e-mail: thdfks37@ncc.re.kr; bnf333@ncc.re.kr. Y. Kim. Department of Pathology, National Cancer Center,. Goyang, Gyeonggi, Republic of Korea. e-mail: radkyj@ncc.re.kr. B. H. Choi · C. W. Lee. Division of Diagnostic Radiology, Center for Breast. Cancer, National Cancer Center,. Goyang, Republic of Korea. e-mail: iawy82@ncc.re.kr; cwlee@ncc.re.kr. E. S. Lee. Center for Breast Cancer, National Cancer Center,. Goyang, Kyonggi-do, Republic of Korea. e-mail: eslee@ncc.re.kr. 300. . . . (a) superior margin: 18 mm,. . (b) inferior margin: 17 mm,. . (c) medial margin: 10 mm,. . (d) lateral margin: 10 mm,. . (e) deep margin: 4 mm,. . (f) superficial margin: 14 mm.. 7. Lymph nodes:. . (a) metastasis in one out of five axillary. lymph nodes (ypN1mi(sn)) (sentinel. LN: 1/5),. . (b) perinodal extension: absent,. . (c) size of metastatic carcinoma: 1 mm.. 8. Arteriovenous invasion: absent.. 9. Lymphovascular invasion: absent.. . 10. Tumor border: infiltrative.. . 11. Microcalcification: present, non-tumoral.. . 12. Pathological TN category (AJCC 2017):. ypT1aN1mi(sn).. Result. Intensity Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (7/8). 3. 1/3-2/3. C-erbB2. Equivocal (2+). Ki-67. Positive in 1%. of tumor cells. S. Park et al.. 301. . . HR(+) HER2(+) Breast Cancer. 302. F. ig. 5. a. b. . 2. " +11,Case 1,Important Radiologic,HR(+) HER2(+) Breast Cancer,Important Radiologic. Findings. 1 2 3 4 5. 6. 1.3.  +17,Case 1,Patient History,HR(+) HER2(+) Breast Cancer,"Patient History and Progress. Female/47 years old, pre-menopause.. Screen detected mass lesion on left breast 5. o’clock direction.. No family history.. No comorbidities.. 1.2. " +4,Case 1,Courses of Treatment,HR(+) HER2(-) Breast Cancer,"HR(+) HER2(−) Breast Cancer. Yunju Kim, Bo Hwa Choi, Eun-Gyeong Lee,. Ji Young You, and Youngmi Kwon. 1. . 1.1. . Courses of Treatment. Operation + Letrozole 2.5 mg/day. 1.3.1. . Operation. Left total mastectomy, sentinel lymph node. 2. Histologic grade: 2/3 (tubule formation: 2/3,. nuclear pleomorphism: 2/3, mitotic count:. 2/3, 11/10 HPF).. 3. Intraductal component: present, intratu­. moral/extratumoral (30%) (nuclear grade:. low, necrosis: absent, architectural pattern:. cribriform/solid, extensive intraductal com­. ponent: present).. 4. Skin and nipple: dermal involvement of tumor.. 5. Surgical margins: deep margin: 7 mm.. 6. Lymph nodes:. . (a) metastasis in one out of seven axillary. lymph nodes (pN1mi) (sentinel LN: 1/7),. Y. Kim. Department of Pathology, National Cancer Center,. Goyang, Gyeonggi, Republic of Korea. e-mail: radkyj@ncc.re.kr. B. H. Choi. Division of Diagnostic Radiology, Center for Breast. Cancer, National Cancer Center,. Goyang, Republic of Korea. e-mail: iawy82@ncc.re.kr. E.-G. Lee. Division of Surgery, Center for Breast Cancer,. National Cancer Center, Goyang, Republic of Korea. e-mail: bnf333@ncc.re.kr. J. Y. You. Division of Breast and Endocrine, Department of. General Surgery, Korea University Medical Center,. Seoul, Republic of Korea. e-mail: joliejean@korea.ac.kr. Y. Kwon (*). Department of Radiology, Center for Breast Cancer,. National Cancer Center, Goyang, Gyeonggi,. Republic of Korea. e-mail: ymk@ncc.re.kr. 174. . (b) perinodal extension: present,. . (c) size of metastatic carcinoma: 0.2 mm.. 7. Arteriovenous. invasion:. present,. peritumoral.. 8. Lymphovascular. invasion:. present,. peritumoral.. 9. Tumor border: infiltrative.. . 10. Microcalcification:. present,. tumoral/. non-tumoral.. . 11. Pathological TN category (AJCC 2017):. pT2N1mi.. Result. Intensity. Positive. %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (1+). Ki-67. Positive in 4% of" +12,Case 1,Important Radiologic,HR(+) HER2(-) Breast Cancer,"Important Radiologic. Findings. See Figs. 1, 2 and 3.. 1.3. " +18,Case 1,Patient History,HR(+) HER2(-) Breast Cancer,"Patient History and Progress. Female/87 years old, post-menopause.. Screen detected mass lesion on left breast sub­. areolar area.. No family history.. Hypertension, diabetes mellitus, arrhythmia,. total knee replacement, cerebrovascular accident.. 1.2. " +5,Case 1,Courses of Treatment,HR(−) HER2(+) Breast Cancer,"HR(−) HER2(+) Breast Cancer. Youngmi Kwon, Yunju Kim, Bo Hwa Choi,. Ji Young You, Ran Song, Jeayeon Woo,. and Soojin Park. 1. . 1.1. . pertuzumab) + Operation + Post-operative radia­. tion therapy + Trastuzumab.. Result. Intensity. Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in 42%. of tumor cells. 1.4.1. . Operation. 8. 1.4.2. . Pathology Report. No residual tumor with stromal fibrosis.. . 1. Post-chemotherapy status.. . 2. Lymph nodes: no metastasis in six axillary. lymph nodes (ypN0) (sentinel LN: 0/1, non-­. sentinel LN: 0/5).. . HR(−) HER2(+) Breast Cancer. 432. 2. " +13,Case 1,Important Radiologic,HR(−) HER2(+) Breast Cancer,"Important Radiologic Findings. 1 2 3. 4. Y. Kwon. Department of Radiology, Center for Breast Cancer,. National Cancer Center, Goyang, Gyeonggi,. Republic of Korea. e-mail: ymk@ncc.re.kr. Y. Kim. Department of Pathology, National Cancer Center,. Goyang, Gyeonggi, Republic of Korea. e-mail: radkyj@ncc.re.kr. B. H. Choi. Division of Diagnostic Radiology,. Center for Breast Cancer, National Cancer Center,. Goyang, Gyeonggi, Republic of Korea. e-mail: iawy82@ncc.re.kr. J. Y. You. Division of Breast and Endocrine,. Department of General Surgery,. Korea University Medical Center, Seoul,. Republic of Korea. e-mail: joliejean@korea.ac.kr. R. Song · J. Woo. Division of Surgery, Center for Breast Cancer,. National Cancer Center, Goyang, Gyeonggi, Republic. of Korea. e-mail: thdfks37@ncc.re.kr; jaeyeon1205@ncc.re.kr. S. Park (*). Department of Surgery, Wonkwang University. Sanbon Hospital, Gunpo, Gyeonggi,. Republic of Korea. e-mail: amiamo.com@gmail.com. 428. . ­. . . Y. Kwon et al.. 429. F. ig. 4. . After Neoadjuvant. Chemotherapy. 5 6. 7" +19,Case 1,Patient History,HR(−) HER2(+) Breast Cancer,"Patient History and Progress. Female/59 years old, post-menopause.. Self-detected mass lesion on right breast 12. o’clock direction.. No family history.. S/P Tuberculosis.. 1.2. " +6,Case 1,Courses of Treatment,HR(−) HER2(−) Breast Cancer,"HR(−) HER2(−) Breast Cancer. Eun Sook Lee, Chan Wha Lee, Youngmi Kwon,. Jeayeon Woo, and Yunju Kim. 1. . 1.1. . Courses of Treatment. Neoadjuvant chemotherapy (#4  cycles of. doxorubicin. and. cyclophosphamide. +. #4  cycles of docetaxel) + Operation + Post-. operative radiation therapy.. 1.3.1. . Operation. 7. 1.3.2. . Pathology Report. Breast, left, lumpectomy:. . 1. No residual tumor with stromal degeneration.. . (a) Post-chemotherapy status.. . (b) Lymph nodes: no metastasis in four axil­. lary lymph nodes (ypN0(sn)) (sentinel. LN: 0/1, non-sentinel LN: 0/3).. . 2. Fibroadenomatous change.. Result. Intensity. Positive. %. Estrogen. receptor. Negative (2/8). 1. <1%. Progesterone. receptor. Negative (2/8). 1. <1%. C-erbB2. Negative (0). Ki-67. Positive in 65%. of tumor cells. . ­. . . HR(−) HER2(−) Breast Cancer. 578. . 2. " +14,Case 1,Important Radiologic,HR(−) HER2(−) Breast Cancer,"Important Radiologic Findings. 1 2. 3. E. S. Lee. Center for Breast Cancer, National Cancer Center,. Goyang, Kyonggi-do, Republic of Korea. e-mail: eslee@ncc.re.kr. C. W. Lee. Division of Diagnostic Radiology, Center for Breast Cancer,. National Cancer Center, Goyang, Republic of Korea. e-mail: drlee4958@gmail.com. Y. Kwon. Department of Radiology, Center for Breast Cancer,. National Cancer Center, Goyang, Republic of Korea. e-mail: ymk@ncc.re.kr. J. Woo. Division of Surgery, Center for Breast Cancer,. National Cancer Center, Goyang, Republic of Korea. e-mail: jaeyeon1205@gmail.com. Y. Kim (*). Department of Pathology, National Cancer Center,. Goyang, Gyeonggi, Republic of Korea. e-mail: radkyj@ncc.re.kr. . © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023. E. S. Lee (ed.), A Practical Guide to Breast Cancer Treatment,. https://doi.org/10.1007/978-981-19-9044-1_8. 576. . . E. S. Lee et al.. 577. 1.2.1. . After Neoadjuvant. Chemotherapy. 4 5. 6. 1.3. " +20,Case 1,Patient History,HR(−) HER2(−) Breast Cancer,"Patient History and Progress. Female/40 years old, pre-menopause.. Screen detected a mass lesion at 1 o’clock. direction of the left breast.. No family history.. No comorbidities.. BRCA 1 and 2 mutation: Not detected,. CHEK2 VUS (variant of uncertain).. 1.2. " +7,Case 1,Courses of Treatment,Local Recurrence,"Local Recurrence. Yunju Kim, Eun-Gyeong Lee, Ran Song,. and Eun Sook Lee. 1. . 1.1. . Courses of Treatment. Right breast IDC → Neoadjuvant chemotherapy. → Operation → Adjuvant therapy → Right. breast recurrence (IDC).. 1.2.1. . Primary Treatment. 1 2 3. 4. Neoadjuvant Chemotherapy. Neoadjuvant chemotherapy #4 cycles of doxoru­. bicin and cyclophosphamide followed by #4. cycles of docetaxel and trastuzumab.. Operation. ­. 5. Pathology Report. Invasive Ductal Carcinoma. 1. Post-chemotherapy status.. 2. Size of tumor: 0.4 cm (ypT1a).. Y. Kim. Department of Pathology, National Cancer Center,. Goyang, Gyeonggi, Republic of Korea. e-mail: radkyj@ncc.re.kr. E.-G. Lee · R. Song. Division of Surgery, Center for Breast Cancer,. National Cancer Center, Goyang, Republic of Korea. e-mail: bnf333@ncc.re.kr; thdfks37@ncc.re.kr. E. S. Lee (*). Center for Breast Cancer, National Cancer Center,. Goyang, Kyonggi-do, Republic of Korea. e-mail: eslee@ncc.re.kr. © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023. E. S. Lee (ed.), A Practical Guide to Breast Cancer Treatment,. https://doi.org/10.1007/978-981-19-9044-1_9. . 718. . . . . . . 3. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 1/3, 1/10HPF).. 4. Intraductal component: present, intratumoral/. extratumoral (10%) (nuclear grade: high,. Y. Kim et al.. 719. necrosis: absent, architectural pattern: cribri­. form, extensive intraductal component: absent).. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) Superior margin: 40 mm.. . (b) Inferior margin: 30 mm.. . (c) Medial margin: 5 mm.. . (d) Lateral margin: 15 mm.. . (e) Deep margin: 1 mm from invasive ductal. carcinoma.. 7. Lymph nodes: no metastasis in two axillary. lymph nodes (ypN0(sn)) (sentinel LN: 0/2).. 8. Vascular invasion: absent.. 9. Lymphatic invasion: present, intratumoral.. . 10. Tumor border: infiltrative.. . 11. Microcalcification:. present,. tumoral/. non-tumoral.. . 12. Pathologic stage (AJCC 2010): ypT1aN0(sn).. Result. Intensity. Positive %. Estrogen. receptor. Weak (2/7). 1. <10%. Progesterone. receptor. Negative (0/7). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in 7%. of tumor cells. Adjuvant Therapy. Postoperative radiation therapy.. Trastuzumab for 1 year + Tamoxifen 20 mg/. day for 8.9 years.. 1.2.2. . Treatments After Recurrence. 6 7. 8. Neoadjuvant Therapy. Neoadjuvant. chemotherapy. #6. cycles. of. docetaxel and trastuzumab and pertuzumab.. Operation. 9. Pathology Report. No residual tumor with stromal degeneration.. . . . ­. Local Recurrence. 720. . . . . . 1. Post-chemotherapy status.. . 2. Post-lumpectomy status.. Result. Intensity. Positive %. Estrogen. receptor. Negative (2/8). 1. <1%. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in 18%. of tumor cells. Adjuvant Therapy. Postoperative radiation therapy.. Trastuzumab and pertuzumab.. 2. " +21,Case 1,Patient History,Local Recurrence,"Patient History and Progress. Female/41 years old, pre-menopause.. Screen detected mass lesion on lower medial. and lower outer portion of right breast.. Family history of breast cancer, maternal aunt.. No comorbidities.. BRCA 1 and 2 mutation: Not detected.. 1.2. " +8,Case 1,Courses of Treatment,Metastatic Breast Cancer,"Metastatic Breast Cancer. Youngmi Kwon, Yunju Kim, Bo Hwa Choi,. Eun-Gyeong Lee, Ji Young You, and Eun Sook Lee. 1. . 1.1. . Courses of Treatment. Left breast cancer  →  Operation  +  Adjuvant. therapy → Chest wall recurrence → Palliative. therapy. →. Pleural. fissure. recur­. rence → Palliative therapy.. 1.2.1. . Primary Treatment. Operation. Mar. 2007 Left modified radical mastectomy.. Pathology: Invasive ductal carcinoma, stage. pT1N0, Size of tumor: 1.5  *  1.0  cm, Lymph. node: 0/21.. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Equivocal (2+). Ki-67. Positive in 11%. of tumor cells. Adjuvant Therapy. Adjuvant Chemotherapy #5 cycles (Fluorouracil. & Epirubicin & Cyclophosphamide).. Concurrent Trastuzumab therapy #9 cycles.. Zoladex for 2 years + Tamoxifen 20 mg/day. for 5 years.. Y. Kwon. Department of Radiology, Center for Breast Cancer,. National Cancer Center, Goyang, Gyeonggi,. Republic of Korea. e-mail: ymk@ncc.re.kr. Y. Kim. Department of Pathology, National Cancer Center,. Goyang, Gyeonggi, Republic of Korea. e-mail: radkyj@ncc.re.kr. B. H. Choi. Division of Diagnostic Radiology, Center for Breast Cancer,. National Cancer Center, Goyang, Republic of Korea. e-mail: iawy82@ncc.re.kr. E.-G. Lee. Division of Surgery, Center for Breast Cancer,. National Cancer Center, Goyang, Republic of Korea. e-mail: bnf333@ncc.re.kr. J. Y. You. Division of Breast and Endocrine, Department of. General Surgery, Korea University Medical Center,. Seoul, Republic of Korea. e-mail: joliejean@korea.ac.kr. E. S. Lee (*). Center for Breast Cancer, National Cancer Center,. Goyang, Kyonggi-do, Republic of Korea. e-mail: eslee@ncc.re.kr. 862. 1.2.2. . Treatments After Recurrence. Chest Wall Recurrence. >2/3. Progesterone. receptor. Strong (7/8). 3. 1/3–2/3. Result. Intensity. Positive %. C-erbB2. Equivocal (2+). Ki-67. Positive in. 21% of tumor. cells. SISH. Negative. Operation. Apr. 2014 Left chest wall wide excision and. bilateral salpingo-oophorectomy.. Pathology: Invasive ductal carcinoma, clini­. cally recurrent, size of tumor: 1.0 cm, residual.. Adjuvant Therapy. Post-operative radiation therapy to chest wall+. Letrozole 2.5 mg/day for 5 years.. Pleural Fissure Recurrence. Mar. 2022 PET-CT: R/O pleural/fissural seedings. in left hemithorax.. See Figs. 2 and 3.. Palliative Therapy" +22,Case 1,Patient History,Metastatic Breast Cancer,"Patient History and Progress. Female/49 years old, post-menopause.. No family history.. 1.2. " +23,Case 10,Courses of Treatment,Benign and Proliferative,"Courses of Treatment. →2021-11-09 excision (Lt. 3H SA, Lt. nipple. mass).. Pathology Report. • Breast, “left subareolar 3 o’clock”, excision:. –. – Atypical ductal hyperplasia.. • Breast, “left nipple mass,” excision:. –. – Nipple adenoma (florid papillomatosis).. . . C. W. Lee et al.. 29. . . 11. " +31,Case 10,Important Radiologic,Benign and Proliferative,Important Radiologic. Findings. 16. 17. 10.3.  +37,Case 10,Patient History,Benign and Proliferative,Bloody discharge from left nipple.. No family history.. No comorbidities.. 10.2.  +24,Case 10,Courses of Treatment,Carcinoma In Situ,"10.1. . Courses of Treatment. Operation + Tamoxifen 20 mg/day for 5 years.. Operation. 47. 48. Pathology Report. Ductal carcinoma in situ, pathological TN cat­. egory (AJCC 2017): pTisN0(sn). . 1. Size of tumor: 2.0 cm (pTis).. . 2. Nuclear grade: low.. . 3. Necrosis: absent.. . 4. Architectural pattern: solid.. . 5. Skin: no involvement of tumor.. . 6. Surgical margins:. . (a) deep margin: 2 mm,. . (b) superficial margin: 2 mm.. E. S. Lee et al.. 73. . ­. tumoral.. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Intermediate. (6/8). 3. 10%-1/3. C-erbB2. Negative (1+). Ki-67. Positive in 1%. of tumor cells. Carcinoma In Situ. 74. . . ­. E. S. Lee et al.. 75. 11. " +32,Case 10,Important Radiologic,Carcinoma In Situ,Important Radiologic. Findings. 43 44 45. 46. 10.3.  +38,Case 10,Patient History,Carcinoma In Situ,"Patient History and Progress. Female/52 years old, pre-menopause.. Screen detected microcalcification on mid. inner portion left breast.. Outside result of biopsy:. Left 9:30 o’clock, ductal carcinoma in situ.. Right 11  o’clock, flat epithelial atypia with. microcalcification.. No family history.. BRCA 1 and 2 mutation: Not detected.. 10.2. " +25,Case 10,Courses of Treatment,HR(+) HER2(+) Breast Cancer,"10.1. . Courses of Treatment. Neoadjuvant chemotherapy (#6 cycles of. docetaxel and carboplatin and trastuzumab. and pertuzumab)  +  Operation  +  Post-­. operative radiation therapy  +  Trastuzumab. emtansine  +  Letrozole 2.5  mg/day with. goserelin.. S. Park et al.. 329. . . ­. HR(+) HER2(+) Breast Cancer. 330. . 58. Pathology Report. . 1. Invasive Ductal Carcinoma.. . (a) Post-chemotherapy status.. . (b) Size of tumor: 3.0 cm (ypT2).. . (c) Histologic grade: 2/3 (tubule formation:. 3/3, nuclear pleomorphism: 3/3, mitotic. count: 1/3, 3/10 HPF).. . (d) Intraductal component: present, intratu­. moral/extratumoral (5%) (nuclear grade:. high, necrosis: present, architectural pat­. tern: cribriform/solid/comedo, extensive. intraductal component: absent).. . (e) Skin: dermal involvement of tumor.. . (f) Nipple: no involvement of tumor.. . (g) Surgical margins:. • deep margin: (see Note 1),. • superficial margin: (see Note 2).. S. Park et al.. 331. F. i. g. . 55. (white arrow) in the left. breast. Hypermetabolic. lymph nodes at the left. axilla, internal. mammary chain, and. supraclavicular area. (black arrows). . (h) Lymph nodes:. • metastasis in seven out of nine axil­. lary lymph nodes (ypN2a) (sentinel. LN: 1/3, axillary LN: 6/6),. • perinodal extension: present,. • size of metastatic carcinoma: 10 mm.. . (i) Arteriovenous invasion: absent.. . (j) Lymphovascular invasion: present, intra­. tumoral/peritumoral.. . (k) Tumor border: infiltrative.. . (l) Microcalcification:. present,. tumoral/. non-tumoral.. . (m) Pathological TN category (AJCC 2017):. ypT2N2a.. HR(+) HER2(+) Breast Cancer. 332. . . . 2. Fibroadenoma. Note: 1. The deep margin of the lumpectomy. specimen (slides 1 and 2) is close to invasive duc­. tal carcinoma (<1 mm) but this margin submitted. for frozen diagnosis (Fro 5) is free of tumor.. 2. The superficial margin of the lumpectomy. specimen (slide 1) is close to invasive ductal car­. cinoma (<1 mm) but this margin submitted for. frozen diagnosis (Fro 6) is free of tumor.. Result. Intensity. Positive. %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Weak (3/8). 2. <1%. C-erbB2. Positive (3+). Ki-67. Positive in 4% of. tumor cells. S. Park et al.. 333. . 11. " +33,Case 10,Important Radiologic,HR(+) HER2(+) Breast Cancer,Important Radiologic. Findings. 52 53 54 55 56. 57. 10.3.  +39,Case 10,Patient History,HR(+) HER2(+) Breast Cancer,"Patient History and Progress. Female/32 years old, pre-menopause.. Self-detected skin changes and mass lesion on. left breast.. Family history of breast cancer, maternal aunt.. No comorbidities.. BRCA 1 and 2 mutation: Not detected, NBN. and PALB2 VUS (variant of uncertain).. 10.2. " +26,Case 10,Courses of Treatment,HR(+) HER2(-) Breast Cancer,"Courses of Treatment. Operation. +. Adjuvant. chemotherapy. (#4  cycles of docetaxel & cyclophospha­. mide). +. Post-operative. radiation. ther­. apy + Tamoxifen 20 mg/day.. Operation. Left breast conserving surgery, axillary lymph. 5. Surgical margins:. . (a) superior margin: 10 mm,. . (b) inferior margin: 30 mm,. . (c) medial margin: (see note),. . (d) lateral margin: 19 mm,. . (e) deep margin: 11 mm,. . (f) superficial margin: 2 mm.. 6. Lymph nodes:. . (a) metastasis in one out of seventeen axil­. lary lymph nodes (pN1a) (sentinel LN:. 1/3, axillary LN: 0/14),. . (b) perinodal extension: absent,. . (c) size of metastatic carcinoma: 5 mm.. 7. Arteriovenous invasion: absent.. 8. Lymphovascular. invasion:. present,. peritumoral.. 9. Tumor border: pushing.. . 10. Microcalcification: absent.. . 11. Pathological TN category (AJCC 2017):. pT2N1a.. Note: 1. The medial margin of the lumpec­. tomy specimen (slide 7) is close to ductal. carcinoma in situ (2  mm) but this margin. submitted for frozen diagnosis (Fro 6) is free. of tumor.. Result. Intensity. Positive %. Estrogen receptor. Intermediate (6/8). 2. 1/3–2/3. Progesterone receptor. Intermediate (6/8). 2. 1/3–2/3. C-erbB2. Negative (1+). Ki-67. Positive in 19% of tumor cells. Y. Kim et al." +34,Case 10,Important Radiologic,HR(+) HER2(-) Breast Cancer,"Important Radiologic. Findings. See Figs. 48, 49, 50 and 51.. 10.3. " +40,Case 10,Patient History,HR(+) HER2(-) Breast Cancer,No comorbidities.. 10.2.  +27,Case 10,Courses of Treatment,HR(−) HER2(+) Breast Cancer,"10.1. . Courses of Treatment. Neoadjuvant chemotherapy (#6 cycles of. docetaxel and carboplatin and trastuzumab and. pertuzumab)  +  Operation  +  Trastuzumab and. pertuzumab.. Operation. 77. a. b. . . Y. Kwon et al.. 469. Pathology Report. No residual tumor with stromal degeneration.. . 1. Post-chemotherapy status.. . 2. Lymph nodes: no metastasis in six axillary. lymph nodes (ypN0(sn)) (sentinel LN: 0/1,. non-sentinel LN: 0/5).. Result. Intensity. Positive %. Estrogen. receptor. Negative (2/8). 1. <1%. Progesterone. receptor. Negative (2/8). 1. <1%. C-erbB2. Positive (3+). Ki-67. Positive in. 33% of tumor. cells. 11. " +35,Case 10,Important Radiologic,HR(−) HER2(+) Breast Cancer,Important Radiologic. Findings. 69 70 71. 72. . . . HR(−) HER2(+) Breast Cancer. 466. . Y. Kwon et al.. 467. 10.3. . After Neoadjuvant. Chemotherapy. 73 74 75. 76. . ­. . ­. . HR(−) HER2(+) Breast Cancer. 468. 10.4.  +41,Case 10,Patient History,HR(−) HER2(+) Breast Cancer,"Patient History and Progress. Female/36 years old, pre-menopause.. Self-detected palpable mass lesion on left. breast 9 o’clock direction.. Family history of breast cancer, aunt. (paternal).. S/P Tuberculosis, s/p salpingectomy.. BRCA 1 and 2 mutation: Not detected, ATM. VUS (variant of uncertain).. 10.2. " +28,Case 10,Courses of Treatment,HR(−) HER2(−) Breast Cancer,"10.1. . Courses of Treatment. Neoadjuvant chemotherapy (#4  cycles of. doxorubicin and cyclophosphamide  +  #4. cycles of paclitaxel and cisplatin) + Operation. + Post-operative radiation therapy  +  ada­. gloxad simolenin plus capecitabine.. Operation. 73. E. S. Lee et al.. 609. . . . HR(−) HER2(−) Breast Cancer. 610. . ­. . . E. S. Lee et al.. 611. . . ­. ­. HR(−) HER2(−) Breast Cancer. 612. Pathology Report. Invasive Ductal Carcinoma. 1. Post-chemotherapy status.. 2. Size of tumor: 1.9 cm (ypT1c).. 3. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 3/3, 21/10HPF).. 4. Intraductal component: absent.. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) Superior margin: 8 mm.. . (b) Inferior margin: 25 mm.. . (c) Medial margin: 10 mm.. . (d) Lateral margin: 20 mm.. . (e) Deep margin: <1 mm from invasive duc­. tal carcinoma (slide 2).. . (f) Superficial margin: 3 mm.. 7. Lymph nodes: no metastasis in three axillary. lymph nodes (ypN0(sn)) (sentinel LN: 0/1,. axillary LN: 0/2).. 8. Arteriovenous invasion: absent.. 9. Lymphovascular. invasion:. present,. intratumoral.. . 10. Tumor border: infiltrative.. . 11. Microcalcification: present, non-tumoral.. . 12. Pathological TN category (AJCC 2017):. ypT1cN0(sn).. Result. Intensity. Positive. %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Negative (1+). Ki-67. Positive in 86%. of tumor cells. 11. " +36,Case 10,Important Radiologic,HR(−) HER2(−) Breast Cancer,Important Radiologic. Findings. 66 67. 68. After Neoadjuvant. Chemotherapy. 69 70 71. 72. 10.3.  +42,Case 10,Patient History,HR(−) HER2(−) Breast Cancer,"Patient History and Progress. Female/56 years old, post-menopause.. Self-detected palpable mass lesion on right. breast.. No family history.. Asthma.. 10.2. " +29,Case 10,Courses of Treatment,Local Recurrence,"10.1. . Courses of Treatment. Right breast IDC→ Operation → Adjuvant ther­. apy → Right breast recurrence (IDC).. Primary Treatment. 76 77. 78. Operation. ­. ­. 79. 80. Pathology Report. . 1. Invasive ductal carcinoma.. . (a) Size of tumor: 1.8 cm (pT1c).. . (b) Histologic grade: 2/3 (tubule formation:. 3/3, nuclear pleomorphism: 2/3, mitotic. count: 1/3, 5/10HPF).. . (c) Intraductal component: present, intratu­. moral/extratumoral (10%) (nuclear grade:. low,. necrosis:. present,. architectural. ­. pattern: cribriform/solid, extensive intra­. ductal component: absent).. . (d) Skin: no involvement of tumor.. . (e) Surgical margins:. . ­. . . Local Recurrence. 746. a. b. . a. b. . • Deep margin: <1  mm from invasive. ductal carcinoma (slide 3).. • Superficial margin: (see note 1).. . (f) Lymph nodes:. • Metastasis in one out of five axillary. lymph nodes (pN1mi(sn)) (see note 2). (sentinel LN: 1/4, non-sentinel LN: 0/1).. • Perinodal extension: absent.. • Size of metastatic carcinoma: 1.2 mm.. . (g) Arteriovenous invasion: absent.. . (h) Lymphovascular invasion: present, intra­. tumoral/peritumoral.. . (i) Tumor border: infiltrative.. . (j) Microcalcification: present, non-tumoral.. . (k) Pathological TN category (AJCC 2017):. pT1cN1mi(sn).. . 2. Intraductal papilloma.. Note: 1. The superficial margin of the lumpec­. tomy specimen (slide 3) is close to ductal carci­. noma in situ (<1 mm), but this margin submitted. for frozen diagnosis (Fro 2) is free of tumor.. 2. Micrometastasis is present only in the per­. manent section of Fro 3.. Result. Intensity. Positive %. Estrogen. receptor. Strong (7/8). 2. >2/3. Progesterone. receptor. Strong (7/8). 2. >2/3. C-erbB2. Negative (1+). Ki-67. Positive in 5%. of tumor cells. Adjuvant Therapy. Tamoxifen 20 mg/day for 3.5 years.. Treatments After Recurrence. 81. 82. Operation. 83. 84. Y. Kim et al.. 747. . . . ­. Adjuvant Therapy. Adjuvant chemotherapy #4 cycles of doxorubicin. and cyclophosphamide followed by #4 cycles of. docetaxel.. Plan for postoperative radiation therapy.. Plan for letrozole with goserelin.. Local Recurrence. 748. . 11. " +43,Case 10,Patient History,Local Recurrence,"Patient History and Progress. Female/42 years old, pre-menopause.. Screen detected mass lesion on right breast 5. o’clock direction.. Outside result of biopsy: Invasive ductal. carcinoma.. No family history.. s/p myomectomy.. 10.2. " +30,Case 10,Courses of Treatment,Metastatic Breast Cancer,"10.1. . Courses of Treatment. Left breast cancer → Operation → Adjuvant. therapy → Ipsilateral breast and lung recur­. rence → Palliative therapy → Progression on. lung, left breast.. Primary Treatment. See Figs. 31, 32, and 33.. Operation. Dec. 2020 Left breast conserving surgery, senti­. nel lymph node biopsy.. Pathology: Invasive ductal carcinoma, stage. pT2N0(sn).. Size of tumor: 2.1 cm, lymph node: 0/1.. Y. Kwon et al.. Progesterone. receptor. Negative. (0/8). 0. 0. C-erbB2. Negative. (1+). Ki-67. Positive. in 68%. of tumor. cells. Adjuvant Therapy. Adjuvant chemotherapy #4 cycles (Docetaxel &. cyclophosphamide).. Treatments After Recurrence. Mar. 2021 PET-CT. . 1. R/O malignancy vs post-op change in left. breast upper outer periphery (2h′). rec) follow-up or further evaluation.. . 2. A few solid nodules in BLL; lung metastasis. cannot be excluded.. Negative. (0/8). 0. 0. Progesterone. receptor. Negative. (0/8). 0. 0. C-erbB2. Negative (1+). Ki-67. Positive in. 77% of tumor. cells. → Chemotherapy #6 cycles (albumin-bound. paclitaxel & atezolizumab): Progressive disease. on lung, breast.. Metastatic Breast Cancer. 878. <1%. Progesterone. receptor. Negative. (0/8). 0. 0. C-erbB2. Equivocal. (2+). Ki-67. Positive in. 52% of. tumor cells. SISH. Negative. Palliative Chemotherapy and Radiation. Chemotherapy #5 cycles (Doxorubicin &. Cisplatin).. Radiation therapy to lung~" +44,Case 10,Patient History,Metastatic Breast Cancer,"Patient History and Progress. Female/53 years old, post-menopause.. No family history.. S/p cholecystectomy, s/p knee giant cell tumor. excision, s/p interstitial mammoplasty.. S/p otitis media operation.. 10.2. " +45,Case 11,Courses of Treatment,Benign and Proliferative,"11.1. . Courses of Treatment. →2021-10-29 excision, Rt.. Benign and Proliferative Case Series. 30. . ­. . . Pathology Report. Diagnosis. • Breast, right, excision:. –. – Intraductal papilloma.. 12. " +53,Case 11,Important Radiologic,Benign and Proliferative,Important Radiologic. Findings. 18. 11.3.  +59,Case 11,Patient History,Benign and Proliferative,"Patient History and Progress. Female/39 years old, pre-menopause.. Serous discharge from right nipple.. No family history.. Asthma, hyperthyroidism.. 11.2. " +46,Case 11,Courses of Treatment,Carcinoma In Situ,"11.1. . Courses of Treatment:. Operation. Operation. ­. 50. 51. Pathology Report. . . 1. Ductal Carcinoma In Situ, Pathological TN. Category (AJCC 2017): pTis. . (a) Size of tumor: 0.3 cm (pTis).. . (b) Nuclear grade: low.. . (c) Necrosis: absent.. . (d) Architectural pattern: micropapillary/. cribriform.. . (e) Skin: no involvement of tumor.. . (f) Surgical margins:. • superior margin: 10 mm,. • inferior margin: 2 mm from ductal car­. cinoma in situ (slide 3),. • medial margin: 10 mm,. • lateral margin: <1  mm from lobular. carcinoma in situ (slide 5),. • deep margin: 2 mm,. • superficial margin: 2 mm.. . (g) Microcalcification: present, tumoral/non-. tumoral.. . 2. Lobular Carcinoma In Situ. . (a) Size of tumor: 0.2 cm.. . (b) Nuclear grade: low.. . (c) Necrosis: absent.. . (d) Architectural pattern: solid.. Result. Intensity Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Equivocal (2+). Ki-67. Positive in 3%. of tumor cells. . No residual tumor with foreign body. reaction.. . 1. Post-excision status.. . Carcinoma In Situ. 76. . . 12. " +54,Case 11,Important Radiologic,Carcinoma In Situ,Important Radiologic. Findings. 49. 11.3.  +60,Case 11,Patient History,Carcinoma In Situ,"Patient History and Progress. Female/44 years old, pre-menopause.. Screen detected mass lesion on right breast 8. o’clock direction.. Outside result of biopsy:. Right breast, 8 o’clock, (1) adenosis, (2) fibro­. cystic change, (3) flat epithelial atypia.. Family history, Father: Prostate cancer.. S/P Percutaneous closure of congenital ven­. tricular septal detected.. 11.2. " +47,Case 11,Courses of Treatment,HR(+) HER2(+) Breast Cancer,"11.1. . Courses of Treatment. Operation  +  Adjuvant chemotherapy (#4. cycles of doxorubicin and cyclophospha­. mide). +. Post-operative. radiation. ther­. apy + Trastuzumab + Letrozole 2.5 mg/day.. 63. Pathology Report. . 1. Invasive Ductal Carcinoma.. . (a) Size of tumor: 1.1 cm (pT1c).. . (b) Histologic grade: 2/3 (tubule formation:. 3/3, nuclear pleomorphism: 2/3, mitotic. count: 1/3, 2/10HPF).. . (c) Intraductal component: present, intratu­. moral (20%) (nuclear grade: low, necro­. sis:. absent,. architectural. pattern:. cribriform, extensive intraductal compo­. nent: absent).. S. Park et al.. 335. . . . (d) Surgical margins:. • superior margin: 30 mm,. • inferior margin: 2  mm from invasive. ductal carcinoma (slide 5),. • medial margin: 15 mm,. • lateral margin: 10 mm,. • deep margin: 2 mm,. • superficial margin: 10 mm.. . (e) Arteriovenous invasion: absent.. . (f) Lymphovascular invasion: absent.. . (g) Tumor border: infiltrative.. . (h) Microcalcification: present, non-tumoral.. . (i) Pathological TN category (AJCC 2017):. pT1cNx.. . 2. Intraductal papilloma. HR(+) HER2(+) Breast Cancer. 336. a. b. . Lymph node, right sentinel, excision: No. metastasis in five axillary lymph nodes (pN0(sn)). (right sentinel LN: 0/5).. . 1. Post-excision status.. Result. Intensity. Positive. %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Weak (4/8). 2. 1–10%. C-erbB2. Positive (3+). Ki-67. Positive in 17%. of tumor cells. 12. " +55,Case 11,Important Radiologic,HR(+) HER2(+) Breast Cancer,Important Radiologic. Findings. 59 60 61. 62. HR(+) HER2(+) Breast Cancer. 334. . . 11.3.  +61,Case 11,Patient History,HR(+) HER2(+) Breast Cancer,"Patient History and Progress. Female/60 years old, post-menopause.. Screen detected microcalcification on upper. outer portion of right breast.. No family history.. Hypertension.. 11.2. " +48,Case 11,Courses of Treatment,HR(+) HER2(-) Breast Cancer,"Courses of Treatment. Operation. +. Adjuvant. chemotherapy. (#4  cycles of docetaxel & cyclophospha­. mide). +. Post-operative. radiation. ther­. apy + Letrozole 2.5 mg/day.. Operation. Left breast conserving surgery, sentinel lymph. 5. Surgical margins:. . (a) superior margin: 5 mm,. . (b) inferior margin: 15 mm,. . (c) medial margin: 15 mm,. . (d) lateral margin: 25 mm,. . (e) deep margin: 10 mm,. . (f) superficial margin: positive for invasive. ductal carcinoma (slide 3).. 6. Lymph nodes:. . (a) metastasis in one out of four axillary. lymph nodes (pN1a(sn)) (sentinel LN:. 0/3, intramammary LN: 1/1),. . (b) perinodal extension: absent,. . (c) size of metastatic carcinoma: 3.5 mm.. 7. Arteriovenous invasion: absent.. 8. Lymphovascular invasion: absent.. 9. Tumor border: infiltrative.. . 10. Microcalcification: present, non-tumoral.. . 11. Pathological TN category (AJCC 2017):. pT2N1a(sn).. Result. Intensity. Positive %. Estrogen receptor. Strong (7/8). 2. >2/3. Progesterone receptor. Intermediate (5/8). 2. 10%–1/3. C-erbB2. Negative (0). Ki-67. Positive in 8% of tumor cells. HR(+) HER2(−) Breast Cancer" +56,Case 11,Important Radiologic,HR(+) HER2(-) Breast Cancer,"Important Radiologic. Findings. See Figs. 53, 54, 55 and 56.. 11.3. " +62,Case 11,Patient History,HR(+) HER2(-) Breast Cancer,Dyslipidemia.. 11.2.  +49,Case 11,Courses of Treatment,HR(−) HER2(+) Breast Cancer,"11.1. . operative radiation therapy + Trastuzumab.. Operation. 86. Pathology Report. Invasive Ductal Carcinoma. 1. Post-chemotherapy status.. 2. Size of tumor: 1.5 cm (ypT1c).. 3. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 3/3, 5/HPF).. 4. Intraductal component: present, intratumoral/. extratumoral (40%) (nuclear grade: high, necro­. sis: present, architectural pattern: solid/comedo,. extensive intraductal component: present).. 5. Skin and nipple: no involvement of tumor.. 6. Surgical margins:. . (a) deep margin: 2 mm,. . (b) superficial margin: 2 mm.. 7. Lymph nodes: no metastasis in six axillary. lymph nodes (ypN0) (sentinel LN: 0/3, non-­. sentinel LN: 0/3).. 8. Arteriovenous invasion: absent.. 9. Lymphovascular invasion: present, intratumoral.. . 10. Tumor border: infiltrative.. . 11. Microcalcification:. present,. tumoral/. non-tumoral.. . 12. Pathological TN category (AJCC 2017):. ypT1cN0.. Result. Intensity. Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in. 77% of tumor. cells. HR(−) HER2(+) Breast Cancer. 474. . Y. Kwon et al.. 475. 12. " +57,Case 11,Important Radiologic,HR(−) HER2(+) Breast Cancer,Important Radiologic. Findings. 78 79 80. 81. . ­. HR(−) HER2(+) Breast Cancer. 470. . After Neoadjuvant. Chemotherapy. 82 83 84. 85. . . Y. Kwon et al. +63,Case 11,Patient History,HR(−) HER2(+) Breast Cancer,"Patient History and Progress. Female/56 years old, post-menopause.. Self-detected palpable mass lesion on right. breast.. No family history.. Diabetes mellitus, hepatitis C virus carrier.. 11.2. " +50,Case 11,Courses of Treatment,HR(−) HER2(−) Breast Cancer,"11.1. . Courses of Treatment. Neoadjuvant chemotherapy (#4 cycles of doxo­. rubicin and cyclophosphamide + #4 cycles of. docetaxel) + Operation + Post-operative radia­. tion therapy + Adjuvant capecitabine.. Operation. 82. Pathology Report. Invasive Ductal Carcinoma. 1. Post-chemotherapy status.. 2. Size of tumor: 0.2 cm (ypT1a).. 3. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 6/10HPF).. 4. Intraductal component: absent.. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) Superior margin: 20 mm.. . (b) Inferior margin: 5 mm.. . (c) Medial margin: 10 mm.. . (d) Lateral margin: 20 mm.. . (e) Deep margin: 2 mm.. . (f) Superficial margin: 2 mm.. 7. Lymph nodes: no metastasis in three axillary. lymph nodes (ypN0(sn)) (sentinel LN: 0/3).. 8. Arteriovenous invasion: absent.. 9. Lymphovascular invasion: absent.. . 10. Tumor border: infiltrative.. . 11. Microcalcification:. present,. ­. tumoral/. non-tumoral.. . 12. Pathological TN category (AJCC 2017):. ypT1aN0(sn).. Result. Intensity. Positive. %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (2/8). 1. <1%. C-erbB2. Negative (0). Ki-67. Positive in 2% of. tumor cells. E. S. Lee et al.. 615. . ­. . . HR(−) HER2(−) Breast Cancer. 616. . . ­. E. S. Lee et al.. 617. 12. " +58,Case 11,Important Radiologic,HR(−) HER2(−) Breast Cancer,Important Radiologic. Findings. 74 75 76. 77. E. S. Lee et al.. 613. . . . HR(−) HER2(−) Breast Cancer. 614. . After Neoadjuvant. Chemotherapy. 78 79 80. 81. 11.3.  +64,Case 11,Patient History,HR(−) HER2(−) Breast Cancer,"Patient History and Progress. Female/50 years old, pre-menopause.. Screen detected mass lesion on upper outer. portion of right breast.. Family history of breast cancer, mother and. aunt (paternal).. No comorbidities.. BRCA 1 and 2 mutation: Not detected.. 11.2. " +51,Case 11,Courses of Treatment,Local Recurrence,"11.1. . Courses of Treatment. Right breast IDC → Operation → Adjuvant. therapy → Right breast recurrence (IDC).. Primary Treatment. Operation. Nov. 2008 Right breast conserving surgery, senti­. nel lymph node biopsy (outside).. Pathology Report. Invasive Ductal Carcinoma. . 1. Size of tumor: 1.3 cm (pT1c).. . 2. Lymph nodes: no metastasis in four axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/4).. . 3. Pathologic stage (AJCC 2010): pT1cN0(sn).. Result. Intensity Positive %. Estrogen. receptor. Positive. Progesterone. receptor. Positive. C-erbB2. Negative. Ki-67. Positive in 5–10%. of tumor cells. Adjuvant Therapy. Adjuvant chemotherapy #4 cycles of doxorubicin. and cyclophosphamide.. Postoperative radiation therapy.. Tamoxifen 20 mg/day for 1.8 years.. Treatments After Recurrence. 85 86. 87. Y. Kim et al.. 749. . . . Operation. ­. 88. Pathology Report. Invasive Ductal Carcinomas (×2). 1. Post-chemotherapy status.. 2. Post-lumpectomy status.. 3. Size of tumor: 0.8 cm and 0.3 cm (ypT1b).. 4. Histologic grade: 2/3 (tubule formation: 2/3,. nuclear pleomorphism: 2/3, mitotic count:. 2/3, 12/10HPF).. 5. Intraductal component: present, intratu­. moral/intratumoral (10%) (nuclear grade:. low, necrosis: absent, architectural pattern:. cribriform, extensive intraductal component:. absent).. 6. Skin: no involvement of tumor.. 7. Surgical margins:. . (a) Deep margin: 6 mm.. . (b) Superficial margin: 10 mm.. Local Recurrence. 750. a. b. . 8. Lymph nodes: no metastasis in one axillary. lymph node (ypN0)(sn) (sentinel LN: 0/1).. 9. Vascular invasion: absent.. . 10. Lymphatic invasion: absent.. . 11. Tumor border: infiltrative.. . 12. Microcalcification: absent.. . 13. Pathologic stage (AJCC 2010): ypT1bN0(sn).. Result. Intensity Positive %. Estrogen. receptor. Strong (7/8). 2. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Equivocal (2+). (SISH negative). Ki-67. Positive in 21% of. tumor cells. Adjuvant Therapy. Tamoxifen 20 mg/day for 5 years with goserelin.. 12. " +65,Case 11,Patient History,Local Recurrence,"Patient History and Progress. Female/45 years old, post-menopause.. Screen detected mass lesion on right breast 10. o’clock direction.. No family history.. S/P bilateral salpingo-oophorectomy (right. ovary borderline tumor).. BRCA 1 and 2 mutation: Not detected.. 11.2. " +52,Case 11,Courses of Treatment,Metastatic Breast Cancer,"Courses of Treatment. Both breasts cancer → Operation → Adjuvant. therapy → Right axillary lymph node. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Weak (3/8). 2. <1%. C-erbB2. Equivocal. (2+). Result. Intensity. Positive %. Ki-67. Positive in. 22% of. tumor cells. SISH. Equivocal. HER2/CEP17 gene ratio: 1.93.. Left> Invasive ductal carcinoma, stage. pT2N0(sn).. Size of tumor: 2.1 cm, lymph node: 0/2.. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Weak (4/8). 2. 1–10%. C-erbB2. Equivocal (2+). Ki-67. Positive in 34%. of tumor cells. SISH. Tumor. heterogeneity. HER2/CEP17 gene ratio: 2.03.. Adjuvant Therapy. Adjuvant chemotherapy #2 cycles (Docetaxel &. cyclophosphamide) → Trastuzumab for 1 year +. Letrozole 2.5 mg/day for 2.1 years.. Treatments After Recurrence. Right Axillary Lymph Nodes Recurrence. receptor. Negative (0/8). 0. 0. C-erbB2. Equivocal (2+). Ki-67. Positive in. 25% of tumor. cells. SISH. Positive. Neoadjuvant Chemotherapy. Chemotherapy. #5. cycles. (Docetaxel. &. Carboplatin & Trastuzumab & Pertuzumab).. Operation. Mar. 2022 Right axillary lymph node dissection.. Pathology: No metastasis in four axillary. lymph nodes.. Adjuvant Therapy. Trastuzumab & Pertuzumab + Post-operative. radiation therapy (axillary and subclavian area).. 12. " +66,Case 12,Courses of Treatment,Benign and Proliferative,"12.1. . Courses of Treatment. →2021-10-29 excision, Lt.. Pathology Report. Diagnosis. • Breast, left, excision:. –. – Intraductal papilloma (#1. 2  o’clock, #2.. 5  o’clock & #3. 9  o’clock) with (1) usual. ductal hyperplasia, (2) apocrine metaplasia.. C. W. Lee et al.. 31. 13. " +74,Case 12,Important Radiologic,Benign and Proliferative,Important Radiologic. Findings. 19. 20. 12.3.  +80,Case 12,Patient History,Benign and Proliferative,"Patient History and Progress. Female/70 years old, post-menopause.. Screen detected mass lesion on left breast. 2 o’clock and 5 o’clock and 9 o’clock direction.. No family history.. s/p Right breast conserving surgery (right. breast cancer), hypertension, diabetes mellitus.. 12.2. " +67,Case 12,Courses of Treatment,Carcinoma In Situ,"12.1. . Courses of Treatment. Operation + Tamoxifen 20 mg/day for 5 years.. Operation. ­. ­. 55. 56. Pathology Report. Ductal carcinoma in situ, pathological TN cat­. egory (AJCC 2017): pTisN0(sn). . 1. Size of tumor: 1.0 cm (pTis).. . 2. Nuclear grade: high.. . 3. Necrosis: present.. . 4. Architectural. pattern:. cribriform/solid/. comedo.. . 5. Surgical margins:. . (a) deep margin: 10 mm,. . (b) superficial margin: 12 mm.. . 6. Lymph nodes: no metastasis in two axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/1, left. intramammary LN: 0/1).. . 7. Microcalcification: present, non-tumoral.. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative. (1+). Ki-67. Positive in. 16% of. tumor cells" +75,Case 12,Important Radiologic,Carcinoma In Situ,Important Radiologic. Findings. 52 53. 54. 12.3.  +81,Case 12,Patient History,Carcinoma In Situ,"Patient History and Progress. Female/49 years old, pre-menopause.. Screen detected mass lesion on right breast. 4:30 and 9 o’clock direction.. Outside result of biopsy:. Left breast 4: 30 o’clock, ductal carcinoma in. situ.. Left breast 9 o’clock, intraductal papilloma.. Family history of breast cancer, sister at her. 48 years old.. E. S. Lee et al.. 77. No comorbidities.. BRCA 1 and 2 mutation: Not detected.. 12.2. " +68,Case 12,Courses of Treatment,HR(+) HER2(+) Breast Cancer,"12.1. . Courses of Treatment. Neoadjuvant chemotherapy (#1 cycle of. docetaxel and carboplatin and trastuzumab. and pertuzumab followed by #5 cycles of. docetaxel and carboplatin)  +  Operation  +. Adjuvant chemotherapy (doxorubicin and. cyclophosphamide) + Post-­. operative radiation. therapy + Letrozole 2.5 mg/day.. 69. Pathology Report. Invasive Ductal Carcinoma. 1. Post-chemotherapy status.. 2. Size of tumor: 0.3 cm (ypT1a).. 3. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 2/3, 11/10HPF).. 4. Intraductal component: present, intratu­. moral/extratumoral (50%) (nuclear grade:. high, necrosis: absent, architectural pattern:. micropapillary, extensive intraductal compo­. nent: present).. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) superior margin: 10 mm,. . (b) inferior margin: (see Note 1),. . (c) medial margin: (see Note 2),. . (d) lateral margin: 20 mm,. . (e) deep margin: 2 mm,. . (f) superficial margin: 2 mm.. 7. Lymph nodes: no metastasis in one axillary. lymph node (ypN0(sn)) (sentinel LN: 0/1).. 8. Arteriovenous invasion: absent.. 9. Lymphovascular invasion: absent.. . 10. Tumor border: infiltrative.. . 11. Microcalcification:. present,. tumoral/. non-tumoral.. . 12. Pathological TN category (AJCC 2017):. ypT1aN0(sn).. HR(+) HER2(+) Breast Cancer. 338. . Note: 1. The inferior margin of the lumpec­. tomy specimen (slide A3) is close to ductal carci­. noma in situ (2 mm) but this margin submitted. for frozen diagnosis (Fro 2) is free of tumor.. 2. The medial margin of the lumpectomy. specimen (slide 1) is close to ductal carcinoma in. situ (<1 mm) but this margin submitted for frozen. diagnosis (Fro 3) is free of tumor.. Result. Intensity. Positive %. Estrogen receptor. Strong (8/8). 3. >2/3. Progesterone receptor. Weak (3/8). 1. 1–10%. C-erbB2. Negative (1+). Equivocal (2+) in core needle biopsy. Ki-67. Positive in 4% of tumor cells. SISH. Positive. S. Park et al.. 339. . . HR(+) HER2(+) Breast Cancer. 340. a. b. . 13. " +76,Case 12,Important Radiologic,HR(+) HER2(+) Breast Cancer,Important Radiologic. Findings. 64 65 66 67. 68. S. Park et al.. 337. . . 12.3.  +82,Case 12,Patient History,HR(+) HER2(+) Breast Cancer,"Patient History and Progress. Female/63 years old, post-menopause.. Screen detected mass lesion on left breast 10. o’clock direction.. No family history.. s/p Idiopathic thrombocytopenic purpura. (2020).. 12.2. " +69,Case 12,Courses of Treatment,HR(+) HER2(-) Breast Cancer,"Courses of Treatment. Operation. +. Adjuvant. chemotherapy. (#4  cycles of docetaxel & cyclophospha­. mide). +. Post-operative. radiation. ther­. apy + Tamoxifen 20 mg/day.. Operation. Right breast conserving surgery, sentinel lymph. extratumoral (30%) (nuclear grade: low,. necrosis: present, architectural pattern: solid,. extensive intraductal component: present).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) superior margin: 3 mm,. . (b) inferior margin: 17 mm,. . (c) medial margin: 10 mm,. . (d) lateral margin: <1 mm from ductal carci­. noma in situ (slides 10 and 11),. . (e) deep margin: 5 mm,. . (f) superficial margin: positive for ductal. carcinoma in situ (slide 8).. 6. Lymph nodes: no metastasis in five axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/2,. non-sentinel LN: 0/3).. 7. Arteriovenous invasion: absent.. 8. Lymphovascular. invasion:. present,. peritumoral.. 9. Tumor border: pushing.. . 10. Microcalcification: absent.. . 11. Pathological TN category (AJCC 2017):. pT2N0(sn).. Result. Intensity. Positive %. Estrogen receptor. Weak (4/8). 1. 10%–1/3. Progesterone receptor. Intermediate (5/8). 2. 10%–1/3. C-erbB2. Negative (0). Ki-67. Positive in 4% of tumor cells. Y. Kim et al." +77,Case 12,Important Radiologic,HR(+) HER2(-) Breast Cancer,"Important Radiologic. Findings. See Figs. 58, 59, 60 and 61.. 12.3. " +83,Case 12,Patient History,HR(+) HER2(-) Breast Cancer,"S/P hysterectomy, dyslipidemia, diabetes mel­. litus, s/p cervical spine disc operation.. 12.2. " +70,Case 12,Courses of Treatment,HR(−) HER2(+) Breast Cancer,"12.1. . Invasive Ductal Carcinoma with medullary. pattern. 1. Size of tumor: 2.9 cm (pT2).. 2. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 3/3, 5/HPF).. 3. Intraductal component: present, intratu­. moral/extratumoral (30%) (nuclear grade:. high, necrosis: present, architectural pattern:. Y. Kwon et al.. 477. . solid/comedo, extensive intraductal compo­. nent: present).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) superior margin: 10 mm,. . (b) inferior margin: 5 mm,. . (c) medial margin: 20 mm,. . (d) lateral margin: 15 mm,. . (e) deep margin: 2 mm,. . (f) superficial margin: 2 mm.. 6. Lymph nodes: no metastasis in four axillary. lymph nodes (pN0(sn)) (sentinel LN (fro­. zen): 0/4, sentinel LN (A): 0/0, non-sentinel. LN: 0/0).. 7. Arteriovenous invasion: absent.. 8. Lymphovascular. invasion:. present,. intratumoral.. 9. Tumor border: infiltrative.. . 10. Microcalcification:. present,. tumoral/. non-tumoral.. . 11. Pathological TN category (AJCC 2017):. pT2N0(sn).. Result. Intensity. Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in. 52% of tumor. cells. HR(−) HER2(+) Breast Cancer. 478. 13. " +78,Case 12,Important Radiologic,HR(−) HER2(+) Breast Cancer,Important Radiologic. Findings. 87 88 89 +84,Case 12,Patient History,HR(−) HER2(+) Breast Cancer,"Patient History and Progress. Female/66 years old, post-menopause.. Self-detected palpable mass lesion on left. breast.. No family history.. Hypertension, thyroidectomy (hyperthyroid­. ism), s/p salpingectomy.. 12.2. " +71,Case 12,Courses of Treatment,HR(−) HER2(−) Breast Cancer,"12.1. . Courses of Treatment. Neoadjuvant chemotherapy (#4 cycles of doxo­. rubicin and cyclophosphamide  +  #4 cycles of. docetaxel) + Operation + Adjuvant capecitabine.. Operation. ­. ­. ­. 89. 90. Pathology Report. Invasive Ductal Carcinoma. 1. Post-chemotherapy status.. 2. Size of tumor: 0.5 cm (ypT1a).. 3. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 1/3, 1/10HPF).. 4. Intraductal component: absent.. 5. Surgical margins:. . (a) Deep margin: 2 mm.. . (b) Superficial margin: 8 mm.. 6. Lymph nodes: no metastasis in three axil­. lary lymph nodes (ypN0(sn)) (sentinel LN:. 0/3).. 7. Arteriovenous invasion: absent.. 8. Lymphovascular. invasion:. present,. intratumoral.. 9. Tumor border: infiltrative.. . 10. Microcalcification: present, non-tumoral.. . 11. Pathological TN category (AJCC 2017):. ypT1aN0(sn).. Result. Intensity. Positive. %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Negative (0). Ki-67. Positive in 6% of. tumor cells. E. S. Lee et al.. 619. . . HR(−) HER2(−) Breast Cancer. 620. 13. " +79,Case 12,Important Radiologic,HR(−) HER2(−) Breast Cancer,Important Radiologic. Findings. 83 84. 85. . . . HR(−) HER2(−) Breast Cancer. 618. . ­. . . After Neoadjuvant. Chemotherapy. 86 87. 88. 12.3.  +85,Case 12,Patient History,HR(−) HER2(−) Breast Cancer,"Patient History and Progress. Female/47 years old, post-menopause.. Screen detected a mass lesion on right breast. 10 o’clock direction.. Family history of breast cancer, aunt (mater­. nal) and cousin.. Family history of ovarian cancer, aunt.. Lupus (follow-up), s/p bilateral salpingo-­. oophorectomy, s/p unilateral thyroidectomy.. BRCA 1 mutation carrier.. 12.2. " +72,Case 12,Courses of Treatment,Local Recurrence,"12.1. . Courses of Treatment. Right breast DCIS → Operation → Right breast. recurrence (microinvasive ductal carcinoma).. Primary Treatment. 89 90. 91. Operation. ­. 92. Pathology Report. Ductal carcinoma in situ. . 1. Size of tumor: 2.3 cm (pTis).. . 2. Nuclear grade: low.. . 3. Necrosis: absent.. . 4. Architectural pattern: cribriform, solid and. papillary.. . 5. Skin: no involvement of tumor.. . 6. Surgical margins:. . (a) Superior margin: 20 mm.. . (b) Inferior margin: 20 mm.. . (c) Medial margin: 30 mm.. . (d) Lateral margin: 50 mm.. . (e) Deep margin: 2 mm.. . 7. Lymph nodes: no metastasis in 5 axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/4,. right intramammary LN (Fro 6): 0/1).. Y. Kim et al.. 751. . . ­. . . . ­. . 8. Microcalcification:. present,. tumoral/. non-tumoral.. . 9. Pathologic staging: pTisN0(sn).. Result. Intensity. Positive %. Estrogen. receptor. Strong (7/7). 3. >2/3. Progesterone. receptor. Strong (6/7). 3. 1/3–2/3. C-erbB2. Equivocal (2+). Ki-67. Positive in 10%. of tumor cells. Treatments After Recurrence. 93. Operation. 94. 95. Local Recurrence. 752. a. b. . a. b. . Pathology Report. . 1. Microinvasive Ductal Carcinoma involving. lactiferous duct.. . (a) Post-lumpectomy status.. . (b) Size of invasive component: <0.1  cm. (pT1mi(Paget)).. . (c) Size of intraductal component: 1.3 cm.. . (d) Histologic grade: 2/3 (tubule formation:. 3/3, nuclear pleomorphism: 2/3, mitotic. count: 1/3, 6/10HPF).. . (e) Intraductal component: present, intratu­. moral/extratumoral. (99%). (nuclear. grade: low, necrosis: present, architec­. tural pattern: micropapillary/cribriform,. extensive. intraductal. component:. present).. . (f) Nipple: involvement of lactiferous duct. (slide 10).. . (g) Skin: no involvement of tumor.. . (h) Surgical margins:. Y. Kim et al.. 753. • Deep margin: 3 mm.. • Superficial margin: 4 mm.. . (i) Arteriovenous invasion: absent.. . (j) Lymphovascular invasion: absent.. . (k) Tumor border: infiltrative.. . (l) Microcalcification: present, tumoral.. . (m) Pathologic. stage. (AJCC. 2010):. pT1mi(Paget).. . 2. Lobular carcinoma in situ, 0.3 cm.. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Intermediate. (6/8). 2. 1/3–2/3. C-erbB2. Equivocal (2+). Ki-67. Positive in 13%. of tumor cells. Adjuvant Therapy. Tamoxifen 20 mg/day for 5 years.. 13. " +86,Case 12,Patient History,Local Recurrence,"Patient History and Progress. Female/55 years old, peri-menopause.. Screen detected mass lesion on right breast 9. o’clock direction.. Family history of prostate cancer, father.. s/p hysterectomy, HPV infection.. 12.2. " +73,Case 12,Courses of Treatment,Metastatic Breast Cancer,"12.1. . Courses of Treatment. Left breast cancer → Operation → Adjuvant. therapy → Ipsilateral axillary lymph node. recurrence → Contralateral breast cancer.. Primary Treatment. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Intermediate. (6/8). 2. 1/3–2/3. C-erbB2. Equivocal (2+). Ki-67. Positive in 26%. of tumor cells. SISH. Negative. Adjuvant Therapy. Anastrozole 1 mg/day for 4.3 years.. Treatments After Recurrence. Ipsilateral Axillary Lymph Node. Recurrence. Progesterone. receptor. Weak (4/8). 3. <1%. C-erbB2. Negative (0). Ki-67. Positive in. 31% of. tumor cells. Neoadjuvant Chemotherapy. Chemotherapy. #8. cycles. (Adriamycin. +. Cyclophosphamide #4 → weekly paclitaxel #4).. Y. Kwon et al.. Contralateral Breast Cancer. See Figs. 41 and 42.. Aug. 2021 Right breast biopsy.. Pathology: Ductal carcinoma.. Operation. Oct. 2021 Right total mastectomy, sentinel lymph. node biopsy.. Pathology: Ductal carcinoma in situ, stage. pTisN0(sn).. Size of tumor: 1.6 cm, lymph node: 0/4.. Result. Intensity. Positive %. Estrogen. receptor. Strong (0/8). 0. 0. Progesterone. receptor. Weak (0/8). 0. 0. C-erbB2. Equivocal. (2+). Ki-67. Positive in. 12% of. tumor cells. → Exemestane 25 mg/day~. Adjuvant Therapy. Exemestane 25 mg/day~. Metastatic Breast Cancer. 882. 13. " +87,Case 12,Patient History,Metastatic Breast Cancer,"Patient History and Progress. Female/78 years old, post-menopause.. No family history.. Hypertension, diabetes mellitus.. 12.2. " +88,Case 13,Courses of Treatment,Benign and Proliferative,"13.1. . Courses of Treatment. →2021-10-26 excision, Rt.. . Benign and Proliferative Case Series. 32. . Pathology Report. • Breast, right 12 o’clock, excision:. –. – Flat. epithelial. atypia. with. microcalcification. • Breast, right 2 o’clock, excision:. –. – Atypical. ductal. hyperplasia. with. microcalcification.. 14. " +96,Case 13,Important Radiologic,Benign and Proliferative,Important Radiologic. Findings. 21. 22. 13.3.  +102,Case 13,Patient History,Benign and Proliferative,"Patient History and Progress. Female/45 years old, pre-menopause.. Screen detected microcalcification on upper. center of right breast.. No family history.. No comorbidities.. 13.2. " +89,Case 13,Courses of Treatment,Carcinoma In Situ,". Courses of Treatment. Operation + Tamoxifen 20 mg/day for 5 years.. Operation. 58. 59. Pathology Report. . Ductal carcinoma in situ, pathological TN cat­. egory (AJCC 2017): pTis. . 1. Size of tumor: 0.5 cm (pTis).. . 2. Nuclear grade: low.. . 3. Necrosis: absent.. . 4. Architectural pattern: papillary/cribriform.. . 5. Surgical margins: positive for ductal carci­. noma in situ.. . 6. Microcalcification:. present,. tumoral/non-. tumoral.. Carcinoma In Situ. 80. . . . Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (7/8). 2. >2/3. C-erbB2. Negative (0). Ki-67. Positive in. 1% of tumor. cells. . No residual tumor with foreign body reaction.. . 1. Post-excision status.. E. S. Lee et al.. 81. 14. " +97,Case 13,Important Radiologic,Carcinoma In Situ,Important Radiologic. Findings. 57. 13.3.  +103,Case 13,Patient History,Carcinoma In Situ,"Patient History and Progress. Female/61 years old, post-menopause.. Screen detected mass lesion on left breast. 10 o’clock direction.. Outside result of biopsy: Left breast. 10 o’clock, papillary neoplasm.. Family history of breast cancer, sister.. No comorbidities.. BRCA 1 and 2: Not check.. 13.2. " +90,Case 13,Courses of Treatment,HR(+) HER2(+) Breast Cancer,"13.1. . Courses of Treatment. Operation  +  Adjuvant chemotherapy (#4. cycles. of. docetaxel. and. cyclophospha­. mide). +. Post-operative. radiation. ther­. apy + Trastuzumab + Letrozole 2.5 mg/day.. 73. Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 2.1 cm (pT2).. 2. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 15/10 HPF).. S. Park et al.. 341. . . . 3. Intraductal component: present, intratu­. moral/extratumoral (10%) (nuclear grade:. low, necrosis: present, architectural pattern:. solid/comedo, extensive intraductal compo­. nent: absent).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) superior margin: 10 mm,. . (b) inferior margin: 10 mm,. . (c) medial margin: 5 mm,. . (d) lateral margin: 5 mm,. . (e) deep margin: 2 mm,. . (f) superficial margin: 2 mm.. 6. Lymph nodes: no metastasis in one axillary. lymph node (pN0(sn)) (sentinel LN: 0/1).. 7. Arteriovenous invasion: absent.. 8. Lymphovascular. invasion:. present,. intratumoral.. 9. Tumor border: infiltrative.. . 10. Microcalcification:. present,. tumoral/. non-tumoral.. . 11. Pathological TN category (AJCC 2017):. pT2N0(sn).. Result. Intensity. Positive. %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (7/8). 3. 1/3–2/3. C-erbB2. Positive (3+). Ki-67. Positive in 42%. of tumor cells. HR(+) HER2(+) Breast Cancer. 342. a. b. . 14. " +98,Case 13,Important Radiologic,HR(+) HER2(+) Breast Cancer,Important Radiologic. Findings. 70 71. 72. 13.3.  +104,Case 13,Patient History,HR(+) HER2(+) Breast Cancer,"Patient History and Progress. Female/53 years old, post-menopause.. Screen detected mass lesion on left breast 1:30. o’clock direction.. No family history.. Hypertension, arrhythmia, s/p myomectomy.. 13.2. " +91,Case 13,Courses of Treatment,HR(+) HER2(-) Breast Cancer,"Courses of Treatment. Operation. +. Adjuvant. chemotherapy. (#4 cycles of doxorubicin & cyclophosphamide. followed by #4  cycles of docetaxel)  +  Post-­. operative radiation therapy  +  Letrozole. 2.5 mg/day.. Operation. sive intraductal component: absent).. 4. Skin and nipple: dermal involvement of. tumor.. 5. Surgical margins: (see note).. . (a) deep margin: <1 mm from invasive duc­. tal carcinoma (slide 3).. . (b) superficial margin: 2 mm.. 6. Lymph nodes:. HR(+) HER2(−) Breast Cancer. 8. Lymphovascular. invasion:. present,. intratumoral.. 9. Tumor border: infiltrative.. . 10. Microcalcification: present, tumoral.. . 11. Pathological TN category (AJCC 2017):. pT3N2a.. Note: 1. The medial border of the mastectomy. specimen (slide 10) is close to invasive ductal. carcinoma (<1 mm).. HR(+) HER2(−) Breast Cancer. Intermediate (6/8). 2. 1/3–2/3. C-erbB2. Negative (1+). Ki-67. Positive in 26% of tumor cells. 14. " +99,Case 13,Important Radiologic,HR(+) HER2(-) Breast Cancer,"Important Radiologic. Findings. See Figs. 63, 64, 65 and 66.. 13.3. " +105,Case 13,Patient History,HR(+) HER2(-) Breast Cancer,"S/P Tuberculosis, S/P appendectomy.. 13.2. " +92,Case 13,Courses of Treatment,HR(−) HER2(+) Breast Cancer,"13.1. . Courses of Treatment. Neoadjuvant chemotherapy (#6 cycles of. docetaxel and carboplatin and trastuzumab and. pertuzumab) + Operation + Post-operative radia­. 2. Size of tumor: 0.3 cm (ypT1a).. 3. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 3/3, 4/HPF).. 4. Intraductal component: present, intratu­. moral/extratumoral (30%) (nuclear grade:. high, necrosis: present, architectural pattern:. cribriform/solid, extensive intraductal com­. ponent: present).. . Y. Kwon et al.. 483. 5. Skin and nipple: no involvement of tumor.. 6. Surgical margins:. . (a) deep margin: 2 mm,. . (b) superficial margin: 2 mm.. 7. Lymph nodes: no metastasis in six axillary. lymph nodes (ypN0) (sentinel LN: 0/3, non-­. sentinel LN: 0/3).. 8. Arteriovenous invasion: absent.. 9. Lymphovascular. invasion:. present,. intratumoral.. . 10. Tumor border: infiltrative.. . 11. Microcalcification:. present,. tumoral/. non-tumoral.. . 12. Pathological TN category (AJCC 2017):. ypT1aN0.. Result. Intensity. Positive %. Estrogen. receptor. Negative. (0/8). 0. 0. Progesterone. receptor. Negative. (0/8). 0. 0. C-erbB2. Positive. (3+). Result. Intensity. Positive %. Ki-67. Positive in. 4% of. tumor cells. 14. " +100,Case 13,Important Radiologic,HR(−) HER2(+) Breast Cancer,Important Radiologic. Findings. 92 93. 94. . Y. Kwon et al.. 479. 95 96 97. 98. 13.4.  +106,Case 13,Patient History,HR(−) HER2(+) Breast Cancer,"Patient History and Progress. Female/44 years old, pre-menopause.. Self-detected palpable mass lesion on left. breast 11 o’clock direction.. No family history.. No comorbidities.. 13.2. " +93,Case 13,Courses of Treatment,HR(−) HER2(−) Breast Cancer,"13.1. . Courses of Treatment. Neoadjuvant chemotherapy (#4  cycles of. doxorubicin and cyclophosphamide  +  #4. cycles of docetaxel)  +  Operation  +  Post-. operative radiation therapy  +  Adjuvant. capecitabine.. Operation. 98. Pathology Report. Invasive Ductal Carcinoma. 1. Post-chemotherapy status.. 2. Size of tumor: 1.5 cm (ypT1c).. 3. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 2/3, 12/10HPF).. 4. Intraductal component: present, intratu­. moral/extratumoral (5%) (nuclear grade:. high, necrosis: absent, architectural pattern:. solid, extensive intraductal component:. absent).. 5. Surgical margins:. . (a) Superior margin: 15 mm.. . (b) Inferior margin: 20 mm.. . (c) Medial margin: 5 mm (see note 1).. . (d) Lateral margin: 15 mm.. . (e) Deep margin: 3 mm.. . (f) Superficial margin: 10 mm.. 6. Lymph nodes: no metastasis in two axillary. lymph nodes (ypN0(sn)) (sentinel LN: 0/1,. non-sentinel LN: 0/1).. 7. Arteriovenous invasion: absent.. 8. Lymphovascular. invasion:. present,. intratumoral.. 9. Tumor border: infiltrative.. . 10. Microcalcification: present, non-tumoral.. . 11. Pathological TN category (AJCC 2017):. ypTlcN0 (sn).. Result. Intensity. Positive. %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Negative (0). Ki-67. Positive in 16%. of tumor cells. E. S. Lee et al.. 621. . . . HR(−) HER2(−) Breast Cancer. 622. . . ­. . E. S. Lee et al.. 623. . . HR(−) HER2(−) Breast Cancer. 624. 14. " +101,Case 13,Important Radiologic,HR(−) HER2(−) Breast Cancer,Important Radiologic. Findings. 91 92. 93. After Neoadjuvant. Chemotherapy. 94 95 96. 97. 13.3.  +107,Case 13,Patient History,HR(−) HER2(−) Breast Cancer,"Patient History and Progress. Female/67 years old, post-menopause.. Self-detected mass lesion on left breast.. No family history.. Hepatitis C virus carrier, arrhythmia.. 13.2. " +94,Case 13,Courses of Treatment,Local Recurrence,"13.1. . Courses of Treatment. Right breast microinvasive ductal carcinoma →. Operation → Right breast recurrence (DCIS).. Primary Treatment. 96 97. 98. . . . Local Recurrence. 754. a. b. . a. b. . Operation. ­. 99. 100. Pathology Report. Microinvasive Ductal Carcinoma. 1. Size of invasive component: <0.1  cm. (pT1mi).. 2. Size of intraductal component: 4.5 cm.. 3. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 2/3, 11/HPF).. 4. Intraductal component: present, intratu­. moral/extratumoral (98%) (nuclear grade:. high, necrosis: present, architectural pattern:. micropapillary/cribriform, extensive intra­. ductal component: present).. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) Deep margin: <1 mm from ductal carci­. noma in situ (slide 3).. . (b) Superficial margin: <1 mm from ductal. carcinoma in situ (slide 10).. 7. Lymph nodes: no metastasis in three axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/3). 8. Arteriovenous invasion: absent.. 9. Lymphovascular invasion: absent.. . 10. Tumor border: infiltrative.. . 11. Microcalcification:. present,. tumoral/. non-tumoral.. . 12. Pathologic stage (AJCC 2010): pT1miN0(sn).. Result. Intensity. Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in 35%. of tumor cells. Y. Kim et al.. 755. Treatments After Recurrence. 101. Operation. 102. Pathology Report. Ductal Carcinoma In Situ. . 1. Post-nipple-sparing mastectomy status.. . 2. Size of tumor: 1.0 cm (rpTis(Paget)).. . 3. Nuclear grade: high.. . 4. Necrosis: present.. . 5. Architectural pattern: micropapillary/cribri­. form/comedo.. . 6. Nipple: involvement of lactiferous duct with. Paget’s disease.. . 7. Surgical margins:. . (a) Superior margin: 5 mm.. . (b) Inferior margin: 5 mm.. . (c) Medial margin: 5 mm.. . (d) Lateral margin: 5 mm.. . (e) Deep margin: 2 mm.. . (f) Superficial margin: 2 mm.. . 8. Microcalcification: present, tumoral.. . 9. Pathological TN category (AJCC 2017):. rpTis.. Result. Intensity. Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (2/8). 1. <1%. C-erbB2. Positive (3+). Ki-67. Positive in 19%. of tumor cells. 14. " +108,Case 13,Patient History,Local Recurrence,"Patient History and Progress. Female/42 years old, pre-menopause.. Screen detected mass lesion on right breast 3. o’clock direction and bloody discharge from. right nipple.. Outside result of biopsy: Ductal carcinoma in. situ.. No family history.. No comorbidities.. BRCA 1 and 2 mutation: not detected.. 13.2. " +95,Case 13,Courses of Treatment,Metastatic Breast Cancer,"13.1. . Courses of Treatment. Right breast cancer → Operation → Adjuvant. therapy → Ipsilateral axillary lymph node. recurrence.. Primary Treatment. Estrogen. receptor. Intermediate. (6/8). 1. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (0). Ki-67. Positive in. 18% of tumor. cells. Adjuvant Therapy. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (1+). Ki-67. Positive in. 44% of tumor. cells. See Figs. 45 and 46.. Neoadjuvant Chemotherapy. Neoadjuvant. chemotherapy. #8. cycles. (Adriamycin. +. Cyclophosphamide. #4. →. Docetaxel #4).. Operation. Oct. 2021 Right axillary tail wide excision and. bilateral salpingo-oophorectomy.. Pathology: DUCTAL CARCINOMA IN. SITU, stage yrpTis, size of tumor: 0.2 cm.. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (0). Ki-67. Positive in. 2% of. tumor cells. Adjuvant Therapy. Post-operative radiation therapy + Letrozole" +109,Case 13,Patient History,Metastatic Breast Cancer,"Patient History and Progress. Female/39 years old, post-menopause.. Family history of ovarian cancer, paternal. aunt.. BRCA. 1. mutation: VUS. (variant. of. uncertain).. S/p bilateral salpingo-oophorectomy.. 13.2. " +110,Case 14,Courses of Treatment,Benign and Proliferative,"14.1. . Courses of Treatment. →2021-10-15 excision, Rt.. Pathology Report. • Breast, right, excision:. –. – Atypical ductal hyperplasia involving. intraductal papilloma with marked cautery. artifact.. C. W. Lee et al.. 33. . . 15. " +118,Case 14,Important Radiologic,Benign and Proliferative,Important Radiologic. Findings. 23. 24. 14.3.  +124,Case 14,Patient History,Benign and Proliferative,"Patient History and Progress. Female/60 years old, post-menopause.. Screen detected mass lesion on right breast. 9 o’clock direction.. Family history of breast cancer, mother.. s/p Total hysterectomy (leiomyoma) and Left. salpingo-oophorectomy.. 14.2. " +111,Case 14,Courses of Treatment,Carcinoma In Situ,"14.1. . Courses of Treatment:. Operation. Operation. 61. 62. Pathology Report. . Ductal carcinoma in situ, pathological TN cat­. egory (AJCC 2017): pTis. . 1. Size of tumor: 0.3 cm (pTis).. . 2. Nuclear grade: low.. . 3. Necrosis: absent.. . 4. Architectural pattern: papillary.. . 5. Surgical margins:. . (a) superior margin: 5 mm,. . (b) inferior margin: 7 mm,. . (c) medial margin: 20 mm,. . (d) lateral margin: positive for ductal carci­. noma in situ (slide 5),. . (e) deep margin: positive for ductal carci­. noma in situ (slide 5),. . (f) superficial margin: 5 mm.. . 6. Microcalcification: present, tumoral.. Result. Intensity. Positive %. Estrogen. receptor. Weak (4/8). 2. 1%–10%. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Negative (1+). Ki-67. Positive in 1%. of tumor cells. . No residual tumor with foreign body reaction.. . 1. Post-excision status.. Note: Atypical ductal hyperplasia is pres­. ent only in the frozen section of Fro 1. . Carcinoma In Situ. 82. . . . 15. " +119,Case 14,Important Radiologic,Carcinoma In Situ,Important Radiologic. Findings. 60. 14.3.  +125,Case 14,Patient History,Carcinoma In Situ,"Patient History and Progress. Female/54 years old, pre-menopause.. Screen detected microcalcification on upper. inner portion of left.. No family history.. Taking medication for bladder dysfunction.. 14.2. " +112,Case 14,Courses of Treatment,HR(+) HER2(+) Breast Cancer,"14.1. . Courses of Treatment. Operation  +  Adjuvant chemotherapy (#4. cycles of doxorubicin and cyclophosphamide. followed by #4 cycles of docetaxel and trastu­. zumab)  +  Post-operative radiation ther­. apy + Trastuzumab + Tamoxifen 20 mg/day.. 77. Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 1.5 cm (pT1c(m)).. 2. Histologic grade: 2/3 (tubule formation: 2/3,. nuclear pleomorphism: 3/3, mitotic count:. 2/3, 11/10 HPF).. S. Park et al.. 343. . . . 3. Intraductal component: present, intratu­. moral/extratumoral (50%) (nuclear grade:. high, necrosis: present, architectural pattern:. cribriform/solid/comedo, extensive intra­. ductal component: present).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) superior margin: 10 mm,. . (b) inferior margin: 10 mm,. . (c) medial margin: 10 mm,. . (d) lateral margin: 5 mm,. . (e) deep margin: 2 mm,. . (f) superficial margin: 2 mm.. 6. Lymph nodes:. . (a) metastasis in one out of one axillary. lymph node (pN1mi(sn)) (sentinel LN:. 1/1),. . (b) perinodal extension: present,. . (c) size of metastatic carcinoma: 2 mm.. 7. Arteriovenous invasion: absent.. HR(+) HER2(+) Breast Cancer. 344. a. b. c. d. . 8. Lymphovascular. invasion:. present,. intratumoral.. 9. Tumor border: infiltrative.. . 10. Microcalcification:. present,. tumoral/. non-tumoral.. . 11. Pathological TN category (AJCC 2017):. pT1c(m)N1mi(sn).. Invasive Ductal Carcinoma. . 1. Size of tumor: 0.6, 0.5 and 0.5 cm.. . 2. Histologic grade: 2/3 (tubule formation: 2/3,. nuclear pleomorphism: 2/3, mitotic count:. 2/3, 11/10 HPF).. . 3. Intraductal component: absent.. . 4. Skin: no involvement of tumor.. S. Park et al.. 345. . 5. Surgical margins:. . (a) superior margin: 10 mm,. . (b) inferior margin: 10 mm,. . (c) medial margin: 5 mm,. . (d) lateral margin: 5 mm,. . (e) deep margin: 2 mm,. . (f) superficial margin: 2 mm.. . 6. Arteriovenous invasion: absent.. . 7. Lymphovascular invasion: absent.. . 8. Tumor border: infiltrative.. . 9. Microcalcification: present, tumoral.. Result. Intensity. Positive. %. Estrogen. receptor. IDC—strong. (8/8). 3. >2/3. In situ—negative. (2/8). 1. <1%. Progesterone. receptor. IDC—strong. (8/8). 3. >2/3. In situ—negative. (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in 17%. of tumor cells. 15. " +120,Case 14,Important Radiologic,HR(+) HER2(+) Breast Cancer,Important Radiologic. Findings. 74 75. 76. 14.3.  +126,Case 14,Patient History,HR(+) HER2(+) Breast Cancer,"Patient History and Progress. Female/51 years old, peri-menopause.. Screen detected mass lesion on portion of. lower of right breast.. Family history of breast cancer, sister.. Hypothyroidism (taking on synthroid).. BRCA 1 and 2 mutation: Not detected.. 14.2. " +113,Case 14,Courses of Treatment,HR(+) HER2(-) Breast Cancer,"14.1. . Courses of Treatment. Neoadjuvant therapy (Palbociclib 125 mg/day. &. tamoxifen. 20. mg/day. with. gosere­. lin)  +  Operation  +  Post-operative radiation. therapy. +. Letrozole. 2.5. mg/day. with. goserelin.. Operation. Left breast conserving surgery, sentinel lymph. . (a) superior margin: 5 mm.. . (b) inferior margin: (see note 1).. . (c) medial margin: (see note 2).. . (d) lateral margin: (see note 3).. . (e) deep margin: <1  mm from mucinous. carcinoma (slide 1).. . (f) superficial margin: <1  mm from muci­. 11. Microcalcification:. present,. tumoral/. non-tumoral.. . 12. Pathological TN category (AJCC 2017):. ypT1cN0(sn).. Note: 1. The inferior margin of the lumpec­. tomy specimen (slide 4) is close to mucinous. carcinoma (<1 mm) but this margin submitted. for frozen diagnosis (Fro 3) is free of tumor.. 2. The medial margin of the lumpectomy speci­. men (slide 3) is close to mucinous carcinoma. (1 mm) but this margin submitted for frozen. diagnosis (Fro 4) is free of tumor.. 3. The lateral margin of the lumpectomy speci­. men (slide 7) is close to ductal carcinoma in. situ (<1 mm) but this margin submitted for. frozen diagnosis (Fro 11) is free of tumor.. Result. Intensity. Positive. %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (0). Ki-67. Positive in 3% of. tumor cells. 15. " +121,Case 14,Important Radiologic,HR(+) HER2(-) Breast Cancer,"Important Radiologic. Findings. See Figs. 68, 69, 70, 71 and 72.. 14.3. " +127,Case 14,Patient History,HR(+) HER2(-) Breast Cancer,"Patient History and Progress. Female/43 years old, pre-menopause.. Screen detected mass lesion on left breast 1. and 3 o’clock direction.. No family history.. No comorbidities.. 14.2. " +114,Case 14,Courses of Treatment,HR(−) HER2(+) Breast Cancer,"14.1. . Courses of Treatment. Neoadjuvant chemotherapy (#3 cycles of. docetaxel and trastuzumab and pertuzumab after. followed #3 cycles of trastuzumab and pertu­. zumab #4) + Operation + Post-operative radia­. tion therapy + Trastuzumab emtansine.. Operation. Microinvasive Ductal Carcinoma. 1. Size of invasive component: <0.1  cm. (pT1mi).. 2. Size of intraductal component: 2.5 cm.. 3. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 3/3, 4/HPF).. 4. Intraductal component: present, intratu­. moral/extratumoral (99%) (nuclear grade:. high, necrosis: present, architectural pattern:. cribriform/solid/comedo, extensive intra­. ductal component: present).. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) superior margin: (see Note 1),. . (b) inferior margin: (see Note 2),. . (c) medial margin: positive for ductal carci­. noma in situ (Fro 3) (see Note 3),. . (d) lateral margin: 10 mm,. . (e) deep margin: <1 mm from ductal carci­. noma in situ (slide 8),. . (f) superficial margin: 2 mm.. 7. Lymph nodes:. . (a) metastasis in four out of nine axillary. lymph nodes (pN2a),. . (b) perinodal extension: present,. . (c) size of metastatic carcinoma: 19 mm.. 8. Arteriovenous invasion: absent.. 9. Lymphovascular invasion: present, intratumoral.. . 10. Tumor border: infiltrative.. . 11. Microcalcification:. present,. tumoral/. non-tumoral.. . 12. Pathological TN category (AJCC 2017):. pT1miN2a.. Note: 1. The superior margin of the lumpec­. tomy specimen (slide 1) is close to ductal carci­. noma in situ (<1 mm) but this margin submitted. for frozen diagnosis (Fro 1) is free of tumor.. 2. The inferior margin of the lumpectomy. specimen (slide 5) is close to ductal carcinoma in. situ (2 mm) but this margin submitted for frozen. diagnosis (Fro 2) is free of tumor.. 3. Ductal carcinoma in situ is present only in. the permanent section of Fro 3.. Result. Intensity. Positive %. Estrogen. receptor. Negative. (2/8). 1. <1%. Progesterone. receptor. Negative. (0/8). 0. 0. C-erbB2. Positive. (3+). Ki-67. Positive. in 41% of. tumor. cells. 15. " +122,Case 14,Important Radiologic,HR(−) HER2(+) Breast Cancer,Important Radiologic. Findings. 100 101 102. 103. . HR(−) HER2(+) Breast Cancer. After Neoadjuvant. Chemotherapy. 104 105 106. 107. HR(−) HER2(+) Breast Cancer. 486. 14.4.  +128,Case 14,Patient History,HR(−) HER2(+) Breast Cancer,"Patient History and Progress. Female/74 years old, post-menopause.. Screen detected mass lesion on right breast 12. o’clock direction.. No family history.. S/P retroperitoneum, excision (paragang­. lioma).. 14.2. " +115,Case 14,Courses of Treatment,HR(−) HER2(−) Breast Cancer,"14.1. . Courses of Treatment. Operation  +  Adjuvant chemotherapy (#4. cycles of doxorubicin and cyclophosphamide. + #12 cycles of paclitaxel)  +  Post-­. operative. radiation therapy.. Operation. 103. Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 3.0 cm (pT2).. 2. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 3/3, 3/HPF).. . E. S. Lee et al.. 625. . . ­. . 3. Intraductal component: present, intratu­. moral/extratumoral (5%) (nuclear grade:. high, necrosis: present, architectural pattern:. solid/comedo, extensive intraductal compo­. nent: absent).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) Superior margin: 10 mm.. . (b) Inferior margin: 10 mm.. . (c) Medial margin: 10 mm.. . (d) Lateral margin: 10 mm.. . (e) Deep margin: 1 mm from invasive ductal. carcinoma (slide 2).. . (f) Superficial margin: 2 mm.. 6. Lymph nodes: no metastasis in two axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/2).. 7. Arteriovenous invasion: absent.. 8. Lymphovascular. invasion:. present,. intratumoral.. 9. Tumor border: infiltrative.. . 10. Microcalcification:. present,. tumoral/. non-tumoral.. . 11. Pathological TN category (AJCC 2017):. pT2N0(sn).. Result. Intensity. Positive. %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Negative (1+). Ki-67. Positive in 56%. of tumor cells. HR(−) HER2(−) Breast Cancer. 626. . 15. " +123,Case 14,Important Radiologic,HR(−) HER2(−) Breast Cancer,Important Radiologic. Findings. 99 100 101. 102. 14.3.  +129,Case 14,Patient History,HR(−) HER2(−) Breast Cancer,"Patient History and Progress. Female/43 years old, pre-menopause.. Self-detected palpable mass lesion on right. breast.. Family history of breast cancer, grandmother.. s/p Right breast, mammotome excision, s/p. right ear, benign excision.. BRCA 1 and 2 mutation: Not detected.. 14.2. " +116,Case 14,Courses of Treatment,Local Recurrence,"14.1. . Courses of Treatment. Right breast infiltrating ductal carcinoma →. Operation → Left breast recurrence (IDC).. Primary Treatment. 103. 104. Operation. Aug. 2003 Right breast conserving surgery, axil­. lary lymph node dissection, left breast mass. excision.. Pathology Report. . Infiltrating Ductal Carcinoma. 1. Size of tumor: 2 cm (pT1c).. 2. Histologic grade: 2/3 (tubule formation: 2/3,. nuclear pleomorphism: 2/3, mitotic count:. 2/3).. 3. Ductal carcinoma in situ: present, intratu­. moral (5%) (nuclear grade: low, necrosis:. absent, architectural pattern: solid, extensive. intraductal component: absent).. 4. Skin: no involvement of tumor.. 5. Surgical margins: clear. . (a) Superior margin: 30 mm.. . (b) Inferior margin: 35 mm.. . (c) Medial margin: 35 mm.. . (d) Lateral margin: 25 mm.. . (e) Deep margin: 10 mm.. 6. Lymph nodes:. . (a) Metastasis in 2 out of 22 axillary lymph. nodes (pN1a) (sentinel LN: 1/2, axillary. LN: 1/20).. . (b) Perinodal extension: absent.. . (c) Size of metastatic carcinoma: 6 mm.. 7. Vascular invasion: absent.. 8. Lymphatic invasion: absent.. 9. Tumor border: infiltrative.. . 10. Microcalcification: absent.. . 11. Pathologic staging: pT1cN1a.. Result. Intensity. Positive %. Estrogen. receptor. Intermediate (5/7) 2. 1/3–2/3. Progesterone. receptor. Weak (2/7). 1. <10%. C-erbB2. Equivocal (2+). Ki-67. Positive in 2%. of tumor cells. . Ductal hyperplasia with organizing hematoma.. Adjuvant Therapy. Adjuvant chemotherapy #6 cycles of fluorouracil. and doxorubicin and cyclophosphamide.. Postoperative radiation therapy.. Tamoxifen 20 mg/day for 1.7 years followed. by anastrozole 1 mg/day for 1 year followed by. tamoxifen 20 mg/day for 2.3 years.. Treatments After Recurrence. 105 106. 107. . . Y. Kim et al.. 757. . ­. . . . ­. Operation. ­. 108. Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 1.1 cm (pT1c).. 2. Histologic grade: 2/3 (tubule formation: 2/3,. nuclear pleomorphism: 2/3, mitotic count:. 2/3, 11/10HPF).. 3. Intraductal component: present, intratu­. moral/extratumoral (20%) (nuclear grade:. low, necrosis: absent, architectural pattern:. cribriform, extensive intraductal component:. absent).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) Superior margin: 10 mm.. . (b) Inferior margin: 10 mm.. . (c) Medial margin: 10 mm.. . (d) Lateral margin: 10 mm.. Local Recurrence. 758. . (e) Deep margin: 2 mm.. . (f) Superficial margin: 2 mm.. 6. Lymph nodes: no metastasis in one axillary. lymph node (pN0(sn)) (sentinel LN: 0/1).. 7. Arteriovenous invasion: absent.. 8. Lymphovascular invasion: absent.. 9. Tumor border: infiltrative.. . 10. Microcalcification:. present,. tumoral/. non-tumoral.. . 11. Pathological TN category (AJCC 2017):. pT1cN0(sn).. Result. Intensity. Positive %. Estrogen. receptor. Weak (4/8). 2. 1–10%. Progesterone. receptor. Weak (4/8). 2. 1–10%. C-erbB2. Negative (0). Ki-67. Not informative. Adjuvant Therapy. Postoperative radiation therapy.. Anastrozole 1 mg/day for 5 years.. 15. " +130,Case 14,Patient History,Local Recurrence,"Patient History and Progress. Female/72 years old, post-menopause.. Screen detected mass lesion on right breast 1. o’clock direction and left 9 o’clock direction.. No family history.. Diabetes mellitus.. BRCA 1 and 2 mutation: Not detected, ATM. and POLE VUS (variant of uncertain).. . . ­. Local Recurrence. 756. 14.2. " +117,Case 14,Courses of Treatment,Metastatic Breast Cancer,"Courses of Treatment. Right breast cancer → Operation → Adjuvant. therapy → Ipsilateral axillary lymph node. recurrence.. Primary Treatment. Estrogen. receptor. Intermediate. (6/8). 2. 1/3–2/3. Progesterone. receptor. Strong (7/8). 2. >2/3. C-erbB2. Negative (0). Ki-67. Positive in. 35% of tumor. cells. Adjuvant Therapy. Tamoxifen 20 mg/day for 0.75 year.. Treatments After Recurrence. Progesterone. receptor. Strong. (8/8). 3. >2/3. C-erbB2. Negative. (0). Ki-67. Positive. in 27%. of tumor. cells. Neoadjuvant Chemotherapy. Neoadjuvant. chemotherapy. #8. cycles. (Adriamycin & Cyclophosphamide #4 →. Docetaxel #4).. Operation. May 2018 Right axillary lymph node dissection. and bilateral salpingo-oophorectomy.. Pathology: Metastatic ductal carcinoma in 1. out of 9 lymph nodes, size of metastasis: 9 mm.. Result. Intensity. Positive %. Estrogen. receptor. Strong (7/8). 2. >2/3. Progesterone. receptor. Negative (2/8). 1. <1%. C-erbB2. Negative (0). Ki-67. Positive in 2%. of tumor cells. Adjuvant Therapy. Post-operative radiation therapy + Tamoxifen. 20 mg/day~. 15. " +131,Case 14,Patient History,Metastatic Breast Cancer,Hepatitis B carrier.. 14.2.  +132,Case 15,Courses of Treatment,Benign and Proliferative,"15.1. . Courses of Treatment. →2021-10-12 excision, Lt.. Benign and Proliferative Case Series. 34. . . Pathology Report. • Breast, left, excision:. –. – Atypical ductal hyperplasia, focal. –. – Fibroadenomatous change.. 16. " +140,Case 15,Important Radiologic,Benign and Proliferative,Important Radiologic. Findings. 25. 26. 15.3.  +146,Case 15,Patient History,Benign and Proliferative,"Patient History and Progress. Female/33 years old, pre-menopause.. Screen detected mass lesion on left breast. 3 o’clock direction.. Family history of pancreatic cancer, maternal. grandmother.. No comorbidities.. BRCA 1 and 2 mutation: Not detected.. 15.2. " +133,Case 15,Courses of Treatment,Carcinoma In Situ,"15.1. . Courses of Treatment. Operation + Postoperative radiation therapy +. Tamoxifen 20 mg/day for 5 years.. Operation. 67. 68. E. S. Lee et al.. 83. 2. Nuclear grade: high.. 3. Necrosis: present.. 4. Architectural pattern: micropapillary/cribri­. form/solid/comedo.. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) superior margin: 5 mm,. . (b) inferior margin: 15 mm,. . (c) medial margin: 10 mm,. . (d) lateral margin: 20 mm,. Carcinoma In Situ. 84. a. b. . . ­. . (e) deep margin: 1  mm from ductal carci­. noma in situ (slide 1),. . (f) superficial margin: 15 mm.. 7. Lymph nodes: no metastasis in two axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/2).. 8. Arteriovenous invasion: absent.. 9. Lymphovascular invasion: absent.. . 10. Tumor border: infiltrative.. . 11. Microcalcification: present, ­. tumoral/non-. tumoral.. Result. Intensity. Positive %. Estrogen. receptor. Strong (7/8). 3. 1/3–2/3. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in. 11% of tumor. cells. 16. " +141,Case 15,Important Radiologic,Carcinoma In Situ,Important Radiologic. Findings. 63 64 65. 66. 15.3.  +147,Case 15,Patient History,Carcinoma In Situ,"Patient History and Progress. Female/52 years old, pre-menopause.. Screen detected mass lesion on right breast. 1 o’clock direction.. No family history.. No comorbidities.. 15.2. " +134,Case 15,Courses of Treatment,HR(+) HER2(+) Breast Cancer,"15.1. . Courses of Treatment. Operation  +  Adjuvant chemotherapy (#4. cycles of doxorubicin and cyclophospha­. mide). +. Post-operative. radiation. ther­. apy + Trastuzumab + Tamoxifen 20 mg/day.. 82. . ­. ­. . HR(+) HER2(+) Breast Cancer. 346. . . Pathology Report. . 1. Invasive Ductal Carcinoma with apocrine. differentiation.. . (a) Size of tumor: 1.3 cm (pT1c).. . (b) Histologic grade: 2/3 (tubule formation:. 3/3, nuclear pleomorphism: 2/3, mitotic. count: 1/3, 5/10 HPF).. . (c) Intraductal component: present, intratu­. moral/extratumoral (15%) (nuclear grade:. low, necrosis: absent, architectural pat­. tern: solid, extensive intraductal compo­. nent: absent).. . (d) Skin: no involvement of tumor.. S. Park et al.. 347. a. b. . . (e) Surgical margins:. • nipple margin: positive for ductal car­. cinoma in situ (Fro 1),. • superior margin: 10 mm,. • inferior margin: 15 mm,. • medial margin: 20 mm,. • lateral margin: (see note),. • deep margin: 5 mm,. • superficial margin: <1 mm from inva­. sive ductal carcinoma (slide 2).. . (f) Lymph nodes: no metastasis in one axil­. lary lymph node (pN0(sn)) (sentinel LN:. 0/1).. . (g) Arteriovenous invasion: absent.. . (h) Lymphovascular invasion: absent.. . (i) Tumor border: infiltrative.. . (j) Microcalcification:. present,. tumoral/. non-tumoral.. . (k) Pathological TN category (AJCC 2017):. pT1cN0(sn).. . 2. Fibroadenoma. . 3. Capillary hemangioma. Note: 1. The lateral margin of the lumpectomy. specimen (slide 13) is close to ductal carcinoma. in situ (3 mm) but this margin submitted for fro­. zen diagnosis (Fro 5) is free of tumor.. Result. Intensity. Positive. %. Estrogen. receptor. Strong (7/8). 2. >2/3. Progesterone. receptor. Strong (7/8). 2. >2/3. C-erbB2. Positive (3+). Ki-67. Positive in 12%. of tumor cells. HR(+) HER2(+) Breast Cancer. 348. 16. " +142,Case 15,Important Radiologic,HR(+) HER2(+) Breast Cancer,Important Radiologic. Findings. 78 79 80. 81. 15.3.  +148,Case 15,Patient History,HR(+) HER2(+) Breast Cancer,"Patient History and Progress. Female/42 years old, pre-menopause.. Self-detected palpable mass lesion on right. breast 6 o’clock direction.. Family history of breast cancer, maternal aunt.. No comorbidities.. BRCA 1 and 2 mutation: Not detected.. 15.2. " +135,Case 15,Courses of Treatment,HR(+) HER2(-) Breast Cancer,"15.1. . Courses of Treatment. Operation  +  Post-operative radiation ther­. apy + Anastrozole 1 mg/day.. Operation. Left breast conserving surgery, sentinel lymph. (a) superior margin: 35 mm.. . (b) inferior margin: 10 mm.. . (c) medial margin: 15 mm.. . (d) lateral margin: 5 mm.. . (e) deep margin: 12 mm.. . (f) superficial margin: 4 mm.. 6. Lymph nodes: no metastasis in two axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/2).. 7. Arteriovenous invasion: absent.. 8. Lymphovascular invasion: absent.. 9. Tumor border: infiltrative.. . 10. Microcalcification:. present,. tumoral/. non-tumoral.. . 11. Pathological TN category (AJCC 2017):. pT1bN0(sn).. Y. Kim et al.. 2. 10%–1/3. C-erbB2. Negative (1+). Ki-67. Positive in 19% of tumor cells. HR(+) HER2(−) Breast Cancer. 220. 16. " +143,Case 15,Important Radiologic,HR(+) HER2(-) Breast Cancer,"Important Radiologic. Findings. See Figs. 74, 75, 76 and 77.. 15.3. " +149,Case 15,Patient History,HR(+) HER2(-) Breast Cancer,"Patient History and Progress. Female/58 years old, post-menopause.. Screen detected mass lesion on left breast 12. o’clock direction.. No family history.. Hypertension, dyslipidemia, s/p transobtura­. tor tape for stress urinary incontinence.. 15.2. " +136,Case 15,Courses of Treatment,HR(−) HER2(+) Breast Cancer,"15.1. . 116. Pathology Report. Invasive Ductal Carcinoma. 1. Post-chemotherapy status.. 2. Size of tumor: 1.9 cm (ypT1c).. 3. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 2/3, 12/10HPF).. 4. Intraductal component: absent.. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) superior margin: 30 mm,. . (b) inferior margin: 55 mm,. . (c) medial margin: 20 mm,. . (d) lateral margin: 15 mm,. . (e) deep margin: 1 mm from invasive ductal. carcinoma (slide 2),. . (f) superficial margin: 10 mm.. 7. Lymph nodes:. . (a) metastasis in two out of seven axillary. lymph nodes (ypN1a) (sentinel LN: 1/2,. axillary LN: 1/5),. . (b) perinodal extension: absent,. . (c) size of metastatic carcinoma: 5 mm.. 8. Arteriovenous invasion: absent.. 9. Lymphovascular invasion: present, intratu­. moral/peritumoral.. . 10. Tumor border: infiltrative.. . 11. Microcalcification: present, non-tumoral.. . 12. Pathological TN category (AJCC 2017):. ypT1cN1a.. Result. Intensity Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in. 25% of tumor. cells. Y. Kwon et al.. 493. . HR(−) HER2(+) Breast Cancer. 494. 16. " +144,Case 15,Important Radiologic,HR(−) HER2(+) Breast Cancer,Important Radiologic. Findings. 109 110 111. . After Neoadjuvant. Chemotherapy. 113 114. 115. . HR(−) HER2(+) Breast Cancer. 492 +150,Case 15,Patient History,HR(−) HER2(+) Breast Cancer,"Patient History and Progress. Female/61 years old, post-menopause.. Self-detected palpable mass lesion on right. breast 12 o’clock direction.. No family history.. Hypertension.. HR(−) HER2(+) Breast Cancer. 488. . Y. Kwon et al.. 489. 15.2. " +137,Case 15,Courses of Treatment,HR(−) HER2(−) Breast Cancer,"15.1. . Courses of Treatment. Operation + operation.. Operation. ­. 107. Pathology Report. . 1. Invasive Ductal Carcinoma.. . (a) Size of invasive component: 0.4  cm. (pT1a).. . (b) Size of intraductal component: 4.0 cm.. . (c) Histologic grade: 3/3 (tubule formation:. 3/3, nuclear pleomorphism: 3/3, mitotic. count: 3/3, 30/10HPF).. E. S. Lee et al.. 627. . . . HR(−) HER2(−) Breast Cancer. 628. . . (d) Intraductal component: present, intratu­. moral/extratumoral (90%) (nuclear grade:. high, necrosis: present, architectural pat­. tern: solid/comedo, extensive intraductal. component: present).. . (e) Skin: no involvement of tumor.. . (f) Surgical margins:. • Superior margin: 30 mm.. • Inferior margin: 5 mm.. • Medial margin: 15 mm.. • Lateral margin: <1  mm from ductal. carcinoma in situ (slide 15).. • Deep margin: positive for ductal carci­. noma in situ (slides 4 and 14).. • Superficial margin: <1 mm from duc­. tal carcinoma in situ (slide 13).. . (g) Arteriovenous invasion: absent.. . (h) Lymphovascular invasion: absent.. . (i) Tumor border: infiltrative.. . (j) Microcalcification: present, tumoral.. . (k) Pathological TN category (AJCC 2017):. pT1aNx.. . 2. Intraductal papilloma with:. . (a) Usual ductal hyperplasia.. . (b) Apocrine metaplasia.. . (c) Epithelial displacement.. Result. Intensity. Positive. %. Estrogen. receptor. Negative (2/8). 1. <1%. Progesterone. receptor. Negative (2/8). 1. <1%. C-erbB2. Negative (1+). Ki-67. Positive in 23%. of tumor cells. Operation. ­. 108. E. S. Lee et al.. 629. . Pathology Report. . 1. No residual carcinoma with foreign body. reaction.. . (a) Post-excision status.. . 2. Intraductal papilloma with usual ductal. hyperplasia.. 16. " +145,Case 15,Important Radiologic,HR(−) HER2(−) Breast Cancer,Important Radiologic. Findings. 104 105. 106. 15.3.  +151,Case 15,Patient History,HR(−) HER2(−) Breast Cancer,"Patient History and Progress. Female/74 years old, post-menopause.. Self-detected bloody discharge on the nipple. of the left breast.. No family history.. S/P hysterectomy (due to myoma), hyperten­. sion, s/p shoulder calcific tendinitis operation.. 15.2. " +138,Case 15,Courses of Treatment,Local Recurrence,"15.1. . Courses of Treatment. Right breast IDC → Operation → Adjuvant. therapy →Left breast and axillary lymph node. recurrence (IDC) → Left axillary lymph node. recurrence.. Primary Treatment. 109. 110. Operation. 111. Pathology Report. Invasive Ductal Carcinomas (×2).. 1. Size of tumor: 2.1 cm, 0.7 cm (pT2(m)).. 2. Histologic grade: 2 (tubule formation: 2/3,. nuclear pleomorphism: 3/3, mitotic count:. 1/3, 8/10HPF).. . . Y. Kim et al.. 759. a. b. . . 3. Intraductal component: present, intratu­. moral/extratumoral (3%) (nuclear grade:. high, necrosis: present, architectural pattern:. comedo and cribriform, extensive intraductal. component: absent).. 4. Skin and nipple: no involvement of tumor.. 5. Surgical margins: free from tumor.. . (a) Deep margin: 5 mm.. . (b) Superficial margin: 15 mm.. 6. Lymph nodes:. . (a) Metastasis in one out of nine axillary. lymph nodes (pN1a) (sentinel LN: 1/1,. axillary LN: 0/8).. . (b) Perinodal extension: absent.. . (c) Size of metastatic carcinoma: 5 mm.. 7. Vascular invasion: absent.. 8. Lymphatic invasion: absent.. 9. Neural invasion: present.. . 10. Tumor border: infiltrative.. . 11. Microcalcification: present, tumoral.. . 12. Pathologic stage (AJCC 2010): pT2(m)N1a.. Result. Intensity. Positive %. Estrogen. receptor. Strong (7/7). 3. >2/3. Progesterone. receptor. Weak (3/7). 2. <10%. C-erbB2. Positive (3+). Ki-67. Positive in 29%. of tumor cells. Adjuvant Therapy. Adjuvant chemotherapy #4 cycles of doxorubicin. and cyclophosphamide followed by #4 cycles of. docetaxel and trastuzumab for 1 year.. Anastrozole 1 mg/day for 1.3 years.. Treatments After Recurrence. 112 113. 114. Neoadjuvant Chemotherapy. Neoadjuvant chemotherapy #2  cycles of cyclo­. phosphamide and methotrexate and fluorouracil. (stop d/t no response).. Local Recurrence. 760. . . ­. Operation (First Recurrence). 115. Pathology Report. Invasive Ductal Carcinoma. 1. Post-chemotherapy status.. 2. Size of tumor: 2.3��cm (ypT2).. 3. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 6/10HPF).. 4. Intraductal component: present, intratu­. moral/extratumoral (30%) (nuclear grade:. low, necrosis: present, architectural pattern:. solid/comedo, extensive intraductal compo­. nent: present).. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) Deep margin: <1 mm from invasive duc­. tal carcinoma (slide 7).. . (b) Superficial margin: 2 mm.. 7. Lymph nodes:. . (a) Metastasis in one out of one axillary. lymph node (ypN1a(sn)) (axillary LN. (#A): 1/1, axillary LN (Fro 1): 0/0, axil­. lary LN #2: 0/0).. . (b) Perinodal extension: present.. . (c) Size of metastatic carcinoma: 20 mm.. 8. Arteriovenous invasion: absent.. 9. Lymphovascular. invasion:. present,. intratumoral.. . 10. Tumor border: infiltrative.. . 11. Microcalcification:. present,. ­. tumoral/. non-tumoral.. . 12. Pathological TN category (AJCC 2017):. ypT2N1a(sn).. Result. Intensity Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (1+). Ki-67. Positive in 41%. of tumor cells. Adjuvant Therapy. Adjuvant chemotherapy #4 cycles of cyclophos­. phamide and docetaxel.. Operation (Second Recurrence). Oct. 2021 Left axillary lymph node dissection.. Pathology Report. . 1. Post-lumpectomy status.. . 2. Lymph nodes:. . (a) Metastasis in three out of five axillary. lymph nodes (left axillary LN (Fro 1):. 0/1, “left axillary LN”: 3/4).. Y. Kim et al.. 761. a. b. c. d. . . (b) Perinodal extension: present.. . (c) Size of metastatic carcinoma: 5 mm.. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (1+). Ki-67. Positive in 6%. of tumor cells. Adjuvant Therapy. Postoperative radiation therapy.. Letrozole 2.5 mg/day for 5 years.. 16. " +152,Case 15,Patient History,Local Recurrence,"Patient History and Progress. Female/63 years old, post-menopause.. Self-detected mass lesion on right breast 9. o’clock direction.. Family history of breast cancer, mother.. Hypertension, s/p Left leg fracture operation.. BRCA 1 and 2 mutation: Not detected.. 15.2. " +139,Case 15,Courses of Treatment,Metastatic Breast Cancer,"15.1. . Courses of Treatment. Right breast cancer → Operation → Adjuvant. therapy → Ipsilateral axillary lymph node. recurrence.. Primary Treatment. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (1+). Ki-67. Positive in. 31% of tumor. cells. Adjuvant Therapy. Tamoxifen 20 mg/day for 5.2 years.. Treatments After Recurrence. See Figs. 50 and 51.. Metastatic Breast Cancer. Progesterone. receptor. Strong. (8/8). 3. >2/3. C-erbB2. Negative. (0). Operation. Dec. 2020 Right axillary lymph node sampling.. Pathology: Metastatic ductal carcinoma in 1. out of 7 lymph nodes, size of metastasis: 11 mm.. Adjuvant Therapy. Letrozole 2.5 mg/day~. 16. " +153,Case 15,Patient History,Metastatic Breast Cancer,"Patient History and Progress. Female/74 years old, post-menopause.. No family history.. Hypertension.. 15.2. " +154,Case 16,Courses of Treatment,Benign and Proliferative,"16.1. . Courses of Treatment. →2021-09-13 needle biopsy.. Pathology Report. Diagnosis. • Breast, right, needle biopsy:. –. – Ductal carcinoma in situ.. Nuclear grade: low.. Necrosis: present.. C. W. Lee et al.. 35. . ­. . Benign and Proliferative Case Series. 36. . Architectural pattern: micropapillary/. cribriform/comedo.. Microcalcification: present, tumoral.. →2021-10-08 Rt. BCS + Lt. mastopexy.. Pathology Report. Diagnosis. . 1. Breast, right, lumpectomy: Microinvasive. Ductal Carcinoma.. . (a) Size of tumor: <0.1 cm (pT1mi).. . (b) Size of in situ component: 4.0 cm.. . (c) Histologic grade: not applicable.. . (d) Intraductal component: present, intratu­. moral/extratumoral. (>95%). (nuclear. grade: high, necrosis: present, architec­. tural pattern: micropapillary/cribriform/. solid/comedo, extensive intraductal com­. ponent: present).. . (e) Skin: no involvement of tumor.. . (f) Surgical margins:. • Nipple margin: positive for ductal car­. cinoma in situ (Fro 10) (see Note 1).. • Superior margin: (see Note 2).. • Inferior margin: 20 mm.. • Medial margin: (see Note 3).. • Lateral margin: 5 mm.. • Deep margin: <1 mm from ductal car­. cinoma in situ (slides 1 & 2).. • Superficial margin: 10 mm. . (g) Lymph nodes: no metastasis in three axil­. lary lymph nodes (pN0(sn)) (sentinel LN:. 0/3).. . (h) Arteriovenous invasion: absent.. . (i) Lymphovascular invasion: absent.. C. W. Lee et al.. 37. . (j) Tumor border: infiltrative.. . (k) Microcalcification: present, tumoral.. . (l) Pathological TN category (AJCC 2017):. pT1miN0(sn).. Note: 1. Ductal carcinoma in situ is. present only in the permanent section of. Fro 10.. . 2. The superior margin of the lumpectomy spec­. imen (slide 3) is positive for ductal carcinoma. in situ but this margin submitted for frozen. diagnosis (Fro 2) is free of tumor.. . 3. The medial margin of the lumpectomy speci­. men (slide 6) is close to ductal carcinoma in. situ (2 mm) but this margin submitted for fro­. zen diagnosis (Fro 4) is free of tumor.. . 4. Histologic mapping has been done.. Result. Intensity Positive%. Estrogen. receptor. Strong (2/8). 1. <1%. Progesterone. receptor. Strong (0/8). 0. 0. C-erbB2. Negative (3+). Ki-67. Positive in. 20% of tumor. cells. Diagnosis. • Breast, left, excision:. –. – Usual ductal hyperplasia, focal.. Postoperative radiotherapy for right. breast.. 17. " +162,Case 16,Important Radiologic,Benign and Proliferative,Important Radiologic. Findings. 27 28. 29. 16.3.  +168,Case 16,Patient History,Benign and Proliferative,"Patient History and Progress. Female/59 years old, post-menopause.. Screen detected mass lesion on right breast. 7 o’clock direction.. No family history.. s/p Total hysterectomy, s/p left nephrectomy. (donor), s/o cholecystectomy.. 16.2. " +155,Case 16,Courses of Treatment,Carcinoma In Situ,"16.1. . Courses of Treatment:. Operation. Operation. 73. 74. Pathology Report. Ductal carcinoma in situ, pathological TN cat­. egory (AJCC 2017): pTis(Paget)N0 (sn). . 1. Size of tumor: 1.5 cm (pTis(Paget)).. . 2. Nuclear grade: high.. . 3. Necrosis: present.. Carcinoma In Situ. 4. Architectural. pattern:. cribriform/solid/. comedo.. . 5. Nipple: Paget disease with involvement of. lactiferous duct.. . 6. Surgical margins:. . (a) deep margin: 10 mm,. . (b) superficial margin: 10 mm.. . 7. Lymph nodes: no metastasis in one axillary. lymph node (pN0(sn)) (sentinel LN: 0/1).. . 8. Microcalcification:. present,. tumoral/non-. tumoral.. Result. Intensity. Positive %. Estrogen. receptor. Negative (2/8). 1. <1%. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in. 30% of tumor. cells. 17. " +163,Case 16,Important Radiologic,Carcinoma In Situ,Important Radiologic. Findings. 69 70 71. 72. E. S. Lee et al.. 85. . . . ­. 16.3.  +169,Case 16,Patient History,Carcinoma In Situ,"Patient History and Progress. Female/75 years old, post-menopause.. Screen detected microcalcification on left. breast 12 o’clock direction.. Outside result of biopsy: Left breast 12 o’clock,. fibrosis.. Family history of breast cancer, mother.. Hypertension.. BRCA 1 and 2: Not examination.. 16.2. " +156,Case 16,Courses of Treatment,HR(+) HER2(+) Breast Cancer,"16.1. . Courses of Treatment. Operation  +  Adjuvant chemotherapy (#4. cycles. of. docetaxel. and. cyclophospha­. mide). +. Post-operative. radiation. ther­. apy + Trastuzumab + Letrozole 2.5 mg/day.. 87. Pathology Report. . 1. Invasive Ductal Carcinoma.. . (a) Size of tumor: 1.1 cm (pT1c).. . (b) Histologic grade: 3/3 (tubule formation:. 3/3, nuclear pleomorphism: 3/3, mitotic. count: 2/3, 10/10 HPF).. . (c) Intraductal component: present, extratu­. moral (30%) (nuclear grade: high, necro­. sis:. present,. architectural. pattern:. papillary/cribriform, extensive intraductal. component: present).. . (d) Skin: no involvement of tumor.. . (e) Surgical margins:. • superior margin: (see note),. • inferior margin: 15 mm,. • medial margin: 6 mm,. • lateral margin: 10 mm,. • deep margin: 3 mm,. • superficial margin: 11 mm.. . S. Park et al.. 349. . (f) Lymph nodes: no metastasis in two axil­. lary lymph nodes (pN0(sn)) (sentinel LN:. 0/2).. . (g) Arteriovenous invasion: absent.. . (h) Lymphovascular invasion: absent.. . (i) Tumor border: infiltrative.. . (j) Microcalcification: present, tumoral.. . (k) Pathological TN category (AJCC 2017):. pT1cN0(sn).. . 2. Intraductal papilloma with usual ductal. hyperplasia.. . . HR(+) HER2(+) Breast Cancer. 350. Note: 1. The superior margin of the lumpec­. tomy specimen (slide 3) is close to ductal carci­. noma in situ (2 mm) but this margin submitted. for frozen diagnosis (Fro 3) is free of tumor.. Result. Intensity. Positive. %. Estrogen. receptor. Strong (7/8). 2. >2/3. Progesterone. receptor. Strong (7/8). 2. >2/3. C-erbB2. Positive (3+). Ki-67. Positive in 10%. of tumor cells. . a. b. . S. Park et al.. 351. 17. " +164,Case 16,Important Radiologic,HR(+) HER2(+) Breast Cancer,Important Radiologic. Findings. 83 84 85. 86. 16.3.  +170,Case 16,Patient History,HR(+) HER2(+) Breast Cancer,"Patient History and Progress. Female/54 years old, peri-menopause.. Self-detected palpable mass lesion on right. breast 6 o’clock direction.. No family history.. Diabetes. mellitus,. S/P. hysterectomy,. agoraphobia.. 16.2. " +157,Case 16,Courses of Treatment,HR(+) HER2(-) Breast Cancer,"16.1. . Courses of Treatment. Operation  +  Post-operative radiation ther­. apy + Tamoxifen 20 mg/day.. Operation. Left breast conserving surgery, sentinel lymph. cribriform/solid, extensive intraductal com­. ponent: present).. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) superior margin: 20 mm.. . (b) inferior margin: (see note).. . (c) medial margin: 10 mm.. . (d) lateral margin: 15 mm.. . (e) deep margin: positive for ductal carci­. noma in situ (slide 6).. . (f) superficial margin: 15 mm.. 7. Lymph nodes: no metastasis in three axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/2,. non-sentinel LN: 0/1).. 8. Arteriovenous invasion: absent.. 9. Lymphovascular invasion: absent.. . 10. Tumor border: infiltrative.. . Intensity. Positive. %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Intermediate. (6/8). 1. >2/3. C-erbB2. Negative (1+). Ki-67. Positive in 3% of" +165,Case 16,Important Radiologic,HR(+) HER2(-) Breast Cancer,"Important Radiologic. Findings. See Figs. 79, 80, 81 and 82.. 16.3. " +171,Case 16,Patient History,HR(+) HER2(-) Breast Cancer,"Patient History and Progress. Female/51 years old, peri-menopause.. Screen detected mass lesion on left breast 2. o’clock direction.. No family history.. No comorbidities.. 16.2. " +158,Case 16,Courses of Treatment,HR(−) HER2(+) Breast Cancer,"16.1. . Courses of Treatment. Operation + adjuvant chemotherapy (#4 cycles of. docetaxel and cyclophosphamide)  +  Post-­. operative radiation therapy + Trastuzumab.. Operation. 121. Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 1.5 cm (pT1c).. 2. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 3/3, 4/HPF).. HR(−) HER2(+) Breast Cancer. 496. a. b. . 3. Intraductal component: present, intratu­. moral/extratumoral (30%) (nuclear grade:. high, necrosis: present, architectural pattern:. cribriform/solid/comedo, extensive intra­. ductal component: present).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) superior margin: 10 mm,. . (b) inferior margin: 10 mm,. . (c) medial margin: (see note),. . (d) lateral margin: 10 mm,. . (e) deep margin: 2 mm,. . (f) superficial margin: 2 mm.. 6. Lymph nodes: no metastasis in three axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/1,. non-sentinel LN: 0/2).. 7. Arteriovenous invasion: absent.. 8. Lymphovascular. invasion:. present,. intratumoral.. 9. Tumor border: infiltrative.. . 10. Microcalcification:. present,. tumoral/. non-tumoral.. . 11. Pathological TN category (AJCC 2017):. pT1cN0(sn).. Result. Intensity. Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in. 64% of tumor. cells. Y. Kwon et al.. 497. 17. " +166,Case 16,Important Radiologic,HR(−) HER2(+) Breast Cancer,Important Radiologic. Findings. 117 118 119.  +172,Case 16,Patient History,HR(−) HER2(+) Breast Cancer,"Patient History and Progress. Female/57 years old, post-menopause.. Self-detected palpable mass lesion on left. breast.. No family history.. Hypothyroidism (taking on synthroid).. 16.2. " +159,Case 16,Courses of Treatment,HR(−) HER2(−) Breast Cancer,"16.1. . Courses of Treatment. Neoadjuvant chemotherapy (#4  cycles of. doxorubicin and cyclophosphamide  +  #4. cycles of docetaxel)  +  Operation  +  Post-. operative radiation therapy.. Operation. 117. Pathology Report. No residual tumor with foamy histiocytic. collection. . 1. Post-chemotherapy status.. . 2. Lymph nodes: no metastasis in six axillary. lymph nodes (ypN0) (sentinel LN: 0/2, non-­. sentinel LN: 0/4).. . 3. Microcalcification: present, non-tumoral.. Result. Intensity. Positive. %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Equivocal (2+). Ki-67. Positive in 88%. of tumor cells. SISH. Negative. HR(−) HER2(−) Breast Cancer. 632. . ­. . . . E. S. Lee et al.. 633. . 17. " +167,Case 16,Important Radiologic,HR(−) HER2(−) Breast Cancer,Important Radiologic. Findings. 109 110 111. 112. HR(−) HER2(−) Breast Cancer. 630. . . . ­. E. S. Lee et al.. 631. . After Neoadjuvant. Chemotherapy. 113 114 115. 116. 16.3.  +173,Case 16,Patient History,HR(−) HER2(−) Breast Cancer,"Patient History and Progress. Female/42 years old, pre-menopause.. Self-detected palpable mass lesion on left. breast.. No family history.. s/p Cholecystectomy, s/p appendectomy, s/p. vocal cord operation.. 16.2. " +160,Case 16,Courses of Treatment,Local Recurrence,"16.1. . Courses of Treatment. Left breast DCIS → Operation → Adjuvant. therapy → Left breast recurrence (DCIS).. Primary Treatment. 116. 117. Operation. 118. Pathology Report. Ductal Carcinoma In Situ. . 1. Size of tumor: 3.0 cm (pTis).. . 2. Nuclear grade: low.. . 3. Necrosis: present.. . 4. Architectural pattern: micropapillary/cribri­. form/comedo.. Local Recurrence. 762. . 5. Skin: no involvement of tumor.. . 6. Surgical margins:. . (a) Nipple margin: positive for atypical duc­. tal hyperplasia (Fro 1) (see note 1).. . (b) Superior margin: (see note 2).. . (c) Inferior margin: 20 mm.. . (d) Medial margin: 5 mm.. . (e) Lateral margin: 15 mm.. . (f) Deep margin: 2 mm.. . (g) Superficial margin: 2 mm.. . 7. Microcalcification:. present,. tumoral/. non-tumoral.. . 8. Pathologic stage (AJCC 2010): pTis.. Note: 1. Atypical ductal hyperplasia is present. only in the permanent section of Fro 1.. 2. The superior margin of the lumpectomy. specimen (slide 1) is positive for ductal carci­. noma in situ, but this margin submitted for frozen. diagnosis (Fro 2) is free of tumor.. Result. Intensity Positive %. Estrogen. receptor. Intermediate. (6/8). 2. 1/3–2/3. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in 36%. of tumor cells. . ­. . a. b. . Y. Kim et al.. 763. Adjuvant Therapy. Postoperative radiation therapy.. Tamoxifen 20 mg/day for 5 years.. Treatments After Recurrence. 119. 120. Operation. 121. Pathology Report. Ductal Carcinoma In Situ.. . 1. Post-lumpectomy status.. . 2. Size of tumor: 0.5 cm (rpTis).. . 3. Nuclear grade: high.. . 4. Necrosis: absent.. . 5. Architectural. pattern:. micropapillary/. cribriform.. . 6. Skin and nipple: Paget’s disease.. . 7. Surgical margins:. . (a) Superior margin: 5 mm.. . (b) Inferior margin: 5 mm.. . (c) Medial margin: 5 mm.. . (d) Lateral margin: 5 mm.. . (e) Deep margin: 2 mm.. . (f) Superficial margin: 2 mm.. . 8. Microcalcification:. present,. tumoral/. non-tumoral.. . 9. Pathological TN category (AJCC 2017):. rpTis(Paget).. . ­. . ­. Result. Intensity. Positive %. Estrogen. receptor. Negative (2/8). 1. <1%. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in 58%. of tumor cells. 17. " +174,Case 16,Patient History,Local Recurrence,"Patient History and Progress. Female/43 years old, pre-menopause.. Screen detected mass lesion on left breast 7. o’clock direction.. Outside result of biopsy: Ductal carcinoma in. situ.. No family history.. No comorbidities.. 16.2. " +161,Case 16,Courses of Treatment,Metastatic Breast Cancer,"16.1. . Courses of Treatment. Left breast cancer → Operation → Adjuvant. therapy → Ipsilateral axillary lymph node. recurrence.. Primary Treatment. pT2N1a(sn).. Size of tumor: 2.5  cm and 1.0  cm, lymph. node: 1/2, size of metastatic carcinoma: 2.1 mm.. Result. Intensity Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (7/8). 3. 1/3–2/3. C-erbB2. Equivocal (2+). Ki-67. Positive in. 49% of tumor. cells. SISH. Negative. Oncotype Dx RS scores: 29.. Adjuvant Chemotherapy. Adjuvant. chemotherapy. (Adriamycin. +. Cyclophosphamide #2 → weekly Paclitaxel #12).. Treatments After Recurrence. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (1+). Ki-67. Positive in. 46% of tumor. cells. Neoadjuvant Endocrine Therapy. Tamoxifen 20 mg/day + zoladex.. Operation. Bilateral salpingo-oophorectomy → Progressive. disease (Lt. axillary lymph node).. Adjuvant Therapy. Letrozole 2.5 mg/day.. Progesterone. receptor. Negative. (0/8). 0. 0. C-erbB2. Equivocal. (2+). Ki-67. Positive in. 31% of. tumor cells. SISH. Positive. Adjuvant Therapy. Post-operative radiation therapy + Letrozole. 2.5 mg/day~. 17. " +175,Case 16,Patient History,Metastatic Breast Cancer,"Patient History and Progress. Female/46 years old, post-menopause.. No family history.. S/p myomectomy & bilateral salpingo-. oophorectomy.. 16.2. " +176,Case 17,Courses of Treatment,Benign and Proliferative,"17.1. . Courses of Treatment. →2021-09-17 excision, Rt.. Pathology Report. Diagnosis. • Breast, right, excision:. –. – Atypical ductal hyperplasia involving. mammary cyst.. –. – Usual ductal hyperplasia, focal with. microcalcification.. 18. " +184,Case 17,Important Radiologic,Benign and Proliferative,Important Radiologic. Findings. 30. 31. . Benign and Proliferative Case Series. 38. . 17.3.  +190,Case 17,Patient History,Benign and Proliferative,"Patient History and Progress. Female/39 years old, pre-menopause.. Screen detected mass lesion on right breast 9. o’clock direction.. No family history.. s/p appendectomy (cecal cancer), s/p hyster­. ectomy, and bilateral salpingo-oophorectomy.. s/p partial hepatectomy.. 17.2. " +177,Case 17,Courses of Treatment,Carcinoma In Situ,"17.1. . Courses of Treatment. Operation + Tamoxifen 20 mg/day for 5 years.. Operation. 79. 80. Pathology Report. Ductal carcinoma in situ, pathological TN cat­. egory (AJCC 2017): pTis(Paget)N0(sn). . 1. Size of tumor: 1.5 cm (pTis(Paget)).. . 2. Nuclear grade: high.. . 3. Necrosis: present.. . 4. Architectural. pattern:. cribriform/solid/. comedo.. . 5. Nipple: Paget disease with involvement of. lactiferous duct.. . 6. Surgical margins:. . (a) deep margin: 10 mm,. . (b) superficial margin: 10 mm.. . 7. Lymph nodes: no metastasis in one axillary. lymph node (pN0(sn)) (sentinel LN: 0/1).. . 8. Microcalcification:. present,. tumoral/non-. tumoral.. . Carcinoma In Situ. 88. . a. b. . . Result. Intensity. Positive %. Estrogen. receptor. Weak (3/8). 1. 1%–10%. Progesterone. receptor. Weak (4/8). 3. <1%. C-erbB2. Positive (3+). Ki-67. Positive in. 11% of. tumor cells. E. S. Lee et al.. 89. a. b. . . Carcinoma In Situ. 90. 18. " +185,Case 17,Important Radiologic,Carcinoma In Situ,Important Radiologic. Findings. 75 76 77. 78. 17.3.  +191,Case 17,Patient History,Carcinoma In Situ,"Patient History and Progress. Female/40 years old, pre-menopause.. Screen detected nodule and microcalcification. on upper outer portion of right breast.. No family history.. No comorbidities.. 17.2. " +178,Case 17,Courses of Treatment,HR(+) HER2(+) Breast Cancer,"17.1. . Courses of Treatment. Operation  +  Adjuvant chemotherapy (#4. cycles of doxorubicin and cyclophospha­. mide) + Trastuzumab + Tamoxifen 20 mg/day.. ­. ­. ­. 92 93. 94. Pathology Report. [Right].. . 1. Ductal carcinoma in situ.. . (a) Size of tumor: 0.7 cm (pTis).. . (b) Nuclear grade: low.. . (c) Necrosis: present.. . (d) Architectural pattern: solid/comedo.. . (e) Surgical margins: (see note).. . (f) Lymph nodes: not submitted (pNx).. . (g) Microcalcification: absent.. . (h) Pathological TN category (AJCC 2017):. pTisNx.. . 2. Fibrocystic change.. . ­. . HR(+) HER2(+) Breast Cancer. 352. . Note: 1. The nearest resection margin of the. excision specimen (slides A1 and A2) is close to. ductal carcinoma in situ (<1 mm) but this margin. submitted for frozen diagnosis (Fro 13) is free of. tumor.. [Left].. . 1. Invasive Ductal Carcinoma.. . (a) Size of tumor: 1.4 cm (pT1c).. . (b) Histologic grade: 2/3 (tubule formation:. 3/3, nuclear pleomorphism: 2/3, mitotic. count: 1/3, 4/10 HPF).. . (c) Intraductal component: present, intratu­. moral/extratumoral (5%) (nuclear grade:. low, necrosis: absent, architectural pat­. tern: cribriform, extensive intraductal. component: absent).. . (d) Skin: no involvement of tumor.. S. Park et al.. 353. . (e) Surgical margins:. • nipple margin: positive for ductal car­. cinoma in situ (Fro 3) (see note),. • deep margin: 27 mm,. • superficial margin: <1 mm from inva­. sive ductal carcinoma (slide 2).. . (f) Lymph nodes: no metastasis in three axil­. lary lymph nodes (pN0(sn)) (sentinel LN:. 0/3).. . (g) Arteriovenous invasion: absent.. . (h) Lymphovascular invasion: absent.. . (i) Tumor border: infiltrative.. . a. b. . HR(+) HER2(+) Breast Cancer. 354. a. b. c. d. . . S. Park et al.. 355. . (j) Microcalcification: present, tumoral.. . (k) Pathological TN category (AJCC 2017):. pT1cN0(sn).. . 2. Fibroadenoma.. Note: 1. Ductal carcinoma in situ is present. only in the permanent section of Fro 3.. Result. Intensity. Positive. %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (7/8). 3. 1/3–2/3. C-erbB2. Equivocal (2+). Ki-67. Positive in 19%. of tumor cells. SISH. Positive. 18. " +186,Case 17,Important Radiologic,HR(+) HER2(+) Breast Cancer,Important Radiologic. Findings. 88 89 90. 91. 17.3.  +192,Case 17,Patient History,HR(+) HER2(+) Breast Cancer,"Patient History and Progress. Female/38 years old, post-menopause.. Self-detected palpable mass lesion on left. breast 1 o’clock direction.. Family history of prostate cancer, maternal. father.. S/P salpingo-oophorectomy (2022).. BRCA 2 mutation carrier.. 17.2. " +179,Case 17,Courses of Treatment,HR(+) HER2(-) Breast Cancer,"Courses of Treatment. Operation  +  Post-operative radiation ther­. apy + Tamoxifen 20 mg/day.. Operation. Left breast conserving surgery, sentinel lymph. sive intraductal component: present).. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) superior margin: 5 mm.. . (b) inferior margin: (see note 1).. . (c) medial margin: 5 mm.. . (d) lateral margin: (see note 2).. . (e) deep margin: 1 mm from invasive ductal. carcinoma (slide 5).. . (f) superficial margin: 3 mm.. 7. Lymph nodes: no metastasis in one axillary. lymph node (pN0(i+)(sn)) (see note 3) (sen­. tinel LN: 0/1).. 8. Arteriovenous invasion: absent.. 9. Lymphovascular invasion: absent.. . 10. Tumor border: infiltrative.. . 11. Microcalcification: present, non-tumoral.. . 12. Pathological TN category (AJCC 2017):. 3. A few isolated tumor cells are present only in. the permanent section of Fro 5.. Result. Intensity. Positive %. Estrogen receptor. Strong (8/8). 3. >2/3. Progesterone receptor. Weak (4/8). 1. 10%–1/3. C-erbB2. Negative (0). Ki-67. Positive in 1% of tumor cells. Y. Kim et al." +187,Case 17,Important Radiologic,HR(+) HER2(-) Breast Cancer,"Important Radiologic. Findings. See Figs. 84, 85, 86 and 87.. 17.3. " +193,Case 17,Patient History,HR(+) HER2(-) Breast Cancer,"o’clock direction.. No family history.. S/P Lumbar spine disc herniation operation,. s/p pain block in lumbar spine.. S/p hormone replacement due to amenorrhea.. 17.2. " +180,Case 17,Courses of Treatment,HR(−) HER2(+) Breast Cancer,"17.1. . Courses of Treatment. Operation + Adjuvant chemotherapy (#4 cycles. of doxorubicin and cyclophosphamide  +  #4. cycles of docetaxel and trastuzumab)  +  Post-­. operative radiation therapy + Trastuzumab.. Operation. 126. Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 1.8 and 1.5 cm (pT1c(2)).. 2. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 3/3, 3/HPF).. Y. Kwon et al.. 499. . 3. Intraductal component: present, intratu­. moral/extratumoral (50%) (nuclear grade:. high, necrosis: present, architectural pattern:. solid/comedo, extensive intraductal compo­. nent: present).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) superior margin: (see note),. . (b) inferior margin: 10 mm,. . (c) medial margin: 5 mm,. . (d) lateral margin: 30 mm,. . (e) deep margin: 2 mm,. . (f) superficial margin: 2 mm.. 6. Lymph nodes:. . (a) metastasis in one out of three axillary. lymph nodes (pN1a(sn)) (sentinel LN:. 1/2, axillary LN: 0/1),. . (b) perinodal extension: present,. . (c) size of metastatic carcinoma: 9 mm.. 7. Arteriovenous invasion: absent.. 8. Lymphovascular. invasion:. present,. intratumoral.. 9. Tumor border: infiltrative.. . 10. Microcalcification:. present,. tumoral/. non-tumoral.. . 11. Pathological TN category (AJCC 2017):. pT1c(2)N1a(sn).. Result. Intensity. Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in 20%. of tumor cells. HR(−) HER2(+) Breast Cancer. 500. 18. " +188,Case 17,Important Radiologic,HR(−) HER2(+) Breast Cancer,Important Radiologic. Findings. 122 123 124. 125. . HR(−) HER2(+) Breast Cancer. 498. . . . 17.3.  +194,Case 17,Patient History,HR(−) HER2(+) Breast Cancer,"Patient History and Progress. Female/41 years old, pre-menopause.. Self-detected palpable mass lesion on left. breast.. Family history of breast cancer, aunt. (maternal).. S/P Lumbar spine disc operation.. BRCA 1 and 2 mutation: Not detected,. MUTYH VUS (variant of uncertain).. 17.2. " +181,Case 17,Courses of Treatment,HR(−) HER2(−) Breast Cancer,"17.1. . Courses of Treatment. Operation  +  Adjuvant chemotherapy (#2. cycles of doxorubicin and cyclophosphamide,. refuse) + Post-operative radiation therapy.. Operation. 122. Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 1.3 cm (pT1c).. 2. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 3/3, 5/HPF).. HR(−) HER2(−) Breast Cancer. . E. S. Lee et al.. 635. 3. Intraductal component: present, intratu­. moral/extratumoral (10%) (nuclear grade:. high, necrosis: present, architectural pattern:. solid/comedo, extensive intraductal compo­. nent: absent).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) Superior margin: 10 mm.. . (b) Inferior margin: (see note).. . (c) Medial margin: 10 mm.. . (d) Lateral margin: 10 mm.. . (e) Deep margin: 2 mm.. . (f) Superficial margin: 2 mm.. . . HR(−) HER2(−) Breast Cancer. 636. 6. Lymph nodes: no metastasis in one axillary. lymph node (pN0(sn)) (sentinel LN: 0/1).. 7. Arteriovenous invasion: absent.. 8. Lymphovascular. invasion:. present,. intratumoral.. 9. Tumor border: infiltrative.. . 10. Microcalcification:. present,. tumoral/. non-tumoral.. . 11. Pathological TN category (AJCC 2017):. pT1cN0(sn).. Note: 1. The inferior margin of the lumpec­. tomy specimen (slides 4 and 5) is close to inva­. sive ductal carcinoma (3  mm) and ductal. carcinoma in situ (<1 mm), but this margin sub­. mitted for frozen diagnosis (Fro 2) is free of. tumor.. Result. Intensity. Positive. %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Equivocal (2+). Ki-67. Positive in 12%. of tumor cells. 18. " +189,Case 17,Important Radiologic,HR(−) HER2(−) Breast Cancer,Important Radiologic. Findings. 118 119 120. 121. 17.3.  +195,Case 17,Patient History,HR(−) HER2(−) Breast Cancer,"Patient History and Progress. Female/70 years old, post-menopause.. Screen detected mass at the upper outer quad­. rant of the left breast.. Family history of breast cancer, niece.. h/o Tuberculosis, s/p appendectomy, s/p. myomectomy.. BRCA 1 and 2 mutation: Not tested.. 17.2. " +182,Case 17,Courses of Treatment,Local Recurrence,"17.1. . Courses of Treatment. Right breast DCIS → Operation → Adjuvant. therapy → Right breast recurrence (mucinous. carcinoma).. Primary Treatment. 122. Operation. 123. Pathology Report. Ductal Carcinoma In Situ. . 1. Post-excisional biopsy status.. . 2. Size of tumor: 1.5 cm, residual.. . 3. Nuclear grade: high.. . 4. Necrosis: present.. . 5. Architectural. pattern:. cribriform/solid/. comedo.. . 6. Skin: no involvement of tumor.. . 7. Surgical margins:. . (a) Superior margin: 5 mm.. . (b) Inferior margin: 7 mm.. . (c) Medial margin: 15 mm.. . (d) Lateral margin: (see note).. . (e) Deep margin: 2 mm.. . (f) Superficial margin: 8 mm.. . 8. Microcalcification:. present,. tumoral/. non-tumoral.. Y. Kim et al.. 765. Note: 1. The lateral margin of the lumpectomy. specimen (slide 7) is close to ductal carcinoma in. situ (<1 mm), but this margin submitted for fro­. zen diagnosis (Fro 5) is free of tumor.. Result. Intensity. Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in 56%. of tumor cells. Adjuvant Therapy. Postoperative radiation therapy.. Treatments After Recurrence. 124 125. 126. Operation. 127. 128. Pathology Report. . Mucinous Carcinoma. 1. Post-lumpectomy status.. 2. Size of tumor: 1.1 cm (rpT1c).. 3. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, <1/10HPF).. 4. Intraductal component: present, extratumoral. (5%) (nuclear grade: low, necrosis: present,. architectural pattern: solid/comedo, exten­. sive intraductal component: absent).. 5. Skin and nipple: no involvement of tumor.. 6. Surgical margins:. . (a) Deep margin: 10 mm.. . (b) Superficial margin: 4 mm.. 7. Lymph nodes: no metastasis in five axillary. lymph nodes (rpN0(sn)) (sentinel LN: 0/2,. axillary LN: 0/2, intramammary LN: 0/1).. 8. Arteriovenous invasion: absent.. 9. Lymphovascular invasion: absent.. . 10. Tumor border: infiltrative.. . 11. Microcalcification: absent.. . . . Local Recurrence. 766. . . Y. Kim et al.. 767. . 12. Pathological TN category (AJCC 2017):. rpT1cN0(sn).. Result. Intensity. Positive %. Estrogen. receptor. Intermediate. (6/8). 2. 1/3–2/3. Progesterone. receptor. Weak (4/8). 2. 1–10%. C-erbB2. Negative (0). Ki-67. Positive in 22%. of tumor cells. . . 1. Fibroadenoma.. . 2. Usual ductal hyperplasia with apocrine. metaplasia.. Adjuvant Therapy. Tamoxifen 20 mg/day for 5 years.. 18. " +196,Case 17,Patient History,Local Recurrence,"Patient History and Progress. Female/43 years old, pre-menopause.. Screen detected mass lesion on right breast 7. o’clock direction.. Outside result of mammotome biopsy: ductal. carcinoma in situ.. No family history.. s/p Total thyroidectomy (thyroid cancer).. BRCA 2 VUS (variant of uncertain).. 17.2. " +183,Case 17,Courses of Treatment,Metastatic Breast Cancer,17.1. . Courses of Treatment. Right breast cancer → Operation → Adjuvant. therapy → Ipsilateral axillary lymph node. recurrence.. Primary Treatment. Estrogen. receptor. Strong. (7/8). 3. 1/3–2/3. Progesterone. receptor. Strong. (7/8). 2. >2/3. C-erbB2. Negative. (0). Ki-67. Positive in. 15% of. tumor. cells. Adjuvant Therapy. Adjuvant chemotherapy #8 cycles (Adriamycin +. Cyclophosphamide #4 → Docetaxel #4).. Post-operative radiation therapy + Letrozole. 2.5 mg/day for 3 years.. Treatments After Recurrence. receptor. Negative (0/8). 0. 0. C-erbB2. Negative (0). Ki-67. Positive in. <1% of tumor. cells. Operation. Jun. 2021 Right axillary lymph node dissection.. Pathology: No metastasis in four axillary. lymph nodes.. Adjuvant Therapy. Exemestane 25 mg/day~. 18.  +197,Case 17,Patient History,Metastatic Breast Cancer,"Patient History and Progress. Female/69 years old, post-menopause.. Family history of breast cancer, daughter.. BRCA. 1. mutation: VUS. (variant. of. uncertain).. 17.2. " +198,Case 18,Courses of Treatment,Benign and Proliferative,"18.1. . Courses of Treatment. →2021-08-27 excision, Rt.. Pathology Report. Diagnosis. • Breast, right, excision:. –. – Atypical ductal hyperplasia with micro-. calcification.. Post-excision status.. –. – Intraductal papilloma.. C. W. Lee et al.. 39. . . 19. " +206,Case 18,Important Radiologic,Benign and Proliferative,Important Radiologic. Findings. 32. 33. 18.3.  +212,Case 18,Patient History,Benign and Proliferative,"Patient History and Progress. Female/57 years old, pre-menopause.. Screen detected mass lesion on right breast. 9 ~ 10 o’clock direction.. No family history.. No comorbidities.. s/p Right breast excision.. 18.2. " +199,Case 18,Courses of Treatment,Carcinoma In Situ,"18.1. . Courses of Treatment. Operation + Postoperative radiation therapy.. Operation. 83. 84. Pathology Report. Ductal carcinoma in situ, pathological TN cat­. egory (AJCC 2017): pTis. . 1. Size of tumor: 1.1 cm (pTis).. . 2. Nuclear grade: low.. . 3. Necrosis: present.. . 4. Architectural pattern: micropapillary/cribri­. form/solid.. . 5. Surgical margins:. . (a) superior margin: 20 mm,. . (b) inferior margin: (see Note 1),. . (c) medial margin: 5 mm,. . (d) lateral margin: (see Note 2),. . (e) deep margin: 2 mm,. . (f) superficial margin: 5 mm.. . 6. Microcalcification: present, non-tumoral.. Note: 1. The inferior margin of the lumpec­. tomy specimen (slide 5) is close to ductal car­. cinoma in situ (2 mm) but this margin submitted. for frozen diagnosis (Fro 3) is free of tumor.. 2. The lateral margin of the lumpectomy spec­. imen (slide 6) is close to ductal carcinoma in situ. (2  mm) but this margin submitted for frozen. diagnosis (Fro 7) is free of tumor.. Result. Intensity Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (1+). Ki-67. Positive in 5%. of tumor cells. . . E. S. Lee et al.. 91. . . ­. 19. " +207,Case 18,Important Radiologic,Carcinoma In Situ,Important Radiologic. Findings. 81. 82. 18.3.  +213,Case 18,Patient History,Carcinoma In Situ,"Patient History and Progress. Female/64 years old, post-menopause.. Screen detected mass lesion on right breast. 8 o’clock direction.. Outside result of biopsy:. Right breast 8  o’clock, atypical intraductal. papillary neoplasm, favor ductal carcinoma in. situ.. No family history.. Hypertension, diabetes mellitus.. 18.2. " +200,Case 18,Courses of Treatment,HR(+) HER2(+) Breast Cancer,"18.1. . Courses of Treatment. Operation  +  Adjuvant chemotherapy (#4. cycles of doxorubicin and cyclophosphamide. followed by #4 cycles of docetaxel and trastu­. zumab)  +  Post-operative radiation ther­. apy  +  Trastuzumab  +  Letrozole 2.5  mg/day. with goserelin.. 99. Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: up to 3.0  cm, multifocal. (pT2(Paget)).. . ­. HR(+) HER2(+) Breast Cancer. 356. . 2. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 3/3, 23/10 HPF).. 3. Intraductal component: present, intratu­. moral/extratumoral (20%) (nuclear grade:. high, necrosis: present, architectural pattern:. papillary/solid/comedo, extensive intraductal. component: absent).. 4. Nipple: Paget’s disease.. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) superior margin: 12 mm,. . (b) inferior margin: (see Note 1),. . (c) medial margin: 15 mm,. . (d) lateral margin: 8 mm,. . (e) deep margin: <1 mm from ductal carci­. noma in situ (slide 3),. . (f) superficial margin: <2 mm from invasive. ductal carcinoma (slide 13).. 7. Lymph nodes:. . (a) metastasis in three out of four axillary. lymph nodes (pN1a(sn)) (see Note 2). (sentinel LN: 3/4),. . (b) perinodal extension: present,. . (c) size of metastatic carcinoma: 4 mm.. 8. Arteriovenous invasion: absent.. 9. Lymphovascular. invasion:. present,. peritumoral.. . 10. Tumor border: infiltrative.. . 11. Microcalcification:. present,. tumoral/. non-tumoral.. . 12. Pathological TN category (AJCC 2017):. pT2(Paget)N1a(sn).. Note: 1. The inferior margin of the lumpec­. tomy specimen (slide 3) is close to ductal carci­. noma in situ (<1 mm) but this margin submitted. for frozen diagnosis (Fro 8 and 9) is free of tumor.. 2. A few isolated tumor cells are present only. in the permanent section of Fro 5 for immunohis­. tochemical staining.. Result. Intensity. Positive. %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Positive (3+). Ki-67. Positive in 77%. of tumor cells. S. Park et al.. 357. . . HR(+) HER2(+) Breast Cancer. 358. a. b. . 19. " +208,Case 18,Important Radiologic,HR(+) HER2(+) Breast Cancer,Important Radiologic. Findings. 95 96 97. 98. 18.3.  +214,Case 18,Patient History,HR(+) HER2(+) Breast Cancer,"Patient History and Progress. Female/38 years old, pre-menopause.. Self-detected palpable mass lesion on portion. of outer half of left breast.. No family history.. Lumbar spine disc.. BRCA 1 and 2 mutation: Not examination.. 18.2. " +201,Case 18,Courses of Treatment,HR(+) HER2(-) Breast Cancer,"Courses of Treatment. Operation (1st & 2nd, Aug. 2010)  +  Post-­. operative radiation therapy  +  Tamoxifen. 20 mg/day.. Operation (3rd, Jan. 2021) + Adjuvant che­. motherapy (docetaxel & cyclophosphamide) +. Letrozole 2.5 mg/day.. Operation (1st, Aug. 2010). comedo.. . 5. Surgical margins:. . (a) superior margin: 30 mm.. . (b) inferior margin: positive (slide 3).. . (c) medial margin: 10 mm.. . (d) lateral margin: 10 mm.. . (e) deep margin: 2 mm.. . 6. Microcalcification:. present,. tumoral/. non-tumoral.. . 7. Pathologic stage (AJCC 2010): pTis.. Flat Epithelial Atypia. • With microcalcification.. Result. Intensity. Positive. %. Estrogen. receptor. Strong (7/7). 3. >2/3. Progesterone. receptor. Strong (6/7). 3. 1/3–2/3. C-erbB2. Equivocal (2+). Ki-67. Positive in 1% of. tumor cells. Operation (2nd, Aug. 2010). Left breast conserving surgery, sentinel lymph. with microcalcification.. Operation (3rd, Jan. 2021). Left total mastectomy, sentinel lymph node. biopsy, right total mastectomy (Figs. 99 and 100).. Pathology Report. [Right]. . 1. Fibroadenoma. . 2. Sclerosing adenosis with microcalcification.. [Left]. Invasive Ductal Carcinoma. 1. Post-lumpectomy status.. 2. Size of tumor: 2.0 cm (rpT1c).. Y. Kim et al.. . (a) deep margin: 3 mm.. . (b) superficial margin: 2 mm.. 7. Lymph nodes: no metastasis in two axillary. lymph nodes (rpN0(sn)) (axillary LN: 0/2).. 8. Arteriovenous. invasion:. present,. intratumoral.. 9. Lymphovascular invasion: present, intratu­. moral/peritumoral.. . 10. Tumor border: infiltrative.. . 11. Microcalcification: present, tumoral.. . 12. Pathological TN category (AJCC 2017):. rpT1cN0(sn).. Result. Intensity. Positive %. Estrogen receptor. Strong (8/8). 3. >2/3. Progesterone receptor. Intermediate (5/8). 3. 1–10%. C-erbB2. Negative (0). Ki-67. Positive in 8% of tumor cells. Y. Kim et al." +209,Case 18,Important Radiologic,HR(+) HER2(-) Breast Cancer,"Important Radiologic. Findings. See Figs. 89, 90, 91, 92, 93, 94, 95 and 96.. 18.3. " +215,Case 18,Patient History,HR(+) HER2(-) Breast Cancer,"S/P unilateral salpingo-oophorectomy, s/p. hysterectomy, Hypertension.. 18.2. " +202,Case 18,Courses of Treatment,HR(−) HER2(+) Breast Cancer,"18.1. . Courses of Treatment. Neoadjuvant chemotherapy (#6 cycles of. docetaxel and carboplatin and trastuzumab and. pertuzumab) + Operation + Post-operative radia­. tion therapy + Trastuzumab.. . Y. Kwon et al.. 503. 3/3, 3/1HPF).. 4. Intraductal component: absent.. 5. Surgical margins:. . (a) superior margin: 40 mm,. . (b) inferior margin: 15 mm,. . (c) medial margin: 10 mm,. . (d) lateral margin: 15 mm,. . (e) deep margin: 5 mm,. . (f) superficial margin: 8 mm.. 6. Lymph nodes: no metastasis in two axillary. lymph nodes (ypN0(sn)) (sentinel LN: 0/1,. axillary LN: 0/1).. 7. Arteriovenous invasion: absent.. 8. Lymphovascular. invasion:. present,. intratumoral.. HR(−) HER2(+) Breast Cancer. 504. a. b. . 9. Tumor border: infiltrative.. . 10. Microcalcification: present, non-tumoral.. . 11. Pathological TN category (AJCC 2017):. ypT1bN0(sn).. Result. Intensity. Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in. 41% of tumor. cells. 19. " +210,Case 18,Important Radiologic,HR(−) HER2(+) Breast Cancer,Important Radiologic. Findings. 127 128 129. 130. . Y. Kwon et al.. 501. . . . HR(−) HER2(+) Breast Cancer. 502. 18.3. . After Neoadjuvant. Chemotherapy. 131 132 133. 134. 18.4.  +216,Case 18,Patient History,HR(−) HER2(+) Breast Cancer,"Patient History and Progress. Female/61 years old, post-menopause.. Self-detected bloody discharge on nipple of. left breast.. No family history.. S/p hysterectomy.. 18.2. " +203,Case 18,Courses of Treatment,HR(−) HER2(−) Breast Cancer,"18.1. . Courses of Treatment. Neoadjuvant chemotherapy (#4  cycles of. doxorubicin and cyclophosphamide  +  #4. cycles of paclitaxel)  +  Operation  +  Post-. operative radiation therapy  +  Adjuvant. capecitabine.. Operation. 130. Pathology Report. . 1. Invasive Ductal Carcinoma.. . (a) Post-chemotherapy status.. . (b) Size of tumor: 0.7 cm (ypT1b).. . (c) Histologic grade: 3/3 (tubule formation:. 3/3, nuclear pleomorphism: 3/3, mitotic. count: 3/3, 95/10HPF).. . (d) Intraductal component: absent.. . (e) Skin and nipple: no involvement of tumor.. . (f) Surgical margins:. • Superior margin: 20 mm.. • Inferior margin: 20 mm.. • Medial margin: 10 mm.. • Lateral margin: 10 mm.. • Deep margin: 1.5  mm from invasive. ductal carcinoma (slide 2).. • Superficial margin: 15 mm.. . (g) Lymph nodes: no metastasis in three axillary. lymph nodes (ypN0(sn)) (sentinel LN: 0/3).. . (h) Arteriovenous invasion: absent.. . (i) Lymphovascular invasion: absent.. . (j) Tumor border: infiltrative.. . (k) Microcalcification: present, non-tumoral.. . (l) Pathological TN category (AJCC 2017):. ypT1bN0(sn).. . 2. Sclerosing adenosis with microcalcification.. Note: 1. A few isolated tumor cells are present. only in the permanent section of Fro 7 for immu­. nohistochemical staining.. Result. Intensity Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Negative (0). Ki-67. Positive in 63%. of tumor cells. E. S. Lee et al.. 637. . HR(−) HER2(−) Breast Cancer. 638. . ­. . . ­. . E. S. Lee et al.. 639. . . . HR(−) HER2(−) Breast Cancer. 640. 19. " +211,Case 18,Important Radiologic,HR(−) HER2(−) Breast Cancer,Important Radiologic Findings. 123 124. 125. After Neoadjuvant. Chemotherapy. 126 127 128. 129. 18.3.  +217,Case 18,Patient History,HR(−) HER2(−) Breast Cancer,"Patient History and Progress. Female/57 years old, post-menopause.. Self-detected palpable mass lesion and skin. change on left breast.. Family history of breast cancer, aunt. (paternal).. No comorbidities.. BRCA 1 and 2 mutation: Not detected.. 18.2. " +204,Case 18,Courses of Treatment,Local Recurrence,"18.1. . Courses of Treatment. Left breast IDC→ Operation → Adjuvant. . therapy → Right breast recurrence (IDC).. Primary Treatment. Operation. May 2001 Left modified radical mastectomy. (outside).. Pathology Report. Invasive Ductal Carcinoma. . 1. Size of tumor: 3.0 cm (pT2).. . 2. Lymph nodes: two metastases in 24 axillary. lymph nodes (pN1) (sentinel LN: 0/2, axillary. LN: 0/2, intramammary LN: 0/1).. . 3. Pathological TN category: pT2N1.. Result. Intensity. Positive %. Estrogen. receptor. Negative. 0. 0. Progesterone. receptor. Negative. 0. 0. C-erbB2. Negative (0). Ki-67. Positive in 70%. of tumor cells. Adjuvant Therapy. Adjuvant chemotherapy #4 cycles of doxorubicin. and cyclophosphamide followed by #4 cycles of. docetaxel.. Treatments After Recurrence. 129 130. 131. . . Local Recurrence. 768. Operation. 132. Pathology Report. Invasive Ductal Carcinoma. 1. Post left mastectomy status.. 2. Size of tumor: 1.6 cm (pT1c).. 3. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 3/3, 12/HPF).. 4. Intraductal component: present, intratu­. moral/extratumoral (30%) (nuclear grade:. high, necrosis: present, architectural pattern:. micropapillary/comedo,. extensive. intra­. ductal component: present).. 5. Nipple: involvement of lactiferous duct.. 6. Skin: no involvement of tumor.. 7. Surgical margins:. . (a) Deep margin: 2 mm.. . (b) Superficial margin: 2 mm.. 8. Lymph nodes:. . . Y. Kim et al.. 769. . (a) Metastasis in one out of four axillary. lymph nodes (pN1mi(sn)) (sentinel LN:. 1/3, non-sentinel LN: 0/1).. . (b) Perinodal extension: absent.. . (c) Size of metastatic carcinoma: 0.8 mm.. 9. Arteriovenous invasion: absent.. . 10. Lymphovascular. invasion:. present,. intratumoral.. . 11. Tumor border: infiltrative.. . 12. Microcalcification:. present,. tumoral/. non-tumoral.. . 13. Pathological TN category (AJCC 2017):. pT1cN1mi(sn).. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (1+). Ki-67. Positive in 80%. of tumor cells. Adjuvant Therapy. Anastrozole 1 mg/day (stop d/t low compliance).. 19. " +218,Case 18,Patient History,Local Recurrence,"Patient History and Progress. Female/71 years old, post-menopause.. Screen detected mass lesion on right breast.. No family history.. Diabetes mellitus, Grave’s disease.. BRCA 2 mutation carrier.. 18.2. " +205,Case 18,Courses of Treatment,Metastatic Breast Cancer,"18.1. . Courses of Treatment. Left breast cancer → Operation → Ipsilateral. chest wall recurrence → Neoadjuvant chemo­. therapy → operation → targeted therapy →. Ipsilateral lymph node recurrence.. Primary Treatment. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in. 23% of tumor. cells. Treatments After Recurrence. See Figs. 58 and 59.. Nov. 2018 Muscle, left breast biopsy.. Pathology: Invasive ductal carcinoma, clini­. cally recurrent.. Metastatic Breast Cancer. receptor. Intermediate. (5/8). 3. 1–10%. C-erbB2. Positive (3+). Ki-67. Positive in. 39% of tumor. cells. Neoadjuvant Chemotherapy. Chemotherapy. #3. cycle. (Docetaxel. &. Trastuzumab + Pertuzumab).. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Negative (2/8). 1. <1%. C-erbB2. Equivocal (2+). Ki-67. Positive in. 34% of tumor. cells. Adjuvant Therapy. Trastuzumab + Pertuzumab.. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Equivocal (2+). Ki-67. Positive in. 25% of tumor. cells. SISH. Positive. Operation. Jan. 2020 Left axillary lymph node dissection.. Pathology: Metastatic ductal carcinoma in. three out of eight axillary lymph nodes.. Y. Kwon et al.. 891. Size of metastatic carcinoma: 20 mm.. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Negative (2/8). 1. <1%. C-erbB2. Positive (3+). Ki-67. Positive in 30%. of tumor cells. Adjuvant Therapy. Post-operative radiation therapy + Letrozole. 2.5 mg/day~. 19. " +219,Case 18,Patient History,Metastatic Breast Cancer,"Patient History and Progress. Female/64 years old, post-menopause.. No family history.. Hypertension, diabetes mellitus.. 18.2. " +220,Case 19,Courses of Treatment,Benign and Proliferative,"19.1. . Courses of Treatment. →2021-08-03 excision, Lt.. Pathology Report. Diagnosis. • Breast, left 1 o’clock, excision:. –. – Fibroadenoma.. –. – Intraductal papilloma with usual ductal. hyperplasia.. • Breast, left 8 o’clock, excision:. –. – Intraductal papilloma with (1) usual ductal. hyperplasia, (2) microcalcification.. 20. " +228,Case 19,Important Radiologic,Benign and Proliferative,Important Radiologic. Findings. 34 35. 36. Benign and Proliferative Case Series. 40. . . . C. W. Lee et al.. 41. 19.3.  +234,Case 19,Patient History,Benign and Proliferative,"Patient History and Progress. Female/42 years old, pre-menopause.. Screen detected mass lesion on left breast. 8 o’clock direction.. Outside result of biopsy: papillary neoplasm.. No family history.. No comorbidities.. 19.2. " +221,Case 19,Courses of Treatment,Carcinoma In Situ,"19.1. . Courses of Treatment:. Operation. Operation. ­. 89. 90. Carcinoma In Situ. 92. Pathology Report. Right.. Ductal carcinoma in situ. . 1. Post-mammotome status.. . 2. Size of tumor: 0.3 cm, residual.. . 3. Nuclear grade: high.. . 4. Necrosis: absent.. . 5. Architectural pattern: cribriform/solid.. . 6. Skin and nipple: no involvement of tumor.. . 7. Surgical margins:. . (a) deep margin: 5 mm,. . (b) superficial margin: <1  mm from ductal. carcinoma in situ (slide 11).. . 8. Lymph nodes: no metastasis in two axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/2).. . 9. Microcalcification: present, tumoral.. Left.. Ductal carcinoma in situ, pathological TN cat­. egory (AJCC 2017): pTisN0(sn). . 1. Size of tumor: 6.0 cm (pTis).. . 2. Nuclear grade: low.. . 3. Necrosis: absent.. . 4. Architectural pattern: micropapillary/cribri­. form/solid.. . 5. Skin and nipple: no involvement of tumor.. . 6. Surgical margins: (see note).. . (a) deep margin: 1  mm from ductal carci­. noma in situ (slide 4),. . (b) superficial margin: <1  mm from ductal. carcinoma in situ (slide 8).. . 7. Lymph nodes: no metastasis in three axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/3).. . 8. Microcalcification: present, tumoral.. Note: 1. Atypical ductal hyperplasia is pres­. ent only in the permanent section of Fro 3.. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (1+). Ki-67. Positive in. 14% of tumor. cells. . ­. . E. S. Lee et al.. 93. . ­. . Carcinoma In Situ. 94. . E. S. Lee et al.. 95. . 20. " +229,Case 19,Important Radiologic,Carcinoma In Situ,Important Radiologic. Findings. 85 86 87. 88. 19.3.  +235,Case 19,Patient History,Carcinoma In Situ,"Patient History and Progress. Female/48 years old, pre-menopause.. Screen detected diffuse non-mass lesions on. upper, central, and lower portion of left breast.. Screen detected microcalcification on inner. subareolar of right breast.. Outside result of excisional biopsy: bilateral. ductal carcinoma in situ.. No family history.. S/P L-spine operation.. BRCA 1 and 2 mutation: Not detected.. 19.2. " +222,Case 19,Courses of Treatment,HR(+) HER2(+) Breast Cancer,"19.1. . Courses of Treatment. Neoadjuvant chemotherapy (#6 cycles of. docetaxel and carboplatin and trastuzumab. and pertuzumab)  +  Operation  +  Post-­. operative radiation therapy + Trastuzumab +. Letrozole 2.5 mg/day.. 105. Pathology Report. Invasive Ductal Carcinoma. 1. Post-chemotherapy status.. 2. Size of tumor: 1.5 cm (ypT1c).. S. Park et al.. 359. . . 3. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 2/3, 10/10 HPF).. 4. Intraductal component: absent.. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) superior margin: 20 mm,. . (b) inferior margin: 20 mm,. . (c) medial margin: 25 mm,. . (d) lateral margin: 10 mm,. . (e) deep margin: 13 mm,. . (f) superficial margin: 18 mm.. 7. Lymph nodes: no metastasis in one axillary. lymph node (ypN0(sn)) (sentinel LN: 0/0,. sentinel LN #2: 0/1).. 8. Arteriovenous invasion: absent.. 9. Lymphovascular invasion: absent.. . 10. Tumor border: infiltrative.. . 11. Microcalcification: present, non-tumoral.. . 12. Pathological TN category (AJCC 2017):. ypT1cN0(sn).. Result. Intensity. Positive. %. Estrogen. receptor. Intermediate. (6/8). 2. 1/3–2/3. Progesterone. receptor. Negative (2/8). 1. <1%. C-erbB2. Positive (3+). Ki-67. Positive in 3% of. tumor cells. HR(+) HER2(+) Breast Cancer. 360. . . . S. Park et al.. 361. a. b. . 20. " +230,Case 19,Important Radiologic,HR(+) HER2(+) Breast Cancer,Important Radiologic. Findings. 100 101 102 103. 104. 19.3.  +236,Case 19,Patient History,HR(+) HER2(+) Breast Cancer,"Patient History and Progress. Female/71 years old, post-menopause.. Self-detected palpable mass lesion on left. breast 11 o’clock direction.. No family history.. Hypertension,. dyslipidemia,. s/p. appendectomy.. 19.2. " +223,Case 19,Courses of Treatment,HR(+) HER2(-) Breast Cancer,"Courses of Treatment. Operation + Tamoxifen 20 mg/day with leup­. rolide acetate.. Operation. Left nipple–areolar complex sparing mastectomy. with immediate implant reconstruction, sentinel. lymph node biopsy (Figs. 106 and 107).. Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 1.7 cm and 0.5 cm (pT1c(2)).. 2. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 2/3, 11/10 HPF).. 3. Intraductal component: present, intratu­. moral/extratumoral (20%) (nuclear grade:. low, necrosis: present, architectural pattern:. cribriform/solid/comedo, extensive intra­. ductal component: present).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) deep margin: 2 mm.. . (b) superficial margin: 2 mm.. HR(+) HER2(−) Breast Cancer. . 10. Microcalcification:. present,. tumoral/. non-tumoral.. . 11. Pathological TN category (AJCC 2017):. pT1c(2)N0(sn).. Result. Intensity. Positive. %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Equivocal (2+). (SISH negative). Ki-67. Positive in 9% of. tumor cells. Y. Kim et al." +231,Case 19,Important Radiologic,HR(+) HER2(-) Breast Cancer,"Important Radiologic. Findings. See Figs. 101, 102, 103, 104 and 105.. 19.3. " +237,Case 19,Patient History,HR(+) HER2(-) Breast Cancer,No comorbidities.. 19.2.  +224,Case 19,Courses of Treatment,HR(−) HER2(+) Breast Cancer,"19.1. . Operation. 140. Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 2.1 cm (pT2).. 2. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 12/3, 2/10HPF).. 3. Intraductal component: present, extratumoral. (5%) (nuclear grade: high, necrosis: present,. architectural pattern: solid/comedo, exten­. sive intraductal component: absent).. 4. Surgical margins:. . (a) superior margin: 10 mm,. . (b) inferior margin: 20 mm,. . (c) medial margin: 10 mm,. . (d) lateral margin: 10 mm,. . (e) deep margin: 2 mm,. . (f) superficial margin: 5 mm.. 5. Lymph nodes: no metastasis in two axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/2).. 6. Arteriovenous invasion: absent.. 7. Lymphovascular. invasion:. present,. peritumoral.. 8. Tumor border: infiltrative.. 9. Microcalcification:. present,. tumoral/. non-tumoral.. . 10. Pathological TN category (AJCC 2017):. pT2N0(sn).. Result. Intensity. Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in 39%. of tumor cells. . ­. . Y. Kwon et al.. 507. a. b. . 20. " +232,Case 19,Important Radiologic,HR(−) HER2(+) Breast Cancer,Important Radiologic. Findings. 136 137 138. 139 +238,Case 19,Patient History,HR(−) HER2(+) Breast Cancer,"Patient History and Progress. Female/52 years old, pre-menopause.. Self-detected palpable mass lesion on left. breast 1 and 2 o’clock direction.. No family history.. Hepatitis B virus carrier, liver cirrhosis.. Y. Kwon et al.. 505. 19.2. " +225,Case 19,Courses of Treatment,HR(−) HER2(−) Breast Cancer,"19.1. . Courses of Treatment. Operation  +  adjuvant chemotherapy (#4. cycles of doxorubicin and cyclophospha­. mide + #3 cycles of paclitaxel-stop d/t drug-­. induced. pneumonitis). +. Post-operative. radiation therapy.. Operation. 134. Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 2.2 cm (pT2).. 2. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 3/3, 4/HPF).. 3. Intraductal component: present, intratu­. moral/extratumoral (20%) (nuclear grade:. high, necrosis: present, architectural pattern:. solid/comedo, extensive intraductal compo­. nent: absent).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) Superior margin: 10 mm.. . (b) Inferior margin: 10 mm.. . (c) Medial margin: 10 mm.. . (d) Lateral margin: 10 mm.. . (e) Deep margin: 2 mm.. . (f) Superficial margin: 2 mm.. 6. Arteriovenous invasion: absent.. 7. Lymphovascular invasion: absent.. 8. Tumor border: infiltrative.. 9. Microcalcification: present, tumoral/non-. tumoral.. . 10. Pathological TN category (AJCC 2017):. pT2Nx.. Result. Intensity. Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Negative (1+). Ki-67. Positive in 91%. of tumor cells. E. S. Lee et al.. 641. . . . HR(−) HER2(−) Breast Cancer. 642. . 20. " +233,Case 19,Important Radiologic,HR(−) HER2(−) Breast Cancer,Important Radiologic Findings. 131 132. 133. 19.3.  +239,Case 19,Patient History,HR(−) HER2(−) Breast Cancer,"Patient History and Progress. Female/63 years old, post-menopause.. Screen detected mass lesion on right breast 10. o’clock direction.. No family history.. Hepatitis B virus carrier, h/o Tuberculosis.. 19.2. " +226,Case 19,Courses of Treatment,Local Recurrence,"19.1. . Courses of Treatment. Left breast IDC → Adjuvant therapy.. Primary Treatment. 133 134 135 136. 137. Neoadjuvant Chemotherapy. Neoadjuvant chemotherapy #4 cycles of doxoru­. bicin and cyclophosphamide followed by. #4 cycles of docetaxel and trastuzumab.. Operation. ­. ­. 138. 139. Pathology Report. . Complex. sclerosing. lesion. with. microcalcification.. . Invasive Ductal Carcinoma, associated with. complex sclerosing lesion. 1. Post-chemotherapy status.. 2. Size of invasion component: 1.3  cm. (ypT1c(m)).. 3. Size of intraductal component: 1.6 cm.. . Local Recurrence. 770. architectural pattern: micropapillary/cribri­. form, extensive intraductal component:. present).. 6. Skin: no involvement of tumor.. 7. Surgical margins:. . (a) Superior margin: 15 mm.. . (b) Inferior margin: 4 mm.. . (c) Medial margin: (see NOTE 1).. . (d) Lateral margin: 50 mm.. . (e) Deep margin: 7 mm.. . (f) Superficial margin: 14 mm.. Y. Kim et al.. 771. 8. Lymph nodes:. . (a) Metastasis in two out of eight axillary. lymph nodes (ypN1a(sn)) (sentinel LN:. 2/2, axillary LN: 0/6).. . (b) Perinodal extension: present.. . (c) Size of metastatic carcinoma: 3 mm.. 9. Arteriovenous invasion: absent.. . 10. Lymphovascular. invasion:. present,. peritumoral.. . 11. Tumor border: infiltrative.. . 12. Microcalcification:. present,. tumoral/. non-tumoral.. . 13. Pathologic stage (AJCC 2010): ypT1c(m). N1a(sn).. . a. b. . a. b. . Local Recurrence. 772. Note 1: The medial margin of the lumpectomy. specimen (slide 4) is <1 mm from invasive ductal. carcinoma, but this margin submitted for frozen. diagnosis (Fro 6) is free of tumor.. Result. Intensity. Positive %. Estrogen. receptor. Weak (4/8). 2. 1–10%. Progesterone. receptor. Weak (4/8). 2. 1–10%. C-erbB2. Positive (3+). Ki-67. Positive in 1%. of tumor cells. Adjuvant Therapy. Postoperative radiation therapy.. Trastuzumab for 1 year.. Tamoxifen 20 mg/day for 5 years.. 20. " +240,Case 19,Patient History,Local Recurrence,"Patient History and Progress. Female/52 years old, pre-menopause.. Screen detected mass lesion on right breast. subareolar area and left breast subareolar area.. No family history.. Hypertension.. 19.2. " +227,Case 19,Courses of Treatment,Metastatic Breast Cancer,19.1. . Courses of Treatment. Right breast cancer → Operation → Adjuvant. therapy → Ipsilateral axillary lymph node. recurrence → Operation → Endocrine therapy. → Progressive disease.. Primary Treatment. Positive %. Estrogen. receptor. Strong (7/8). 3. 1/3–2/3. Progesterone. receptor. Strong (7/8). 3. 1/3–2/3. C-erbB2. Negative (0). Ki-67. Positive in. 26% of. tumor cells. Adjuvant Therapy. Adjuvant chemotherapy #8 cycles (Adriamycin. & Cyclophosphamide #4 → Docetaxel #4).. Post-operative radiation therapy + Tamoxifen. 20 mg/day for 3.8 years.. Treatments After Recurrence. Progesterone. receptor. Weak (4/8). 2. 1–10%. C-erbB2. Negative (0). Ki-67. Positive in. 6% of tumor. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Intermediate. (5/8). 2. 10%–1/3. C-erbB2. Negative (1+). Ki-67. Positive in 7%. of tumor cells. Adjuvant Therapy. Letrozole 2.5 mg/day for 0.75 year → Progressive. disease.. See Figs. 64 and 65.. Mar. 2022 Right axillary lymph node biopsy.. Pathology: Metastatic ductal carcinoma.. Result. Intensity. Positive %. Estrogen. receptor. Weak (3/8). 1. 1–10%. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Negative (1+). Ki-67. Positive in. 11% of tumor. cells. Palliative Chemotherapy +241,Case 19,Patient History,Metastatic Breast Cancer,"Patient History and Progress. Female/45 years old, post-menopause.. No family history.. S/p bilateral salpingo-oophorectomy.. 19.2. " +242,Case 2,Courses of Treatment,Benign and Proliferative,"2.1. . Courses of Treatment. → 2022-02-14 Excision, Lt.. 2.3.1. . Pathology Report. • Breast, left, excision:. –. – Atypical ductal hyperplasia with micro­. -. calcification.. –. – Intraductal papilloma with usual ductal. hyperplasia.. 3. " +250,Case 2,Important Radiologic,Benign and Proliferative,Important Radiologic. Findings. 3. 2.3.  +256,Case 2,Patient History,Benign and Proliferative,"Patient History and Progress. Female/47 years old, pre-menopause.. Screen detected mass lesion on left breast. 2 o’clock direction.. Outside result of biopsy: Intraductal papilloma.. No family history.. No comorbidities.. 2.2. " +243,Case 2,Courses of Treatment,Carcinoma In Situ,2.1.  +251,Case 2,Important Radiologic,Carcinoma In Situ,Important Radiologic. Findings. 7. 8. 2.3. . Course of Treatment:. Operation. 2.3.1. . Operation. 9. 10. 2.3.2. . Pathology Report. Lobular carcinoma in situ. . 1. Size of tumor: 0.2 cm2.. . 2. Nuclear grade: low.. . 3. Necrosis: absent.. . 4. Architectural pattern: solid.. . 5. Surgical margin: 2 mm from nearest margin.. . ­. E. S. Lee et al.. 55. . a. b. . Carcinoma In Situ. 56. . . . 3.  +257,Case 2,Patient History,Carcinoma In Situ,"Patient History and Progress. Female/47 years old, pre-menopause.. Nipple discharge on left breast.. Family history of breast cancer, mother and. sister, aunt, cousin sister.. Thrombocytopenia (Follow-up at outside. hospital).. BRCA 2 VUS (variant of uncertain).. 2.2. " +244,Case 2,Courses of Treatment,HR(+) HER2(+) Breast Cancer,"2.1. . Courses of Treatment. Neoadjuvant chemotherapy (#6 cycles of. docetaxel and carboplatin and trastuzumab. and pertuzumab)  +  Operation  +  Post-­. operative radiation therapy  +  Trastuzumab. emtansine + Tamoxifen 20 mg/day.. 12. 2.3.1. . Pathology Report. . 1. Microinvasive ductal carcinoma.. . (a) Post-chemotherapy status.. . (b) Size of tumor: <0.1 cm (ypT1mi).. HR(+) HER2(+) Breast Cancer. 304. . . . S. Park et al.. 305. . (c) Histologic grade: 2/3 (tubule formation:. 3/3, nuclear pleomorphism: 2/3, mitotic. count: 2/3, 11/10 HPF).. . (d) Intraductal component: absent.. . (e) Skin: no involvement of tumor.. . (f) Surgical margins:. • superior margin: 2 mm from microin­. vasive ductal carcinoma (Fro 6),. • inferior margin: 30 mm,. • medial margin: >10 mm,. • lateral margin: >10 mm,. • deep margin: 2 mm,. • superficial margin: 2 mm.. . a. b. . ­. HR(+) HER2(+) Breast Cancer. 306. . (g) Lymph nodes: no metastasis in two axil­. lary lymph nodes (ypN0(sn)) (sentinel. LN: 0/2).. . (h) Arteriovenous invasion: absent.. . (i) Lymphovascular invasion: absent.. . (j) Tumor border: infiltrative.. . (k) Microcalcification:. present,. tumoral/. non-tumoral.. . (l) Pathological TN category (AJCC 2017):. ypT1miN0(sn).. . (m) Related slides:. . 2. Sclerosing adenosis with microcalcification.. Result. Intensity. Positive. %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Equivocal (2+). Ki-67. Positive in 2% of. tumor cells. 3. " +252,Case 2,Important Radiologic,HR(+) HER2(+) Breast Cancer,Important Radiologic. Findings. 8 9 10. 11. 2.3.  +258,Case 2,Patient History,HR(+) HER2(+) Breast Cancer,"Patient History and Progress. Female/42 years old, pre-menopause.. Screen detected mass lesion on left breast. 1:30 and 2 o’clock direction.. No family history.. S/P Cervical spine disc operation.. 2.2. " +245,Case 2,Courses of Treatment,HR(+) HER2(-) Breast Cancer,"Courses of Treatment. Operation  +  Post-operative radiation ther­. apy + Anastrozole 1 mg/day.. 2.3.1. . Operation. Left breast conserving surgery, sentinel lymph. low, necrosis: absent, architectural pattern:. cribriform, extensive intraductal component:. absent).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) superior margin: 20 mm,. . (b) inferior margin: 15 mm,. . (c) medial margin: 20 mm,. . (d) lateral margin: 10 mm,. . (e) deep margin: 2 mm,. . (f) superficial margin: 2 mm.. 6. Lymph nodes: no metastasis in one axillary. lymph node (pN0(sn)) (sentinel LN: 0/1).. 7. Arteriovenous invasion: absent.. 8. Lymphovascular invasion: absent.. 9. Tumor border: infiltrative.. . 10. Microcalcification:. present,. tumoral/. non-tumoral.. . 11. Pathological TN category (AJCC 2017):. pT1bN0(sn).. Y. Kim et al." +253,Case 2,Important Radiologic,HR(+) HER2(-) Breast Cancer,"Important Radiologic. Findings. See Figs. 5, 6, 7 and 8.. HR(+) HER2(−) Breast Cancer. 3. >2/3. C-erbB2. Negative (0). Ki-67. Positive in 5% of tumor cells. 2.3. " +259,Case 2,Patient History,HR(+) HER2(-) Breast Cancer,"Hepatitis B virus carrier, dyslipidemia.. 2.2. " +246,Case 2,Courses of Treatment,HR(−) HER2(+) Breast Cancer,"2.1. . Courses of Treatment. Neoadjuvant chemotherapy (#2 cycles of. docetaxel and carboplatin and trastuzumab and. pertuzumab + #4 cycles of docetaxel and trastu­. zumab and pertuzumab)  +  Operation  +  Post-­. operative radiation therapy  +  Trastuzumab. emtansine.. 2.4.1. . Operation. 17. 2.4.2. . Pathology Report. Invasive Ductal Carcinoma. 1. Post-chemotherapy status.. 2. Size of invasive component: 0.6 cm, multifo­. cal (pT1b).. 3. Size of intraductal component: 3.0 cm.. 4. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 2/3, 10/10HPF).. 5. Intraductal component: present, extratumoral. (80%) (nuclear grade: high, necrosis: pres­. ent, architectural pattern: solid/comedo,. extensive intraductal component: present).. 6. Skin: no involvement of tumor.. 7. Surgical margins:. . (a) subareolar margin: positive for ductal. carcinoma in situ (Fro 6),. . (b) superior margin: 10 mm,. . (c) inferior margin: positive for ductal carci­. noma in situ (Fro 3) (see note),. . (d) medial margin: 5 mm,. . (e) lateral margin: (see note),. . (f) deep margin: (see note),. . (g) superficial margin: <1 mm from ductal. carcinoma in situ (slide 7).. . Y. Kwon et al.. 437. 8. Lymph nodes: no metastasis in two axillary. lymph nodes (ypN0(sn)) (sentinel LN: 0/2).. 9. Arteriovenous invasion: absent.. . 10. Lymphovascular invasion: absent.. . 11. Tumor border: infiltrative.. . 12. Microcalcification: present, non-tumoral.. . 13. Pathological TN category (AJCC 2017):. ypT1bN0(sn).. Result. Intensity. Positive %. Estrogen. receptor. Negative. (0/8). 0. 0. Progesterone. receptor. Negative. (0/8). 0. 0. C-erbB2. Positive. (3+). Ki-67. Positive in. 79% of. tumor cells. 3. " +254,Case 2,Important Radiologic,HR(−) HER2(+) Breast Cancer,Important Radiologic Findings. 9 10 11. 434. 2.3. . After Neoadjuvant. Chemotherapy. 13 14 15. 16. . Y. Kwon et al.. 435. . ­. . . HR(−) HER2(+) Breast Cancer. 436. 2.4.  +260,Case 2,Patient History,HR(−) HER2(+) Breast Cancer,"Patient History and Progress. Female/68 years old, post-menopause.. A self-detected skin change and nipple retrac­. tion on left breast.. No family history.. Hypothyroidism.. 2.2. " +247,Case 2,Courses of Treatment,HR(−) HER2(−) Breast Cancer,"2.1. . Courses of Treatment. Neoadjuvant chemotherapy (#4  cycles of. doxorubicin and cyclophosphamide + #4. cycles of docetaxel) + Operation + Post-. operative radiation therapy.. 2.3.1. . Operation. 15. 2.3.2. . Pathology Report. No residual tumor with stromal fibrosis. . 1. Post-chemotherapy status.. . 2. Lymph nodes:. . (a) No metastasis in ten axillary lymph node. (ypN0) (sentinel LN: 0/3, non-sentinel. LN: 0/7).. Result. Intensity. Positive. %. Estrogen. receptor. Negative (2/8). 1. <1%. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Equivocal (2+). SISH (−). Ki-67. Positive in 67%. of tumor cells. E. S. Lee et al.. 581. . . . HR(−) HER2(−) Breast Cancer. 582. . ­. 3. " +255,Case 2,Important Radiologic,HR(−) HER2(−) Breast Cancer,Important Radiologic. Findings. 8 9 10. 11. E. S. Lee et al.. 579. . . . HR(−) HER2(−) Breast Cancer. 580. . 2.2.1. . After Neoadjuvant. Chemotherapy. 12 13. 14. 2.3.  +261,Case 2,Patient History,HR(−) HER2(−) Breast Cancer,"Patient History and Progress. Female/49 years old, pre-menopause.. Self-detected palpable mass lesion on right. breast.. No family history.. No comorbidities.. 2.2. " +248,Case 2,Courses of Treatment,Local Recurrence,"2.1. . Courses of Treatment. Left breast IDC → Operation → Adjuvant. . therapy → Left breast recurrence (IDC).. 2.2.1. . Primary Treatment. 10. Operation. Nov. 2008 Left breast conserving surgery, senti­. nel lymph node biopsy (outside).. Pathology Report. Invasive Ductal Carcinoma. . 1. Size of tumor: 0.4 cm (pT1a).. . 2. Lymph nodes: no metastasis in three axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/3).. . 3. Pathologic stage (AJCC 2010): pT1aN0(sn).. Result. Intensity. Positive %. Estrogen. receptor. Negative. Progesterone. receptor. Negative. C-erbB2. Positive. Adjuvant Therapy. Postoperative radiation therapy.. Y. Kim et al.. 721. . . . 2.2.2. . Treatments After Recurrence. 11. 12. Operation. ­. 13. Pathology Report. Invasive Ductal Carcinoma, clinically recurrent. 1. Post-lumpectomy status.. 2. Size of tumor: 0.8 cm (rpT1b).. 3. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 3/3, 27/10HPF).. 4. Intraductal component: absent, extratumoral. (20%) (nuclear grade: high, necrosis: absent,. architectural pattern: micropapillary/cribri­. form, extensive intraductal component: absent).. 5. Surgical margins:. . (a) Deep margin: 1.5 mm.. . (b) Superficial margin: 7 mm.. 6. Lymph nodes: no metastasis in one axillary. lymph node (rpN0(sn)) (sentinel LN: 0/1).. 7. Arteriovenous invasion: absent.. 8. Lymphovascular invasion: absent.. 9. Tumor border: infiltrative.. . 10. Microcalcification: present, tumoral.. . 11. Pathologic stage (AJCC 2017): rpT1bN0(sn).. Local Recurrence. 722. . . ­. Result. Intensity. Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in 50%. of tumor cells. Adjuvant Therapy. Adjuvant chemotherapy #4 cycles of docetaxel. with concurrent trastuzumab for 2 years.. 3. " +262,Case 2,Patient History,Local Recurrence,"Patient History and Progress. Female/54 years old, peri-menopause.. Screen detected mass lesion on left breast. . 2 o’clock direction.. No family history.. No comorbidities.. 2.2. " +249,Case 2,Courses of Treatment,Metastatic Breast Cancer,"Courses of Treatment. Right breast cancer  →  Operation  +  Adjuvant. therapy → Lung metastasis → Palliative therapy. → Progression on rib and lung  →  Palliative. therapy → Progression on liver  →  Palliative. therapy.. 2.2.1. . Primary Treatment. Radiologic Finding. Estrogen. receptor. Strong (6/7). 2. >2/3. Progesterone. receptor. Negative (0/7). 0. 0. C-erbB2. Negative (0). Ki-67. Positive in 15%. of tumor cells. Adjuvant Therapy. Post-operative radiation therapy  +  Tamoxifen. 20 mg/day for 2.5 years.. Letrozole 2.5 mg/day for 1 year: stop due to. skin rash → Change to Tamoxifen 20 mg/day for. 1.5 years.. Metastatic Breast Cancer. Treatments After Recurrence. Lung Metastasis. Letrozole 2.5 mg/day for 3 years → Progressive. disease on right 8th rib, lung.. Sep. 2017 CT chest r/o lung metastasis.. See Figs. 5 and 6.. Operation. Apr. 2019 Right upper lobe lung wedge. resection.. Pathology: Metastatic ductal carcinoma from. breast.. Size of tumor: 0.9 × 0.7 × 0.5 cm.. Radiation Therapy. Radiation therapy to Right 8th rib.. Progression on Liver. Fulvestrant 250  mg  1/month  +  Palbociclib. 100  mg/day: Progressive disease on liver →. Exemestane 25 mg/day + Everolimus 5 mg/day. → Palliative chemotherapy (weekly Paclitaxel #6. cycles): Progressive disease on liver →. Doxorubicin & Cyclophosphamide." +263,Case 20,Courses of Treatment,Benign and Proliferative,"20.1. . Courses of Treatment. →2021-05-10 excision, Lt.. Pathology Report. Diagnosis. • Breast, left, excision:. –. – Atypical ductal hyperplasia.. –. – Fibrocystic change with microcalcification.. 21. " +271,Case 20,Important Radiologic,Benign and Proliferative,Important Radiologic. Findings. 37. 38. . Benign and Proliferative Case Series. 42. . 20.3.  +277,Case 20,Patient History,Benign and Proliferative,"Patient History and Progress. Female/44 years old, pre-menopause.. Screen detected microcalcification on upper. outer portion of left breast.. Family history of breast cancer, sister.. No comorbidities.. 20.2. " +264,Case 20,Courses of Treatment,Carcinoma In Situ,"20.1. . Courses of Treatment. First Operation + Tamoxifen 20  mg/day for. 4 months.. Second Operation.. Carcinoma In Situ. 96. . ­. . Operation. First operation: Breast conserving surgery, senti­. nel lymph node biopsy (left).. Second operation: Skin sparing mastectomy. with latissimus dorsi flap reconstruction (left).. Third operation: Excision (right).. 93. 94. Pathology Report. Left.. . Invasive ductal Carcinoma, pathologic stage. (AJCC 2010): pT1aN0(sn). 1. Size of invasive component: 0.5 cm (pT1a).. 2. Size of intraductal component: 4.0 cm.. 3. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 5/10HPF).. 4. Intraductal component: present, intratumoral/. extratumoral (90%) (nuclear grade: low,. necrosis: absent, architectural pattern: solid. and papillary, extensive intraductal compo­. nent: present).. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) superior margin: 3  mm from atypical. ductal hyperplasia (slide 1),. . (b) inferior margin: (see Note 1),. . (c) medial margin: (see Note 2),. . (d) lateral margin: 40 mm,. . (e) deep margin: positive for ductal carci­. noma in situ (slide 9),. . (f) superficial margin: 3 mm.. 7. Lymph nodes: no metastasis in seven axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/7,. axillary LN: 0/0).. 8. Vascular invasion: absent.. 9. Lymphatic invasion: absent.. . 10. Tumor border: pushing.. . 11. Microcalcification: present, non-tumoral.. Note: 1. Atypical ductal hyperplasia is. present only in the permanent section of Fro. 3. The inferior margin of the lumpectomy. specimen (slides 2, 5, 7, 9, and 11) is positive. for ductal carcinoma in site 2. The medial. margin of the lumpectomy specimen (slide. 3) is close to ductal carcinoma in situ (1 mm). but this margin submitted for frozen diagno­. sis (Fro 4) is free of tumor.. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (1+). Ki-67. Positive in. 29% of tumor. cells. . E. S. Lee et al.. 97. . . Carcinoma In Situ. 98. . 1. Atypical ductal hyperplasia, focal.. . (a) Post-lumpectomy status.. . 2. No residual tumor with foreign body reaction.. Right.. . Ductal carcinoma in situ, pathological TN cat­. egory (AJCC 2017): pTis. . 1. Size of tumor: 0.5 cm (pTis).. . 2. Nuclear grade: low.. . 3. Necrosis: absent.. . 4. Architectural. pattern:. micropapillary/. cribriform.. . 5. Skin: no involvement of tumor.. . 6. Surgical margins:. . (a) superior margin: 10 mm,. . (b) inferior margin: 10 mm,. . (c) medial margin: <1 mm from ductal carci­. noma in situ (slide 6),. . (d) lateral margin: 5 mm,. . (e) deep margin: 2 mm,. . (f) superficial margin: 2 mm.. . 7. Microcalcification:. present,. tumoral/non-. tumoral.. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (7/8). 3. >2/3. C-erbB2. Negative (0). Ki-67. Positive in. <1% of. tumor cells. . No residual tumor with foreign body reaction.. . 1. Post-excision status.. 21. " +272,Case 20,Important Radiologic,Carcinoma In Situ,Important Radiologic. Findings. 91. 92. 20.3.  +278,Case 20,Patient History,Carcinoma In Situ,"Patient History and Progress. Female/48 years old, pre-menopause.. Screen detected mass lesion on left breast 3. o’clock direction at first visit.. Pain on right breast at second visit.. No family history.. No comorbidities.. NGS: negative.. 20.2. " +265,Case 20,Courses of Treatment,HR(+) HER2(+) Breast Cancer,"20.1. . Courses of Treatment. Operation  +  Adjuvant chemotherapy (#4. cycles of doxorubicin and cyclophosphamide. followed by #11 cycles of weekly pacli­. taxel). +. Post-operative. radiation. ther­. apy + Trastuzumab + Letrozole 2.5 mg/day.. 110. Pathology Report. Invasive Ductal Carcinoma. 1. Post-mammotome excision status.. 2. Size of tumor: 2.1 cm (pT2).. HR(+) HER2(+) Breast Cancer. 362. . . 3. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 2/3, 10/10 HPF).. 4. Intraductal component: absent.. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) superior margin: 5 mm,. . (b) inferior margin: 6 mm,. . (c) medial margin: 5 mm,. . (d) lateral margin: 5 mm,. . (e) deep margin: 4 mm,. . (f) superficial margin: 6 mm.. 7. Lymph nodes: no metastasis in one axillary. lymph node (pN0(sn)) (sentinel LN: 0/1).. 8. Arteriovenous invasion: absent.. 9. Lymphovascular invasion: absent.. . 10. Tumor border: infiltrative.. . 11. Microcalcification: present, tumoral.. . 12. Pathological TN category (AJCC 2017):. pT2N0(sn).. Result. Intensity. Positive. %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in 15%. of tumor cells. S. Park et al.. 363. . . HR(+) HER2(+) Breast Cancer. 364. a. b. . 21. " +273,Case 20,Important Radiologic,HR(+) HER2(+) Breast Cancer,Important Radiologic. Findings. 106 107 108. 109. 20.3.  +279,Case 20,Patient History,HR(+) HER2(+) Breast Cancer,"Patient History and Progress. Female/75 years old, post-menopause.. Screen detected mass lesion on right breast 8. o’clock direction.. No family history.. Asthma (follow-up).. 20.2. " +266,Case 20,Courses of Treatment,HR(+) HER2(-) Breast Cancer,"Courses of Treatment. Operation  +  Post-operative radiation ther­. apy + Tamoxifen 20 mg/day.. Operation. Left breast conserving surgery, sentinel lymph. extensive intraductal component: present).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) superior margin: 15 mm.. . (b) inferior margin: 20 mm.. . (c) medial margin: 15 mm.. . (d) lateral margin: 5 mm.. . (e) deep margin: 5 mm.. . tumoral/. non-tumoral.. . 11. Pathological TN category (AJCC 2017):. pT1bN0(sn).. Note: 1. Atypical ductal hyperplasia is. present in the permanent section of Fro 1.. Y. Kim et al.. 2. 1/3–2/3. C-erbB2. Equivocal (2+). Ki-67. Positive in 21% of tumor cells. SISH. Negative. HR(+) HER2(−) Breast Cancer. 238. 21. " +274,Case 20,Important Radiologic,HR(+) HER2(-) Breast Cancer,"Important Radiologic. Findings. See Figs. 108, 109, 110, 111 and 112.. 20.3. " +280,Case 20,Patient History,HR(+) HER2(-) Breast Cancer,"o’clock direction.. No family history.. S/P Tuberculosis, S/P duodenal adenoma. excision.. 20.2. " +267,Case 20,Courses of Treatment,HR(−) HER2(+) Breast Cancer,"20.1. . Courses of Treatment. Neoadjuvant chemotherapy (#6 cycles of. docetaxel and carboplatin and trastuzumab and. pertuzumab) + Operation + Post-operative radia­. tion therapy + Trastuzumab.. Operation. 147. Pathology Report. Invasive Ductal Carcinoma. 1. Post-chemotherapy status.. 2. Size of tumor: 1.1 cm (ypT1c).. 3. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 3/3, 3/HPF).. 4. Intraductal component: present, intratu­. moral/extratumoral (10%) (nuclear grade:. high, necrosis: absent, architectural pattern:. solid, extensive intraductal component:. absent).. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) superior margin: 10 mm,. . (b) inferior margin: 10 mm,. . (c) medial margin: 15 mm,. . (d) lateral margin: 10 mm,. . (e) deep margin: 2 mm,. . (f) superficial margin: 2 mm.. 7. Lymph nodes:. . (a) metastasis in one out of two axillary. lymph nodes (ypN1a(sn)) (sentinel LN:. 1/2),. . (b) perinodal extension: absent,. . (c) size of metastatic carcinoma: 2.5 mm.. a. b. . Y. Kwon et al.. 511. 8. Arteriovenous invasion: absent.. 9. Lymphovascular. invasion:. present,. intratumoral.. . 10. Tumor border: infiltrative.. . 11. Microcalcification:. present,. tumoral/. non-tumoral.. . 12. Pathological TN category (AJCC 2017):. ypT1cN1a(sn).. Result. Intensity. Positive %. Estrogen. receptor. Negative. (0/8). 0. 0. Progesterone. receptor. Negative. (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in. 45% of. tumor cells. 21. " +275,Case 20,Important Radiologic,HR(−) HER2(+) Breast Cancer,Important Radiologic. Findings. 141 142. 143. HR(−) HER2(+) Breast Cancer. 508. . . . Y. Kwon et al.. 509. 20.3. . After Neoadjuvant. Chemotherapy. 144 145. 146. . . . HR(−) HER2(+) Breast Cancer. 510. 20.4.  +281,Case 20,Patient History,HR(−) HER2(+) Breast Cancer,"Patient History and Progress. Female/54 years old, post-menopause.. Screen detected mass lesion on left breast 11. o’clock direction.. Family history of breast cancer, aunt. (paternal).. No comorbidities.. BRCA 1 and 2 mutation: Not detected.. 20.2. " +268,Case 20,Courses of Treatment,HR(−) HER2(−) Breast Cancer,"20.1. . Courses of Treatment. Neoadjuvant chemotherapy (#4  cycles of. doxorubicin and cyclophosphamide  +  #4. cycles of docetaxel)  +  Operation  +  Post-. operative radiation therapy.. Operation. 143. Pathology Report. No residual tumor with stromal fibrosis. E. S. Lee et al.. 645. . . . HR(−) HER2(−) Breast Cancer. 646. . 1. Post-chemotherapy status.. . 2. Lymph nodes: no metastasis in seven axillary. lymph nodes (ypN0) (sentinel LN: 0/1, non-­. sentinel LN: 0/6).. . 3. Microcalcification:. present,. tumoral/. non-tumoral.. Result. Intensity. Positive. %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Negative (1+). Ki-67. Positive in 46%. of tumor cells. . . E. S. Lee et al.. 647. 21. " +276,Case 20,Important Radiologic,HR(−) HER2(−) Breast Cancer,Important Radiologic. Findings. 135 136 137. 138. E. S. Lee et al.. 643. . . . ­. HR(−) HER2(−) Breast Cancer. 644. . After Neoadjuvant. Chemotherapy. 139 140 141. 142. 20.3.  +282,Case 20,Patient History,HR(−) HER2(−) Breast Cancer,"Patient History and Progress. Female/59 years old, post-menopause.. Screen detected mass lesion on left breast 9:30. o’clock direction.. Family history of breast cancer, aunt. (maternal).. No comorbidities.. BRCA 1 and 2 mutation: Not detected.. 20.2. " +269,Case 20,Courses of Treatment,Local Recurrence,"20.1. . Courses of Treatment. Right breast DCIS → Operation → Adjuvant. therapy → Right breast recurrence (microinva­. sive ductal carcinoma).. Primary Treatment. 140. Operation. Jul. 2017 Right breast conserving surgery, senti­. nel lymph node biopsy (outside).. Pathology Report. Ductal Carcinoma In Situ. 1. Size of tumor: 1.2 cm.. 2. Nuclear grade: high.. 3. Necrosis: present, central.. 4. Architectural pattern: comedo.. 5. Skin: no involvement of tumor.. 6. Surgical margins: uninvolved by DCIS dis­. tance from closest margin: 2  mm (specify. margin: 9H).. 7. Lymph nodes: no metastasis in five lymph. nodes (pN0(sn)).. 8. Lymphovascular invasion: not identified.. 9. Perineural invasion: not identified.. . 10. Pathological TN category: pTisN0.. Result. Intensity. Positive %. Estrogen. receptor. Negative. 0. 0. Progesterone. receptor. Negative. 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in 35%. of tumor cells. . ­. Y. Kim et al.. 773. Adjuvant Therapy. Postoperative radiation therapy.. Treatments After Recurrence. 141 142. 143. Operation. ­. 144. 145. Pathology Report. . 1. Microinvasive Ductal Carcinoma. . (a) Size of invasive component: <0.1  cm. (pT1mi).. . (b) Size of in situ component: 1.5 cm.. . (c) Histologic grade: not applicable.. . (d) Intraductal component: present, intratu­. moral/extratumoral (99%) (nuclear grade:. high, necrosis: present, architectural pat­. tern: micropapillary/cribriform/solid/com­. edo, extensive intraductal component:. present).. . (e) Surgical margins:. • Deep margin: 3 mm.. • Superficial margin: 8 mm.. . (f) Lymph nodes: no metastasis in three axil­. lary lymph nodes (pN0(sn)) (sentinel LN:. 0/3).. . (g) Arteriovenous invasion: absent.. . . . Local Recurrence. 774. . a. b. . . (h) Lymphovascular invasion: absent.. . (i) Tumor border: infiltrative.. . (j) Microcalcification:. present,. tumoral/. non-tumoral.. . (k) Pathological TN category (AJCC 2017):. pT1miN0(sn).. . (l) Related slides: none.. . 2. Fibroadenoma.. Result. Intensity. Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Weak (3/8). 2. <1%. C-erbB2. Positive (3+). Ki-67. Positive in 23%. of tumor cells. 21. " +283,Case 20,Patient History,Local Recurrence,"Patient History and Progress. Female/41 years old, pre-menopause.. Screen detected mass lesion on right breast 12. o’clock direction.. Outside result of biopsy: Ductal carcinoma in. situ.. No family history.. s/p Right breast conserving surgery (Breast. cancer), s/p parotidectomy, Panic disorder.. BRCA 1 VUS (variant of uncertain), APC,. and MSH2 VUS.. 20.2. " +270,Case 20,Courses of Treatment,Metastatic Breast Cancer,"Courses of Treatment. Left breast cancer → Operation → Adjuvant. therapy → Ipsilateral axillary lymph node. recurrence.. Primary Treatment. Operation. Sep. 1998 Left breast conserving surgery, axil­. lary lymph node dissection.. Pathology: Invasive ductal carcinoma, stage. pT1aN0.. Size of tumor: N.A, lymph node: 0/16.. Result. Intensity. Positive %. Estrogen. receptor. Positive. N.A. N.A. Progesterone. receptor. Positive. N.A. N.A. C-erbB2. N.A. Ki-67. N.A. Adjuvant Therapy. Adjuvant. chemotherapy. #3. cycles. (Cyclophosphamide. &. Methotrexate. &. Fluorouracil).. Post-operative radiation therapy +Tamoxifen. 20 mg/day for 0.5 year.. Treatments After Recurrence. 3. >2/3. Progesterone. receptor. Intermediate. (6/8). 2. 1/3–2/3. C-erbB2. Negative (0). Ki-67. Positive in 32%. of tumor cells. Neoadjuvant Chemotherapy. Neoadjuvant. chemotherapy. #6. cycles. (Adriamycin & Cyclophosphamide #4 →. Docetaxel #2).. Estrogen. receptor. Strong. (8/8). 3. >2/3. Progesterone. receptor. Weak (3/8). 1. 1–10%. C-erbB2. Negative. (0). Ki-67. Positive in. 12% of" +284,Case 20,Patient History,Metastatic Breast Cancer,"Family history of breast cancer, maternal. cousin.. BRCA 1 & 2 mutation: Not detected.. 20.2. " +285,Case 21,Courses of Treatment,Benign and Proliferative,"21.1. . Courses of Treatment. →2021-07-07 excision, both.. Pathology Report. Diagnosis. • Breast, left, excision:. –. – Intraductal papilloma.. –. – Sclerosing. adenosis. with. microcal-. cification.. Diagnosis. • Breast, right, excision:. –. – Intraductal papilloma.. –. – Sclerosing adenosis with microcalcification.. C. W. Lee et al.. 43. . . . Benign and Proliferative Case Series. 44. 22. " +293,Case 21,Important Radiologic,Benign and Proliferative,Important Radiologic. Findings. 39 40. 41. 21.3.  +299,Case 21,Patient History,Benign and Proliferative,"Patient History and Progress. Female/42 years old, pre-menopause.. Screen detected mass lesion on right breast 7. o’clock direction and left 1 o’clock direction.. Outside result of biopsy: both papillary. neoplasm.. No family history.. s/p Right breast mammotome biopsy (result:. fibroadenoma).. 21.2. " +286,Case 21,Courses of Treatment,Carcinoma In Situ,"21.1. . Courses of Treatment. Operation + Postoperative radiation therapy +. Tamoxifen 20 mg/day for 5 years.. . . E. S. Lee et al.. 99. Operation. 98. 99. Pathology Report. Ductal carcinoma in situ, pathological TN cat­. egory (AJCC 2017): pTisN0 (sn). . 1. Size of tumor: 3.0 cm (pTis).. . 2. Nuclear grade: low.. . 3. Necrosis: absent.. . 4. Architectural pattern: papillary/micropapil­. lary/cribriform/solid.. . 5. Skin: no involvement of tumor.. . 6. Surgical margins:. . (a) superior margin: 20 mm,. . (b) inferior margin: (see Note 1),. . (c) medial margin: (see Note 2),. . (d) lateral margin: 20 mm,. . (e) deep margin: <1 mm from ductal carci­. noma in situ (slides 2 and 6),. . (f) superficial margin: <1  mm from ductal. carcinoma in situ (slide 3).. . 7. Lymph nodes: no metastasis in two axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/2).. . 8. Microcalcification:. present,. ­. tumoral/non-. tumoral.. Note: 1. The inferior margin of the lumpec­. tomy specimen (slide 9) is positive for ductal. carcinoma in situ but this margin submitted. for frozen diagnosis (Fro 2) is free of tumor.. 2. The medial margin of the lumpectomy speci­. men (slide 4) is close to ductal carcinoma in. situ (2 mm) and atypical ductal hyperplasia is. present only in the permanent section of Fro 3.. Result. Intensity Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (1+). Ki-67. Positive in 5%. of tumor cells. . . Carcinoma In Situ. 100. . ­. 22. " +294,Case 21,Important Radiologic,Carcinoma In Situ,Important Radiologic. Findings. 95 96. 97. 21.3.  +300,Case 21,Patient History,Carcinoma In Situ,"Patient History and Progress. Female/37 years old, pre-menopause.. Screen detected mass lesion on right breast. 9 o’clock direction.. Outside result of biopsy: Right 9 o’clock, duc­. tal carcinoma in situ.. No family history.. Thyroid papillary carcinoma: follow-up at. outside hospital.. BRCA 1 and 2: not detected, POLE VUS. (variant of uncertain).. 21.2. " +287,Case 21,Courses of Treatment,HR(+) HER2(+) Breast Cancer,"21.1. . Courses of Treatment. Neoadjuvant chemotherapy (#6 cycles of. docetaxel and carboplatin and trastuzumab. and pertuzumab)  +  Operation  +  Post-­. operative radiation therapy  +  Letrozole. 2.5 mg/day.. 117. Pathology Report. Invasive Ductal Carcinoma. 1. Post-chemotherapy status.. 2. Size of tumor: 1.1 cm (ypT1c).. 3. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 1/10 HPF).. S. Park et al.. 365. . . 4. Intraductal component: present, intratu­. moral/extratumoral (20%) (nuclear grade:. low, necrosis: absent, architectural pattern:. micropapillary/cribriform, extensive intra­. ductal component: absent).. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) superior margin: 25 mm,. . (b) inferior margin: 50 mm,. . (c) medial margin: 10 mm,. . (d) lateral margin: 20 mm,. . (e) deep margin: 15 mm,. . (f) superficial margin: 10 mm.. 7. Lymph nodes: no metastasis in one axillary. lymph node (ypN0(sn)) (sentinel LN: 0/1).. 8. Arteriovenous invasion: absent.. 9. Lymphovascular invasion: present, intratu­. moral/peritumoral.. . 10. Tumor border: infiltrative.. . 11. Microcalcification:. present,. tumoral/. non-tumoral.. . 12. Pathological TN category (AJCC 2017):. ypT1cN0(sn).. Result. Intensity. Positive. %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Weak (4/8). 2. 1–10%. C-erbB2. Equivocal (2+). Ki-67. Positive in 1% of. tumor cells. SISH. Positive. HR(+) HER2(+) Breast Cancer. 366. . S. Park et al.. 367. . F. ig. 115. HR(+) HER2(+) Breast Cancer. 368. a. b. . 22. " +295,Case 21,Important Radiologic,HR(+) HER2(+) Breast Cancer,Important Radiologic. Findings. 111 112 113 114 115. 116. 21.3.  +301,Case 21,Patient History,HR(+) HER2(+) Breast Cancer,"Patient History and Progress. Female/69 years old, post-menopause.. Screen detected mass lesion on right breast 6. o’clock direction.. Family history of breast cancer, paternal aunt,. cousin (paternal).. No comorbidities.. BRCA 1 and 2 mutation: Not detected.. 21.2. " +288,Case 21,Courses of Treatment,HR(+) HER2(-) Breast Cancer,"21.1. . Courses of Treatment. Operation  +  Post-operative radiation ther­. apy + Letrozole 2.5 mg/day.. Operation (1st, Dec. 2020). nent: absent).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) superior margin: 5 mm.. . (b) inferior margin: 20 mm.. . (c) medial margin: 10 mm.. . (d) lateral margin: 20 mm.. . (e) deep margin: 2 mm.. . (f) superficial margin: 2 mm.. 6. Arteriovenous invasion: absent.. 7. Lymphovascular. invasion:. present,. intratumoral.. Positive. %. Estrogen. receptor. Intermediate. (6/8). 3. 10%–. 1/3. Progesterone. receptor. Strong (7/8). 3. 1/3–2/3. C-erbB2. Negative (0). Ki-67. Positive in 2% of. tumor cells. HR(+) HER2(−) Breast Cancer" +296,Case 21,Important Radiologic,HR(+) HER2(-) Breast Cancer,"Important Radiologic. Findings. See Figs. 114, 115, 116 and 117.. 21.3. " +302,Case 21,Patient History,HR(+) HER2(-) Breast Cancer,"Patient History and Progress. Female/78 years old, post-menopause.. Screen detected mass lesion on left breast 12. o’clock direction.. No family history.. Hypertension, s/p hysterectomy.. 21.2. " +289,Case 21,Courses of Treatment,HR(−) HER2(+) Breast Cancer,"21.1. . Operation. 156. Pathology Report. Invasive Ductal Carcinoma. 1. Post-chemotherapy status.. 2. Size of tumor: 1.0 cm (ypT1b).. 3. Histologic grade: 3/3 (tubule formation: 2/3,. nuclear pleomorphism: 3/3, mitotic count:. 3/3, 49/10HPF).. 4. Intraductal component: absent.. Y. Kwon et al.. 515. a. b. . 5. Surgical margins:. . (a) superior margin: 15 mm,. . (b) inferior margin: 35 mm,. . (c) medial margin: 5 mm,. . (d) lateral margin: 15 mm,. . (e) deep margin: 10 mm,. . (f) superficial margin: 3 mm.. 6. Lymph nodes: no metastasis in three axillary. lymph nodes (ypN0(sn)) (sentinel LN: 0/2,. axillary LN: 0/1).. 7. Arteriovenous invasion: absent.. 8. Lymphovascular invasion: absent.. 9. Tumor border: infiltrative.. . 10. Microcalcification: present, non-tumoral.. . 11. Pathological TN category (AJCC 2017):. ypT1bN0(sn).. Result. Intensity. Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in. 39% of tumor. cells. HR(−) HER2(+) Breast Cancer. 516. 22. " +297,Case 21,Important Radiologic,HR(−) HER2(+) Breast Cancer,Important Radiologic. Findings. 148 149 150. 151. . HR(−) HER2(+) Breast Cancer. 512. . . . ­. Y. Kwon et al.. 513. 21.3. . After Neoadjuvant. Chemotherapy. 152 153 154. 155. . HR(−) HER2(+) Breast Cancer +303,Case 21,Patient History,HR(−) HER2(+) Breast Cancer,"Patient History and Progress. Female/55 years old, pre-menopause.. Self-detected palpable mass lesion on right. breast.. No family history.. S/P Tuberculosis.. 21.2. " +290,Case 21,Courses of Treatment,HR(−) HER2(−) Breast Cancer,"21.1. . Courses of Treatment. Neoadjuvant chemotherapy (#4  cycles of. doxorubicin and cyclophosphamide  +  #4. cycles of docetaxel)  +  Operation  +  Post-. operative radiation therapy  +  Letrozole. 2.5 mg + Adjuvant capecitabine.. Operation. 152. Pathology Report. Microinvasive Ductal Carcinoma. 1. Post-chemotherapy status.. 2. Size of invasive component: <0.1  cm. (ypT1mi).. 3. Size of intraductal component: 2.0 cm.. 4. Histologic grade: not applicable.. 5. Intraductal component: present, intratu­. moral/extratumoral (>95%) (nuclear grade:. high, necrosis: present, architectural pattern:. cribriform/solid/comedo, extensive intra­. ductal component: present).. 6. Skin: no involvement of tumor.. 7. Surgical margins:. HR(−) HER2(−) Breast Cancer. 650. . . ­. . . (a) Superior margin: positive for ductal car­. cinoma in situ (Fro 1) (see note).. . (b) Inferior margin: 5 mm.. . (c) Medial margin: 5 mm.. . (d) Lateral margin: 5 mm.. . (e) Deep margin: 2 mm.. . (f) Superficial margin: <1  mm from inva­. sive ductal carcinoma (slide 5).. 8. Lymph nodes:. . (a) Metastasis in two out of six axillary. lymph nodes (ypN1a(sn)) (sentinel LN:. 2/2, axillary LN: 0/4).. . (b) Perinodal extension: absent.. . (c) Size of metastatic carcinoma: 3 mm.. 9. Arteriovenous invasion: absent.. . 10. Lymphovascular. invasion:. present,. peritumoral.. . 11. Tumor border: infiltrative.. . 12. Microcalcification: absent.. . 13. Pathological TN category (AJCC 2017):. ypT1miN1a(sn).. Note: 1. Ductal carcinoma in situ is present. only in the permanent section of Fro 1.. Result. Intensity. Positive %. Estrogen. receptor. Weak (3/8). 1. 1–10%. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Negative (0). Ki-67. Positive in 52%. of tumor cells. E. S. Lee et al.. 651. . ­. 22. " +298,Case 21,Important Radiologic,HR(−) HER2(−) Breast Cancer,Important Radiologic Findings. 144 145 146. 147. . HR(−) HER2(−) Breast Cancer. 648. . . . . . E. S. Lee et al.. 649. . After Neoadjuvant. Chemotherapy. 148 149 150. 151. 21.3.  +304,Case 21,Patient History,HR(−) HER2(−) Breast Cancer,"Patient History and Progress. Female/50 years old, pre-menopause.. Screen detected mass lesion on left breast 1. o’clock direction.. No family history.. No comorbidities.. BRCA 1 and 2 mutation: Not detected, STK11. VUS (variant of uncertain).. 21.2. " +291,Case 21,Courses of Treatment,Local Recurrence,"21.1. . Courses of Treatment. Right breast DCIS→ → Operation → Right. breast recurrence (DCIS).. Y. Kim et al.. 775. Primary Treatment. 146. Operation. ­. 147. 148. Pathology Report. Ductal Carcinoma In Situ. . 1. Size of tumor: 5.5 cm (pTis).. . 2. Nuclear grade: low.. . 3. Necrosis: present.. . 4. Architectural pattern: micropapillary/solid/. comedo.. . 5. Skin: no involvement of tumor.. . 6. Surgical margins:. . (a) Deep margin: (see note).. . (b) Superficial margin: <1  mm from ductal. carcinoma in situ (slide MG5).. . 7. Lymph nodes: no metastasis in two axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/2).. . . . Local Recurrence. 776. . 8. Microcalcification:. present,. tumoral/. non-tumoral.. . 9. Pathologic stage (AJCC 2010): pTisN0(sn).. Note: 1. The deep margin of the mastectomy. specimen (slide 7) is close to ductal carcinoma in. situ (<1 mm), but this margin submitted for fro­. zen diagnosis (Fro 4) is free of tumor.. Result. Intensity Positive %. Estrogen. receptor. Intermediate (5/8) 2. 10%-1/3. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in 22%. of tumor cells. Treatments After Recurrence. 149. 150. Operation. 151. Pathology Report. Ductal Carcinoma In Situ. . 1. Post-nipple-sparing mastectomy status.. . 2. Size of tumor: 1.1 cm (rpTis).. . 3. Nuclear grade: low.. . 4. Necrosis: absent.. . 5. Architectural pattern: solid.. . 6. Skin and nipple: no involvement of tumor.. . 7. Surgical margins:. . (a) Superior margin: 5 mm.. . (b) Inferior margin: 11 mm.. . (c) Medial margin: 5 mm.. . (d) Lateral margin: 10 mm.. . (e) Deep margin: (see note).. . (f) Superficial margin: 2 mm.. . 8. Microcalcification: present, tumoral.. . 9. Pathological TN category (AJCC 2017):. rpTis.. Note: 1. The deep margin of the lumpectomy. specimen (slide 1) is close to ductal carcinoma in. situ (<1 mm), but this margin submitted for fro­. zen diagnosis (Fro 5) is free of tumor.. Result. Intensity. Positive %. Estrogen. receptor. Weak (4/8). 1. 10%-1/3. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in 8%. of tumor cells. Adjuvant Therapy. Postoperative radiation therapy.. . ­. . Y. Kim et al.. 777. a. b. . . 22. " +305,Case 21,Patient History,Local Recurrence,"Patient History and Progress. Female/55 years old, peri-menopause.. Screen detected calcification on upper portion. of right breast.. Outside result of biopsy: suggestive ductal. carcinoma in situ.. No family history.. S/p hysterectomy.. 21.2. " +292,Case 21,Courses of Treatment,Metastatic Breast Cancer,"Left breast cancer → Operation → Adjuvant. therapy → Neck node recurrence → Lymph. nodes, bone metastasis → Skull, brain. metastasis.. Primary Treatment. Operation. Apr. 2002 Left breast conserving surgery, senti­. nel lymph node biopsy.. Y. Kwon et al.. 895. Pathology: Microinvasive infiltrating duct car­. cinoma, stage T1miN0(sn).. Size of tumor: N.A, lymph node: 0/2.. Result. Intensity. Positive %. Estrogen. receptor. Positive. Intermediate. 60%. Progesterone. receptor. Positive. Weak. 20%. C-erbB2. Negative. (1+). Ki-67. N.A. Adjuvant Therapy. Post-operative radiation therapy +Tamoxifen. 20 mg/day for 5 years.. Treatments After Recurrence" +306,Case 22,Courses of Treatment,Benign and Proliferative,"22.1. . Courses of Treatment. →2021-07-07 excision, Rt.. Diagnosis. • Breast, right, excision:. –. – Atypical. ductal. hyperplasia. with. microcalcification.. . C. W. Lee et al.. 45. . ­. . 23. " +314,Case 22,Important Radiologic,Benign and Proliferative,Important Radiologic. Findings. 42. 22.3.  +320,Case 22,Patient History,Benign and Proliferative,"Patient History and Progress. Female/50 years old, peri-menopause.. Screen detected microcalcification on upper. outer portion of right breast.. No family history.. Hypertension (taking medication), carotid. atherosclerosis.. 22.2. " +307,Case 22,Courses of Treatment,Carcinoma In Situ,"22.1. . Courses of Treatment:. Operation. Operation. 103. 104. Pathology Report. Ductal carcinoma in situ, pathological TN cat­. egory (AJCC 2017): pTis(Paget)N0(sn). . 1. Size of tumor: 0.5 cm (pTis(Paget)).. . 2. Nuclear grade: high.. . 3. Necrosis: absent.. . 4. Architectural pattern: micropapillary.. . 5. Nipple: Paget disease with involvement of. lactiferous duct.. . 6. Surgical margins: deep margin: 20 mm.. . 7. Lymph nodes: no metastasis in two axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/2).. . 8. Microcalcification: present, non-tumoral.. Result. Intensity Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in. 14% of tumor. cells. E. S. Lee et al.. 101. E. S. Lee et al.. 103. 23. " +315,Case 22,Important Radiologic,Carcinoma In Situ,Important Radiologic. Findings. 100 101. 102. 22.3.  +321,Case 22,Patient History,Carcinoma In Situ,"Patient History and Progress. Female/57 years old, post-menopause.. Visible detected redness on Left nipple.. Outside result of biopsy: Paget’s disease.. Family history of breast cancer, sister at her. 45 years old.. No comorbidities.. BRCA 1 and 2 mutation: Not detected.. 22.2. " +308,Case 22,Courses of Treatment,HR(+) HER2(+) Breast Cancer,"22.1. . Courses of Treatment. Neoadjuvant chemotherapy (#6 cycles of. docetaxel and carboplatin and trastuzumab. and pertuzumab) + Operation + Trastuzumab. + Letrozole 2.5 mg/day.. 125. Pathology Report. Invasive Ductal Carcinoma. 1. Post-chemotherapy status.. 2. Size of tumor: 0.5 cm (ypT1a).. S. Park et al.. 369. . . ­. 3. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, <1/10HPF).. 4. Intraductal component: absent.. 5. Surgical margins:. . (a) superior margin: 10 mm,. . (b) inferior margin: (see Note 1),. . (c) medial margin: 5 mm,. . (d) lateral margin: 5 mm,. . (e) deep margin: <1 mm from invasive duc­. tal carcinoma (slide 1),. . (f) superficial margin: 1 mm from invasive. ductal carcinoma (slide 3).. 6. Lymph nodes:. . (a) metastasis in two out of three axillary. lymph nodes (ypN1mi(sn)) (see note). (sentinel LN: 1/1, axillary LN: 1/2),. . (b) perinodal extension: absent,. . (c) size of metastatic carcinoma: 0.3 mm.. 7. Arteriovenous invasion: absent.. 8. Lymphovascular invasion: absent.. 9. Tumor border: infiltrative.. . 10. Microcalcification: present, non-tumoral.. . 11. Pathological TN category (AJCC 2017):. ypT1aN1mi(sn).. HR(+) HER2(+) Breast Cancer. 370. . ­. S. Park et al.. 371. . . Note: 1. The inferior margin of the lumpec­. tomy specimen (slide 3) is close to invasive duc­. tal carcinoma (<1 mm) but this margin submitted. for frozen diagnosis (Fro 5) is free of tumor.. 2. Micrometastasis is present only in the per­. manent section of Fro 1.. Result. Intensity. Positive. %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Equivocal (2+). Ki-67. Positive in <1%. of tumor cells. SISH. Positive. HR(+) HER2(+) Breast Cancer. 372. . . S. Park et al.. 373. a. b. . 23. " +316,Case 22,Important Radiologic,HR(+) HER2(+) Breast Cancer,Important Radiologic. Findings. 118 119 120 121 122 123. 124. 22.3.  +322,Case 22,Patient History,HR(+) HER2(+) Breast Cancer,"Patient History and Progress. Female/54 years old, post-menopause.. Self-detected nipple retraction on left breast.. No family history.. Hepatitis B carrier.. 22.2. " +309,Case 22,Courses of Treatment,HR(+) HER2(-) Breast Cancer,". Courses of Treatment. Neoadjuvant chemotherapy (#4  cycles of. doxorubicin & cyclophosphamide followed by. #4  cycles of docetaxel)  +  Operation  +  Post-­. operative radiation therapy  +  Letrozole. 2.5 mg/day.. Operation. tumor.. 6. Surgical margins:. . (a) deep margin: positive for invasive carci­. noma (slide 1).. . (b) superficial margin: positive for invasive. carcinoma (slide 4).. 7. Lymph nodes:. . (a) metastasis in nine out of nine axillary. lymph nodes (ypN2a).. . (b) perinodal extension: present.. . (c) size of metastatic carcinoma: 6 mm.. 8. Arteriovenous. invasion:. present,. peritumoral.. 9. Lymphovascular. invasion:. present,. peritumoral.. . 10. Tumor border: infiltrative.. HR(+) HER2(−) Breast Cancer. Result. Intensity. Positive. %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Negative (2/8). 1. <1%. C-erbB2. Equivocal (2+). (SISH negative). Ki-67. Positive in 14%" +317,Case 22,Important Radiologic,HR(+) HER2(-) Breast Cancer,"Important Radiologic. Findings. See Figs. 119, 120, 121, 122, 123 and 124.. 22.3. " +323,Case 22,Patient History,HR(+) HER2(-) Breast Cancer,"Patient History and Progress. Female/61 years old, post-menopause.. Screen detected mass lesion on entire left. breast.. No family history.. Diabetes mellitus, Spinal stenosis.. 22.2. " +310,Case 22,Courses of Treatment,HR(−) HER2(+) Breast Cancer,"22.1. . Courses of Treatment. Operation + Adjuvant chemotherapy (#4 cycles. of doxorubicin and cyclophosphamide)  +  Post-­. operative radiation therapy + Trastuzumab.. Operation. 161. . a. b. . HR(−) HER2(+) Breast Cancer. 518. Pathology Report. Invasive Ductal Carcinoma with apocrine dif­. ferentiation and medullary pattern. 1. Size of invasive component: 1.3 cm (pT1c).. 2. Size of intraductal component: 3.0 cm.. 3. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 2/3, 15/10HPF).. 4. Intraductal component: present, extratumoral. (70%) (nuclear grade: high, necrosis: pres­. ent, architectural pattern: solid/comedo,. extensive intraductal component: present).. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) superior margin: 6 mm,. . (b) inferior margin: 6 mm,. . (c) medial margin: positive for ductal carci­. noma in situ (Fro 4) (see note),. . (d) lateral margin: 6 mm,. . (e) deep margin: 2 mm,. . (f) superficial margin: 5 mm.. 7. Lymph nodes: no metastasis in two axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/2).. 8. Arteriovenous invasion: absent.. 9. Lymphovascular invasion: absent.. . 10. Tumor border: infiltrative.. . 11. Microcalcification:. present,. tumoral/. non-tumoral.. . 12. Pathological TN category (AJCC 2017):. pT1cN0(sn).. Note: 1. Ductal carcinoma in situ is present. only in the permanent section of Fro 4.. Result. Intensity. Positive %. Estrogen. receptor. Negative (2/8). 1. <1%. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in 49%. of tumor cells. 23. " +318,Case 22,Important Radiologic,HR(−) HER2(+) Breast Cancer,Important Radiologic Findings. 157 158 159. 160. . . . Y. Kwon et al.. 517. 22.3.  +324,Case 22,Patient History,HR(−) HER2(+) Breast Cancer,"Patient History and Progress. Female/53 years old, peri-menopause.. Self-detected palpable mass lesion on right. breast 4 o’clock direction.. No family history.. S/P hemorrhoids operation.. 22.2. " +311,Case 22,Courses of Treatment,HR(−) HER2(−) Breast Cancer,"22.1. . Courses of Treatment. Neoadjuvant chemotherapy (#4  cycles of. doxorubicin and cyclophosphamide  +  #4. cycles of docetaxel)  +  Operation  +  Post-. operative radiation therapy  +  Adjuvant. capecitabine.. Operation. 161. Pathology Report. Invasive Ductal Carcinoma. 1. Post-chemotherapy status.. 2. Size of tumor: 0.9 cm (ypT1b).. 3. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 3/3, 11/10HPF).. 4. Intraductal component: absent.. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) Superior margin: 25 mm.. . (b) Inferior margin: 20 mm.. . (c) Medial margin: 5 mm.. . (d) Lateral margin: 10 mm.. . (e) Deep margin: 5 mm.. . (f) Superficial margin: 10 mm.. 7. Lymph nodes:. . (a) Metastasis in two out of three axillary. lymph nodes (ypN1a(sn)) (sentinel LN:. 2/3).. . (b) Perinodal extension: absent.. . (c) Size of metastatic carcinoma: 5 mm.. 8. Arteriovenous invasion: absent.. 9. Lymphovascular invasion: absent.. . 10. Tumor border: infiltrative.. . 11. Microcalcification: absent.. . 12. Pathological TN category (AJCC 2017):. ypT1bN1a(sn).. Result. Intensity. Positive. %. Estrogen. receptor. Negative (2/8). 1. <1%. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Negative (1+). Ki-67. Positive in 12%. of tumor cells. HR(−) HER2(−) Breast Cancer. 654. . ­. . . E. S. Lee et al.. 655. . . ­. HR(−) HER2(−) Breast Cancer. 656. . 23. " +319,Case 22,Important Radiologic,HR(−) HER2(−) Breast Cancer,Important Radiologic. Findings. 153 154 155. 156. HR(−) HER2(−) Breast Cancer. 652. . . . . ­. E. S. Lee et al.. 653. . After Neoadjuvant. Chemotherapy. 157 158 159. 160. 22.3.  +325,Case 22,Patient History,HR(−) HER2(−) Breast Cancer,"Patient History and Progress. Female/57 years old, post-menopause.. Self-detected palpable mass lesion on right. breast.. Family history of breast cancer, uncle. (paternal).. s/p retinal detachments operation.. BRCA 1 and 2 mutation: Not detected, PALB2. PV, STK11 VUS (variant of uncertain).. 22.2. " +312,Case 22,Courses of Treatment,Local Recurrence,"22.1. . Courses of Treatment. Left breast mucinous carcinoma→ Adjuvant. therapy → Right breast recurrence (mucinous. carcinoma).. Primary Treatment. 152. Operation. Apr. 2007 Left breast mass excision (outside).. Pathology Report. Mucinous Carcinoma. . 1. Size of tumor: 2.0 cm.. . 2. Margin involved.. Result. Intensity Positive %. Estrogen receptor. Strong. (7/8). 3. >2/3. Progesterone. receptor. Weak. (3/8). 1. 10%-1/3. C-erbB2. Negative. (0). Operation (2nd). ­. 153. Pathology Report. No residual carcinoma with foreign body. reaction.. . 1. Post-excisional biopsy status.. Local Recurrence. 778. a. b. . . Adjuvant Therapy. Adjuvant chemotherapy #4 cycles of doxorubicin. and cyclophosphamide.. Postoperative radiation therapy.. Letrozole 2.5  mg/day 1.7  years, tamoxifen. 20 mg/day for 2.2 years.. Treatments After Recurrence. 154. Letrozole 2.5  mg/day (rejection of surgical. treatment).. 23. " +326,Case 22,Patient History,Local Recurrence,"Patient History and Progress. Female/80 years old, post-menopause.. Screen detected mass lesion on upper outer. portion of Left breast.. Outside. result. of. biopsy:. Mucinous. carcinoma.. No family history.. Dementia.. BRCA 1 and 2 mutation: No examination.. 22.2. " +313,Case 22,Courses of Treatment,Metastatic Breast Cancer,"Courses of Treatment. Left breast cancer → Operation → Adjuvant. therapy → Right axillary lymph node recur­. rence → Right breast recurrence → Chest wall. → Bone → Pleural effusion metastasis.. Primary Treatment. mide #3 → Doxorubicin + Docetaxel #3).. Operation. Mar. 2008 Left total mastectomy, axillary lymph. node dissection.. Pathology: Invasive apocrine carcinoma, stage. ypT1bN2a.. Size of tumor: 1.0 cm, lymph node: 6/6, size. of metastatic carcinoma: 10 mm.. Result. Intensity Positive %. Estrogen. receptor. Negative (0/7). 0. 0. Progesterone. receptor. Negative (0/7). 0. 0. C-erbB2. Negative (1+). Ki-67. Positive in 5%. of tumor cells. Adjuvant Therapy. Post-operative radiation therapy.. Treatments After Recurrence. Right Axillary Lymph Node Recurrence. 0. Progesterone. receptor. Negative. (0/7). 0. 0. C-erbB2. Negative. (1+). Ki-67. N.A. Neoadjuvant Chemotherapy. Chemotherapy #15 cycles (Capecitabine).. Operation. Apr. 2014 Right axillary lymph node dissection.. Pathology: Metastatic ductal carcinoma in. eight out of eight axillary lymph nodes, size of. metastatic carcinoma: 18 mm.. Metastatic Breast Cancer. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Negative (1+). Ki-67. Positive in 6%. of tumor cells. Adjuvant Therapy. Post-operative radiation therapy (axilla).. Right Breast Recurrence. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Negative (1+). Ki-67. Positive in. 42% of tumor. cells. Neoadjuvant Chemotherapy. Chemotherapy #8 cycles (paclitaxel + Cisplatin).. Radiation therapy (breast).. Chemotherapy #12 cycles (Cyclophosphamide. + Methotrexate).. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Negative (1+). Ki-67. Positive in 1%. of tumor cells. Chest Wall → Bone → Pleural Effusion. Metastasis. Jan. 2018 Right chest wall skin biopsy.. Pathology: Metastatic ductal carcinoma.. Result. Intensity Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Negative (1+). Ki-67. Positive in 3%. of tumor cells. Palliative Therapy. Chemotherapy #10 cycles (Harven): Progressive. disease.. Chemotherapy #31 cycles (Capecitabine):. Progressive disease on bone.. Chemotherapy #11 cycles (Gemcitabine):. Progressive disease on bone.. Chemotherapy. (Vinorelbine. tartrate. +Cisplatin)~. See Figs. 77 and 78.. Y. Kwon et al." +327,Case 22,Patient History,Metastatic Breast Cancer, +328,Case 23,Courses of Treatment,Benign and Proliferative,"23.1. . Courses of Treatment. →2021-07-13 Excision, Lt.. Benign and Proliferative Case Series. 46. Pathology Report. Diagnosis. • Breast, left, excision:. –. – Atypical ductal hyperplasia involving intra­. ductal papilloma with microcalcification.. 24. " +336,Case 23,Important Radiologic,Benign and Proliferative,Important Radiologic. Findings. 43 44. 45. 23.3.  +342,Case 23,Patient History,Benign and Proliferative,"Patient History and Progress. Female/47 years old, pre-menopause.. Screen detected mass lesion on left breast 1. o’clock direction.. Outside result of biopsy: atypical papilloma.. No family history.. No comorbidities.. 23.2. " +329,Case 23,Courses of Treatment,Carcinoma In Situ,"23.1. . Courses of Treatment:. Operation. Operation. 107. 108. Pathology Report. Lobular carcinoma in situ, pathological TN. category (AJCC 2017): pTis. . 1. Size of tumor: 0.5 cm (pTis).. . 2. Nuclear grade: low.. . 3. Necrosis: absent.. . 4. Architectural pattern: solid.. . 5. Skin: no involvement of tumor.. . 6. Surgical margins:. . (a) superior margin: <1 mm (slide 3),. . (b) inferior margin: 20 mm,. . (c) medial margin: 5 mm,. . (d) lateral margin: 5 mm,. . (e) deep margin: 10 mm,. . (f) superficial margin: 1 mm (slide 1).. . 7. Microcalcification: present, tumoral.. Result. Intensity. Positive %. Estrogen. receptor. Strong (7/8). 3. 1/3–2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (1+). Ki-67. Positive in 7%. of tumor cells. . . ­. Carcinoma In Situ. 104. . . 24. " +337,Case 23,Important Radiologic,Carcinoma In Situ,Important Radiologic. Findings. 105. 106. 23.3.  +343,Case 23,Patient History,Carcinoma In Situ,"Patient History and Progress. Female/44 years old, pre-menopause.. Screen detected microcalcification on upper. outer portion of right breast.. No family history.. No comorbidities.. 23.2. " +330,Case 23,Courses of Treatment,HR(+) HER2(+) Breast Cancer,"23.1. . Courses of Treatment. Neoadjuvant chemotherapy (#6 cycles of. docetaxel and carboplatin and trastuzumab. and pertuzumab)  +  Operation  +  Post-­. HR(+) HER2(+) Breast Cancer. 374. . ­. . operative radiation therapy + Trastuzumab +. Tamoxifen 20 mg/day.. ­. ­. 132. 133. Pathology Report. . 1. No residual tumor with stromal degeneration.. . (a) Post-chemotherapy status.. . (b) Lymph nodes: no metastasis in six axillary. lymph nodes (ypN0) (axillary LN: 0/6).. . 2. Atypical ductal hyperplasia, focal.. . 3. Intraductal papilloma.. . 4. Fibroadenoma.. Result. Intensity. Positive. %. Estrogen. receptor. Weak (4/8). 2. 1–10%. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Positive (3+). Ki-67. Positive in 30%. of tumor cells. S. Park et al.. 375. . . HR(+) HER2(+) Breast Cancer. 376. F. i. g. 130. ­. S. Park et al.. 377. a. b. . a. b. . HR(+) HER2(+) Breast Cancer. 378. 24. " +338,Case 23,Important Radiologic,HR(+) HER2(+) Breast Cancer,Important Radiologic. Findings. 126 127 128 129 130. 131. 23.3.  +344,Case 23,Patient History,HR(+) HER2(+) Breast Cancer,"Patient History and Progress. Female/46 years old, pre-menopause.. Self-detected palpable mass lesion on both. breast.. Family history of breast cancer, sister.. Hypertension, S/P varicose veins operation.. BRCA 1 and 2 mutation: Not detected. (BRCAPRO mutation probability 0.118).. 23.2. " +331,Case 23,Courses of Treatment,HR(+) HER2(-) Breast Cancer,"2.5 mg/day.. Operation. Right breast conserving surgery, sentinel lymph. . (d) Histologic grade: 3/3 (tubule formation:. 3/3, nuclear pleomorphism: 3/3, mitotic. count: 2/3, 10/10 HPF). . (e) Intraductal component: present, intratu­. moral/extratumoral. (99%). (nuclear. grade: high, necrosis: present, architec­. tural pattern: solid/comedo, extensive. intraductal component: present).. . (f) Skin: no involvement of tumor.. . (g) Surgical margins:. • superior margin: 10 mm.. • inferior margin: (see note).. • medial margin: 5 mm.. • lateral margin: 10 mm.. HR(+) HER2(−) Breast Cancer. . (j) Lymphovascular invasion: absent.. . (k) Tumor border: infiltrative.. . (l) Microcalcification:. present,. tumoral/. non-tumoral.. . (m) Pathological TN category (AJCC 2017):. ypT1miN0(sn).. . 2. Intraductal papilloma with usual ductal. hyperplasia.. . 3. Fibroadenoma.. . 4. Complex sclerosing lesion.. Note: 1. The inferior margin of the lumpec­. tomy specimen (slide 7) is close to ductal car­. cinoma in situ (2  mm) but this margin. submitted for frozen diagnosis (Fro 4) is free. of tumor.. Result. Intensity. Positive %. Estrogen receptor. Strong (7/8). 3. 1/3–2/3. Progesterone receptor. Weak (3/8). 1. 1–10%. C-erbB2. Negative (1+). Ki-67. Positive in 15% of tumor cells. HR(+) HER2(−) Breast Cancer. 248. 24. " +339,Case 23,Important Radiologic,HR(+) HER2(-) Breast Cancer,"Important Radiologic. Findings. See Figs. 126, 127, 128, 129 and 130.. Y. Kim et al." +345,Case 23,Patient History,HR(+) HER2(-) Breast Cancer,"sister.. Diabetes mellitus, s/p right thyroidectomy. (thyroid cancer), s/p cholecystectomy, s/p. hysterectomy.. BRCA 1 and 2 mutation: Not detected.. 23.2. " +332,Case 23,Courses of Treatment,HR(−) HER2(+) Breast Cancer,"23.1. . Courses of Treatment. Operation + Operation + Adjuvant paclitaxel and. trastuzumab.. Operation. ­. 166. Pathology Report. Breast, right, nipple-sparing mastectomy:. Microinvasive Ductal Carcinoma. 1. Size of invasive component: <0.1  cm. (pT1mi).. 2. Size of intraductal component: 6.0 cm.. 3. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 3/3, 3/10HPF).. 4. Intraductal component: present, intratu­. moral/extratumoral (99%) (nuclear grade:. high, necrosis: present, architectural pattern:. micropapillary/cribriform/solid/comedo,. extensive intraductal component: present).. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) deep margin: 2 mm,. . (b) superficial margin: 2 mm.. 7. Lymph nodes: no metastasis in one axillary. lymph node (pN0(sn)) (sentinel LN: 0/1).. 8. Arteriovenous invasion: absent.. 9. Lymphovascular invasion: absent.. . 10. Tumor border: infiltrative.. HR(−) HER2(+) Breast Cancer. 520. . . 11. Microcalcification:. present,. tumoral/. non-tumoral.. . 12. Pathological TN category (AJCC 2017):. pT1miN0(sn).. Result. Intensity. Positive %. Estrogen. receptor. Negative. (0/8). 0. 0. Progesterone. receptor. Negative. (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in. 32% of tumor. cells. Operation. ­. 167. Pathology Report. Invasive Ductal Carcinoma. 1. Post nipple-sparing mastectomy status.. 2. Size of tumor: 0.7 cm (rpT1b).. 3. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 3/3, 21/10HPF).. Y. Kwon et al.. 521. . 4. Intraductal component: absent.. 5. Skin and nipple: no involvement of tumor.. 6. Surgical margins:. . (a) superior margin: 3 mm,. . (b) inferior margin: 21 mm,. . (c) medial margin: 25 mm,. . (d) lateral margin: 10 mm,. . (e) deep margin: 2 mm,. . (f) superficial margin: 18 mm.. 7. Lymph nodes: not submitted (rpNx).. 8. Arteriovenous invasion: absent.. 9. Lymphovascular invasion: absent.. . 10. Tumor border: infiltrative.. . 11. Microcalcification: absent.. . 12. Pathological TN category (AJCC 2017):. rpT1bNx.. 24. " +340,Case 23,Important Radiologic,HR(−) HER2(+) Breast Cancer,Important Radiologic. Findings. 162 163 164. 165. . Y. Kwon et al.. 519. . . ­. . 23.3.  +346,Case 23,Patient History,HR(−) HER2(+) Breast Cancer,"Patient History and Progress. Female/49 years old, pre-menopause.. Self-detected bloody discharge on nipple of. right breast.. No family history.. No comorbidities.. 23.2. " +333,Case 23,Courses of Treatment,HR(−) HER2(−) Breast Cancer,23.1. . Courses of Treatment. Neoadjuvant chemotherapy (#4  cycles of. doxorubicin and cyclophosphamide  +  #4. cycles of docetaxel)  +  Operation  +  Post-. operative radiation therapy.. Operation. 169. E. S. Lee et al.. 657. . . ­. . HR(−) HER2(−) Breast Cancer. 658. . . . Pathology Report. No residual tumor with foamy histiocytic. collection. . 1. Post-chemotherapy status.. . 2. Lymph nodes: no metastasis in one axillary. lymph node (ypN0(sn)) (sentinel LN: 0/1).. Note: Histologic mapping has been done.. Result. Intensity Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Negative (1+). Ki-67. Positive in 74%. of tumor cells. E. S. Lee et al.. 659. . 24.  +341,Case 23,Important Radiologic,HR(−) HER2(−) Breast Cancer,Important Radiologic Findings. 162 163. 164. After Neoadjuvant. Chemotherapy. 165 166 167. 168. 23.3.  +347,Case 23,Patient History,HR(−) HER2(−) Breast Cancer,"Patient History and Progress. Female/56 years old, post-menopause.. Self-detected mass lesion on right breast.. Family history of breast cancer, aunt. (maternal).. s/p Right knee fracture operation.. BRCA 1 and 2 mutation: Not detected,. POLD1 VUS (variant of uncertain).. 23.2. " +334,Case 23,Courses of Treatment,Local Recurrence,"23.1. . Courses of Treatment. Left breast medullary carcinoma → Operation. → Adjuvant therapy → Left breast recurrence. (IDC)/Right breast intraductal papilloma.. Primary Treatment. Operation. 2003 Left breast conserving surgery, axillary. lymph node dissection (outside).. Pathology Report. Medullary Carcinoma.. Y. Kim et al.. 779. Adjuvant Therapy. Adjuvant chemotherapy #6 cycles of doxorubicin. and cyclophosphamide.. Postoperative radiation therapy.. Treatments After Recurrence. 155 156. 157. Operation. 158. 159. Pathology Report. . . 1. Intraductal papilloma with:. . (a) sclerosing adenosis.. . (b) microcalcification.. . 2. Sclerosing adenosis.. . 3. Columnar cell hyperplasia.. . 4. Fibroadenomatous change.. . . 1. Invasive Ductal Carcinoma with focal papil­. lary pattern.. . . . Local Recurrence. 780. . . . (a) Size of tumor: 1.9 cm (pT1c(2)).. . (b) Histologic grade: 3/3 (tubule formation:. 3/3, nuclear pleomorphism: 3/3, mitotic. count: 3/3, 11/HPF).. . (c) Intraductal component: present, extratu­. moral (5%) (nuclear grade: high, necrosis:. absent, architectural pattern: papillary/solid,. extensive intraductal component: absent).. . (d) Skin: no involvement of tumor.. . (e) Surgical margins:. • Deep margin: (see note).. • Superficial margin: 15 mm.. . (f) Lymph nodes: no lymph node identified.. . (g) Arteriovenous invasion: absent.. . (h) Lymphovascular invasion: absent.. . (i) Tumor border: infiltrative.. . (j) Microcalcification: absent.. . (k) Pathological TN category (AJCC 2017):. pT1c.. . 2. Invasive Ductal Carcinoma.. . (a) Size of tumor: 0.6 cm.. . (b) Histologic grade: 2/3 (tubule formation:. 3/3, nuclear pleomorphism: 2/3, mitotic. count: 1/3, 1/10HPF).. . (c) Intraductal component: present, intratu­. moral/extratumoral (30%) (nuclear grade:. low, necrosis: absent, architectural pat­. tern: cribriform, extensive intraductal. component: present).. . (d) Arteriovenous invasion: absent.. . (e) Lymphovascular invasion: absent.. . (f) Tumor border: infiltrative.. Note: 1. The deep margin of the lumpectomy. specimen (slide 2) is close to invasive ductal car­. cinoma (<1 mm), but this margin separately sub­. mitted for permanent diagnosis (slide B) is free. of tumor.. Y. Kim et al.. 781. . . Result. Intensity. Positive %. Estrogen. receptor. Negative (2/8). 1. <1%. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Negative (1+). Ki-67. Positive in 48%. of tumor cells. Adjuvant Therapy. Adjuvant chemotherapy #4 cycles of cyclophos­. phamide and docetaxel.. 24. " +348,Case 23,Patient History,Local Recurrence,"Patient History and Progress. Female/49 years old, pre-menopause.. Palpable mass lesion on left breast 2 o’clock. direction.. Family history of breast cancer, maternal. grandmother.. s/p Left breast conserving surgery (breast can­. cer), s/p Bilateral salpingo-oophorectomy.. BRCA 1 mutation carrier.. 23.2. " +335,Case 23,Courses of Treatment,Metastatic Breast Cancer,"Courses of Treatment. Left breast cancer → Neoadjuvant chemother­. apy → Operation → Adjuvant therapy →. Pericardial effusion, Metastatic lymph nodes. → Bone, brain metastasis.. Primary Treatment. Docetaxel #4).. Result. Intensity. Positive. %. Estrogen. receptor. Negative (0/7). 0. 0. Progesterone. receptor. Negative (0/7). 0. 0. C-erbB2. Negative (0). Ki-67. Positive in. 40% of tumor. cells. Metastatic Breast Cancer. 900. Clinical stage: cT3N1M0.. Estrogen. receptor. Weak (3/8). 1. 1–10%. Progesterone. receptor. Negative. (0/8). 0. 0. C-erbB2. Negative (0). Ki-67. Positive in. 21% of. tumor cells. Adjuvant Therapy. Post-operative radiation therapy + Tamoxifen. 20 mg/day for 5 years.. Treatments After Recurrence. Chemotherapy #12 cycles (Gemcitabine &. Cisplatin): Progressive disease on leptomenin­. geal, brain.. Intrathecal chemotherapy (Methotrexate).. Chemotherapy. (Vinorelbine. tartrate. &. Cisplatin)~" +349,Case 23,Patient History,Metastatic Breast Cancer, +350,Case 24,Courses of Treatment,Benign and Proliferative,"24.1. . Courses of Treatment. →2021-07-14 excision, both.. . . C. W. Lee et al.. 47. . . Pathology Report. Diagnosis. • Breast, right, excision:. –. – Intraductal papilloma.. Post-excision status.. Usual ductal hyperplasia.. Apocrine metaplasia.. –. – Sclerosing adenosis with microcalcification.. Diagnosis. • Breast, left, excision:. –. – Atypical ductal hyperplasia, focal.. –. – Intraductal papilloma.. 25. " +358,Case 24,Important Radiologic,Benign and Proliferative,Important Radiologic. Findings. 46 47. 48. 24.3.  +364,Case 24,Patient History,Benign and Proliferative,"Patient History and Progress. Female/44 years old, pre-menopause.. Screen detected mass lesion in both breasts.. No family history.. s/p total thyroidectomy (thyroid cancer), s/p. right breast excision (intraductal papilloma).. 24.2. " +351,Case 24,Courses of Treatment,Carcinoma In Situ,"24.1. . Courses of Treatment:. Operation. Operation. 112. 113. E. S. Lee et al.. . 2. Nuclear grade: low.. . 3. Necrosis: absent.. . 4. Architectural pattern: solid.. . 5. Surgical margins:. . (a) superior margin: 11 mm,. . (b) inferior margin: 3 mm,. . (c) medial margin: 15 mm,. . (d) lateral margin: 15 mm,. . (e) deep margin: 2 mm,. . (f) superficial margin: 4 mm.. . 6. Microcalcification: absent.. Carcinoma In Situ. 106. a. b. . ­. a. b. . E. S. Lee et al.. 107. . . Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Equivocal. (2+). Ki-67. Positive in 6%. of tumor cells. 25. " +359,Case 24,Important Radiologic,Carcinoma In Situ,Important Radiologic. Findings. 109 110 111. 24.3.  +365,Case 24,Patient History,Carcinoma In Situ,"Patient History and Progress. Female/42 years old, pre-menopause.. Screen detected mass lesion on left breast. 2 o’clock direction.. Outside result of biopsy: Left breast 2 o’clock,. fibroadenoma, favor lobular carcinoma in situ.. No family history.. S/P Retinal detachment operation 15  years. ago.. 24.2. " +352,Case 24,Courses of Treatment,HR(+) HER2(+) Breast Cancer,"24.1. . Courses of Treatment. Neoadjuvant chemotherapy (#6 cycles of. docetaxel and carboplatin and trastuzumab. and pertuzumab)  +  Operation  +  Post-­. operative. radiation. ther­. apy + Trastuzumab + Tamoxifen 20 mg/day.. 140. Pathology Report. Ductal Carcinoma In Situ. . 1. Post-chemotherapy status.. . 2. Size of tumor: 0.2 cm (ypTis).. . 3. Nuclear grade: low.. . 4. Necrosis: absent.. . 5. Architectural pattern: solid.. . 6. Surgical margins:. . (a) superior margin: 5 mm,. . (b) inferior margin: 5 mm,. . (c) medial margin: 15 mm,. . (d) lateral margin: 10 mm,. . (e) deep margin: 5 mm,. . (f) superficial margin: 5 mm.. . 7. Lymph nodes: no metastasis in two axillary. lymph nodes (ypN0(sn)) (sentinel LN: 0/2).. . 8. Microcalcification:. present,. tumoral/. non-tumoral.. . 9. Pathological TN category (AJCC 2017):. ypTisN0(sn).. . . S. Park et al.. 379. . Result. Intensity. Positive %. Estrogen receptor. Negative (0/8). 0. 0. Strong (8/8) in core needle biopsy. 3. >2/3. Progesterone receptor. Negative (0/8). 0. 0. Intermediate (6/8) in core needle. biopsy. 3. 10%-1/3. C-erbB2. Positive (3+). Ki-67. Not informative due to low cellularity. HR(+) HER2(+) Breast Cancer. 380. F. ig. 137. 381. . a. b. . HR(+) HER2(+) Breast Cancer. 382. 25. " +360,Case 24,Important Radiologic,HR(+) HER2(+) Breast Cancer,Important Radiologic. Findings. 134 135 136 137 138. 139. 24.3.  +366,Case 24,Patient History,HR(+) HER2(+) Breast Cancer,"Patient History and Progress. Female/41 years old, pre-menopause.. Self-detected palpable mass lesion and nipple. discharge on right breast.. No family history.. S/P appendectomy, s/p hepatitis A.. 24.2. " +353,Case 24,Courses of Treatment,HR(+) HER2(-) Breast Cancer,"24.1. . Courses of Treatment. Neoadjuvant chemotherapy (#4  cycles of. doxorubicin & cyclophosphamide followed by. #4 cycles of docetaxel) & letrozole 2.5 mg/day. with leuprolide acetate  +  Operation  +  Post-­. operative radiation therapy.. Operation (1st, Jan. 2021). Right breast conserving surgery, axillary lymph. sive intraductal component: absent).. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) superior margin: positive for ductal car­. cinoma in situ (Fro 1) (see note).. . (b) inferior margin: 10 mm.. . (a) metastasis in five out of twelve axillary. lymph nodes (ypN2a) (sentinel LN: 3/3,. axillary LN: 2/9). . (b) perinodal extension: present.. . (c) size of metastatic carcinoma: 6 mm.. 8. Arteriovenous invasion: absent.. 9. Lymphovascular. invasion:. present,. intratumoral.. . 10. Tumor border: infiltrative.. . 11. Microcalcification:. present,. tumoral/. non-tumoral.. . 12. Pathological TN category (AJCC 2017):. ypT1cN2a.. Note: 1. Ductal carcinoma in situ is pres­. ent only in the permanent section of Fro 1.. Result. Intensity. Positive. %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Weak (3/8). 1. 1–10%. C-erbB2. Equivocal (2+). (SISH equivocal). Ki-67. Positive in 1% of. tumor cells. Operation (2nd, Feb. 2021)" +361,Case 24,Important Radiologic,HR(+) HER2(-) Breast Cancer,"Important Radiologic. Findings. See Figs. 132, 133, 134, 135 and 136.. 24.3. " +367,Case 24,Patient History,HR(+) HER2(-) Breast Cancer,"Patient History and Progress. Female/45 years old, pre-menopause.. Screen detected mass lesion on right breast 9. o’clock direction and right axillary LN.. No family history.. No comorbidities.. 24.2. " +354,Case 24,Courses of Treatment,HR(−) HER2(+) Breast Cancer,24.1. . Courses of Treatment. Neoadjuvant chemotherapy (#3 cycles of. docetaxel and carboplatin and trastuzumab and. pertuzumab) + Operation + Post-operative radia­. tion therapy + Trastuzumab and pertuzumab.. Operation. 176. . . HR(−) HER2(+) Breast Cancer. 526. Pathology Report. . 1. No residual tumor with stromal fibrosis.. . (a) Post-chemotherapy status.. . (b) Lymph nodes: no metastasis in two axil­. lary lymph nodes (ypN0(sn)) (sentinel. LN: 0/2).. . 2. Sclerosing adenosis with microcalcification.. Result. Intensity. Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in. 36% of tumor. cells. 25.  +362,Case 24,Important Radiologic,HR(−) HER2(+) Breast Cancer,Important Radiologic. Findings. 168 169 170. 171. HR(−) HER2(+) Breast Cancer. 522. . . . Y. Kwon et al.. . After Neoadjuvant. Chemotherapy. 172 173 174 +368,Case 24,Patient History,HR(−) HER2(+) Breast Cancer,"Patient History and Progress. Female/55 years old, pre-menopause.. Self-detected palpable mass lesion on left. breast 10–12 o’clock direction.. No family history.. Hypertension.. 24.2. " +355,Case 24,Courses of Treatment,HR(−) HER2(−) Breast Cancer,"24.1. . Courses of Treatment. Neoadjuvant chemotherapy (#4  cycles of. doxorubicin and cyclophosphamide  +  #4. cycles of paclitaxel)  +  Operation  +  Post-. operative radiation therapy  +  Adjuvant. capecitabine.. Operation. 177. HR(−) HER2(−) Breast Cancer. 660. . . ­. ­. . E. S. Lee et al.. 661. . . ­. . ­. HR(−) HER2(−) Breast Cancer. 662. Pathology Report. Invasive Ductal Carcinoma. 1. Post-chemotherapy status.. 2. Size of tumor: 2.7 cm (ypT2).. 3. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 3/3, 54/10HPF).. 4. Intraductal component: present, intratu­. moral/extratumoral (5%) (nuclear grade:. high, necrosis: absent, architectural pattern:. micropapillary, extensive intraductal compo­. nent: absent).. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) Superior margin: (see note).. . (b) Inferior margin: 15 mm.. . (c) Medial margin: 10 mm.. . (d) Lateral margin: 20 mm.. . (e) Deep margin: 10 mm.. . (f) Superficial margin: 2.5 mm.. 7. Lymph nodes: no metastasis in three axil­. lary lymph nodes (ypN0(sn)) (sentinel. LN: 0/3).. . . E. S. Lee et al.. 663. 8. Arteriovenous invasion: absent.. 9. Lymphovascular invasion: absent.. . 10. Tumor border: infiltrative.. . 11. Microcalcification: present, non-tumoral.. . 12. Pathological TN category (AJCC 2017):. ypT2N0(sn).. Note: 1. The superior margin of the lumpec­. tomy specimen (slide 3) is positive for invasive. ductal carcinoma, but this margin submitted for. frozen diagnosis (Fro 1) is free of tumor.. Result. Intensity. Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Negative (0). Ki-67. Positive in. 54% of tumor. cells. 25. " +363,Case 24,Important Radiologic,HR(−) HER2(−) Breast Cancer,Important Radiologic. Findings. 170 171. 172. After Neoadjuvant. Chemotherapy. 173 174 175. 176. 24.3.  +369,Case 24,Patient History,HR(−) HER2(−) Breast Cancer,"Patient History and Progress. Female/44 years old, pre-menopause.. Self-detected mass lesion on right breast.. Family history of breast cancer, aunt. (paternal).. Family history of ovarian cancer, sister.. No comorbidities.. BRCA 1 and 2 mutation: Not detected,. EPCAM and MLH1 VUS (variant of uncertain).. 24.2. " +356,Case 24,Courses of Treatment,Local Recurrence,"24.1. . Courses of Treatment. Left breast IDC → Neoadjuvant chemotherapy. → Operation → Adjuvant therapy → Left chest. wall recurrence (IDC).. Primary Treatment. 160 161 162. 163. Neoadjuvant Chemotherapy. #4 cycles of doxorubicin and cyclophosphamide. followed by #4 cycles of docetaxel.. Operation. 164. Pathology Report. Invasive Ductal Carcinoma. 1. Post-chemotherapy status.. 2. Size of tumor: 5.0 cm (ypT2).. 3. Histologic grade: 3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 2/3, 16/10HPF).. 4. Intraductal component: present, intratu­. moral/extratumoral (20%) (nuclear grade:. Local Recurrence. 782. . . . high, necrosis: present, architectural pattern:. solid/comedo, extensive intraductal compo­. nent: absent).. 5. Skin and nipple: no involvement of tumor.. 6. Surgical margins:. . (a) Deep margin: <1 mm from invasive duc­. tal carcinoma (slides 2 and 8).. . (b) Superficial margin: 20 mm.. 7. Lymph nodes: no metastasis in 17 axillary. lymph nodes (ypN0) (sentinel LN: 0/6, non-­. sentinel LN: 0/11).. 8. Arteriovenous invasion: present, intratumoral.. 9. Lymphovascular. invasion:. present,. intratumoral.. . 10. Tumor border: infiltrative.. . 11. Microcalcification:. present,. tumoral/. non-tumoral.. . 12. Pathological TN category (AJCC 2017):. ypT2N0.. Y. Kim et al.. 783. . . . ­. Result. Intensity. Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Equivocal (2+). (SISH negative). Ki-67. Positive in 46%. of tumor cells. Adjuvant Therapy. Postoperative radiation therapy.. Adjuvant. chemotherapy. #8. cycles. of. capecitabine.. Treatments After Recurrence. 165. 166. Operation. 167. Pathology Report. Invasive Ductal Carcinoma. 1. Post-modified radical mastectomy status.. 2. Size of tumor: 1.0 cm (rpT1b).. 3. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 3/3, 10/HPF).. 4. Intraductal component: absent.. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) Superior margin: 8 mm.. . (b) Inferior margin: 10 mm.. . (c) Medial margin: 20 mm.. . (d) Lateral margin: 5 mm.. . (e) Deep margin: 9 mm.. . (f) Superficial margin: 3 mm.. Local Recurrence. 784. 7. Arteriovenous invasion: absent.. 8. Lymphovascular invasion: absent.. 9. Tumor border: infiltrative.. . 10. Microcalcification: absent.. . 11. Pathological TN category (AJCC 2017):. rpT1b.. Result. Intensity. Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Negative (1+). Ki-67. Positive in 72%. of tumor cells. Adjuvant Therapy. Adjuvant chemotherapy #8 cycles of paclitaxel.. 25. " +370,Case 24,Patient History,Local Recurrence,"Patient History and Progress. Female/45 years old, pre-menopause.. Screen detected mass lesion on upper outer. portion of left breast.. Outside result of biopsy: Invasive ductal. carcinoma.. Family history of breast cancer, maternal aunt,. another aunt.. No comorbidities.. BRCA 1 and 2 mutation: Not detected.. 24.2. " +357,Case 24,Courses of Treatment,Metastatic Breast Cancer,Courses of Treatment. Right breast cancer → Operation → Adjuvant. therapy → Lung metastasis.. Primary Treatment. Estrogen. receptor. Strong (7/7). 3. >2/3. Result. Intensity. Positive %. Progesterone. receptor. Strong (7/7). 3. >2/3. C-erbB2. Negative (1+). Ki-67. Positive in. 30% of tumor. cells. Adjuvant Therapy. Adjuvant chemotherapy #8 cycles (Adriamycin +. Cyclophosphamide #4 → Docetaxel #4).. Post-operative radiation therapy + Tamoxifen. 20 mg/day → Letrozole 2.5 mg/day.. Treatments After Recurrence. >2/3. Progesterone. receptor. Intermediate. (6/8). 2. 1/3–2/3. C-erbB2. Negative (1+). Ki-67. Positive in 7%. of tumor cells. Palliative Therapy +371,Case 24,Patient History,Metastatic Breast Cancer,24.2.  +372,Case 25,Courses of Treatment,Benign and Proliferative,"25.1. . Courses of Treatment. →2021-07-27 excision, Lt.. Diagnosis. • Breast, left, excision:. –. – Atypical ductal hyperplasia involving. intraductal papilloma.. –. – Tubular adenoma.. 26. " +380,Case 25,Important Radiologic,Benign and Proliferative,Important Radiologic. Findings. 49. 50. Benign and Proliferative Case Series. 48. . . 25.3.  +386,Case 25,Patient History,Benign and Proliferative,"Patient History and Progress. Female/46 years old, pre-menopause.. Screen detected mass lesion on left breast 3. o’clock direction.. Outside result of biopsy: Intraductal papilloma.. No family history.. No comorbidities.. 25.2. " +373,Case 25,Courses of Treatment,Carcinoma In Situ,"25.1. . Courses of Treatment. Operation + Postoperative radiation therapy. (Left) + Tamoxifen 20 mg/day for 5 years.. Operation. 116. 117. Pathology Report. Right.. Lobular carcinoma in situ. . 1. Size of tumor: 0.3 cm.. . 2. Nuclear grade: low.. . 3. Necrosis: absent.. . 4. Architectural pattern: solid.. . 5. Skin: no involvement of tumor.. . 6. Surgical margins:. . (a) superior margin: 2 mm,. . (b) inferior margin: 5 mm,. . (c) medial margin: 2 mm,. . (d) lateral margin: 2 mm,. . (e) deep margin: 2 mm,. . (f) superficial margin: 2 mm.. . 7. Microcalcification:. present,. tumoral/non-. tumoral.. Left.. Invasive ductal carcinoma, pathological TN. category (AJCC 2017): pT1cN0(sn). 1. Size of invasive component: 1.5 cm (pT1c).. 2. Size of intraductal component: 5.0 cm.. Carcinoma In Situ. 108. . a. b. c. d. . ­. E. S. Lee et al.. 109. 3. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 3/3, 4/HPF).. 4. Intraductal component: present, intratu­. moral/extratumoral (70%) (nuclear grade:. high, necrosis: present, architectural pattern:. cribriform/solid/comedo, extensive intra­. ductal component: present).. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) superior margin: 5 mm,. . (b) inferior margin: 10 mm,. . (c) medial margin: 10 mm,. . (d) lateral margin: 10 mm,. . (e) deep margin: 2 mm,. . (f) superficial margin: <1 mm from ductal. carcinoma in situ (slide 2).. 7. Lymph nodes: no metastasis in one axillary. lymph node (pN0(sn)) (sentinel LN: 0/1).. 8. Arteriovenous invasion: absent.. 9. Lymphovascular. invasion:. present,. intratumoral.. . 10. Tumor border: infiltrative.. . 11. Microcalcification: present, tumoral/non-. tumoral.. Result. Intensity. Positive %. Estrogen. receptor. Strong (7/8). 3. 1/3–2/3. Progesterone. receptor. Strong (7/8). 3. 1/3–2/3. C-erbB2. Equivocal (2+). Ki-67. Positive in. 25% of tumor. cells. 26. " +381,Case 25,Important Radiologic,Carcinoma In Situ,Important Radiologic. Findings. 114. 115. 25.3.  +387,Case 25,Patient History,Carcinoma In Situ,"Patient History and Progress. Female/52 years old, pre-menopause.. Screen detected mass lesion on left breast. 1 o’clock direction.. Outside result of biopsy: Left breast 1 o’clock,. ductal carcinoma in situ, r/o invasion.. No family history.. S/P Robotic cholecystectomy (GB stone).. BRCA 1 and 2: Not examination.. 25.2. " +374,Case 25,Courses of Treatment,HR(+) HER2(+) Breast Cancer,"25.1. . Courses of Treatment. Operation  +  Adjuvant chemotherapy (#4. cycles of doxorubicin and cyclophosphamide. followed by #4 cycles of docetaxel and. ­. trastuzumab) + Post-operative radiation ther­. apy + Trastuzumab + Letrozole 2.5 mg/day.. ­. 145. 146. Pathology Report. [Right].. . 1. Invasive Ductal Carcinoma. . (a) Size of tumor: 1.2 cm (pT1c).. . (b) Histologic grade: 2/3 (tubule formation:. 2/3, nuclear pleomorphism: 2/3, mitotic. count: 3/3, 15/10 HPF).. . (c) Intraductal component: present, extratu­. moral (30%) (nuclear grade: low, necro­. sis:. present,. architectural. pattern:. cribriform/solid/comedo, extensive intra­. ductal component: absent).. . (d) Skin: no involvement of tumor.. . (e) Surgical margins:. • superior margin: 8 mm,. • inferior margin: 15 mm,. • medial margin: 15 mm,. • lateral margin: 15 mm,. • deep margin: 2 mm,. • superficial margin: 10 mm.. . (f) Lymph nodes: no metastasis in one axil­. lary lymph node (pN0(sn)) (sentinel LN:. 0/1).. . (g) Arteriovenous invasion: absent.. . (h) Lymphovascular. invasion:. present,. peritumoral.. . ­. ­. S. Park et al.. hyperplasia, (2) microcalcification.. Result. Intensity. Positive. %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Positive (3+). Ki-67. Positive in 26%. of tumor cells. [Left].. Invasive ductal carcinoma with micropapil­. lary pattern.. 1. Size of tumor: 1.1 cm (pT1c).. 2. Histologic grade: 2/3 (tubule formation: 2/3,. nuclear pleomorphism: 2/3, mitotic count:. 2/3, 6/10 HPF).. 3. Intraductal component: present, extratumoral. (26%) (nuclear grade: low, necrosis: absent,. HR(+) HER2(+) Breast Cancer. 384. . . architectural pattern: micropapillary/cribri­. form, extensive intraductal component:. absent).. 4. Surgical margins:. . (a) superior margin: 16 mm,. . (b) inferior margin: (see note),. . (c) medial margin: 20 mm,. . (d) lateral margin: (see note),. . (e) deep margin: 2 mm,. . (f) superficial margin: <1 mm from invasive. ductal carcinoma (slides 2 and 3).. 5. Lymph nodes:. . (a) metastasis in one out of seven axillary. lymph nodes (pN1a) (sentinel LN: 1/3,. non-sentinel LN: 0/4),. S. Park et al.. 385. a. b. . a. b. . . (b) perinodal extension: absent,. . (c) size of metastatic carcinoma: 6 mm.. 6. Arteriovenous invasion: absent.. 7. Lymphovascular invasion: absent.. 8. Tumor border: infiltrative.. 9. Microcalcification: present, tumoral.. . 10. Pathological TN category (AJCC 2017):. pT1cN1a.. HR(+) HER2(+) Breast Cancer. 386. Note: 1. The inferior margin of the lumpec­. tomy specimen (slides 2 and 3) is close to inva­. sive ductal carcinoma (<1 mm) but this margin. submitted for frozen diagnosis (Fro 3) is free of. tumor.. 2. The lateral margin of the lumpectomy spec­. imen (slide 8) is close to ductal carcinoma in situ. (<1  mm) but this margin submitted for frozen. diagnosis (Fro 5) is free of tumor.. Result. Intensity. Positive. %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Equivocal (2+). Ki-67. Positive in 19%. of tumor cells. SISH. Negative. 26. " +382,Case 25,Important Radiologic,HR(+) HER2(+) Breast Cancer,Important Radiologic. Findings. 141 142 143. 144. 25.3.  +388,Case 25,Patient History,HR(+) HER2(+) Breast Cancer,"Patient History and Progress. Female/62 years old, post-menopause.. Screen detected mass lesion on right breast 5. o’clock direction and left breast subareolar area.. No family history.. Hypertension, dyslipidemia.. 25.2. " +375,Case 25,Courses of Treatment,HR(+) HER2(-) Breast Cancer,"Courses of Treatment. Neoadjuvant therapy (giredestrant 30  mg/day. with palbociclib 100  mg/day) + Operation +. Adjuvant chemotherapy (#4 cycles of doxorubi­. cin & cyclophosphamide followed by #4 cycles of. docetaxel) + Post-­. operative radiation ther­. apy + Letrozole 2.5 mg/day.. Operation. Left breast conserving surgery, axillary lymph. solid/comedo, extensive intraductal compo­. nent: absent).. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (f) superficial margin: 2 mm.. 7. Lymph nodes:. . (a) metastasis in eight out of twelve axillary. lymph nodes (ypN2a) (sentinel LN: 2/2,. axillary LN: 6/10). . (b) perinodal extension: present.. . (c) size of metastatic carcinoma: 5 mm.. 8. Arteriovenous invasion: absent.. 9. Lymphovascular. invasion:. present,. intratumoral.. . 10. Tumor border: infiltrative.. . 11. Microcalcification:. present,. tumoral/. non-tumoral.. . 12. Pathological TN category (AJCC 2017):. ypT1cN2a.. Y. Kim et al.. 1/3–2/3. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Negative (0). Ki-67. Positive in 43%. of tumor cells. 26. " +383,Case 25,Important Radiologic,HR(+) HER2(-) Breast Cancer,"Important Radiologic. Findings. See Figs. 139, 140, 141, 142 and 143.. 25.3. " +389,Case 25,Patient History,HR(+) HER2(-) Breast Cancer,o’clock direction and left axillary LN.. No family history.. No comorbidities.. 25.2.  +376,Case 25,Courses of Treatment,HR(−) HER2(+) Breast Cancer,"25.1. . Courses of Treatment. Operation  +  Post-operative radiation therapy. (adjuvant chemotherapy refuse).. Operation. 180. Pathology Report. Invasive Ductal Carcinoma. 1. Size of invasive component: 2.5 cm (pT2).. 2. Size of intraductal component: 4.0 cm.. 3. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 2/3, 11/10HPF).. 4. Intraductal component: present, intratu­. moral/extratumoral (50%) (nuclear grade:. high, necrosis: present, architectural pattern:. cribriform/solid/comedo, extensive intra­. ductal component: present).. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) superior margin: 15 mm,. . (b) inferior margin: positive for ductal carci­. noma in situ (Fro 2) (see note),. . (c) medial margin: 10 mm,. . (d) lateral margin: 20 mm,. . (e) deep margin: <2 mm from ductal carci­. noma in situ (slide 11),. . (f) superficial margin: 13 mm.. 7. Lymph nodes:. . (a) metastasis in two out of four axillary. lymph nodes (pN1a(sn)) (sentinel LN:. 2/4),. . (b) perinodal extension: present,. . (c) size of metastatic carcinoma: 8 mm.. 8. Arteriovenous invasion: absent.. 9. Lymphovascular. invasion:. present,. peritumoral.. HR(−) HER2(+) Breast Cancer. 528. a. b. . . 10. Tumor border: infiltrative.. . 11. Microcalcification:. present,. ­. tumoral/. non-tumoral.. . 12. Pathological TN category (AJCC 2017):. pT2N1a(sn).. Note: 1. Ductal carcinoma in situ is focally. present only in the permanent section of Fro 2.. Result. Intensity. Positive %. Estrogen. receptor. Negative. (0/8). 0. 0. Progesterone. receptor. Negative. (0/8). 0. 0. C-erbB2. Positive. (3+). Ki-67. Positive in. 52% of. tumor cells. 26. " +384,Case 25,Important Radiologic,HR(−) HER2(+) Breast Cancer,Important Radiologic Findings. 177 178. 179. . Y. Kwon et al.. 527. . . ­. 25.3.  +390,Case 25,Patient History,HR(−) HER2(+) Breast Cancer,"Patient History and Progress. Female/82 years old, post-menopause.. Screen detected mass lesion on left breast 2:30. o’clock direction.. No family history.. S/P Left hemiplegia (due to brain hemor­. rhage), hypertension, S/P spinal stenosis opera­. tion, s/p Tuberculosis.. 25.2. " +377,Case 25,Courses of Treatment,HR(−) HER2(−) Breast Cancer,"25.1. . Courses of Treatment. Neoadjuvant chemotherapy (#4 cycles of doxo­. rubicin and cyclophosphamide + #4 cycles of. docetaxel) + Operation + Post-operative radia­. tion therapy + Adjuvant capecitabine.. Operation. 185. Pathology Report. Invasive Ductal Carcinoma with (a) focal squa­. mous differentiation, (b) focal papillary pattern.. 1. Post-chemotherapy status.. 2. Size of tumor: 1.2 cm (ypT1c).. 3. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 1/3, <1/10HPF).. 4. Intraductal component: present, intratumoral/. extratumoral (15%) (nuclear grade: high,. necrosis: absent, architectural pattern: papil­. lary, extensive intraductal component: absent).. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) Superior margin: 10 mm.. . (b) Inferior margin: 15 mm.. . (c) Medial margin: 10 mm.. . (d) Lateral margin: 35 mm.. . (e) Deep margin: 6 mm.. . (f) Superficial margin: 15 mm.. 7. Lymph nodes: no metastasis in two axillary. lymph nodes (ypN0(sn)) (sentinel LN: 0/1,. non-sentinel LN: 0/1).. 8. Arteriovenous invasion: absent.. 9. Lymphovascular invasion: absent.. . 10. Tumor border: infiltrative.. . 11. Microcalcification: absent.. . 12. Pathological TN category (AJCC 2017):. ypT1cN0(SN).. Result. Intensity Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Negative (0). Ki-67. Positive in 28%. of tumor cells. HR(−) HER2(−) Breast Cancer. 664. . . . ­. E. S. Lee et al.. 665. . . ­. . HR(−) HER2(−) Breast Cancer. 666. . . E. S. Lee et al.. 667. 26. " +385,Case 25,Important Radiologic,HR(−) HER2(−) Breast Cancer,Important Radiologic. Findings. 178 179. 180. 25.3. . After Neoadjuvant. Chemotherapy. 181 182 183. 184. 25.4.  +391,Case 25,Patient History,HR(−) HER2(−) Breast Cancer,"Patient History and Progress. Female/70 years old, post-menopause.. Screen detected mass lesion on left breast 2. o’clock direction.. Family history of breast cancer, cousin. (paternal).. Macular degeneration.. BRCA 1 and 2 mutation: Not tested.. 25.2. " +378,Case 25,Courses of Treatment,Local Recurrence,"25.1. . Courses of Treatment. Left breast IDC → Operation → Adjuvant ther­. apy → Left breast recurrence (DCIS).. Primary Treatment. Operation. Nov. 2007 Left breast conserving surgery, axil­. lary lymph node dissection (outside).. Pathology Report. Invasive Ductal Carcinoma. . 1. Size of tumor: 1.1 cm (pT1c).. . 2. Histologic grade: 3/3.. . 3. Lymph nodes: three metastases in fourteen. axillary lymph nodes (pN1).. Result. Intensity. Positive %. Estrogen. receptor. Negative (0/7). 0. 0. Progesterone. receptor. Strong (6/7). 3. 1/3–2/3. C-erbB2. Equivocal (2+). (SISH negative). Adjuvant Therapy. Adjuvant chemotherapy #4 cycles of doxorubicin. and cyclophosphamide followed by #4 cycles of. docetaxel.. Postoperative radiation therapy.. Letrozole 2.5 mg/day for 5 years.. Treatments After Recurrence. 168. Operation. 169. Pathology Report. Ductal Carcinoma In Situ with apocrine dif­. ferentiation involving fibroadenoma. . 1. Post-lumpectomy status.. . 2. Size of tumor: 0.6 cm (rpTis).. . 3. Nuclear grade: low.. . 4. Necrosis: present.. . 5. Architectural. pattern:. cribriform/solid/. comedo.. . Y. Kim et al.. 785. Intensity. Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Equivocal (2+). Ki-67. Positive in 9%. of tumor cells. 26. " +392,Case 25,Patient History,Local Recurrence,"Patient History and Progress. Female/69 years old, post-menopause.. For chemotherapy after left breast cancer. surgery.. No family history.. s/p Left breast conserving surgery, s/p total. Thyroidectomy (thyroid cancer).. s/p. Hysterectomy. and. bilateral. salpingo-oophorectomy.. 25.2. " +379,Case 25,Courses of Treatment,Metastatic Breast Cancer,"Courses of Treatment. Left breast cancer → Operation → Adjuvant. therapy → Ipsilateral breast skin metastasis.. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (0). Ki-67. Positive in. 7% of tumor. cells. Adjuvant Therapy. Tamoxifen 20 mg/day for 0.75 year.. Treatments After Recurrence. See Figs. 89 and 90.. Jun. 2021 Left breast skin biopsy.. Pathology: Invasive ductal carcinoma, clini­. cally recurrent.. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Intermediate. (5/8). 2. 10%–1/3. C-erbB2. Negative (1+). Ki-67. Positive in. 40% of tumor. cells. Strong (8/8). 3. >2/3. C-erbB2. Equivocal (2+). Ki-67. Positive in. 42% of tumor. cells. SISH. Negative. Oncotype Dx RS scores: 39.. Adjuvant Therapy. → Adjuvant chemotherapy #4 (Docetaxel &. Cyclophosphamide). → Letrozole 2.5 mg/day ~. 26. " +393,Case 25,Patient History,Metastatic Breast Cancer,"Hyperthyroidism,. s/p. bilateral. salpingo-oophorectomy.. 25.2. " +394,Case 26,Courses of Treatment,Benign and Proliferative,"26.1. . Courses of Treatment. →2021-06-16 excision, Rt.. Pathology Report. Diagnosis. • Breast, right, excision:. –. – Intraductal papilloma with usual ductal. hyperplasia.. . . Benign and Proliferative Case Series. 50. 27. " +402,Case 26,Important Radiologic,Benign and Proliferative,Important Radiologic. Findings. 51. 52. 26.3.  +408,Case 26,Patient History,Benign and Proliferative,"Patient History and Progress. Female/72 years old, post-menopause.. Screen detected nodular asymmetry on outer. central portion of right breast.. No family history.. s/p Total thyroidectomy (thyroid cancer).. C. W. Lee et al.. 49. 26.2. " +395,Case 26,Courses of Treatment,Carcinoma In Situ,"26.1. . Courses of Treatment. Operation + Tamoxifen 20 mg/day for 5 years.. Operation. 121. 122. Pathology Report. Lobular carcinoma in situ, pathological TN. category (AJCC 2017): pTis. . 1. Size of tumor: up to 0.6 cm (pTis).. . 2. Nuclear grade: low.. . . ­. Carcinoma In Situ. 110. . 3. Necrosis: absent.. . 4. Architectural pattern: solid.. . 5. Surgical margins:. . (a) superior margin: 5 mm,. . (b) inferior margin: 5 mm,. . (c) medial margin: 10 mm,. . (d) lateral margin: 20 mm,. . (e) deep margin: 5 mm,. . (f) superficial margin: <1 mm from lobular. carcinoma in situ (slide 2).. . 6. Microcalcification: absent.. Result. Intensity. Positive %. Estrogen. receptor. Intermediate. (6/8). 2. 1/3–2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Equivocal (2+). Ki-67. Positive in 4%. of tumor cells. . a. b. . E. S. Lee et al.. 111. a. b. . . . 27. " +403,Case 26,Important Radiologic,Carcinoma In Situ,Important Radiologic. Findings. 118 119. 120. 26.3.  +409,Case 26,Patient History,Carcinoma In Situ,"Patient History and Progress. Female/48 years old, pre-menopause.. Screen detected mass and microcalcification. on upper portion of right breast.. No family history.. No comorbidities.. 26.2. " +396,Case 26,Courses of Treatment,HR(+) HER2(+) Breast Cancer,"26.1. . Courses of Treatment. Neoadjuvant chemotherapy (#6 cycles of. docetaxel and carboplatin and trastuzumab. and pertuzumab)  +  Operation  +  Post-­. operative radiation therapy + Trastuzumab +. Letrozole 2.5 mg/day.. 153. 154. Pathology Report. Invasive Ductal Carcinoma. 1. Post-chemotherapy status.. 2. Size of tumor: 2.3 cm (ypT2).. . . HR(+) HER2(+) Breast Cancer. moral/extratumoral (50%) (nuclear grade:. high, necrosis: present, architectural pattern:. solid/comedo, extensive intraductal compo­. nent: present).. 5. Surgical margins:. . (a) deep margin: <1 mm from ductal carci­. noma in situ (slides 1 and 2),. . (b) superficial margin: <1 mm from ductal. carcinoma in situ (slide 3).. S. Park et al.. 389. a. b. . . 6. Lymph nodes: no metastasis in three axillary. lymph nodes (ypN0(sn)) (sentinel LN: 0/3).. 7. Arteriovenous invasion: absent.. 8. Lymphovascular invasion: absent.. 9. Tumor border: infiltrative.. . 10. Microcalcification: present, tumoral.. . 11. Pathological TN category (AJCC 2017):. ypT2N0(sn).. Result. Intensity. Positive. %. Estrogen. receptor. Weak (4/8). 2. 1–10%. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in 46%. of tumor cells. HR(+) HER2(+) Breast Cancer. 390. 27. " +404,Case 26,Important Radiologic,HR(+) HER2(+) Breast Cancer,Important Radiologic. Findings. 147 148 149 150 151. 152. . S. Park et al.. 387. 26.3.  +410,Case 26,Patient History,HR(+) HER2(+) Breast Cancer,"Patient History and Progress. Female/61 years old, post-menopause.. Self-detected palpable mass lesion on right. breast 11 o’clock direction.. No family history.. S/P. Tuberculosis,. diabetes. mellitus,. dyslipidemia.. 26.2. " +397,Case 26,Courses of Treatment,HR(+) HER2(-) Breast Cancer,"26.1. . Courses of Treatment. Operation + Adjuvant chemotherapy (#4 cycles. of doxorubicin & cyclophosphamide) + Post-. operative radiation therapy + Tamoxifen. 20 mg/day.. Operation. Left breast conserving surgery, sentinel lymph. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) superior margin: 25 mm.. Y. Kim et al.. (f) superficial margin: 15 mm.. 6. Lymph nodes: no metastasis in two axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/2). 7. Arteriovenous invasion: absent.. 8. Lymphovascular invasion: absent.. 9. Tumor border: infiltrative.. . 10. Microcalcification:. present,. ­. tumoral/. non-tumoral.. . 11. Pathological TN category (AJCC 2017):. pT1cN0(sn).. Result. Intensity Positive %. Estrogen. receptor. Strong (7/8). 2. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (0). Result. Intensity Positive %. Ki-67. Positive in 62%. of tumor cells. 27. " +405,Case 26,Important Radiologic,HR(+) HER2(-) Breast Cancer,"Important Radiologic. Findings. See Figs. 145, 146, 147 and 148.. 26.3. " +411,Case 26,Patient History,HR(+) HER2(-) Breast Cancer,"Patient History and Progress. Female/48 years old, pre-menopause.. Screen detected mass lesion on left breast 1. o’clock direction.. Family history of breast cancer, maternal aunt.. No comorbidities.. BRCA 1 and 2 mutation: Not detected.. 26.2. " +398,Case 26,Courses of Treatment,HR(−) HER2(+) Breast Cancer,"26.1. . Courses of Treatment. Operation + Adjuvant chemotherapy (#4 cycles. of doxorubicin  +  cyclophosphamide)  +  Post-­. operative radiation therapy + Trastuzumab.. Operation. 184. Pathology Report. Invasive Ductal Carcinoma with medullary. pattern. 1. Size of tumor: 1.5 cm (pT1c).. 2. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 2/3, 12/10HPF).. 3. Intraductal component: present, intratu­. moral/extratumoral (5%) (nuclear grade:. high, necrosis: absent, architectural pattern:. solid, extensive intraductal component:. absent).. HR(−) HER2(+) Breast Cancer. 530. . 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) superior margin: 20 mm,. . (b) inferior margin: 5 mm,. . (c) medial margin: 5 mm,. . (d) lateral margin: 5 mm,. . (e) deep margin: 2 mm,. . (f) superficial margin: 2 mm.. 6. Lymph nodes: no metastasis in one axillary. lymph node (pN0(sn)) (sentinel LN: 0/1).. 7. Arteriovenous invasion: absent.. 8. Lymphovascular. invasion:. present,. intratumoral.. 9. Tumor border: infiltrative.. . 10. Microcalcification:. present,. tumoral/. non-tumoral.. . 11. Pathological TN category (AJCC 2017):. pT1cN0(sn).. Result. Intensity. Positive %. Estrogen. receptor. Negative. (0/8). 0. 0. Progesterone. receptor. Negative. (2/8). 1. <1%. C-erbB2. Positive (3+). Ki-67. Positive in. 23% of. tumor cells. Y. Kwon et al.. 531. 27. " +406,Case 26,Important Radiologic,HR(−) HER2(+) Breast Cancer,Important Radiologic. Findings. 181 182. 183. Y. Kwon et al.. 529. . . . 26.3.  +412,Case 26,Patient History,HR(−) HER2(+) Breast Cancer,"Patient History and Progress. Female/49 years old, pre-menopause.. Self-detected palpable mass lesion on right. breast 1 o’clock direction.. No family history.. No comorbidities.. 26.2. " +399,Case 26,Courses of Treatment,HR(−) HER2(−) Breast Cancer,"26.1. . Courses of Treatment. Neoadjuvant chemotherapy (#4  cycles of. doxorubicin and cyclophosphamide  +  #3. cycles of docetaxel + Trastuzumab) + Operati. on + Adjuvant capecitabine + Trastuzumab.. Operation. 193 194. 195. Pathology Report. . No residual tumor with stromal fibrosis. . 1. Post-chemotherapy status.. . 2. Lymph nodes: no metastasis in two axillary. lymph nodes (ypN0(sn)) (sentinel LN: 0/2).. . Invasive Ductal Carcinoma. 1. Post-chemotherapy status.. 2. Size of tumor: 1.8 cm (ypT1c).. 3. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, <1/10HPF).. 4. Intraductal component: present, intratumoral. (60%) (nuclear grade: high, necrosis: absent,. architectural pattern: solid, extensive intra­. ductal component: present).. 5. Surgical margins:. . (a) Deep margin: 1 mm from ductal carci­. noma in situ (slide 3).. . (b) Superficial margin: 13 mm.. 6. Lymph nodes:. . (a) Metastasis in one out of eight axillary. lymph nodes (ypN1mi) (see note). (sentinel LN: 1/2, non-sentinel LN:. 0/6).. . (b) Perinodal extension: absent.. . (c) Size of metastatic carcinoma: 0.5 mm.. 7. Arteriovenous invasion: absent.. 8. Lymphovascular. invasion:. present,. intratumoral.. 9. Tumor border: infiltrative.. HR(−) HER2(−) Breast Cancer. 668. . . . ­. E. S. Lee et al.. 669. . . ­. . HR(−) HER2(−) Breast Cancer. 670. . 10. Microcalcification: present, non-tumoral.. . 11. Pathological TN category (AJCC 2017):. ypT1cN1mi.. Note: 1. Micrometastasis is present only in the. permanent section of Fro 3.. Result. Intensity Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Negative (0). Ki-67. Positive in 1%. of tumor cells. . . . E. S. Lee et al.. 671. 27. " +407,Case 26,Important Radiologic,HR(−) HER2(−) Breast Cancer,"Important Radiologic Findings. 186 187. 188. Breast, right, needle biopsy: Invasive ductal car­. cinoma, histologic grade 3 with medullary pattern.. Result. Intensity Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Negative (1+). Ki-67. Positive in 51%. of tumor cells. Breast, left, needle biopsy: Invasive ductal. carcinoma, histologic grade 3.. Result. Intensity Positive %. Estrogen. receptor. Negative (2/8). 1. <1%. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Equivocal (2+). Ki-67. Positive in 39%. of tumor cells. SISH. Tumor. heterogeneity. After Neoadjuvant. Chemotherapy. 189 190 191. 192. 26.3. " +413,Case 26,Patient History,HR(−) HER2(−) Breast Cancer,"Patient History and Progress. Female/53 years old, post-menopause.. Self-detected mass lesion on right breast.. Family history of breast cancer, grandmother.. Family history of ovarian cancer, sister.. S/P appendectomy, s/p bilateral salpingo-­. oophorectomy, s/p left shoulder operation.. BRCA 1 mutation carrier.. 26.2. " +400,Case 26,Courses of Treatment,Local Recurrence,"26.1. . Courses of Treatment. Right breast DCIS→ Operation → Adjuvant. therapy → Right breast recurrence (IDC).. Primary Treatment. 170. 171. Local Recurrence. 786. a. b. . . Operation. 172. Pathology Report. Ductal Carcinoma In Situ. . 1. Post-excisional biopsy status.. . 2. Size of tumor: 2.0 cm, residual.. . 3. Nuclear grade: low.. . 4. Necrosis: absent.. . 5. Architectural. pattern:. cribriform. and. papillary.. . 6. Skin: no involvement of tumor.. . 7. Surgical margins:. . (a) Superior margin: 25 mm.. . (b) Inferior margin: 7 mm.. . (c) Medial margin: 30 mm.. . (d) Lateral margin: 20 mm.. . (e) Deep margin: 3 mm.. . (f) Superficial margin: 13 mm.. . 8. Microcalcification: absent.. Result. Intensity. Positive %. Estrogen. receptor. Strong (7/8). 2. >2/3. Progesterone. receptor. Strong (8/8). 2. >2/3. C-erbB2. Negative (0). Ki-67. Positive in 5%. of tumor cells. Adjuvant Therapy. Postoperative radiation therapy.. Treatments After Recurrence. 173. 174. Operation. ­. 175. Pathology Report. Invasive Ductal Carcinoma. 1. Post-lumpectomy status.. 2. Size of tumor: 1.2 cm (rpT1c).. 3. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 2/3, 11/10HPF).. Y. Kim et al.. 787. 4. Intraductal component: present, intratu­. moral/extratumoral (10%) (nuclear grade:. low, necrosis: absent, architectural pattern:. cribriform, extensive intraductal component:. absent).. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) Deep margin: 2 mm.. . (b) Superficial margin: 2 mm.. 7. Lymph nodes: not submitted.. 8. Arteriovenous invasion: absent.. 9. Lymphovascular. invasion:. present,. intratumoral.. . 10. Tumor border: infiltrative.. . 11. Microcalcification:. present,. tumoral/. non-tumoral.. . 12. Pathological TN category (AJCC 2017):. rpT1c.. . . Local Recurrence. 788. . . Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 2. >2/3. Progesterone. receptor. Strong (8/8). 2. >2/3. C-erbB2. Negative (1+). Ki-67. Positive in 11%. of tumor cells. Adjuvant Therapy. Anastrozole 1 mg/day.. 27. " +414,Case 26,Patient History,Local Recurrence,"Patient History and Progress. Female/40 years old, post-menopause.. Bloody nipple discharge from right breast.. Outside result of biopsy: Ductal carcinoma in. situ.. No family history.. No comorbidities.. BRCA 1 and 2 mutation: Not detected.. 26.2. " +401,Case 26,Courses of Treatment,Metastatic Breast Cancer,"26.1. . Courses of Treatment. Right breast cancer → Operation → Adjuvant. therapy → Stomach and bone metastasis.. Primary Treatment. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (1+). Ki-67. Positive in. 29% of tumor. cells. Left> Invasive lobular carcinoma, stage. pT1c(m)N1mi.. Size of tumor: up to 1.5 cm, multiple, lymph. node: 2/7, size of metastatic carcinoma: 1.5 mm.. Result. Intensity Positive %. Estrogen. receptor. Strong (7/8). 2. >2/3. Progesterone. receptor. Strong (7/8). 3. 1/3–2/3. C-erbB2. Negative (0). Ki-67. Positive in. 17% of tumor. cells. Adjuvant Therapy. Adjuvant chemotherapy #8 cycles (Adriamycin. & Cyclophosphamide #4 → Docetaxel #4).. Post-operative radiation therapy +Tamoxifen. 20 mg/day for 5 years.. Treatments After Recurrence. See Figs. 93 and 94.. May 2018 Metastasis on stomach, bone.. Stomach biopsy Pathology: Metastatic ductal. carcinoma.. Result. Intensity. Positive %. Estrogen. receptor. Intermediate. (6/8). 2. 1/3–2/3. Progesterone. receptor. Strong (7/8). 3. 1/3–2/3. C-erbB2. Negative (0). Ki-67. Positive in. 8% of tumor. cells. Palliative Therapy. Bilateral salpingo-oophorectomy.. Letrozole 2.5 mg/day + Palbociclib~. Total gastrectomy.. Y. Kwon et al." +415,Case 26,Patient History,Metastatic Breast Cancer,"Patient History and Progress. Female/54 years old, post-menopause.. No family history.. S/p cholecystectomy, s/p total gastrectomy (gas­. tric cancer), s/p bilateral salpingo-oophorectomy.. 26.2. " +416,Case 27,Courses of Treatment,Benign and Proliferative,"27.1. . Courses of Treatment. →2021-06-07 excision, Rt.. Pathology Report. Diagnosis. • Breast, right, excision:. –. – Intraductal papilloma with usual ductal. hyperplasia.. . C. W. Lee et al.. 51. © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023. E. S. Lee (ed.), A Practical Guide to Breast Cancer Treatment,. https://doi.org/10.1007/978-981-19-9044-1_3" +424,Case 27,Important Radiologic,Benign and Proliferative,Important Radiologic. Findings. 53. 27.3.  +430,Case 27,Patient History,Benign and Proliferative,"Patient History and Progress. Female/41 years old, pre-menopause.. Screen detected mass lesion on right breast 4. o’clock direction.. Outside result of biopsy: Papillary neoplasm.. No family history.. No comorbidities.. 27.2. " +417,Case 27,Courses of Treatment,Carcinoma In Situ,"27.1. . Courses of Treatment. Operation + Tamoxifen 20 mg/day for 5 years.. Operation. 126. 127. Pathology Report. Lobular carcinoma in situ, pathological TN. category (AJCC 2017): pTis. . 1. Size of tumor: 1.5 cm(pTis).. . 2. Nuclear grade: low.. Carcinoma In Situ. 113. . 3. Necrosis: absent.. . 4. Architectural pattern: solid.. . 5. Skin: no involvement of tumor.. . 6. Surgical margins:. . (a) superior margin: 50 mm,. . (b) inferior margin: (see Note 1),. . (c) medial margin: 5 mm,. . (d) lateral margin: 10 mm,. . (e) deep margin: positive for lobular carci­. noma in situ (slide 1),. . (f) superficial margin: 5 mm.. . 7. Microcalcification: absent.. Note: 1. The inferior margin of the lumpec­. tomy specimen (slide 4) is close to lobular. carcinoma in situ (<1  mm) but this margin. submitted for frozen diagnosis (Fro 2) is free. of tumor.. Result. Intensity. Positive %. Estrogen. receptor. Strong (7/8). 2. >2/3. Progesterone. receptor. Strong (7/8). 2. >2/3. C-erbB2. Negative (0). Ki-67. Positive in 2%. of tumor cells. 28. " +425,Case 27,Important Radiologic,Carcinoma In Situ,Important Radiologic. Findings. 123 124. 125. 27.3.  +431,Case 27,Patient History,Carcinoma In Situ,"Patient History and Progress. Female/50 years old, pre-menopause.. Screen detected mass lesion on left breast. 2 o’clock direction.. Outside result of mammotome biopsy:. Lobular carcinoma in situ.. No family history.. 27.2. " +418,Case 27,Courses of Treatment,HR(+) HER2(+) Breast Cancer,"27.1. . Courses of Treatment. Neoadjuvant chemotherapy (#6 cycles of. docetaxel and carboplatin and trastuzumab. and pertuzumab)  +  Operation  +  Post-­. operative. radiation. ther­. apy + Trastuzumab + Tamoxifen 20 mg/day.. ­. 160. 161. Pathology Report. [Right].. . 1. Ductal carcinoma in situ involving sclerosing. adenosis.. . (a) Post-chemotherapy status.. . (b) Size of tumor: 0.3 cm (ypTis).. . (c) Nuclear grade: low.. . (d) Necrosis: absent.. . (e) Architectural pattern: cribriform/solid.. . (f) Skin: no involvement of tumor.. . (g) Surgical margins:. • superior margin: 10 mm,. • inferior margin: 20 mm,. • medial margin: 5 mm,. • lateral margin: 15 mm,. • deep margin: 5 mm,. • superficial margin: 5 mm.. . (h) Microcalcification: present, non-tumoral.. . (i) Pathological TN category (AJCC 2017):. ypTis.. . 2. Fibroadenoma.. Result. Intensity. Positive. %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Intermediate. (5/8). 2. 10%-. 1/3. C-erbB2. Negative (0). Ki-67. Positive in <1%. of tumor cells. [Left].. Invasive ductal carcinoma, histologic grade 2. with extensive intraductal component. . 1. No residual tumor with (1) necrotic detritus,. (2) foamy histiocytic collection.. . (a) Post-chemotherapy status. . (b) Lymph nodes: no metastasis in one axil­. lary lymph node (ypN0(sn)) (sentinel LN:. 0/1). . (c) Microcalcification: present, non-tumoral. . 2. Sclerosing adenosis with microcalcification.. Result. Intensity. Positive. %. Estrogen. receptor. Strong (7/8). 3. 1/3–2/3. Progesterone. receptor. Weak (3/8). 1. 1–10%. C-erbB2. Positive (3+). Ki-67. Positive in 32%. of tumor cells. HR(+) HER2(+) Breast Cancer. 392. . . S. Park et al.. 393. . a. b. . HR(+) HER2(+) Breast Cancer. 394. a. b. . . 28. " +426,Case 27,Important Radiologic,HR(+) HER2(+) Breast Cancer,Important Radiologic. Findings. 155 156 157 158. 159. . S. Park et al.. 391. . ­. 27.3.  +432,Case 27,Patient History,HR(+) HER2(+) Breast Cancer,"Patient History and Progress. Female/52 years old, peri-menopause.. Self-detected palpable mass lesion on left. breast 11 o’clock direction.. Family history of breast cancer, cousin. (maternal).. s/p Ovarian cyst excision.. BRCA 1 and 2 mutation: Not detected, NBN. VUS (variant of uncertain).. 27.2. " +419,Case 27,Courses of Treatment,HR(+) HER2(-) Breast Cancer,"27.1. . ductal component: present).. 4. Surgical margins:. . (a) superior margin: positive for ductal car­. cinoma in situ (Fro 1) (see note 1).. . (b) inferior margin: 25 mm.. . (c) medial margin: (see note 2).. . (d) lateral margin: 15 mm.. . (e) deep margin: <1 mm from invasive duc­. tal carcinoma (slide 7).. . (f) superficial margin: <1 mm from invasive. ductal carcinoma (slide 6).. 5. Lymph nodes: no metastasis in one axillary. lymph node (pN0(sn)) (sentinel LN: 0/1). 6. Arteriovenous invasion: absent.. 7. Lymphovascular invasion: absent.. 8. Tumor border: infiltrative.. 9. Microcalcification: present, tumoral.. . 10. Pathological TN category (AJCC 2017):. pT2N0(sn).. HR(+) HER2(−) Breast Cancer. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Intermediate. (6/8). 2. 1/3–2/3. C-erbB2. Negative (1+). Ki-67. Positive in 44%. of tumor cells. Y. Kim et al." +427,Case 27,Important Radiologic,HR(+) HER2(-) Breast Cancer,"Important Radiologic. Findings. See Figs. 150, 151, 152 and 153.. Y. Kim et al." +433,Case 27,Patient History,HR(+) HER2(-) Breast Cancer,"Patient History and Progress. Female/60 years old, post-menopause.. Screen detected mass lesion on left breast 10. o’clock direction.. No family history.. No comorbidities.. 27.2. " +420,Case 27,Courses of Treatment,HR(−) HER2(+) Breast Cancer,"27.1. . Courses of Treatment. Operation  +  Post-operative radiation ther­. apy + Adjuvant paclitaxel and trastuzumab.. Operation. 188. Pathology Report. . 1. Invasive ductal carcinoma with medullary. pattern.. . (a) Size of tumor: 0.8 cm (pT1b).. . (b) Histologic grade: 3/3 (tubule formation:. 3/3, nuclear pleomorphism: 3/3, mitotic. count: 3/3, 4/HPF).. . (c) Intraductal component: present, intratu­. moral/extratumoral (50%) (nuclear grade:. high, necrosis: absent, architectural pat­. tern: solid, extensive intraductal compo­. nent: present).. . (d) Skin: no involvement of tumor.. . (e) Surgical margins:. • superior margin: 5 mm,. • inferior margin: 20 mm,. • medial margin: 5 mm,. • lateral margin: 5 mm,. • deep margin: 1.5 mm from ductal car­. cinoma in situ (slide 1),. • superficial margin: 2 mm.. . (f) Lymph nodes: no metastasis in one axil­. lary lymph node (pN0(sn)) (sentinel LN:. 0/1).. . (g) Arteriovenous invasion: absent.. . (h) Lymphovascular. invasion:. present,. intratumoral.. a. b. . Y. Kwon et al.. 533. . (i) Tumor border: infiltrative.. . (j) Microcalcification:. present,. tumoral/. non-tumoral.. . (k) Pathological TN category (AJCC 2017):. pT1bN0(sn).. . 2. Intraductal papilloma with usual ductal. hyperplasia.. Result. Intensity. Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Equivocal(2+),. SISH(+). Ki-67. Positive in. 26% of tumor. cells. 28. " +428,Case 27,Important Radiologic,HR(−) HER2(+) Breast Cancer,Important Radiologic. Findings. 185 186. 187. . . . HR(−) HER2(+) Breast Cancer. 532. 27.3.  +434,Case 27,Patient History,HR(−) HER2(+) Breast Cancer,"Patient History and Progress. Female/69 years old, post-menopause.. Screen detected mass lesion on right breast 9. o’clock direction.. Family history of breast cancer, sister.. Hypertension, dyslipidemia.. BRCA 1 and 2 mutation: Not examination.. 27.2. " +421,Case 27,Courses of Treatment,HR(−) HER2(−) Breast Cancer,"27.1. . Courses of Treatment. Neoadjuvant chemotherapy (#4  cycles of. doxorubicin and cyclophosphamide  +  #4. cycles of docetaxel)  +  Operation  +  Post-. operative radiation therapy  +  Adjuvant. capecitabine.. Operation. 203. Pathology Report. Invasive Ductal Carcinoma. 1. Post-chemotherapy status.. 2. Size of tumor: 2.8 cm (ypT2).. 3. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 3/3, 14/10HPF).. 4. Intraductal component: absent.. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) Superior margin: 5 mm.. . (b) Inferior margin: 5 mm.. . (c) Medial margin: 5 mm.. . (d) Lateral margin: 5 mm.. . (e) Deep margin: 2 mm.. . (f) Superficial margin: 2 mm.. 7. Lymph nodes: no metastasis in three axillary. lymph nodes (ypN0(i+)(sn)) (sentinel LN:. 0/2, axillary LN: 0/1).. 8. Arteriovenous invasion: absent.. 9. Lymphovascular. invasion:. present,. intratumoral.. . 10. Tumor border: infiltrative.. . 11. Microcalcification:. present,. tumoral/. non-tumoral.. . 12. Pathological TN category (AJCC 2017):. ypT2N0(i+)(sn).. Note: 1. A few isolated tumor cells are present. only in the permanent section of Fro 6 for. ­. immunohistochemical staining.. HR(−) HER2(−) Breast Cancer. 674. . . . E. S. Lee et al.. 675. . ­. ­. Result. Intensity Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Negative (1+). Ki-67. Positive in 89%. of tumor cells. 28. " +429,Case 27,Important Radiologic,HR(−) HER2(−) Breast Cancer,Important Radiologic. Findings. 196 197 198. 199. . HR(−) HER2(−) Breast Cancer. 672. . . . ­. E. S. Lee et al.. 673. . After Neoadjuvant. Chemotherapy. 200 201. 202. 27.3.  +435,Case 27,Patient History,HR(−) HER2(−) Breast Cancer,"Patient History and Progress. Female/36 years old, pre-menopause.. Self-detected palpable mass lesion on left. breast.. Family history of breast cancer, aunt. (maternal).. No comorbidities.. BRCA 1 and 2 mutation: Not detected,. RAD50 VUS (variant of uncertain).. 27.2. " +422,Case 27,Courses of Treatment,Local Recurrence,"27.1. . Courses of Treatment. Right breast tubular carcinoma → Operation. → Adjuvant therapy → Left breast recurrence. (IDC).. Primary Treatment. 176 177 178. 179. Operation. ­. 180. Pathology Report. Tubular Carcinoma. 1. Size of tumor: 1.5 cm (pT1c).. 2. Histologic grade: 1/3 (tubule formation: 1/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 2/10HPF).. Y. Kim et al.. 789. 3. Intraductal component: present, intratu­. moral/extratumoral (5%) (nuclear grade:. low, necrosis: absent, architectural pattern:. cribriform, extensive intraductal component:. absent).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) Superior margin: 18 mm.. . (b) Inferior margin: 13 mm.. . (c) Medial margin: 10 mm.. . (d) Lateral margin: 10 mm.. . (e) Deep margin: 3 mm.. . (f) Superficial margin: 3 mm.. 6. Lymph nodes: no metastasis in one axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/1).. 7. Vascular invasion: absent.. 8. Lymphatic invasion: absent.. 9. Tumor border: infiltrative.. . 10. Microcalcification: present, tumoral.. . 11. Pathologic stage (AJCC 2010): pT1cN0(sn).. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (1+). Ki-67. Positive in 11%. of tumor cells. . . a. b. . Local Recurrence. 790. Adjuvant Therapy. Postoperative radiation therapy.. Tamoxifen 20 mg/day for 5 years.. Treatments After Recurrence. 181 182. 183. Operation. ­. 184. Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 0.3 cm (pT1a).. 2. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 6/10HPF).. 3. Intraductal component: present, intratu­. moral/extratumoral (50%) (nuclear grade:. low, necrosis: absent, architectural pattern:. micropapillary/cribriform, extensive intra­. ductal component: present).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) Superior margin: 10 mm.. . (b) Inferior margin: positive for invasive. ductal carcinoma (Fro 7) (see note).. . (c) Medial margin: 10 mm.. . (d) Lateral margin: 10 mm.. . (e) Deep margin: <1 mm from ductal carci­. noma in situ (slide 1).. . (f) Superficial margin: 2 mm.. 6. Lymph nodes: no metastasis in two axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/2).. 7. Arteriovenous invasion: absent.. 8. Lymphovascular invasion: absent.. 9. Tumor border: infiltrative.. . 10. Microcalcification:. present,. tumoral/. non-tumoral.. . 11. Pathological TN category (AJCC 2017):. pT1aN0(sn).. Note: 1. Invasive ductal carcinoma is focally. present only in the permanent section of Fro 7.. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Intermediate. (6/8). 3. 10%-1/3. C-erbB2. Negative (1+). Ki-67. Positive in 2%. of tumor cells. . . ­. . Y. Kim et al.. 791. a. b. . . ­. Operation. Second Operation (Dec. 2021) Left breast wide. excision.. Pathology Report. Atypical ductal hyperplasia. . 1. Post-lumpectomy status.. Adjuvant Therapy. Postoperative radiation therapy.. 28. " +436,Case 27,Patient History,Local Recurrence,"Patient History and Progress. Female/57 years old, post-menopause.. Screen detected mass lesion on right breast 1. o’clock direction.. Outside result of biopsy: Invasive ductal. carcinoma.. Family history of breast cancer, younger. sister.. No comorbidities.. BRCA 1 and 2 mutation: Not detected.. 27.2. " +423,Case 27,Courses of Treatment,Metastatic Breast Cancer,Courses of Treatment. Left breast cancer → Operation → Adjuvant. therapy. →. Right. shoulder. soft. tissue. metastasis.. Primary Treatment. Estrogen. receptor. Strong (6/7). 3. 1/3–2/3. Progesterone. receptor. Weak (2/7). 1. <10%. C-erbB2. Equivocal. (2+). Ki-67. Positive in. 15% of tumor. cells. FISH. Negative. Adjuvant Therapy. Adjuvant chemotherapy #8 cycles (Adriamycin. & Cyclophosphamide #4 → Docetaxel #4).. Post-operative radiation therapy + Letrozole. 2.5 mg/day for 1 year → Tamoxifen 20 mg/day. for 1 year.. Jun. 2021 Right shoulder soft tissue biopsy.. Pathology: Metastatic ductal carcinoma.. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Weak (3/8). 1. 1–10%. C-erbB2. Negative (1+). Ki-67. Positive in. 6% of tumor. cells. Palliative Therapy. Clinical trial enrolled (SAR439859/placebo +. Letrozole/placebo+ Palbociclib)~. 28.  +437,Case 27,Patient History,Metastatic Breast Cancer,27.2.  +438,Case 28,Courses of Treatment,Carcinoma In Situ,"28.1. . Courses of Treatment. Operation + Tamoxifen 20 mg/day for 5 years.. Operation. 131. 132. Pathology Report. Lobular carcinoma in situ, pathological TN. category (AJCC 2017): pTis. . 1. Size of tumor: 0.7 cm (pTis).. . 2. Nuclear grade: low.. . 3. Necrosis: absent.. . 4. Architectural pattern: solid.. . 5. Skin: No involvement of tumor.. . 6. Surgical margins:. . (a) superior margin: (see Note),. . (b) inferior margin: 25 mm,. . (c) medial margin: 10 mm,. . (d) lateral margin: 20 mm,. . (e) deep margin: 5 mm,. . (f) superficial margin: 2 mm.. . 7. Microcalcification: absent.. Note: 1. The superior margin of the. lumpectomy specimen (slide 1) is close to. lobular carcinoma in situ (1 mm) but this mar­. gin submitted for frozen diagnosis (Fro 1) is. free of tumor.. Result. Intensity. Positive %. Estrogen. receptor. Intermediate. (6/8). 1. >2/3. Progesterone. receptor. Strong (7/8). 2. >2/3. C-erbB2. Negative (1+). Ki-67. Positive in 6%. of tumor cells. . Carcinoma In Situ. . 29. " +445,Case 28,Important Radiologic,Carcinoma In Situ,Important Radiologic. Findings. 128 129. 130. 28.3.  +450,Case 28,Patient History,Carcinoma In Situ,"Patient History and Progress. Female/50 years old, pre-menopause.. Screen detected microcalcification on upper. outer portion of right breast.. Outside result of stereotactic excisional. biopsy: Lobular carcinoma in situ.. No family history.. No comorbidities.. 28.2. " +439,Case 28,Courses of Treatment,HR(+) HER2(+) Breast Cancer,"28.1. . Courses of Treatment. Operation  +  Adjuvant chemotherapy (#3. cycles of doxorubicin and cyclophospha­. mide). +. Post-operative. radiation. ther­. apy + Trastuzumab + Tamoxifen 20 mg/day.. 166. Pathology Report. . 1. Invasive Ductal Carcinoma.. . (a) Size of invasive component: 1.6  cm. (pT1c).. . (b) Size of intraductal component: 3.0 cm.. S. Park et al.. 395. . . . HR(+) HER2(+) Breast Cancer. 396. a. b. . . (c) Histologic grade: 3/3 (tubule formation:. 3/3, nuclear pleomorphism: 3/3, mitotic. count: 3/3, 3/HPF).. . (d) Intraductal component: present, intratu­. moral/extratumoral (50%) (nuclear grade:. high, necrosis: present, architectural pat­. tern: solid/comedo, extensive intraductal. component: present).. . (e) Skin: no involvement of tumor.. . (f) Surgical margins:. • superior margin: 10 mm,. • inferior margin: 10 mm,. • medial margin: 5 mm,. • lateral margin: 5 mm,. • deep margin: 2 mm,. • superficial margin: 2 mm.. . (g) Lymph nodes: no metastasis in two axil­. lary lymph nodes (pN0(sn)) (sentinel LN:. 0/2).. . (h) Arteriovenous invasion: absent.. . (i) Lymphovascular. invasion:. present,. intratumoral.. . (j) Tumor border: infiltrative.. . (k) Microcalcification:. present,. tumoral/. non-tumoral.. . (l) Pathological TN category (AJCC 2017):. pT1cN0(sn).. . 2. Intraductal papilloma with usual ductal. hyperplasia.. Result. Intensity. Positive. %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Equivocal (2+). Ki-67. Positive in 44%. of tumor cells. SISH. Positive. S. Park et al.. 397. 29. " +446,Case 28,Important Radiologic,HR(+) HER2(+) Breast Cancer,Important Radiologic. Findings. 162 163 164. 165. 28.3.  +451,Case 28,Patient History,HR(+) HER2(+) Breast Cancer,"Patient History and Progress. Female/47 years old, pre-menopause.. Self-detected palpable mass lesion on right. breast 6 o’clock direction.. No family history.. Hepatitis B carrier.. 28.2. " +440,Case 28,Courses of Treatment,HR(+) HER2(-) Breast Cancer,". Courses of Treatment. Operation  +  Post-operative radiation ther­. apy  +  Letrozole 2.5  mg/day with palbociclib. 100 mg/day.. Operation. Right breast conserving surgery, sentinel lymph. ponent: absent).. 4. Skin: no involvement of tumor.. HR(+) HER2(−) Breast Cancer. . (e) deep margin: 5 mm.. . (f) superficial margin: 2 mm.. 6. Lymph nodes:. . (a) metastasis in two out of two axillary. lymph nodes (pN1a(sn)) (see note) (sen­. tinel LN: 1/1, axillary LN: 1/1). . (b) perinodal extension: present.. . (c) size of metastatic carcinoma: 6 mm.. 7. Arteriovenous invasion: absent.. 8. Lymphovascular. invasion:. present,. intratumoral.. 9. Tumor border: infiltrative.. . 10. Microcalcification: present, tumoral.. . 11. Pathological TN category (AJCC 2017):. pT2N1a(sn).. Note: 1. Micrometastasis is present only. in the permanent section of Fro 1.. Result. Intensity. Positive %. Estrogen receptor. Strong (8/8). 3. >2/3. Progesterone receptor. Intermediate (6/8). 2. 1/3–2/3. C-erbB2. Negative (1+). Ki-67. Positive in 9% of tumor cells. Y. Kim et al." +447,Case 28,Important Radiologic,HR(+) HER2(-) Breast Cancer,"Important Radiologic. Findings. See Figs. 155, 156, 157 and 158.. 28.3. " +452,Case 28,Patient History,HR(+) HER2(-) Breast Cancer,"Patient History and Progress. Female/72 years old, post-menopause.. Screen detected mass lesion on right breast 8. o’clock direction.. No family history.. S/p cholecystectomy, hypertension.. 28.2. " +441,Case 28,Courses of Treatment,HR(−) HER2(+) Breast Cancer,"28.1. . docetaxel and carboplatin and trastuzumab and. pertuzumab) + Operation + Post-operative radia­. tion therapy + Trastuzumab and pertuzumab.. Operation. 196. Pathology Report. Ductal Carcinoma In Situ. 1. Post-chemotherapy status.. 2. Size of tumor: 0.2 cm (ypTis).. 3. Nuclear grade: high.. 4. Necrosis: absent.. 5. Architectural pattern: solid.. 6. Skin: no involvement of tumor.. 7. Surgical margins:. . (a) superior margin: 20 mm,. . (b) inferior margin: 10 mm,. . (c) medial margin: 30 mm,. . (d) lateral margin: 5 mm,. . (e) deep margin: 2 mm,. . (f) superficial margin: 2 mm.. 8. Lymph nodes: no metastasis in three axillary. lymph nodes (ypN0(sn)) (sentinel LN: 0/3).. 9. Microcalcification:. present,. tumoral/. non-tumoral.. . 10. Pathological TN category (AJCC 2017):. ypTisN0(sn).. Result. Intensity. Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in 38%. of tumor cells. . Y. Kwon et al.. 537. 29. " +448,Case 28,Important Radiologic,HR(−) HER2(+) Breast Cancer,Important Radiologic. Findings. 189 190 191. 192. . HR(−) HER2(+) Breast Cancer. 534. . . ­. F. ig. 192. Chemotherapy. 193 194. 195. . ­. +453,Case 28,Patient History,HR(−) HER2(+) Breast Cancer,"Patient History and Progress. Female/61 years old, post-menopause.. Screen detected mass lesion on right breast 9. o’clock direction.. No family history.. Hypertension.. 28.2. " +442,Case 28,Courses of Treatment,HR(−) HER2(−) Breast Cancer,"28.1. . Courses of Treatment. Operation + Post-operative radiation therapy. (Adjuvant chemotherapy refuse).. Operation. 207. Pathology Report. Malignant Adenomyoepithelioma (Epithelial-­. Myoepithelial Carcinoma). 1. Size of tumor: 2.0 cm (pT1c).. HR(−) HER2(−) Breast Cancer. 676. . . . ­. E. S. Lee et al.. 677. . 2. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 3/3, 23/10HPF).. 3. Intraductal component: absent.. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) Superior margin: 10 mm.. . (b) Inferior margin: 10 mm.. . (c) Medial margin: 15 mm.. . (d) Lateral margin: 25 mm.. . (e) Deep margin: 9 mm.. . (f) Superficial margin: <1  mm from. epithelial-­. myoepithelial. carcinoma. (slides 2 and 7).. 6. Arteriovenous invasion: absent.. 7. Lymphovascular invasion: absent.. 8. Tumor border: pushing.. 9. Microcalcification: present, non-tumoral.. . 10. Pathological TN category (AJCC 2017):. pT1c.. Result. Intensity Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Negative (0). Ki-67. Positive in 18%. of tumor cells. 29. " +449,Case 28,Important Radiologic,HR(−) HER2(−) Breast Cancer,Important Radiologic Findings. 204 205. 206. 28.3.  +454,Case 28,Patient History,HR(−) HER2(−) Breast Cancer,"Patient History and Progress. Female/57 years old, post-menopause.. Self-detected palpable mass lesion on right.. No family history.. S/P. right. neck. excision. (due. to. lymphadenitis).. 28.2. " +443,Case 28,Courses of Treatment,Local Recurrence,"28.1. . Courses of Treatment. Left breast DCIS → Operation → Adjuvant. therapy → Left breast recurrence (microinva­. sive ductal carcinoma).. Primary Treatment. 185 186 187. 188. Local Recurrence. 792. . . ­. . Operation. ­. 189. Pathology Report. Ductal carcinoma in situ. 1. Post mammotome biopsy status.. 2. Size of tumor: 2.0 cm, residual (pTis).. 3. Nuclear grade: high.. 4. Necrosis: present.. 5. Architectural pattern: solid and comedo.. 6. Skin: no involvement of tumor.. 7. Surgical margins:. . (a) Superior margin: 10 mm.. . (b) Inferior margin: 10 mm.. . (c) Medial margin: 10 mm.. . (d) Lateral margin: 10 mm.. . (e) Deep margin: 2 mm.. 8. Lymph nodes: no metastasis in 3 axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/3,. axillary LN: 0/0).. Y. Kim et al.. 793. . . 9. Microcalcification:. present,. tumoral/. non-tumoral.. . 10. Pathologic staging: pTisN0(sn).. Result. Intensity. Positive %. Estrogen. receptor. Negative (0/7). 0. 0. Progesterone. receptor. Negative (0/7). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in 10%. of tumor cells. Adjuvant Therapy. Postoperative radiation therapy.. Treatments After Recurrence. 190 191. 192. Operation. ­. 193. Local Recurrence. 794. Pathology Report. Microinvasive Ductal Carcinoma. 1. Size of tumor: 0.1 cm (pTis).. 2. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, not identified).. 3. Intraductal component: present, intratu­. moral/extratumoral (90%) (nuclear grade:. high, necrosis: present, architectural pattern:. comedo, cribriform, and solid, extensive. intraductal component: absent/present).. 4. Skin: no involvement of tumor.. 5. Surgical margins: (deep margin: 1 mm from. ductal carcinoma in situ).. 6. Vascular invasion: absent.. 7. Lymphatic invasion: absent.. 8. Tumor border: infiltrative.. 9. Microcalcification:. present,. tumoral/. non-tumoral.. . 10. Pathologic stage (AJCC 2010): pTisNx.. Result. Intensity. Positive %. Estrogen. receptor. Strong (7/7). 3. >2/3. Progesterone. receptor. Strong (7/7). 3. >2/3. C-erbB2. Positive (2+). Ki-67. Positive in 25%. of tumor cells. . . ­. a. b. . Y. Kim et al.. 795. Adjuvant Therapy. Tamoxifen 20  mg/day for 6.5  years with. goserelin.. 29. " +455,Case 28,Patient History,Local Recurrence,"Patient History and Progress. Female/50 years old, pre-menopause.. Screen detected mass lesion on left breast 2. o’clock direction.. Outside result of mammotome excision:. Ductal carcinoma in situ.. No family history.. No comorbidities.. 28.2. " +444,Case 28,Courses of Treatment,Metastatic Breast Cancer,28.1. . Courses of Treatment. Right breast cancer → Operation → Adjuvant. therapy. →. Right. shoulder. soft. tissue. metastasis.. Primary Treatment. receptor. Strong (7/8). 2. >2/3. Progesterone. receptor. Strong (7/8). 2. >2/3. C-erbB2. Negative (1+). Ki-67. Positive in 7%. of tumor cells. Adjuvant Therapy. Post-operative radiation therapy + Tamoxifen. 20 mg/day.. Treatments After Recurrence. >2/3. Progesterone. receptor. Weak (3/8). 2. <1%. C-erbB2. Negative (1+). Ki-67. Positive in. 6% of tumor. Apr. 2020 Left axillary lymph node sampling and. bilateral salpingo-oophorectomy.. Pathology: Metastatic ductal carcinoma in one. out of three axillary lymph nodes.. Size of metastatic carcinoma: 6 mm.. Result. Intensity. Positive %. Estrogen. receptor. Intermediate. (5/8). 2. 10–1/3. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Negative (1+). Ki-67. Positive in 1%. of tumor cells. Adjuvant Therapy. Post-operative radiation therapy (axilla).. Liver Metastasis. May 2020 Liver MRI: r/o liver metastasis. +456,Case 28,Patient History,Metastatic Breast Cancer,"Patient History and Progress. Female/51 years old, post-menopause.. No family history.. BRCA 1 & 2 mutation: Not detected, ATM. VUS (variant of uncertain).. Metastatic Breast Cancer. 908. 28.2. " +457,Case 29,Courses of Treatment,Carcinoma In Situ,"29.1. . Courses of Treatment. Operation + Adjuvant chemotherapy #4  cycles. (Doxorubicin and Cyclophosphamide) + Postope. rative radiation therapy (both)  +  Letrozole. 2.5 mg/day for 5 years.. Operation. 136. 137. Pathology Report. Right.. Lobular carcinoma in situ, pathological TN. category (AJCC 2017): pTis. . 1. Size of tumor: 2.5 cm (pTis).. . 2. Nuclear grade: low.. . 3. Necrosis: absent.. . 4. Architectural pattern: solid.. . 5. Surgical margins:. . (a) superior margin: (see Note 1),. . (b) inferior margin: (see Note 2),. . (c) medial margin: 5 mm,. . (d) lateral margin: positive for lobular carci­. noma in situ (Fro 4) (see Note 3),. . (e) deep margin: <1 mm from lobular carci­. noma in situ (slides 4 and 5),. . (f) superficial margin: 3 mm.. . 6. Microcalcification:. present,. tumoral/. non-tumoral.. Note: 1. The superior margin of the. lumpectomy specimen (slide 2) is close to. lobular carcinoma in situ (3 mm) but this mar­. gin submitted for frozen diagnosis (Fro 1) is. free of tumor.. 2. The inferior margin of the lumpectomy. specimen (slide 4) is close to lobular car­. cinoma in situ (<1 mm) but this margin. submitted for frozen diagnosis (Fro 2) is. free of tumor.. 3. Lobular carcinoma in situ is present only in. the permanent section of Fro 4.. Carcinoma In Situ. 116. . . E. S. Lee et al.. 117. a. b. c. d. . ­. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Intermediate. (5/8). 3. 1%–10%. C-erbB2. Negative. (1+). Ki-67. Positive in. 1% of tumor. cells. Left.. Invasive ductal carcinoma, pathological TN. category (AJCC 2017): pT1cN0(sn). . 1. Size of tumor: 1.5 cm (pT1c).. . 2. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 2/3, 11/10HPF).. . 3. Intraductal component: present, intratumoral. (20%) (nuclear grade: low, necrosis: present,. architectural pattern: micropapillary/cribri­. form/solid/comedo,. extensive. intraductal. component: absent).. . 4. Surgical margins:. . (a) superior margin: 20 mm,. . (b) inferior margin: 15 mm,. . (c) medial margin: 10 mm,. . (d) lateral margin: 10 mm,. . (e) deep margin: 8 mm,. . (f) superficial margin: 10 mm.. . 5. Lymph nodes: no metastasis in two axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/2).. . 6. Arteriovenous invasion: absent.. . 7. Lymphovascular. invasion:. present,. intratumoral.. . 8. Tumor border: infiltrative.. . 9. Microcalcification: present, non-tumoral.. Result. Intensity Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Negative (2/8). 1. <1%. C-erbB2. Negative (1+). Ki-67. Positive in 17%. of tumor cells. Carcinoma In Situ. 118. 30. " +464,Case 29,Important Radiologic,Carcinoma In Situ,Important Radiologic. Findings. 133 134. 135. 29.3.  +469,Case 29,Patient History,Carcinoma In Situ,"Patient History and Progress. Female/50 years old, post-menopause.. Screen detected mass lesion on left breast. 2 o’clock direction.. Outside result of biopsy: Left breast 2 o’clock,. invasive ductal carcinoma.. No family history.. No comorbidities.. BRCA 1 and 2 mutation: Not detected, MSH6. VUS (variant of uncertain).. 29.2. " +458,Case 29,Courses of Treatment,HR(+) HER2(+) Breast Cancer,"29.1. . Courses of Treatment. Operation  +  Adjuvant chemotherapy (#4. cycles of docetaxel and cyclophosphamide and. trastuzumab) + Post-operative radiation ther­. apy + Trastuzumab + Letrozole 2.5 mg/day.. 171. Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 2.1 cm (pT2).. 2. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 2/3, 11/10 HPF).. 3. Intraductal component: present, intratu­. moral/extratumoral (5%) (nuclear grade:. low, necrosis: absent, architectural pattern:. papillary/cribriform/solid, extensive intra­. ductal component: absent).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) superior margin: 10 mm,. . (b) inferior margin: 10 mm,. . (c) medial margin: 10 mm,. . (d) lateral margin: 4 mm,. . (e) deep margin: 2 mm,. . (f) superficial margin: <1 mm from invasive. ductal carcinoma (slide 4).. 6. Lymph nodes: no metastasis in three axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/3).. a. b. . HR(+) HER2(+) Breast Cancer. 400. 7. Arteriovenous invasion: absent.. 8. Lymphovascular. invasion:. present,. intratumoral.. 9. Tumor border: infiltrative.. . 10. Microcalcification:. present,. ­. tumoral/. non-tumoral.. . 11. Pathological TN category (AJCC 2017):. pT2N0(sn).. Result. Intensity. Positive. %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (7/8). 3. 1/3–2/3. C-erbB2. Positive (3+). Ki-67. Positive in 28%. of tumor cells. 30. " +465,Case 29,Important Radiologic,HR(+) HER2(+) Breast Cancer,Important Radiologic. Findings. 167 168 169. 29.3.  +470,Case 29,Patient History,HR(+) HER2(+) Breast Cancer,"Patient History and Progress. Female/80 years old, post-menopause.. Self-detected mass lesion on right breast 8. o’clock direction.. No family history.. Hypertension, dyslipidemia, s/p tympano­. plasty.. 29.2. " +459,Case 29,Courses of Treatment,HR(+) HER2(-) Breast Cancer,"Courses of Treatment. Operation  +  Post-operative radiation ther­. apy + Letrozole 2.5 mg/day.. Y. Kim et al.. 265. Operation. Left breast conserving surgery, sentinel lymph. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) superior margin: 20 mm.. . (b) inferior margin: 10 mm.. . (c) medial margin: 15 mm.. . (d) lateral margin: 15 mm.. . (e) deep margin: 10 mm.. . (f) superficial margin: 5 mm.. 6. Lymph nodes: no metastasis in two axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/2,. non-sentinel LN: 0/0). 7. Arteriovenous invasion: absent.. 8. Lymphovascular invasion: absent.. 9. Tumor border: infiltrative.. . 10. Microcalcification: present, non-tumoral.. . 11. Pathological TN category (AJCC 2017):. pT1bN0(sn).. Result. Intensity. Positive. %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (0). Ki-67. Positive in 4% of" +466,Case 29,Important Radiologic,HR(+) HER2(-) Breast Cancer,"Important Radiologic. Findings. See Figs. 160, 161, 162 and 163.. 29.3. " +471,Case 29,Patient History,HR(+) HER2(-) Breast Cancer,"S/P hysterectomy, hypertension, s/p left cere­. bral infarction, s/p transient ischemic attack.. 29.2. " +460,Case 29,Courses of Treatment,HR(−) HER2(+) Breast Cancer,"29.1. . Courses of Treatment. Operation (adjuvant chemotherapy refuse).. Operation. 200. 201. Pathology Report. Microinvasive Ductal Carcinoma. 1. Size of invasive component: <0.1 cm (pT1mi).. 2. Size of intraductal component: 5.0 cm.. 3. Histologic grade: not applicable.. 4. Intraductal component: present, intratu­. moral/extratumoral (99%) (nuclear grade:. high, necrosis: present, architectural pattern:. micropapillary/cribriform/comedo,. exten­. sive intraductal component: present).. 5. Skin: no involvement of tumor.. 6. Surgical margins: (see Note 1).. . (a) deep margin: 2 mm,. . (b) superficial margin: 2 mm.. 7. Lymph nodes: no metastasis in two axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/2,. axillary LN: 0/0).. 8. Arteriovenous invasion: absent.. 9. Lymphovascular invasion: absent.. . 10. Tumor border: infiltrative.. . 11. Microcalcification:. present,. tumoral/. non-tumoral.. . 12. Pathological TN category (AJCC 2017):. pT1miN0(sn).. Breast, left nipple, excision: Ductal carcinoma. in situ (see Note 2).. Breast, left nipple margin, excision: Ductal. carcinoma in situ (see Note 2).. Note: 1. The lateral border of the mastectomy. specimen (slide MG8) is close to ductal carci­. noma in situ (<1 mm).. 2. The nipple margin separately submitted for. permanent diagnosis (slides B&C) is positive for. ductal carcinoma in situ but this margin submit­. ted for frozen diagnosis (Fro 9) is free of tumor.. Result. Intensity. Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in. 29% of tumor. cells. . Y. Kwon et al.. 539. a. b. . . . 30. " +467,Case 29,Important Radiologic,HR(−) HER2(+) Breast Cancer,Important Radiologic. Findings. 197 198. 199. . . ­. . HR(−) HER2(+) Breast Cancer. 538. 29.3.  +472,Case 29,Patient History,HR(−) HER2(+) Breast Cancer,"Patient History and Progress. Female/39 years old, pre-menopause.. Self-detected palpable mass lesion on upper. outer portion of left breast.. No family history.. S/P Left salpingo-oophorectomy.. BRCA 1 and 2 mutation: Not detected.. 29.2. " +461,Case 29,Courses of Treatment,HR(−) HER2(−) Breast Cancer,"29.1. . Courses of Treatment. Neoadjuvant chemotherapy (#4 cycles of doxo­. rubicin and cyclophosphamide + #4 cycles of. docetaxel) + Operation + Post-operative radia­. tion therapy + Adjuvant capecitabine.. Operation. 215. Pathology Report. Microinvasive Ductal Carcinoma. 1. Post-chemotherapy status.. 2. Size of tumor: <0.1 cm (ypT1mi).. 3. Histologic grade: not applicable.. 4. Intraductal component: absent.. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) Superior margin: 10 mm.. . (b) Inferior margin: 10 mm.. . (c) Medial margin: 10 mm.. . (d) Lateral margin: 10 mm.. . (e) Deep margin: 2 mm.. . (f) Superficial margin: 2 mm.. 7. Lymph nodes: no metastasis in six axillary. lymph nodes (ypN0) (sentinel LN: 0/3, non-­. sentinel LN: 0/3).. 8. Arteriovenous invasion: absent.. 9. Lymphovascular invasion: absent.. . 10. Tumor border: infiltrative.. . 11. Microcalcification: present, tumoral/non-. tumoral.. . 12. Pathological TN category (AJCC 2017):. ypT1miN0.. Result. Intensity. Positive. %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Negative (1+). Ki-67. Positive in 43%. of tumor cells. E. S. Lee et al.. 681. . . . ­. ­. HR(−) HER2(−) Breast Cancer. 682. 30. " +468,Case 29,Important Radiologic,HR(−) HER2(−) Breast Cancer,Important Radiologic Findings. 208 209 210. 211. . E. S. Lee et al.. 679. . . ­. . HR(−) HER2(−) Breast Cancer. 680. . After Neoadjuvant. Chemotherapy. 212 213. 214. 29.3.  +473,Case 29,Patient History,HR(−) HER2(−) Breast Cancer,"Patient History and Progress. Female/27 years old, pre-menopause.. Self-detected mass lesion on left breast.. No family history.. No comorbidities.. BRCA 1 and 2 mutation: Not detected.. HR(−) HER2(−) Breast Cancer. 678. 29.2. " +462,Case 29,Courses of Treatment,Local Recurrence,"29.1. . Courses of Treatment. Left breast IDC→ Operation → Adjuvant ther­. apy → Left breast recurrence (IDC).. Primary Treatment. 194 195 196. 197. Operation. ­. 198. Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 3.0 cm (pT2).. . . . ­. Local Recurrence. 796. 2. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 2/3, 12/10HPF).. 3. Intraductal component: present, intratu­. moral/extratumoral (20%) (nuclear grade:. low, necrosis: present, architectural pattern:. cribriform/solid/comedo, extensive intra­. ductal component: present).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) Deep margin: <1 mm from invasive duc­. tal carcinoma (slide 2).. . (b) Superficial margin: <1 mm from ductal. carcinoma in situ (slide 9).. . . Y. Kim et al.. 797. 6. Lymph nodes: no metastasis in one axillary. lymph node (pN0(sn)) (sentinel LN: 0/1).. 7. Arteriovenous invasion: absent.. 8. Extensive lymphovascular invasion: present,. intratumoral/peritumoral.. 9. Tumor border: infiltrative.. . 10. Microcalcification:. present,. tumoral/. non-tumoral.. . 11. Pathologic stage (AJCC 2010): pT2N0(sn).. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Negative (2/8). 1. <1%. C-erbB2. Equivocal (2+). (SISH negative). Ki-67. Positive in 11%. of tumor cells. Adjuvant Therapy. Adjuvant chemotherapy #4 cycles of cyclophos­. phamide and docetaxel.. Tamoxifen 20 mg/day for 3.6 years.. Treatments After Recurrence. 199. 200. Operation. ­. 201. 202. Pathology Report. . Fibrocystic change.. . Invasive Ductal Carcinoma. 1. Post-nipple-sparing mastectomy status.. 2. Size of tumor: 2.0 cm and 1.8 cm (rpT1c(2)).. 3. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 2/3, 11/10HPF).. 4. Intraductal component: absent.. 5. Skin: dermal involvement of tumor.. 6. Surgical margins:. . (a) Deep margin: positive for invasive. . ductal carcinoma (slide 1).. . (b) Superficial margin: 2 mm.. 7. Lymph nodes: no metastasis in one axillary. lymph node (rpN0(sn)) (sentinel LN: 0/1).. . . Local Recurrence. 798. a. b. c. d. . a. b. . 8. Arteriovenous invasion: absent.. 9. Lymphovascular. invasion:. present,. intratumoral.. . 10. Tumor border: infiltrative.. . 11. Microcalcification:. present,. tumoral/. non-tumoral.. . 12. Pathological TN category (AJCC 2017):. rpT1cN0(sn).. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Negative (2/8). 1. <1%. C-erbB2. Equivocal (2+). (SISH negative). Ki-67. Positive in 2%. of tumor cells. Y. Kim et al.. 799. Adjuvant Therapy. Postoperative radiation therapy.. Letrozole 2.5 mg/day.. 30. " +474,Case 29,Patient History,Local Recurrence,"Patient History and Progress. Female/46 years old, pre-menopause.. Screen detected mass lesion on left breast 7:30. o’clock direction.. Outside result of biopsy: (1) Invasive ductal. carcinoma, (2) Atypical ductal hyperplasia.. Family history of breast cancer, mother.. Asthma.. BRCA 1 VUS (variant of uncertain).. 29.2. " +463,Case 29,Courses of Treatment,Metastatic Breast Cancer,"Courses of Treatment. Right breast cancer → Neoadjuvant chemother­. apy → Operation → Adjuvant therapy → Lung. metastasis.. Primary Treatment. receptor. Strong. (6/7). 3. 1/3–2/3. Progesterone. receptor. Strong. (6/7). 3. 1/3–2/3. C-erbB2. Negative. (1+). Ki-67. N.A. Clinical stage: cT3N1M0.. Operation. Oct. 2007 Right total mastectomy, axillary lymph. node dissection.. Pathology: Invasive ductal carcinoma, stage. ypT2N0.. Size of tumor: 2.5 cm, lymph node: 0/6.. Result. Intensity. Positive %. Estrogen. receptor. Strong (6/7). 3. 1/3–2/3. Progesterone. receptor. Weak (2/7). 1. <10%. C-erbB2. Negative. (1+). Ki-67. Positive in. 5% of tumor. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (0). Ki-67. Positive in. 15% of. tumor cells. Aug. 2021 Chest CT:. LN enlargement, right interlobar and right. lower paratracheal, metastasis.. Bronchovascular bundle thickening in RUL. and centrilobular nodules in RLL, lymphangitic. metastasis.. Palliative Therapy. Letrozole 2.5 mg/day + (ribociclib #1→ palboci­. clib~) + zoladex~. Y. Kwon et al.. 911. 30. " +475,Case 29,Patient History,Metastatic Breast Cancer, +476,Case 3,Courses of Treatment,Benign and Proliferative,"3.1. . Courses of Treatment. → 2021-12-10 Excision, Rt.. C. W. Lee et al.. 21. . ­. . ­. 3.3.1. . Pathology Report. Diagnosis. • Breast, right, excision:. –. – Intraductal papilloma.. 4. " +484,Case 3,Important Radiologic,Benign and Proliferative,Important Radiologic. Findings. 4. 5. 3.3.  +490,Case 3,Patient History,Benign and Proliferative,"Patient History and Progress. Female/72 years old, post-menopause.. Screen detected nodular lesion on right breast. 9 o’clock direction.. No family history.. Hypertension.. 3.2. " +477,Case 3,Courses of Treatment,Carcinoma In Situ,"Courses of Treatment. Operation + Tamoxifen 20 mg/day for 5 years.. 3.3.1. . Operation. 13. 14. 3.3.2. . Pathology Report. . Lobular carcinoma in situ. . 1. Size of tumor: 0.3 cm.. . 2. Nuclear grade: low.. . 3. Necrosis: absent.. . 4. Architectural pattern: solid.. . 5. Surgical margins:. . (a) superior margin: <1 mm (slide 3),. . (b) inferior margin: 5 mm,. . (c) medial margin: positive (slide 4),. . (d) lateral margin: 5 mm,. . (e) deep margin: 2 mm,. . (f) superficial margin: 2 mm.. . 6. Microcalcification:. present,. tumoral/non-. tumoral.. Result. Intensity. Positive %. Estrogen. receptor. Strong (7/8). 3. 1/3–2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (1+). Ki-67. Positive in 5%. of tumor cells. . E. S. Lee et al.. 57. . . Carcinoma In Situ. 58. Lobular carcinoma in situ. . 1. Post-excision status.. . 2. Size of tumor: 0.3 cm, residual.. . 3. Nuclear grade: low.. . 4. Necrosis: absent.. . 5. Architectural pattern: solid.. . 6. Surgical margins:. . (a) Superior margin: 5 mm.. . (b) Inferior margin: 5 mm.. . (c) Medial margin: 5 mm.. . (d) Lateral margin: 5 mm.. . (e) Deep margin: 2 mm.. . (f) Superficial margin: 2 mm.. . 7. Microcalcification: present, non-tumoral.. 4. " +485,Case 3,Important Radiologic,Carcinoma In Situ,3.1. . Important Radiologic. Findings. 11. 12. 3.3.  +491,Case 3,Patient History,Carcinoma In Situ,"Patient History and Progress. Female/41 years old, pre-menopause.. Screen detected microcalcifications on right. breast upper outer.. Outside result of biopsy: Right 10 o’clock. 1.. Usual ductal hyperplasia, 2. duct ectasia.. No family history.. S/P Hallux valgus operation.. 3.2. " +478,Case 3,Courses of Treatment,HR(+) HER2(+) Breast Cancer,"3.1. . Courses of Treatment. Operation  +  Adjuvant chemotherapy (#4. cycles of doxorubicin and cyclophospha­. mide). +. Post-operative. radiation. ther­. apy + Trastuzumab + Letrozole 2.5 mg/day.. . . S. Park et al.. 307. . 18. 3.3.1. . Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 1.8 cm (pT1c).. 2. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 2/3, 10/10 HPF).. 3. Intraductal component: present, intratu­. moral/extratumoral (10%) (nuclear grade:. high, necrosis: present, architectural pattern:. solid/comedo, extensive intraductal compo­. nent: absent).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) superior margin: 10 mm,. . (b) inferior margin: (see note),. . (c) medial margin: 5 mm,. . (d) lateral margin: 10 mm,. . (e) deep margin: 2 mm,. . (f) superficial margin: 4 mm.. HR(+) HER2(+) Breast Cancer. 308. 6. Lymph nodes: no metastasis in one axillary. lymph node (pN0(sn)) (sentinel LN: 0/1).. 7. Arteriovenous invasion: absent.. 8. Lymphovascular invasion: absent.. 9. Tumor border: infiltrative.. . 10. Microcalcification:. present,. tumoral/. non-tumoral.. . 11. Pathological TN category (AJCC 2017):. pT1cN0(sn).. Note: 1. The inferior margin of the lumpec­. tomy specimen (slides 3 and 4) is close to ductal. carcinoma in situ (2 mm) but this margin submit­. ted for frozen diagnosis (Fro 2) is free of tumor.. Result. Intensity. Positive. %. Estrogen. receptor. Strong (7/8). 2. >2/3. Progesterone. receptor. Intermediate. (6/8). 2. 1/3–2/3. C-erbB2. Equivocal (2+). Ki-67. Positive in 43%. of tumor cells. SISH. Positive. . . S. Park et al.. 309. a. b. . 4. " +486,Case 3,Important Radiologic,HR(+) HER2(+) Breast Cancer,Important Radiologic. Findings. 13 14 15 16. 17. 3.3.  +492,Case 3,Patient History,HR(+) HER2(+) Breast Cancer,"Patient History and Progress. Female/58 years old, post-menopause.. Screen detected mass lesion on right breast 7. o’clock direction.. No family history.. Dyslipidemia.. 3.2. " +479,Case 3,Courses of Treatment,HR(+) HER2(-) Breast Cancer,"Courses of Treatment. Operation  +  Post-operative radiation ther­. apy + Letrozole 2.5 mg/day.. Y. Kim et al.. moral/extratumoral (5%) (nuclear grade:. low, necrosis: absent, architectural pattern:. cribriform, extensive intraductal component:. absent).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) superior margin: 10 mm,. . (b) inferior margin: 20 mm,. . (c) medial margin: 10 mm,. . (d) lateral margin: 10 mm (see note 1),. . (e) deep margin: 2 mm,. . (f) superficial margin: 2 mm.. 6. Lymph nodes: no metastasis in three axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/1,. non-sentinel LN: 0/2).. 7. Arteriovenous invasion: absent.. 8. Lymphovascular. invasion:. present,. intratumoral.. 9. Tumor border: infiltrative.. . 10. Microcalcification:. present,. tumoral/. non-tumoral.. Breast, right subareolar:. Invasive Ductal Carcinoma. 1. Size of tumor: 1.1 cm (pT1c).. 2. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 2/3, 11/10 HPF).. 3. Intraductal component: present, intratu­. moral/extratumoral (10%) (nuclear grade:. low, necrosis: absent, architectural pattern:. cribriform, extensive intraductal component:. absent).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) superior margin: 10 mm,. . (b) inferior margin: (see note 2),. . (c) medial margin: 10 mm,. . (d) lateral margin: 10 mm,. . (e) deep margin: 1 mm from invasive ductal. carcinoma (slide 9),. . (f) superficial margin: 2 mm.. 6. Arteriovenous invasion: absent.. 7. Lymphovascular. invasion:. present,. intratumoral.. 8. Tumor border: infiltrative.. 9. Microcalcification:. present,. tumoral/. non-tumoral.. . 10. Pathological TN category (AJCC 2017):. pT1cN0(sn).. Result. Intensity. Positive %. Estrogen receptor. Strong (7/8). 2. >2/3. Progesterone receptor. Weak (3/8). 1. 1–10%. C-erbB2. Negative (1+). Ki-67. Positive in 4% of tumor cells. Y. Kim et al." +487,Case 3,Important Radiologic,HR(+) HER2(-) Breast Cancer,"Important Radiologic. Findings. See Figs. 10, 11, 12 and 13.. 3.3. " +493,Case 3,Patient History,HR(+) HER2(-) Breast Cancer,No family history.. L-spine disc herniation.. 3.2.  +480,Case 3,Courses of Treatment,HR(−) HER2(+) Breast Cancer,"3.1. . Courses of Treatment. Palliative chemotherapy (#7 cycles of docetaxel. and. trastuzumab. and. pertuzumab). +. Operation. +. Post-operative. radiation. ther­. apy + Palliative trastuzumab and pertuzumab.. 3.4.1. . Operation. 26. 3.4.2. . Pathology Report. Ductal Carcinoma In Situ. 1. Post-chemotherapy status.. 2. Size of tumor: 0.2 cm (ypTis).. 3. Nuclear grade: high.. 4. Necrosis: absent.. 5. Architectural pattern: solid.. 6. Skin: no involvement of tumor.. 7. Surgical margins:. . (a) superior margin: 12 mm,. . (b) inferior margin: (see note),. . (c) medial margin: 10 mm,. . (d) lateral margin: 20 mm,. . (e) deep margin: 10 mm,. . (f) superficial margin: 12 mm.. 8. Lymph nodes: no metastasis in four axillary. lymph nodes (ypN0(sn)) (sentinel LN: 0/4).. 9. Arteriovenous invasion: absent.. . 10. Lymphovascular invasion: absent.. . 11. Tumor border: pushing.. . 12. Microcalcification:. present,. tumoral/. non-tumoral.. . 13. Pathological TN category (AJCC 2017):. ypTisN0(sn).. Result. Intensity. Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in. 14% of tumor. cells. . ­. . HR(−) HER2(+) Breast Cancer. 442. 4. " +488,Case 3,Important Radiologic,HR(−) HER2(+) Breast Cancer,Important Radiologic. Findings. 18 19 20. 21. . HR(−) HER2(+) Breast Cancer. 438. . . ­. Y. Kwon et al.. 439. F. i. g. . 21. . . ­. ­. . ­. ­. 3.3. . After Neoadjuvant. Chemotherapy. 22 23 24. 25. Y. Kwon et al.. 441. 3.4.  +494,Case 3,Patient History,HR(−) HER2(+) Breast Cancer,"Patient History and Progress. Female/61 years old, post-menopause.. Self-detected nipple retraction on right breast.. Family history of breast cancer, cousin. (maternal).. No comorbidities.. BRCA 1 and 2 mutation: Not detected.. 3.2. " +481,Case 3,Courses of Treatment,HR(−) HER2(−) Breast Cancer,"3.1. . Courses of Treatment. Operation + operation, Transfer.. 3.3.1. . Operation. 20. 3.3.2. . Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 2.3 cm (pT2).. 2. Histologic grade: 3/3 (tubule formation: 2/3,. nuclear pleomorphism: 3/3, mitotic count:. 3/3, 82/10HPF).. 3. Intraductal component: present, extratumoral. (30%) (nuclear grade: high, necrosis: pres­. ent, architectural pattern: solid/comedo,. extensive intraductal component: present).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) superior margin: (see note),. . (b) inferior margin: positive for ductal carci­. noma in situ (Fro 5),. E. S. Lee et al.. 583. . . ­. . ­. ­. HR(−) HER2(−) Breast Cancer. 584. . . ­. ­. . (c) medial margin: positive for ductal carci­. noma in situ (Fro 6),. . (d) lateral margin: 5 mm,. . (e) deep margin: <1 mm from ductal carci­. noma in situ (slide 11),. . (f) superficial margin: 5 mm.. 6. Lymph nodes: no metastasis in three axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/3,. non-sentinel LN: 0/0).. 7. Arteriovenous invasion: absent.. 8. Lymphovascular. invasion:. present,. intratumoral.. E. S. Lee et al.. 585. . 9. Tumor border: infiltrative.. . 10. Microcalcification: present, tumoral.. . 11. Pathological TN category (AJCC 2017):. pT2N0(sn).. Breast, left 2 o’clock, lumpectomy:. Invasive Ductal Carcinoma. 1. Size of invasive component: 0.2 cm.. 2. Size of intraductal component: 2.0 cm.. 3. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 2/3, 13/10HPF).. 4. Intraductal component: present, intratu­. moral/extratumoral (90%) (nuclear grade:. high, necrosis: present, architectural pattern:. solid/comedo, extensive intraductal compo­. nent: present).. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) Superior margin: 5 mm.. . (b) Inferior margin: positive for ductal car­. cinoma in situ (slide 21).. . (c) Medial margin: 5 mm.. . (d) Lateral margin: <1 mm from ductal car­. cinoma in situ (slide 22).. . (e) Deep margin: <1 mm from ductal carci­. noma in situ (slide 21).. . (f) Superficial margin: 1  mm from ductal. carcinoma in situ (slide 18).. 7. Arteriovenous invasion: absent.. 8. Lymphovascular invasion: absent.. 9. Tumor border: infiltrative.. . 10. Microcalcification: present, non-tumoral.. Note: 1. The superior margin of the. lumpectomy specimen (slide 1) is positive for. ductal carcinoma in situ, but this margin sub­. mitted for frozen diagnosis (Fro 4) is free of. tumor.. 21. Result. Intensity. Positive. %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Negative (0). Ki-67. Positive in 53%. of tumor cells. 4. " +489,Case 3,Important Radiologic,HR(−) HER2(−) Breast Cancer,Important Radiologic. Findings. 16 17 18. 19. 3.3.  +495,Case 3,Patient History,HR(−) HER2(−) Breast Cancer,"Patient History and Progress. Female/41 years old, pre-menopause.. Screen detected mass lesion on left breast 3. o’clock direction.. No family history.. No comorbidities.. 3.2. " +482,Case 3,Courses of Treatment,Local Recurrence,"3.1. . Courses of Treatment. Left breast IDC + DCIS → Operation → Left. breast recurrence (DCIS).. 14. 15. 3.2.1. . Operation. 16. 3.2.2. . Pathology Report. Ductal Carcinoma In Situ. . 1. Size of tumor: 1.5 cm.. . 2. Nuclear grade: high.. . 3. Necrosis: present.. . 4. Architectural pattern: solid/comedo.. . 5. Surgical margins:. . (a) Superior margin: 2 mm (slide 6).. . (b) Inferior margin: 1.5 mm (slide 6).. . (c) Medial margin: 10 mm.. . (d) Lateral margin: <1 mm (slide 7).. . (e) Deep margin: 2 mm.. . 6. Microcalcification:. present,. tumoral/. non-tumoral.. Result. Intensity. Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (2/8). 1. <1%. C-erbB2. Positive (3+). Ki-67. Positive in 35%. of tumor cells. Y. Kim et al.. 723. a. b. . a. b. c. d. . 3.2.3. . Operation. 17. 3.2.4. . Pathology Report. Invasive Ductal Carcinoma. 1. Post-excision status.. 2. Size of invasive component: 0.2 cm (pT1a).. 3. Size of intraductal component: 3.5 cm.. 4. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 1/3, <1/10HPF).. 5. Intraductal component: present, extratumoral. (99%) (nuclear grade: high, necrosis: pres­. ent, architectural pattern: micropapillary/. cribriform/solid/comedo, extensive intra­. ductal component: present).. Local Recurrence. 724. 6. Skin: no involvement of tumor.. 7. Surgical margins:. . (a) Superior margin: (see note 1).. . (b) Inferior margin: (see note 2).. . (c) Medial margin: 15 mm.. . (d) Lateral margin: (see note 3).. . (e) Deep margin: <1 mm from ductal carci­. noma in situ (slide 14).. . (f) Superficial margin: 2 mm.. 8. Arteriovenous invasion: absent.. 9. Lymphovascular invasion: absent.. . 10. Tumor border: infiltrative.. . 11. Microcalcification: present, tumoral.. . 12. Pathological TN category (AJCC 2017): pT1a.. Result. Intensity. Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in 65%. of tumor cells. 3.3. . Treatments After Recurrence. 18 19. 20. 3.3.1. . Operation. ­. 21. 3.3.2. . Pathology Report. Ductal Carcinoma In Situ. 1. Post-excision status.. 2. Size of tumor: 1.5 cm (rpTis).. 3. Nuclear grade: high.. 4. Necrosis: present.. 5. Architectural pattern: micropapillary.. 6. Skin: no involvement of tumor.. 7. Surgical margins:. . (a) Deep margin: 2 mm.. . (b) Superficial margin: 2 mm.. 8. Lymph nodes: no metastasis in one axillary. lymph node (pN0(sn)) (sentinel LN:0/1).. . . . Y. Kim et al.. 725. . 9. Microcalcification:. present,. tumoral/. non-tumoral.. . 10. Pathological TN category (AJCC 2017):. rpTisN0(sn).. Result. Intensity Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in 19%. of tumor cells. 4. " +496,Case 3,Patient History,Local Recurrence,"Patient History and Progress. Female/47 years old, pre-menopause.. Screen detected microcalcification on upper. portion of left breast.. Family history of colon cancer, father.. No comorbidities.. 3.2. " +483,Case 3,Courses of Treatment,Metastatic Breast Cancer,"Courses of Treatment. Left. breast. cancer. →. Neoadjuvant. Chemotherapy → Operation → Adjuvant therapy. → Bone, lung, and brain metastasis.. 3.2.1. . Primary Treatment. Docetaxel #4).. Operation. Mar. 2018 Left modified radical mastectomy.. Pathology: Invasive ductal carcinoma, stage. ypT2N1.. Size of tumor: 2.7 * 2.4 cm, lymph node: 2/5,. size of metastatic carcinoma: 4 mm.. Metastatic Breast Cancer. Estrogen. receptor. Negative. (0/8). 0. 0. Progesterone. receptor. Negative. (0/8). 0. 0. C-erbB2. Negative. (1+). Ki-67. Positive. in 26% of. tumor. cells. Adjuvant Therapy. Post-operative radiation therapy +adjuvant che­. motherapy (Xeloda).. 3.2.2. . Treatments After Recurrence. Bone metastasis → Lung metastasis → Brain. metastasis → Progression.. Palliative Therapy. Apr. 2020 Bone scan: multiple bone metastasis in. right T2-5, T7 and left 4th–5th ribs.. → Nab-paclitaxel/atezolizumab #7 cycles:. Progressive disease on pleural nodule.. → Xeloda #7 cycles: Progressive disease on. brain → Whole brain radiation therapy.. → Gemcitabine #2 cycles: Progressive disease. on pleural effusion.. → Eribulin #2 cycles: Progressive disease on. pleural effusion.. → Vinorelbine/carboplatin #3 cycles: clini­. cally progressive disease.. See Figs. 9, 10, 11, and 12.. Y. Kwon et al." +497,Case 3,Patient History,Metastatic Breast Cancer, +498,Case 30,Courses of Treatment,Carcinoma In Situ,"30.1. . Courses of Treatment. Operation + Postoperative Radiation therapy.. Operation. 142. 143. Pathology Report. Ductal carcinoma in situ, pathological TN cat­. egory (AJCC 2017): pTisN0(sn). . 1. Size of tumor: 2.0 cm (pTis).. . 2. Nuclear grade: high.. . 3. Necrosis: present.. . 4. Architectural pattern: micropapillary/cribri­. form/solid/comedo.. . 5. Skin: no involvement of tumor.. . 6. Surgical margins:. . (a) nipple margin: positive for ductal carci­. noma in situ (Fro 4),. . (b) subareolar margin: positive for ductal car­. cinoma in situ (Fro 1),. . (c) deep margin: 2 mm,. . (d) superficial margin: 2 mm.. . 7. Lymph nodes: no metastasis in one axillary. lymph node (pN0(sn)) (sentinel LN: 0/1).. . 8. Microcalcification:. present,. tumoral/non-. tumoral.. . Carcinoma In Situ. 120. . ­. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Intermediate. (5/8). 2. 10%−1/3. C-erbB2. Positive (3+). Ki-67. Positive in. 11% of tumor. cells. 31. " +505,Case 30,Important Radiologic,Carcinoma In Situ,Important Radiologic. Findings. 138 139 140. 141. 30.3.  +510,Case 30,Patient History,Carcinoma In Situ,"Patient History and Progress. Female/60 years old, post-menopause.. Screen detected mass and microcalcification. on left breast 10 o’clock direction.. Outside result of biopsy: Ductal carcinoma in. situ.. No family history.. Claustrophobia, hypertension.. 30.2. " +499,Case 30,Courses of Treatment,HR(+) HER2(+) Breast Cancer,"30.1. . Courses of Treatment. Neoadjuvant chemotherapy (#6 cycles of. docetaxel and carboplatin and trastuzumab. and pertuzumab)  +  Operation  +  Post-­. operative radiation therapy.. 179. Pathology Report. Ductal Carcinoma In Situ. . 1. Post-chemotherapy status.. . 2. Size of tumor: 2.0 cm (ypTis).. . 3. Nuclear grade: high.. . 4. Necrosis: present.. . 5. Architectural pattern: papillary/micropapil­. lary/cribriform/solid/comedo.. . 6. Surgical margins:. . (a) superior margin: 8 mm,. . (b) inferior margin: 7 mm,. . (c) medial margin: 15 mm,. . (d) lateral margin: (see note),. . (e) deep margin: 3 mm,. . (f) superficial margin: 7 mm.. . 7. Lymph nodes: no metastasis in three axillary. lymph nodes (ypN0(sn)) (sentinel LN: 0/3).. . 8. Microcalcification: present, tumoral.. . 9. Pathological TN category (AJCC 2017):. ypTisN0(sn).. Note: 1. The lateral margin of the lumpectomy. specimen (slide 4) is close to ductal carcinoma in. situ (3 mm) but this margin submitted for frozen. diagnosis (Fro 4) is free of tumor.. Result. Intensity Positive %. Estrogen. receptor. Strong (7/8). 3. 1/3–2/3. Progesterone. receptor. Intermediate. (5/8). 2. 10%-1/3. C-erbB2. Positive (3+). Ki-67. Positive in 9%. of tumor cells. S. Park et al.. 403. . . . HR(+) HER2(+) Breast Cancer. 404. a. b. . 31. " +506,Case 30,Important Radiologic,HR(+) HER2(+) Breast Cancer,Important Radiologic. Findings. 172 173 174 175 176 177. 178 +511,Case 30,Patient History,HR(+) HER2(+) Breast Cancer,"Patient History and Progress. Female/31 years old, pre-menopause.. Self-detected palpable mass lesion on outer. inner portion of right breast.. No family history.. No comorbidities.. BRCA 1 and 2 mutation: Not detected.. 30.2. " +500,Case 30,Courses of Treatment,HR(+) HER2(-) Breast Cancer,"Courses of Treatment. Operation  +  Post-operative radiation ther­. apy + Letrozole 2.5 mg/day.. Operation. Left breast conserving surgery, sentinel lymph. ponent: absent).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) superior margin: 15 mm.. . (b) inferior margin: 15 mm.. . (c) medial margin: 10 mm.. . (d) lateral margin: 15 mm.. . (e) deep margin: 3 mm.. . (f) superficial margin: 15 mm.. 6. Lymph nodes: no metastasis in one axillary. lymph node (pN0(i+)(sn)) (see note) (senti­. nel LN: 0/1, non-sentinel LN: 0/0). 7. Arteriovenous invasion: absent.. 8. Lymphovascular. invasion:. present,. intratumoral.. 9. Tumor border: infiltrative.. . 10. Microcalcification: present, non-tumoral.. . 11. Pathological TN category (AJCC 2017):. pT1cN0(i+)(sn).. Note: 1. A few isolated tumor cells are. present only in the permanent section of Fro. 1 for immunohistochemical staining.. Result. Intensity. Positive %. Estrogen receptor. Strong (8/8). 3. >2/3. Progesterone receptor. Strong (7/8). 2. >2/3. C-erbB2. Negative (1+). Ki-67. Positive in 11% of tumor cells. Y. Kim et al." +507,Case 30,Important Radiologic,HR(+) HER2(-) Breast Cancer,"Important Radiologic. Findings. See Figs. 165, 166, 167 and 168.. 30.3. " +512,Case 30,Patient History,HR(+) HER2(-) Breast Cancer,"s/p Left optic nerve palsy, hypertension, s/p. right rotator cuff tear operation.. 30.2. " +501,Case 30,Courses of Treatment,HR(−) HER2(+) Breast Cancer,"30.1. . Courses of Treatment. Neoadjuvant chemotherapy (#6 cycles of. docetaxel and carboplatin and trastuzumab and. pertuzumab) + Operation + Post-operative radia­. tion therapy + Trastuzumab and pertuzumab.. 3. Histologic grade: not applicable.. 4. Intraductal component: absent.. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) superior margin: 10 mm,. . (b) inferior margin: (see note),. . (c) medial margin: 10 mm,. . (d) lateral margin: 10 mm,. . (e) deep margin: 2 mm,. . (f) superficial margin: 2 mm.. 7. Lymph nodes: no metastasis in three axillary. lymph nodes (ypN0(sn)) (sentinel LN: 0/3).. 8. Arteriovenous invasion: absent.. 9. Lymphovascular invasion: absent.. . 10. Tumor border: infiltrative.. . 11. Microcalcification: present, tumoral.. . 12. Pathological TN category (AJCC 2017):. ypT1miN0(sn).. Note: 1. The inferior margin of the lumpec­. tomy specimen (slide 5) is close to microinvasive. ductal carcinoma (2 mm) but this margin submit­. ted for frozen diagnosis (Fro 2) is free of tumor.. Result. Intensity. Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in. 19% of tumor. cells. a. b. . Y. Kwon et al.. 543. 31. " +508,Case 30,Important Radiologic,HR(−) HER2(+) Breast Cancer,Important Radiologic. Findings. 202 203. 204. HR(−) HER2(+) Breast Cancer. 540. . ­. Y. Kwon et al.. 541. 30.3. . After Neoadjuvant. Chemotherapy. 205 206. 207. 30.4.  +513,Case 30,Patient History,HR(−) HER2(+) Breast Cancer,"Patient History and Progress. Female/41 years old, pre-menopause.. Self-detected palpable mass and nipple dis­. charge on left breast.. No family history.. No comorbidities.. BRCA 1 and 2 mutation: Not detected.. 30.2. " +502,Case 30,Courses of Treatment,HR(−) HER2(−) Breast Cancer,"30.1. . Courses of Treatment. Neoadjuvant chemotherapy (#2  cycles of. doxorubicin and cyclophosphamide  +  #3. cycles of paclitaxel) + Operation + Adjuvant. capecitabine.. Operation. 224. Pathology Report. Invasive Ductal Carcinoma. 1. Post-chemotherapy status.. 2. Size of tumor: 3.5 cm (ypT2).. 3. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 3/3, 4/1HPF).. 4. Intraductal component: present, extratumoral. (5%) (nuclear grade: high, necrosis: absent,. architectural pattern: solid, extensive intra­. ductal component: absent).. 5. Skin and nipple: no involvement of tumor.. 6. Surgical margins:. . (a) Deep margin: 1 mm from invasive ductal. carcinoma (slide 6).. . (b) Superficial margin: 2 mm.. . . ­. . HR(−) HER2(−) Breast Cancer. 684. . E. S. Lee et al.. 685. . . . 7. Lymph nodes: no metastasis in two axillary. lymph nodes (ypN0(sn)) (sentinel LN: 0/2).. 8. Arteriovenous invasion: absent.. 9. Lymphovascular. invasion:. present,. intratumoral.. . 10. Tumor border: infiltrative.. . 11. Microcalcification:. present,. tumoral/. non-tumoral.. . 12. Pathological TN category (AJCC 2017):. ypT2N0(sn).. Result. Intensity. Positive. %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Equivocal (2+),. SISH (−). Ki-67. Positive in 86%. of tumor cells. HR(−) HER2(−) Breast Cancer. 686. . 31. " +509,Case 30,Important Radiologic,HR(−) HER2(−) Breast Cancer,Important Radiologic. Findings. 216 217. 218. . E. S. Lee et al.. 683. After Neoadjuvant. Chemotherapy. 219 220 221 222. 223. 30.3.  +514,Case 30,Patient History,HR(−) HER2(−) Breast Cancer,"Patient History and Progress. Female/69 years old, post-menopause.. Self-detected palpable mass lesion on left. breast.. No family history.. h/o Tuberculosis, s/p thoracic vertebra com­. pression fracture.. 30.2. " +503,Case 30,Courses of Treatment,Local Recurrence,"30.1. . Courses of Treatment. Right breast IDC → Operation → Adjuvant. therapy → Left breast recurrence (IDC).. Primary Treatment. 203 204 205. 206. . . . . Local Recurrence. 800. a. b. c. d. . Operation. 207. Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 2.2 cm (pT2).. 2. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 5/10HPF).. 3. Intraductal component: present, intratu­. moral/extratumoral (5%) (nuclear grade:. low, necrosis: present, architectural pattern:. cribriform/solid, extensive intraductal com­. ponent: absent).. 4. Skin and nipple: no involvement of tumor.. 5. No involvement of skeletal muscle.. 6. Surgical margins:. . (a) Deep margin: 8 mm.. . (b) Superficial margin: 15 mm.. 7. Lymph nodes:. . (a) metastasis in 1 out of 5 axillary lymph. nodes (pN1a) (sentinel LN: 1/3, axillary. LN: 0/2).. . (b) perinodal extension: present.. . (c) size of metastatic carcinoma: 11 mm.. 8. Arteriovenous invasion: absent.. 9. Lymphovascular. invasion:. present,. peritumoral.. . 10. Tumor border: infiltrative.. . 11. Microcalcification: present, tumoral.. . 12. Pathologic stage (AJCC 2010): pT2N1a.. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Weak (3/8). 1. 1–10%. C-erbB2. Negative (1+). Ki-67. Positive in 11%. of tumor cells. Adjuvant Therapy. Anastrozole 1 mg/day for 4 years.. Y. Kim et al.. 801. Treatments After Recurrence. 208 209. 210. Operation. 211. Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 0.9 cm (pT1b).. 2. Histologic grade: 2 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 1/3, 3/10HPF).. 3. Intraductal component: present, intratu­. moral/extratumoral (50%) (nuclear grade:. high, necrosis: present, architectural pattern:. comedo, extensive intraductal component:. present).. 4. Skin and nipple: no involvement of tumor.. 5. Surgical margins:. . (a) Deep margin: 2 mm.. . (b) Superficial margin: 20 mm.. 6. Lymph nodes: no metastasis in one axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/1).. 7. Arteriovenous invasion: absent.. 8. Lymphovascular invasion: absent.. . . . Local Recurrence. 802. a. b. c. d. . 9. Tumor border: infiltrative.. . 10. Microcalcification: absent.. . 11. Pathological TN category (AJCC 2017):. pT1bN0(sn).. Result. Intensity. Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Equivocal (2+). (SISH negative). Ki-67. Positive in 6%. of tumor cells. 31. " +515,Case 30,Patient History,Local Recurrence,"Patient History and Progress. Female/89 years old, post-menopause.. Screen detected mass lesion on right breast 1. o’clock direction.. Outside result of biopsy: Invasive ductal. carcinoma.. No family history.. Hypertension, Hypothyroidism, s/p Cardiac. stent insertion (angina).. s/p Shoulder ligament rupture operation.. 30.2. " +504,Case 30,Courses of Treatment,Metastatic Breast Cancer,30.1. . Courses of Treatment. Right breast cancer → Operation → Adjuvant. therapy → Bone metastasis.. Positive %. Estrogen. receptor. Strong (7/8). 3. 1/3–2/3. Progesterone. receptor. Strong (7/8). 3. 1/3–2/3. C-erbB2. Negative (0). Ki-67. Positive in. 5% of tumor. cells. Adjuvant Therapy. Tamoxifen 20 mg/day.. Treatments After Recurrence +516,Case 30,Patient History,Metastatic Breast Cancer,"Patient History and Progress. Female/50 years old, pre-menopause.. No family history.. Hepatitis B virus carrier, s/p myomectomy.. 30.2. " +517,Case 31,Courses of Treatment,Carcinoma In Situ,"31.1. . Courses of Treatment:. Operation. Operation. 146. 147. Pathology Report. Ductal carcinoma in situ, pathological TN cat­. egory (AJCC 2017): pTis. . 1. Size of tumor: 2.0 cm (pTis).. . 2. Nuclear grade: low.. . 3. Necrosis: absent.. . 4. Architectural pattern: papillary/micropapil­. lary/cribriform.. E. S. Lee et al.. 121. . . . 5. Skin: no involvement of tumor.. . 6. Surgical margins:. . (a) deep margin: 2 mm,. . (b) superficial margin: 2 mm.. . 7. Microcalcification:. present,. tumoral/non-. tumoral.. Result. Intensity Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Equivocal (2+). Ki-67. Positive in 3%. of tumor cells. Carcinoma In Situ. 122. a. b. d. e. . . ­. E. S. Lee et al.. 123. 32. " +524,Case 31,Important Radiologic,Carcinoma In Situ,Important Radiologic. Findings. 144. 145. 31.3.  +529,Case 31,Patient History,Carcinoma In Situ,"Patient History and Progress. Female/31 years old, pre-menopause.. Screen detected calcification on left breast. 11 o’clock direction.. Outside result of mammotome biopsy: Ductal. carcinoma in situ.. No family history.. No comorbidities.. BRCA 1 and 2: Not detected.. 31.2. " +518,Case 31,Courses of Treatment,HR(+) HER2(+) Breast Cancer,"31.1. . Courses of Treatment. Operation  +  Adjuvant chemotherapy (#4. cycles of doxorubicin and cyclophosphamide. followed by #4 cycles of docetaxel and trastu­. zumab)  +  Post-operative radiation ther­. apy + Trastuzumab + Letrozole 2.5 mg/day.. 184. Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 1.7 cm (pT1c).. S. Park et al.. micropapillary/comedo,. extensive. intra­. ductal component: absent).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) superior margin: 10 mm,. . (b) inferior margin: 15 mm,. . (c) medial margin: 15 mm,. . (d) lateral margin: 10 mm,. . (e) deep margin: 2 mm,. . (f) superficial margin: 2 mm.. HR(+) HER2(+) Breast Cancer. 406. . . S. Park et al.. 407. 6. Lymph nodes:. . (a) metastasis in one out of two axillary. lymph nodes (pN1a(sn)) (sentinel LN:. 1/1, axillary LN: 0/1),. . (b) perinodal extension: present,. . (c) size of metastatic carcinoma: 8 mm.. 7. Arteriovenous invasion: absent.. 8. Lymphovascular. invasion:. present,. intratumoral.. 9. Tumor border: infiltrative.. . 10. Microcalcification:. present,. tumoral/. non-tumoral.. . 11. Pathological TN category (AJCC 2017):. pT1cN1a(sn).. . a. b. . HR(+) HER2(+) Breast Cancer. 408. Result. Intensity. Positive. %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (7/8). 3. 1/3–2/3. C-erbB2. Positive (3+). Ki-67. Positive in 19%. of tumor cells. 32. " +525,Case 31,Important Radiologic,HR(+) HER2(+) Breast Cancer,Important Radiologic. Findings. 180 181 182. 183. 31.3.  +530,Case 31,Patient History,HR(+) HER2(+) Breast Cancer,"Patient History and Progress. Female/69 years old, post-menopause.. Self-detected nipple retraction on left breast.. No family history.. Hypertension.. 31.2. " +519,Case 31,Courses of Treatment,HR(+) HER2(-) Breast Cancer,"Courses of Treatment. Operation. +. Adjuvant. chemotherapy. (#4 cycles of docetaxel & ­. cyclophosphamide) +. Post-operative radiation therapy + Letrozole. 2.5 mg/day.. Operation. Right breast conserving surgery, sentinel lymph. . (c) medial margin: 10 mm.. . (d) lateral margin: 10 mm.. . (e) deep margin: <1 mm from invasive duc­. tal carcinoma (slide 2).. . (f) superficial margin: 5 mm.. 6. Lymph nodes:. . (a) metastasis in one out of four axillary. lymph nodes (pN1a(sn)) (sentinel LN:. 1/1, axillary LN: 0/3). . (b) perinodal extension: present.. . (c) size of metastatic carcinoma: 10 mm.. 7. Arteriovenous invasion: absent.. 8. Lymphovascular. invasion:. present,. intratumoral.. 9. Tumor border: infiltrative.. . 10. Microcalcification: absent.. . 11. Pathological TN category (AJCC 2017):. pT2N1a(sn).. Result. Intensity. Positive %. Estrogen receptor. Strong (8/8). 3. >2/3. Progesterone receptor. Negative (1/8) IDC. Strong (8/8) DCIS. 1. 3. <1%. >2/3. C-erbB2. Equivocal (2+) (SISH negative). Ki-67. Positive in 43% of tumor cells. HR(+) HER2(−) Breast Cancer" +526,Case 31,Important Radiologic,HR(+) HER2(-) Breast Cancer,"Important Radiologic. Findings. See Figs. 170, 171, 172 and 173.. 31.3. " +531,Case 31,Patient History,HR(+) HER2(-) Breast Cancer,"niece.. S/P. Hysterectomy. and. salpingo-oophorectomy.. BRCA 1 exon 9-13 deletion, exon 2-6. deletion.. 31.2. " +520,Case 31,Courses of Treatment,HR(−) HER2(+) Breast Cancer,"31.1. . Operation. 213. Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 2.1 cm (pT2).. 2. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 3/3, 5/HPF).. 3. Intraductal component: present, intratu­. moral/extratumoral (50%) (nuclear grade:. high, necrosis: present, architectural pattern:. solid/comedo, extensive intraductal compo­. nent: present).. Y. Kwon et al.. 545. a. b. . 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) superior margin: 10 mm,. . (b) inferior margin: 10 mm,. . (c) medial margin: 20 mm,. . (d) lateral margin: 15 mm,. . (e) deep margin: 2 mm,. . (f) superficial margin: 2 mm.. 6. Lymph nodes: no metastasis in one axillary. lymph node (pN0(sn)) (sentinel LN: 0/1).. 7. Arteriovenous invasion: absent.. 8. Lymphovascular invasion: present, intratumoral.. 9. Tumor border: infiltrative.. . 10. Microcalcification:. present,. tumoral/. non-tumoral.. . 11. Pathological TN category (AJCC 2017):. pT2N0(sn).. HR(−) HER2(+) Breast Cancer. 546. . ­. Result. Intensity. Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in. 79% of tumor. cells. 32. " +527,Case 31,Important Radiologic,HR(−) HER2(+) Breast Cancer,Important Radiologic. Findings. 209 210 211. 212. . HR(−) HER2(+) Breast Cancer +532,Case 31,Patient History,HR(−) HER2(+) Breast Cancer,"Patient History and Progress. Female/74 years old, post-menopause.. Screen detected mass lesion on left breast 1. o’clock direction.. No family history.. Hypertension.. 31.2. " +521,Case 31,Courses of Treatment,HR(−) HER2(−) Breast Cancer,"31.1. . Courses of Treatment. Neoadjuvant chemotherapy (#4  cycles of. doxorubicin and cyclophosphamide  +  #4. cycles of docetaxel)  +  Operation  +  Post-. operative radiation therapy  +  Adjuvant. capecitabine.. Operation. 233. Pathology Report. Invasive Ductal Carcinoma. 1. Post-chemotherapy status.. 2. Size of tumor: 0.9 cm (ypT1b).. 3. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 3/3, 18/10HPF).. 4. Intraductal component: absent.. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) Superior margin: 38 mm.. . (b) Inferior margin: 21 mm.. . (c) Medial margin: 20 mm.. . (d) Lateral margin: 15 mm.. . (e) Deep margin: 6 mm.. . (f) Superficial margin: 22 mm.. 7. Lymph nodes: no metastasis in five axillary. lymph nodes (ypN0(sn)) (sentinel LN: 0/3,. non-sentinel LN: 0/2).. E. S. Lee et al.. 689. . . ­. . HR(−) HER2(−) Breast Cancer. 690. 8. Arteriovenous invasion: absent.. 9. Lymphovascular invasion: absent.. . 10. Tumor border: infiltrative.. . 11. Microcalcification: absent.. . 12. Pathological TN category (AJCC 2017):. ypT1bN0(sn).. Result. Intensity Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Negative (0). Ki-67. Positive in 75%. of tumor cells. . . E. S. Lee et al.. 691. 32. " +528,Case 31,Important Radiologic,HR(−) HER2(−) Breast Cancer,Important Radiologic. Findings. 225 226 227. 228. E. S. Lee et al.. 687. . . ­. . HR(−) HER2(−) Breast Cancer. 688. . After Neoadjuvant. Chemotherapy. 229 230 231. 232. 31.3.  +533,Case 31,Patient History,HR(−) HER2(−) Breast Cancer,"Patient History and Progress. Female/41 years old, pre-menopause.. Self-detected mass lesion on right breast.. No family history.. No comorbidities.. BRCA 1 and 2 mutation: Not detected, STK11. VUS (variant of uncertain).. 31.2. " +522,Case 31,Courses of Treatment,Local Recurrence,"31.1. . Courses of Treatment. Right breast Papillary carcinoma in situ→. Operation → Right breast recurrence (DCIS).. Primary Treatment. 212 213 214. 215. Operation. ­. ­. 216 217. 218. Pathology Report. . Y. Kim et al.. 803. . . . ­. . Papillary carcinoma in situ. . 1. Size of tumor: 5.0 cm (pTis).. . 2. Nuclear grade: low.. . 3. Necrosis: present.. . 4. Architectural pattern: papillary/cribriform.. . 5. Surgical margins:. . (a) Deep margin: <1 mm (slide 6).. . (b) Superficial margin: 0.08 mm (slide 2).. . 6. Lymph nodes: no metastasis in four axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/4).. . 7. Microcalcification: absent.. . 8. Pathologic stage (AJCC 2010): pTisN0(sn).. Result. Intensity. Positive %. Estrogen. receptor. Strong (7/8). 3. 1/3–2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Equivocal (2+). Ki-67. Positive in 26%. of tumor cells. . Local Recurrence. 804. . . Y. Kim et al.. 805. . . . 1. Intraductal papillomas, multiple, up to 0.8 cm. . 2. Sclerosing adenosis with microcalcification.. Treatments After Recurrence. 219. 220. Biopsy. Right 1 o’clock.. Ductal carcinoma in situ:. . 1. Nuclear grade: low.. . 2. Necrosis: absent.. . 3. Architectural pattern: papillary/cribriform.. . 4. Microcalcification: absent.. Local Recurrence. 806. . Closed follow-up due to rejection of surgical. treatment.. 32. " +534,Case 31,Patient History,Local Recurrence,"Patient History and Progress. Female/49 years old, pre-menopause.. Screen detected mass lesion on right breast 1. o’clock direction.. No family history.. No comorbidities.. 31.2. " +523,Case 31,Courses of Treatment,Metastatic Breast Cancer,"Courses of Treatment. Right breast cancer → Operation → Adjuvant. therapy → Lung metastasis.. Primary Treatment. receptor. Negative (0/8). 0. 0. C-erbB2. Negative (0). Ki-67. Positive in. 85% of tumor. cells. Adjuvant Therapy. Adjuvant chemotherapy #6 cycles (Fluorouracil. & Doxorubicin & Cyclophosphamide).. Post-operative radiation therapy to right breast.. Olaparib & placebo (clinical trial 0040, for. 1 year).. Operation. Nov. 2014 Bilateral salpingo-oophorectomy (due. to BRCA 1, positive for deleterious mutation).. Treatments After Recurrence" +535,Case 31,Patient History,Metastatic Breast Cancer,BRCA 1: positive for deleterious mutation.. S/p bilateral salpingo-oophorectomy.. 31.2.  +536,Case 32,Courses of Treatment,Carcinoma In Situ,"32.1. . Courses of Treatment. Operation + Postoperative radiation therapy.. Operation. 151. 152. Pathology Report. Ductal carcinoma in situ, pathological TN cat­. egory (AJCC 2017): pTis. . 1. Size of tumor: 4.0 cm (pTis).. . 2. Nuclear grade: high.. . 3. Necrosis: present.. . 4. Architectural pattern: ­. micropapillary/cribri­. form/comedo.. . 5. Skin: no involvement of tumor.. . 6. Surgical margins:. . (a) superior margin: 10 mm,. . (b) inferior margin: 10 mm,. . (c) medial margin: 40 mm,. . (d) lateral margin: 5 mm,. . (e) deep margin: 2 mm,. . (f) superficial margin: 2 mm.. . 7. Microcalcification:. present,. tumoral/non-. tumoral.. Result. Intensity. Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Equivocal. (2+). Ki-67. Positive in. 27% of tumor. cells. . " +543,Case 32,Important Radiologic,Carcinoma In Situ,Important Radiologic. Findings. 148 149. 150. 32.3.  +548,Case 32,Patient History,Carcinoma In Situ,"Patient History and Progress. Female/72 years old, post-menopause.. Screen detected mass lesion on right breast. 8 o’clock direction.. Outside result of biopsy: Ductal carcinoma in. situ.. No family history.. No comorbidities.. 32.2. " +537,Case 32,Courses of Treatment,HR(+) HER2(+) Breast Cancer,32.1. . Courses of Treatment. Neoadjuvant chemotherapy (#3 cycles of. docetaxel. and. trastuzumab. and. pertu­. zumab)  +  Operation  +  Post-operative radia­. tion therapy  +  Trastuzumab emtansine +. Letrozole 2.5 mg/day.. Operation:. Left. axillary. lymph. node. ­. dissection.. Pathology Report. Metastatic Ductal Carcinoma. . 1. Post-chemotherapy status.. . 2. metastasis in 7 out of 20 axillary lymph nodes. (axillary LN: 7/20).. . 3. perinodal extension: present.. . 4. size of metastatic carcinoma: 40 mm.. Result. Intensity. Positive. %. Estrogen. receptor. Intermediate. (5/8). 2. 10%-. 1/3. Progesterone. receptor. Negative (2/8). 1. <1%. C-erbB2. Positive (3+). Ki-67. Positive in 48%. of tumor cells. S. Park et al.. 409. . . HR(+) HER2(+) Breast Cancer +544,Case 32,Important Radiologic,HR(+) HER2(+) Breast Cancer,Important Radiologic. Findings. 185 186 187 188. 189. 32.3.  +549,Case 32,Patient History,HR(+) HER2(+) Breast Cancer,"Patient History and Progress. Female/74 years old, post-menopause.. Self-detected mass lesion on left axillary.. No family history.. S/P Tuberculosis, asthma.. 32.2. " +538,Case 32,Courses of Treatment,HR(+) HER2(-) Breast Cancer,"Courses of Treatment. Operation  +  Post-operative radiation ther­. apy + Letrozole 2.5 mg/day.. Operation. Right breast conserving surgery, sentinel lymph. ponent: absent).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) superior margin: 20 mm.. . (b) inferior margin: 40 mm.. . (c) medial margin: 15 mm.. . (d) lateral margin: 20 mm.. . (e) deep margin: 5 mm.. . (f) superficial margin: 10 mm.. 6. Lymph nodes: no metastasis in one axillary. lymph node (pN0(sn)) (sentinel LN: 0/1,. 11. Pathological TN category (AJCC 2017):. pT1cN0(sn).. Result. Intensity. Positive. %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (0). Ki-67. Positive in 9% of. tumor cells. HR(+) HER2(−) Breast Cancer" +545,Case 32,Important Radiologic,HR(+) HER2(-) Breast Cancer,"Important Radiologic. Findings. See Figs. 175, 176, 177 and 178.. 32.3. " +550,Case 32,Patient History,HR(+) HER2(-) Breast Cancer,"o’clock direction.. No family history.. Hypertension, s/p bronchiectasis, s/p left hip. arthroplasty.. 32.2. " +539,Case 32,Courses of Treatment,HR(−) HER2(+) Breast Cancer,32.1. . Courses of Treatment. Neoadjuvant chemotherapy (#5 cycles of. docetaxel and carboplatin and trastuzumab and. pertuzumab after followed #1 cycle of trastu­. zumab and pertuzumab)  +  Operation  +  Post-­. operative radiation therapy + Trastuzumab.. Operation. 220. Pathology Report. No residual tumor with stromal degeneration.. . 1. Post-chemotherapy status.. . 2. Lymph nodes: no metastasis in three axillary. lymph nodes (ypN0(sn)) (sentinel LN: 0/3).. Result. Intensity. Positive %. Estrogen. receptor. Negative. (2/8). 1. <1%. Progesterone. receptor. Negative. (2/8). 1. <1%. C-erbB2. Positive (3+). Ki-67. Positive in. 45% of tumor. cells. Y. Kwon et al.. 549. a. b. . 33.  +546,Case 32,Important Radiologic,HR(−) HER2(+) Breast Cancer,Important Radiologic. Findings. 214 215. 216. 32.3. . After Neoadjuvant. Chemotherapy. 217 218. 219. Y. Kwon et al.. 547. . . ­. . HR(−) HER2(+) Breast Cancer. 548. . . 32.4.  +551,Case 32,Patient History,HR(−) HER2(+) Breast Cancer,"Patient History and Progress. Female/55 years old, post-menopause.. Screen detected mass lesion on right breast 8. o’clock direction.. No family history.. Hypertension, thyroid nodules.. 32.2. " +540,Case 32,Courses of Treatment,HR(−) HER2(−) Breast Cancer,"32.1. . Courses of Treatment. Neoadjuvant chemotherapy (#4  cycles of. doxorubicin and ­. cyclophosphamide + #4 cycles. of docetaxel)  +  Operation  +  Post-operative. radiation therapy + Adjuvant capecitabine.. . ­. . HR(−) HER2(−) Breast Cancer. 694. . . Operation. 242. Pathology Report. Invasive Ductal Carcinoma. 1. Post-chemotherapy status.. 2. Size of tumor: 2.7 cm (ypT2).. 3. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 3/3, 20/10HPF).. 4. Intraductal component: absent.. 5. Skin: dermal involvement of tumor.. E. S. Lee et al.. 695. 6. Nipple: no involvement of tumor.. 7. Surgical margins:. . (a) Deep margin: 22 mm.. . (b) Superficial margin: 7 mm.. 8. Lymph nodes: no metastasis in 14 axillary. lymph nodes (ypN0) (sentinel LN: 0/1, non-­. sentinel LN: 0/13).. 9. Arteriovenous invasion: absent.. . 10. Lymphovascular invasion: absent.. . 11. Tumor border: infiltrative.. . 12. Microcalcification: absent.. . 13. Pathological TN category (AJCC 2017):. ypT2N0.. Result. Intensity. Positive. %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Negative (0). Ki-67. Positive in 75%. of tumor cells. 33. " +547,Case 32,Important Radiologic,HR(−) HER2(−) Breast Cancer,Important Radiologic. Findings. 234 235 236. 237. . HR(−) HER2(−) Breast Cancer. 692. . ­. . ­. . E. S. Lee et al.. 693. . After Neoadjuvant. Chemotherapy. 238 239 240. 241. 32.3.  +552,Case 32,Patient History,HR(−) HER2(−) Breast Cancer,"Patient History and Progress. Female/49 years old, pre-menopause.. Self-detected mass lesion on left breast.. Family history of breast cancer, aunt and. cousin (paternal).. Family history of prostate cancer, father.. Hyperthyroidism.. BRCA 1 and 2 mutation: Not detected.. 32.2. " +541,Case 32,Courses of Treatment,Local Recurrence,"32.1. . Courses of Treatment. Right breast DCIS → Operation → Adjuvant. therapy → Right breast recurrence (tubular. carcinoma + DCIS).. Primary Treatment. Operation. Aug. 2014 Right breast wide excision (outside).. Pathology Report. Ductal carcinoma in situ involving intraductal. papilloma. . 1. Nuclear grade: low.. . 2. Necrosis: absent.. . 3. Architectural pattern: papillary/cribriform.. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (1+). Ki-67. Positive in. 10.8% of tumor. cells. Adjuvant Therapy. Postoperative radiation therapy.. Tamoxifen 20 mg/day for 2 years.. Treatments After Recurrence. 221. 222. Operation. 223. Pathology Report. Tubular Carcinoma. 1. Post-lumpectomy status.. 2. Size of invasive component: 0.2 cm (rpT1a).. 3. Size of intraductal component: 1.0 cm.. 4. Histologic grade: 1/3 (tubule formation: 1/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 6/10HPF).. 5. Intraductal component: present, intratu­. moral/extratumoral (90%) (nuclear grade:. low, necrosis: present, architectural pattern:. micropapillary/cribriform/comedo,. exten­. sive intraductal component: present).. 6. Skin: no involvement of tumor.. Y. Kim et al.. 807. . ­. . . ­. 7. Surgical margins:. . (a) Superior margin: 10 mm.. . (b) Inferior margin: 10 mm.. . (c) Medial margin: <1 mm from tubular car­. cinoma (slide 5).. . (d) Lateral margin: 10 mm.. . (e) Deep margin: 2 mm.. . (f) Superficial margin: 2 mm.. 8. Arteriovenous invasion: absent.. 9. Lymphovascular invasion: absent.. . 10. Tumor border: infiltrative.. . 11. Microcalcification:. present,. tumoral/. non-tumoral.. . 12. Pathological TN category (AJCC 2017):. rpT1a.. Result. Intensity. Positive %. Estrogen. receptor. Negative (2/8). 1. <1%. Progesterone. receptor. Negative (2/8). 1. <1%. C-erbB2. Negative (1+). Ki-67. Positive in 7%. of tumor cells. Operation. ­. 224. Local Recurrence. 808. a. b. . Pathology Report. Ductal Carcinoma In Situ, residual. . 1. Post-excision status.. . 2. Size of tumor: 0.2 cm.. . 3. Nuclear grade: low.. . 4. Necrosis: present.. . 5. Architectural pattern: cribriform/solid/comedo.. . 6. Surgical margins:. . (a) Nipple margin: (see note).. . (b) Deep margin: 3 mm.. . (c) Superficial margin: 2 mm.. . 7. Lymph nodes: no metastasis in one axillary. lymph node (pN0(sn)) (sentinel LN: 0/1).. . 8. Microcalcification: absent.. Note: 1. Atypical ductal hyperplasia is present. in the section of Fro 1.. 33. " +553,Case 32,Patient History,Local Recurrence,"Patient History and Progress. Female/42 years old, pre-menopause.. Screen detected mass lesion on right breast. . 12 o’clock direction.. Outside result of lumpectomy: Ductal carci­. noma in situ.. No family history.. No comorbidities.. BRCA 2 VUS (variant of uncertain).. 32.2. " +542,Case 32,Courses of Treatment,Metastatic Breast Cancer,Courses of Treatment. Left breast cancer → Operation → Adjuvant. therapy → Lung metastasis.. Primary Treatment. receptor. Intermediate. (4/7). 2. 10%–1/3. Progesterone. receptor. Strong (6/7). 3. 1/3–2/3–. C-erbB2. Positive (3+). Ki-67. Positive in. 20% of tumor. cells. Y. Kwon et al.. & Doxorubicin & Cyclophosphamide).. Post-operative radiation therapy to left breast. + Zoladex for 2 years + Tamoxifen 20 mg/day for. 5 years.. Treatments After Recurrence. 1/3–2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Positive (3+). Ki-67. Positive in. 14% of tumor. cells. Palliative Therapy. Palliative therapy # 37 cycles (Paclitaxel &. Trastuzumab).. Palliative therapy # 38 cycles (Trastuzumab) ~. Metastatic Breast Cancer +554,Case 32,Patient History,Metastatic Breast Cancer,"Patient History and Progress. Female/49 years old, peri-menopause.. No family history.. 32.2. " +555,Case 33,Courses of Treatment,Carcinoma In Situ,"33.1. . Courses of Treatment:. Operation. Operation. 155. 156. Pathology Report. . Ductal carcinoma in situ, pathological TN cat­. egory (AJCC 2017): pTis. . 1. Size of tumor: 0.5 cm (pTis).. . 2. Nuclear grade: low.. . 3. Necrosis: absent.. . 4. Architectural pattern: papillary/cribriform.. . 5. Skin: no involvement of tumor.. . 6. Surgical margins:. . (a) superior margin: 10 mm,. . (b) inferior margin: 10 mm,. . (c) medial margin: 5 mm,. . (d) lateral margin: positive (Fro 5) (see Note),. . (e) deep margin: 2 mm,. . (f) superficial margin: 2 mm.. . 7. Microcalcification:. present,. tumoral/non-. tumoral.. Note: 1. Ductal carcinoma in situ is present. only in the permanent section of Fro 5.. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (0). Ki-67. Positive in. 4% of tumor. cells. . Atypical ductal hyperplasia involving intra­. ductal papilloma.. . 1. with a) foreign body reaction,. . 2. b) fat necrosis.. . (a) Post-excision status.. . . ­. ­. Carcinoma In Situ. 126. a. b. . a. b. . 34. " +562,Case 33,Important Radiologic,Carcinoma In Situ,Important Radiologic. Findings. 153. 154. 33.3.  +567,Case 33,Patient History,Carcinoma In Situ,"Patient History and Progress. Female/68 years old, post-menopause.. Bloody nipple discharge from right breast.. No family history.. S/P Hysterectomy.. 33.2. " +556,Case 33,Courses of Treatment,HR(+) HER2(+) Breast Cancer,"Courses of Treatment. Neoadjuvant chemotherapy (#6 cycles of. docetaxel and carboplatin and trastuzumab. and pertuzumab)  +  Operation  +  Post-­. operative. radiation. ther­. apy + Trastuzumab + Tamoxifen 20 mg/day.. 194. Pathology Report. Invasive ductal carcinoma, histologic grade 2.. No residual tumor with stromal degeneration.. . 1. Post-chemotherapy status.. . 2. Lymph nodes: no metastasis in four axillary. lymph nodes (ypN0(sn)) (sentinel LN: 0/4).. Result. Intensity. Positive. %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Weak (3/8). 1. 1–10%. C-erbB2. Equivocal (2+). Ki-67. Positive in 46%. of tumor cells. SISH. Positive. HR(+) HER2(+) Breast Cancer. 413. . HR(+) HER2(+) Breast Cancer. 414. . a. b. . S. Park et al.. 415. 34. " +563,Case 33,Important Radiologic,HR(+) HER2(+) Breast Cancer,Important Radiologic. Findings. 190 191 192. 193. 33.3.  +568,Case 33,Patient History,HR(+) HER2(+) Breast Cancer,Self-detected palpable mass lesion on left. breast.. No family history.. No comorbidities.. 33.2.  +557,Case 33,Courses of Treatment,HR(+) HER2(-) Breast Cancer,"Courses of Treatment. Operation  +  Post-operative radiation ther­. apy + Tamoxifen 20 mg/day.. Y. Kim et al.. micropapillary/cribriform, extensive intra­. ductal component: present).. 5. Skin: no involvement of tumor.. HR(+) HER2(−) Breast Cancer. . (e) deep margin: 3 mm.. . (f) superficial margin: 5 mm.. Y. Kim et al.. 279. 7. Lymph nodes: no metastasis in three axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/1,. axillary LN: 0/2). 8. Arteriovenous invasion: absent.. 9. Lymphovascular invasion: absent.. . 10. Tumor border: infiltrative.. . 11. Microcalcification: absent.. . 12. Pathological TN category (AJCC 2017):. pT1aN0(sn).. Result. Intensity. Positive. %. Estrogen. receptor. Strong (7/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (1+). Ki-67. Positive in 5% of. tumor cells. 34. " +564,Case 33,Important Radiologic,HR(+) HER2(-) Breast Cancer,"Important Radiologic. Findings. See Figs. 180, 181, 182, 183 and 184.. 33.3. " +569,Case 33,Patient History,HR(+) HER2(-) Breast Cancer,Restless legs.. 33.2.  +558,Case 33,Courses of Treatment,HR(−) HER2(+) Breast Cancer,"33.1. . tion therapy + Trastuzumab.. Operation. 228. Pathology Report. . 1. No residual tumor with foamy histiocytic. collection.. . (a) Post-chemotherapy status.. . (b) Lymph nodes: no metastasis in four axil­. lary lymph nodes (ypN0(sn)) (sentinel. LN: 0/4).. . (c) Microcalcification:. present,. tumoral/. non-tumoral.. . (d) Related slides: C21-518.. . 2. Intraductal papilloma.. Result. Intensity. Positive %. Estrogen. receptor. Negative (2/8). 1. <1%. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in 22%. of tumor cells. 34. " +565,Case 33,Important Radiologic,HR(−) HER2(+) Breast Cancer,Important Radiologic. Findings. 221 222 223. 224. HR(−) HER2(+) Breast Cancer. . HR(−) HER2(+) Breast Cancer. 552. . 33.3. . After Neoadjuvant. Chemotherapy. 225 226. 227. Y. Kwon et al. +570,Case 33,Patient History,HR(−) HER2(+) Breast Cancer,"Patient History and Progress. Female/63 years old, post-menopause.. Self-detected palpable mass lesion on left. breast 2 o’clock direction.. No family history.. Hypertension, chronic kidney disease, ven­. tricular premature contraction.. 33.2. " +559,Case 33,Courses of Treatment,HR(−) HER2(−) Breast Cancer,"33.1. . Courses of Treatment. Neoadjuvant chemotherapy (#4  cycles of. doxorubicin and cyclophosphamide  +  #4. cycles of docetaxel)  +  Operation  +  Post-. operative radiation therapy.. Operation. 251. Pathology Report. Atypical ductal hyperplasia, focal. . 1. Post-chemotherapy status.. . 2. Lymph nodes: no metastasis in one axillary. lymph node (ypN0(sn)) (sentinel LN: 0/1).. Result. Intensity. Positive. %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Negative (1+). Ki-67. Positive in 61%. of tumor cells. E. S. Lee et al.. 697. . . . HR(−) HER2(−) Breast Cancer. 698. . . E. S. Lee et al.. 699. 34. " +566,Case 33,Important Radiologic,HR(−) HER2(−) Breast Cancer,Important Radiologic. Findings. 243 244 245. 246. . ­. HR(−) HER2(−) Breast Cancer. 696. . . ­. . After Neoadjuvant. Chemotherapy. 247 248 249. 250. 33.3.  +571,Case 33,Patient History,HR(−) HER2(−) Breast Cancer,"Patient History and Progress. Female/52 years old, post-menopause.. Screen detected mass lesion on left breast 11. o’clock direction.. No family history.. s/p cervical cancer (stage 0).. BRCA 1 and 2 mutation: Not detected.. 33.2. " +560,Case 33,Courses of Treatment,Local Recurrence,"33.1. . Courses of Treatmaent. Left breast IDC → Neoadjuvant chemotherapy. → Operation → Adjuvant therapy → Left breast. recurrence (IDC).. Primary Treatment. 225 226 227. 228. Neoadjuvant Chemotherapy. Neoadjuvant chemotherapy #6 cycles of trastu­. zumab and pertuzumab and docetaxel and. carboplatin.. Operation. ­. 229. Pathology Report. Invasive Ductal Carcinoma. 1. Post-chemotherapy status.. 2. Size of tumor: 3.5 cm, 1.4 cm (ypT2(2)).. 3. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 3/3, 30/10HPF).. 4. Intraductal component: present, extratumoral. (10%) (nuclear grade: high, necrosis: pres­. ent, architectural pattern: micropapillary/. solid/comedo, extensive intraductal compo­. nent: absent).. 5. Skin: no involvement of tumor.. Y. Kim et al.. 809. . ­. . . . 6. Surgical margins:. . (a) Superior margin: 30 mm.. . (b) Inferior margin: 6 mm.. . (c) Medial margin: 15 mm.. . (d) Lateral margin: (see note 1).. . (e) Deep margin: 6 mm.. . (f) Superficial margin: <1  mm from inva­. sive ductal carcinoma (slide 12).. 7. Lymph nodes: no metastasis in 3 axillary. lymph nodes (ypN0(sn)) (sentinel LN: 0/3).. 8. Arteriovenous invasion: absent.. 9. Lymphovascular. invasion:. present,. ­. intratumoral/peritumoral.. . 10. Tumor border: infiltrative.. . 11. Microcalcification: present, tumoral.. . 12. Pathological TN category (AJCC 2017):. ypT2(2)N0(sn).. Local Recurrence. 810. . . ­. Note: 1. The lateral margin of the lumpec­. tomy specimen (slide 16) is close to ductal car­. cinoma in situ (1.5  mm), but this margin. submitted for frozen diagnosis (Fro 7) is free. of tumor.. Result. Intensity. Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in 59%. of tumor cells. Adjuvant Therapy. Postoperative radiation therapy.. Trastuzumab for 1 year.. Treatments After Recurrence. 230. Operation. 231. Pathology Report. Invasive Ductal Carcinoma. 1. Post-lumpectomy status.. 2. Size of tumor: 1.8 cm (rpT1c).. 3. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 3/3, 22/10HPF).. 4. Intraductal component: present, intratumoral. (5%) (nuclear grade: high, necrosis: absent,. architectural pattern: solid, extensive intra­. ductal component: absent).. 5. Surgical margins:. . (a) Superior margin: 15 mm.. . (b) Inferior margin: positive for invasive. ductal carcinoma (slide 2).. . (c) Medial margin: 10 mm.. . (d) Lateral margin: positive for invasive. ductal carcinoma (slide 4).. . (e) Deep margin: 1 mm from invasive ductal. carcinoma (slide 3).. . (f) Superficial margin: 5 mm.. Y. Kim et al.. 811. a. b. . . 6. Arteriovenous invasion: absent.. 7. Lymphovascular invasion: absent.. 8. Tumor border: infiltrative.. 9. Microcalcification: present, tumoral.. . 10. Pathological TN category (AJCC 2017):. rpT1cNx.. Result. Intensity. Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in 27%. of tumor cells. Operation. 232. Pathology Report. Lateral Margin. Invasive Ductal Carcinoma, residual. . 1. Post-lumpectomy and excision status.. . 2. Size of tumor: 0.6 cm.. . 3. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 3/3, 22/10HPF).. . 4. Intraductal component: present, intratumoral. (20%) (nuclear grade: high, necrosis: absent,. architectural pattern: solid, extensive intra­. ductal component: absent).. . 5. Surgical margins:. . (a) Lateral margin: (see note).. . 6. Vascular invasion: absent.. . 7. Lymphatic invasion: absent.. . 8. Tumor border: infiltrative.. . 9. Microcalcification: absent.. Inferior Margin. No residual tumor. . 1. Post-lumpectomy and excision status.. Note: The lateral margin of the lumpectomy. specimen (slide 4) is close to ductal carcinoma in. situ (4 mm), but this margin submitted for frozen. diagnosis (Fro 2) is free of tumor.. Adjuvant Therapy. Chemotherapy #14  cycles of T-DM1 (trastu­. zumab emtansine).. Local Recurrence. 812. 34. " +572,Case 33,Patient History,Local Recurrence,"Patient History and Progress. Female/45 years old, pre-menopause.. Screen detected mass lesion on upper inner. portion of left breast.. Outside result of biopsy: Invasive ductal. carcinoma.. Family history of breast cancer, mother at her. 50 years old.. S/P. Hysterectomy,. s/p. bilateral. breast. augmentation.. 33.2. " +561,Case 33,Courses of Treatment,Metastatic Breast Cancer,Courses of Treatment. Right breast cancer → Operation → Adjuvant. therapy → Bone metastasis.. Primary Treatment. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Intermediate. (5/8). 2. 10%–. 1/3. Result. Intensity. Positive %. C-erbB2. Equivocal (2+). Ki-67. Positive in 7%. of tumor cells. SISH. Positive. Adjuvant Therapy. Adjuvant chemotherapy #8 cycles (Doxorubicin. & cyclophosphamide #4 → Docetaxel #4).. Post-operative radiation therapy to right breast. +Tamoxifen 20 mg/day for 5 years.. Treatments After Recurrence. invasion.. Palliative Therapy. Radiation therapy to L-spine & T-spine & sacrum.. Palliative Capecitabine & lapatinib (Jul. 2021) ~. Y. Kwon et al. +573,Case 33,Patient History,Metastatic Breast Cancer, +574,Case 34,Courses of Treatment,Carcinoma In Situ,"34.1. . Courses of Treatment:. Operation. Operation. 161. 162. Pathology Report. . Ductal carcinoma in situ, pathological TN cat­. egory (AJCC 2017): pTis. . 1. Size of tumor: 0.5 cm (pTis).. . 2. Nuclear grade: low.. . 3. Necrosis: absent.. . 4. Architectural pattern: papillary/cribriform.. . 5. Surgical margins:. E. S. Lee et al.. 127. . . . . a. b. . Carcinoma In Situ. 128. a. b. . . (a) superior margin: 15 mm,. . (b) inferior margin: 30 mm,. . (c) medial margin: 15 mm,. . (d) lateral margin: 15 mm,. . (e) deep margin: 8 mm,. . (f) superficial margin: 8 mm.. . 6. Microcalcification: absent.. . Right.. Lobular carcinoma in situ, pathological TN. category (AJCC 2017): pTis. . 1. Size of tumor: 0.7 cm (pTis).. . 2. Nuclear grade: low.. . 3. Necrosis: absent.. . 4. Architectural pattern: solid.. . 5. Surgical margins: positive for lobular carci­. noma in situ at the nearest resection margin. (slide 1).. . 6. Microcalcification: absent.. E. S. Lee et al.. 129. . . Result. Intensity. Positive %. Estrogen. receptor. Weak (4/8). 1. 10%−1/3. Progesterone. receptor. Weak (4/8). 1. 10%−1/3. C-erbB2. Equivocal. (2+). Ki-67. Positive in. 3% of tumor. cells. Left.. Intraductal papilloma.. 35. " +581,Case 34,Important Radiologic,Carcinoma In Situ,Important Radiologic. Findings. 157 158 159. 160. 34.3.  +586,Case 34,Patient History,Carcinoma In Situ,"Patient History and Progress. Female/53 years old, pre-menopause.. Screen detected mass lesion on upper outer of. right breast.. No family history.. S/P Total gastrectomy (gastric cancer), micro­. papillary thyroid carcinoma (follow-up).. BRCA 1 and 2: Not examination.. 34.2. " +575,Case 34,Courses of Treatment,HR(+) HER2(+) Breast Cancer,"34.1. . Courses of Treatment. Neoadjuvant chemotherapy (#6 cycles of. docetaxel and carboplatin and trastuzumab. and pertuzumab)  +  Operation  +  Post-­. operative radiation therapy  +  Trastuzumab. and Pertuzumab + Letrozole 2.5 mg/day.. 201. Pathology Report. Invasive ductal carcinoma, histologic grade 2.. No residual tumor with stromal degeneration. . 1. Post-chemotherapy status.. . 2. Lymph nodes: no metastasis in three axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/3).. Result. Intensity. Positive. %. Estrogen. receptor. Intermediate. (6/8). 3. 10%-. 1/3. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in 61%. of tumor cells. . HR(+) HER2(+) Breast Cancer. 416. . . ­. S. Park et al.. 417. . . . HR(+) HER2(+) Breast Cancer. 418. a. b. . 35. " +582,Case 34,Important Radiologic,HR(+) HER2(+) Breast Cancer,Important Radiologic. Findings. 195 196 197 198 199. 200. 34.3.  +587,Case 34,Patient History,HR(+) HER2(+) Breast Cancer,"Patient History and Progress. Female/55 years old, post-menopause.. Self-detected palpable mass lesion on right. breast 9 o’clock direction.. No family history.. No comorbidities.. 34.2. " +576,Case 34,Courses of Treatment,HR(+) HER2(-) Breast Cancer,"34.1. . Courses of Treatment. Operation. Right nipple–areolar complex sparing mastec­. tomy with immediate implant reconstruction,. sentinel lymph node biopsy, left nipple–areo­. lar complex sparing mastectomy with immedi­. ate implant reconstruction (Figs. 190, 191 and. 192).. Pathology Report. [Right]. Invasive Ductal Carcinoma. 1. Size of tumor: 1.8 cm (pT1c).. 2. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. noma in situ (slide 1).. . (b) superficial margin: 5 mm.. 6. Lymph nodes: no metastasis in one axillary. lymph node (pN0(sn)) (sentinel LN: 0/1). 7. Arteriovenous invasion: absent.. Y. Kim et al.. non-tumoral.. . 11. Pathological TN category (AJCC 2017):. pT1cN0(sn).. Result. Intensity. Positive. %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Equivocal (2+). (SISH negative). Ki-67. Positive in 14%. of tumor cells. [Left]. Fibrocystic change.. 35. " +583,Case 34,Important Radiologic,HR(+) HER2(-) Breast Cancer,"Important Radiologic. Findings. See Figs. 186, 187, 188 and 189.. 34.3. " +588,Case 34,Patient History,HR(+) HER2(-) Breast Cancer,"Patient History and Progress. Female/43 years old, pre-menopause.. Screen for high risk for breast cancer.. Family history of breast cancer, mother.. Pancreatic cancer, maternal uncle.. No comorbidities.. BRCA 1 mutation carrier.. 34.2. " +577,Case 34,Courses of Treatment,HR(−) HER2(+) Breast Cancer,"34.1. . Courses of Treatment. Operation + Adjuvant chemotherapy (#4 cycles. of. doxorubicin. +. cyclophosphamide). +. Operation + Trastuzumab.. Operation. 233. Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 1.5 cm (pT1c(Paget)).. 2. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 2/3, 11/10HPF).. 3. Intraductal component: absent.. 4. Nipple: Paget disease.. 5. Skin: no involvement of tumor.. Y. Kwon et al.. 557. a. b. . 6. Surgical margins: deep margin: 2 mm.. 7. Lymph nodes: no metastasis in one axillary. lymph node (pN0(sn)) (sentinel LN: 0/1).. 8. Arteriovenous invasion: absent.. 9. Lymphovascular invasion: present, intratu­. moral.. . 10. Tumor border: infiltrative.. . 11. Microcalcification: present, tumoral/non-. tumoral.. . 12. Pathological TN category (AJCC 2017):. pT1c(Paget)N0(sn).. HR(−) HER2(+) Breast Cancer. 558. . Result. Intensity. Positive %. Estrogen. receptor. Negative (2/8). 1. <1%. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in 25%. of tumor cells. 35. " +584,Case 34,Important Radiologic,HR(−) HER2(+) Breast Cancer,Important Radiologic. Findings. 229 230 231. 232. . HR(−) HER2(+) Breast Cancer. 556. . ­. . . 34.3.  +589,Case 34,Patient History,HR(−) HER2(+) Breast Cancer,"Patient History and Progress. Female/54 years old, post-menopause.. Self-detected palpable mass lesion on left. breast.. No family history.. S/P. unilateral. salpingo-oophorectomy,. dyslipidemia.. HR(−) HER2(+) Breast Cancer. 554. a. b. . Y. Kwon et al.. 555. 34.2. " +578,Case 34,Courses of Treatment,HR(−) HER2(−) Breast Cancer,"34.1. . Courses of Treatment. Operation  +  Adjuvant chemotherapy (#1. cycles of docetaxel and cyclophosphamide,. stop d/t mucositis).. Operation. 255. Pathology Report. Invasive Ductal Carcinoma associated with. paraffinoma. 1. Size of tumor: 3.0 cm (pT2).. . . E. S. Lee et al.. 701. 2. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 2/3, 8/10HPF).. 3. Intraductal component: absent.. 4. Skin and nipple: no involvement of tumor.. 5. Surgical margins:. . (a) Deep margin: 10 mm.. . (b) Superficial margin: 21 mm.. 6. Lymph nodes: no metastasis in five axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/5).. 7. Arteriovenous invasion: absent.. 8. Lymphovascular invasion: absent.. 9. Tumor border: infiltrative.. . 10. Microcalcification: absent.. . 11. Pathological TN category (AJCC 2017):. pT2N0(sn).. Result. Intensity. Positive. %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Negative (0). Ki-67. Positive in 23%. of tumor cells. 35. " +585,Case 34,Important Radiologic,HR(−) HER2(−) Breast Cancer,Important Radiologic. Findings. 252 253. 254. . . HR(−) HER2(−) Breast Cancer. 700. 34.3.  +590,Case 34,Patient History,HR(−) HER2(−) Breast Cancer,"Patient History and Progress. Female/79 years old, post-menopause.. Screen detected mass lesion on left breast 12. o’clock direction.. No family history.. S/P paraffin injection, s/p appendectomy, s/p. hysterectomy, s/p hemicolectomy (colon cancer).. S/P radical total gastrostomy (advanced gas­. tric cancer).. BRCA 1 and 2 mutation: Not detected,. BARD1 VUS (variant of uncertain).. 34.2. " +579,Case 34,Courses of Treatment,Local Recurrence,"34.1. . Courses of Treatment. Right breast IDC → Operation → Adjuvant. therapy → Right breast recurrence (IDC).. Primary Treatment. 233 234. 235. Operation. 236. Pathology Report. Invasive Ductal Carcinoma. 1. Size of invasive component: 0.7 cm (pT1b).. 2. Size of intraductal component: 1.0 cm.. 3. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 3/10HPF).. 4. Intraductal component: present, extratumoral. (60%) (nuclear grade: low, necrosis: present,. architectural pattern: papillary/cribriform,. extensive intraductal component: absent).. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) Superior margin: 28 mm.. . (b) Inferior margin: 12 mm.. . (c) Medial margin: 10 mm.. . (d) Lateral margin: 30 mm.. . . . Y. Kim et al.. 813. a. b. . . . (e) Deep margin: <1 mm from ductal carci­. noma in situ (slide 7).. . (f) Superficial margin: 13 mm.. 7. Arteriovenous invasion: absent.. 8. Lymphovascular invasion: absent.. 9. Tumor border: infiltrative.. . 10. Microcalcification: present, non-tumoral.. . 11. Pathological TN category (AJCC 2017):. pT1b.. Result. Intensity. Positive %. Estrogen. receptor. Intermediate. (6/8). 2. 1/3–2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Positive (3+). Ki-67. Positive in 53%. of tumor cells. Adjuvant Therapy. Postoperative radiation therapy.. Tamoxifen 20 mg/day for 1.8 years.. Treatments After Recurrence. 237. 238. Operation. ­. 239. Pathology Report. Invasive Ductal Carcinoma. 1. Post-lumpectomy status.. 2. Size of tumor: 2.1 cm, multifocal (rpT2).. 3. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 3/3, 4/1HPF).. 4. Intraductal component: present, intratu­. moral/extratumoral (50%) (nuclear grade:. high, necrosis: present, architectural pattern:. papillary/micropapillary/cribriform/solid/. comedo, extensive intraductal component:. present).. 5. Skin: no involvement of tumor.. 6. Surgical margins:. Local Recurrence. 814. . (a) Deep margin: <1 mm from ductal carci­. noma in situ (slides 1 and 3).. . (b) Superficial margin: positive for invasive. ductal carcinoma (slide 5).. 7. Arteriovenous invasion: absent.. 8. Lymphovascular. invasion:. present,. intratumoral.. 9. Tumor border: infiltrative.. . 10. Microcalcification:. present,. tumoral/. non-tumoral.. . 11. Pathological TN category (AJCC 2017):. rpT2.. Result. Intensity. Positive %. Estrogen. receptor. Strong (7/8). 2. >2/3. Progesterone. receptor. Strong (7/8). 3. 1/3–2/3. C-erbB2. Positive (3+). Ki-67. Positive in 51%. of tumor cells. Adjuvant Therapy. Adjuvant chemotherapy #4 cycles of doxorubicin. and cyclophosphamide.. Trastuzumab for 1 year.. Letrozole 2.5 mg/day.. . . Y. Kim et al.. 815. 35. " +591,Case 34,Patient History,Local Recurrence,"Patient History and Progress. Female/47 years old, pre-menopause.. Screen detected microcalcification on upper. outer portion of right breast.. Family history of ovarian cancer mother.. No comorbidities.. BRCA 1 and 2 mutation: Not detected.. 34.2. " +580,Case 34,Courses of Treatment,Metastatic Breast Cancer,"Courses of Treatment. Left breast cancer → Operation → Adjuvant. therapy → Right pleural, liver, right adrenal. gland, bone metastasis → Brain metastasis.. Primary Treatment. (0/8). 0. 0. Progesterone. receptor. Negative. (0/8). 0. 0. C-erbB2. Equivocal. (2+). Ki-67. Positive. in 46% of. tumor. cells. SISH. Positive. Adjuvant Therapy. Adjuvant chemotherapy #8 cycles (Doxorubicin. & cyclophosphamide #4 → Docetaxel & trastu­. zumab #4).. Post-operative radiation therapy to left breast.. Concurrent Trastuzumab #13.. Treatments After Recurrence. Palliative Therapy. Radiation therapy to brain.. Palliative therapy #6 (Pertuzumab & trastu­. zumab & Docetaxel) ~. 35. " +592,Case 34,Patient History,Metastatic Breast Cancer,No family history.. 34.2.  +593,Case 35,Courses of Treatment,Carcinoma In Situ,"35.1. . Courses of Treatment. Operation + Tamoxifen 20 mg/day for 5 years.. Operation. 165. 166. Pathology Report. Lobular carcinoma in situ, pathological TN. category (AJCC 2017): pTis. . 1. Size of tumor: 0.5 cm (pTis).. . 2. Nuclear grade: low.. . 3. Necrosis: absent.. . 4. Architectural pattern: solid.. . 5. Skin: no involvement of tumor.. . 6. Surgical margins:. . (a) superior margin: 5 mm,. . (b) inferior margin: 5 mm,. . (c) medial margin: 10 mm,. . (d) lateral margin: 10 mm,. . (e) deep margin: 2 mm,. . (f) superficial margin: 2 mm.. . 7. Microcalcification:. present,. tumoral/non-. tumoral.. Result. Intensity. Positive %. Estrogen. receptor. Strong (7/8). 3. 1/3–2/3. Progesterone. receptor. Strong (7/8). 3. 1/3–2/3. C-erbB2. Equivocal. (2+). Ki-67. Positive in. 2% of tumor. cells. Carcinoma In Situ. 130. a. b. . a. b. . ­. 36. " +600,Case 35,Important Radiologic,Carcinoma In Situ,Important Radiologic. Findings. 163. 164. 35.3.  +605,Case 35,Patient History,Carcinoma In Situ,"Patient History and Progress. Female/59 years old, post-menopause.. Screen detected ductal dilatation on left breast. 12 o’clock direction.. No family history.. S/P Hysterectomy and bilateral salpingo-­. oophorectomy, S/P total thyroidectomy (thyroid. cancer), hypertension.. 35.2. " +594,Case 35,Courses of Treatment,HR(+) HER2(+) Breast Cancer,"35.1. . Courses of Treatment. Neoadjuvant chemotherapy (#6 cycles of. docetaxel and carboplatin and trastuzumab. S. Park et al.. 209. 210. Pathology Report. Invasive ductal carcinoma, histologic grade 3.. No residual tumor with stromal degeneration.. . 1. Post-chemotherapy status.. . 2. Lymph nodes: no metastasis in seven axillary. lymph nodes (ypN0) (axillary LN (Fro 4): 0/4,. axillary LN: 0/3).. Result. Intensity Positive %. Estrogen. receptor. Intermediate. (5/8). 2. 10%-1/3. Progesterone. receptor. Intermediate. (6/8). 2. 10%-1/3. C-erbB2. Positive (3+). Ki-67. Positive in. 49% of tumor. cells. . S. Park et al.. 421. . HR(+) HER2(+) Breast Cancer. 422. . ­. . . . S. Park et al.. 423. a. b. . a. b. . HR(+) HER2(+) Breast Cancer. 424. 36. " +601,Case 35,Important Radiologic,HR(+) HER2(+) Breast Cancer,Important Radiologic. Findings. 202 203 204 205 206 207. 208. 35.3.  +606,Case 35,Patient History,HR(+) HER2(+) Breast Cancer,"Patient History and Progress. Female/39 years old, pre-menopause.. Self-detected skin change and palpable mass. lesion on right breast 9:30 o’clock direction.. No family history.. No comorbidities.. BRCA 1 and 2 mutation: Not detected.. 35.2. " +595,Case 35,Courses of Treatment,HR(+) HER2(-) Breast Cancer,"35.1. . cribriform/solid/comedo, extensive intra­. ductal component: present).. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) superior margin: 15 mm.. . (b) inferior margin: 15 mm.. . (c) medial margin: 10 mm.. . (d) lateral margin: 10 mm.. . (e) deep margin: 2 mm.. . (f) superficial margin: 2 mm.. 7. Lymph nodes:. . (a) metastasis in two out of five axillary. lymph nodes (ypN1a(sn)) (sentinel LN:. 2/2, axillary LN: 0/3). HR(+) HER2(−) Breast Cancer. . 10. Tumor border: infiltrative.. . 11. Microcalcification:. present,. tumoral/. non-tumoral.. . 12. Pathological TN category (AJCC 2017):. ypT1cN1a(sn).. Result. Intensity. Positive %. Estrogen receptor. Strong (7/8). 2. >2/3. Progesterone receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (1+). Ki-67. Positive in 8% of tumor cells. HR(+) HER2(−) Breast Cancer. 286. 36. " +602,Case 35,Important Radiologic,HR(+) HER2(-) Breast Cancer,"Important Radiologic. Findings. See Figs. 193, 194, 195, 196 and 197.. Y. Kim et al." +607,Case 35,Patient History,HR(+) HER2(-) Breast Cancer,"Patient History and Progress. Female/48 years old, pre-menopause.. Screen detected mass lesion on left breast 4. o’clock direction.. Family history of breast cancer, maternal aunt.. No comorbidities.. BRCA 1 and 2 mutation: no examination.. 35.2. " +596,Case 35,Courses of Treatment,HR(−) HER2(+) Breast Cancer,"35.1. . Courses of Treatment. Neoadjuvant chemotherapy (#5 cycles of. docetaxel. and. trastuzumab. and. pertu­. zumab)  +  Operation  +  Post-operative radiation. therapy + Trastuzumab and pertuzumab.. Operation. 242. Pathology Report. Microinvasive Ductal Carcinoma. 1. Post-chemotherapy status.. 2. Size of invasive component: <0.1  cm. (ypT1mi).. 3. Size of intraductal component: 0.8 cm.. 4. Histologic grade: not applicable.. . HR(−) HER2(+) Breast Cancer. 562. moral/extratumoral (99%) (nuclear grade:. low, necrosis: present, architectural pattern:. solid/comedo, extensive intraductal compo­. nent: present).. 6. Skin: no involvement of tumor.. 7. Surgical margins:. . (a) superior margin: 5 mm,. . (b) inferior margin: 20 mm,. . (c) medial margin: positive for microinva­. sive ductal carcinoma (Fro 3) (see note),. . (d) lateral margin: 5 mm,. . (e) deep margin: 2 mm,. . (f) superficial margin: 2 mm.. 8. Lymph nodes: no metastasis in three axillary. lymph nodes (ypN0(sn)) (sentinel LN: 0/3).. 9. Arteriovenous invasion: absent.. . 10. Lymphovascular invasion: absent.. . 11. Tumor border: infiltrative.. . 12. Microcalcification:. present,. tumoral/. non-tumoral.. . 13. Pathological TN category (AJCC 2017):. ypT1miN0(sn).. Note: 1. Microinvasive ductal carcinoma is. focally present only in the permanent section of. Fro 3.. Result. Intensity. Positive %. Estrogen. receptor. Negative. (0/8). 0. 0. Progesterone. receptor. Negative. (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in. 48% of. tumor cells. 36. " +603,Case 35,Important Radiologic,HR(−) HER2(+) Breast Cancer,Important Radiologic. Findings. 234 235 236. 237. Y. Kwon et al.. 559. . ­. . HR(−) HER2(+) Breast Cancer. 560. . ­. Y. Kwon et al.. 561. 35.3. . After Neoadjuvant. Chemotherapy. 238 239 240. 241. 35.4.  +608,Case 35,Patient History,HR(−) HER2(+) Breast Cancer,"Patient History and Progress. Female/73 years old, post-menopause.. Self-detected palpable mass lesion on right. breast.. Family history of breast cancer, cousin. (maternal).. s/p cholecystectomy, s/p unilateral salpingo-­. oophorectomy, hypertension, diabetes mellitus.. BRCA 1 and 2 mutation: Not detected.. 35.2. " +597,Case 35,Courses of Treatment,HR(−) HER2(−) Breast Cancer,"35.1. . Courses of Treatment. Operation. +. Adjuvant. chemotherapy. (#4  cycles of doxorubicin and cyclophospha­. mide) + Post-operative radiation therapy.. Operation. 259. Pathology Report. Invasive Ductal Carcinoma with apocrine. differentiation. 1. Size of tumor: 1.1 cm (pT1c).. 2. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 2/3, 6/10HPF).. 3. Intraductal component: present, extratumoral. (10%) (nuclear grade: high, necrosis: pres­. ent, architectural pattern: cribriform/solid/. comedo, extensive intraductal component:. absent).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) Superior margin: 8 mm.. . (b) Inferior margin: 13 mm.. . (c) Medial margin: (see note).. . (d) Lateral margin: 15 mm.. . (e) Deep margin: 2 mm.. . (f) Superficial margin: 15 mm.. 6. Arteriovenous invasion: absent.. 7. Lymphovascular invasion: absent.. 8. Tumor border: infiltrative.. 9. Microcalcification:. present,. tumoral/. non-tumoral.. . 10. Pathological TN category (AJCC 2017):. pT1cNx.. Note: 1. The medial margin of the lumpec­. tomy specimen (slide 5) is close to ductal carci­. noma in situ (2 mm), but this margin submitted. for frozen diagnosis (Fro 3) is free of tumor.. Result. Intensity. Positive. %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Equivocal (2+). Ki-67. Positive in 7% of. tumor cells. HR(−) HER2(−) Breast Cancer. 702. . . ­. . E. S. Lee et al.. 703. . 36. " +604,Case 35,Important Radiologic,HR(−) HER2(−) Breast Cancer,Important Radiologic Findings. 256 257. 258. 35.3.  +609,Case 35,Patient History,HR(−) HER2(−) Breast Cancer,"Patient History and Progress. Female/75 years old, post-menopause.. Screen detected mass lesion on left breast 2. o’clock direction.. No family history.. Hypertension, Hyperlipidemia, s/p hysterec­. tomy, arrhythmia (s/p operation).. 35.2. " +598,Case 35,Courses of Treatment,Local Recurrence,"35.1. . Courses of Treatment. Right breast IDC → Neoadjuvant chemotherapy. → Operation → Adjuvant therapy → Right. breast recurrence (DCIS).. Primary Treatment. Operation. First Operation (Aug. 2004) Left breast conserv­. ing surgery, sentinel lymph node biopsy.. Pathology Report. Invasive Ductal Carcinoma. 1. Size of invasive carcinoma: 0.4 cm (pT1a).. 2. Size of intraductal carcinoma: 4 cm.. 3. Histologic grade: 2/3 (tubule formation: 2/3,. nuclear pleomorphism: 2/3, mitotic count: 2/3).. 4. Ductal carcinoma in situ: present, intratu­. moral/extratumoral (95%) (nuclear grade:. low, necrosis: present, architectural pattern:. cribriform and comedo, extensive intraductal. component: present).. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) Superior margin: 20 mm.. . (b) Inferior margin: (see note).. . (c) Medial margin: 20 mm.. . (d) Lateral margin: 10 mm.. . (e) Deep margin: 10 mm.. 7. Lymph nodes: no metastasis in 3 axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/3,. axillary LN: 0/0).. 8. Vascular invasion: absent.. 9. Lymphatic invasion: absent.. . 10. Tumor border: infiltrative.. . 11. Microcalcification: present, tumoral.. . 12. Pathologic staging: pT1aN0(sn).. Note: Ductal carcinoma in situ is noted only in. the permanent section of nipple margin (Fro 4). and inferior margin (Fro 5).. Result. Intensity Positive %. Estrogen. receptor. Strong (6/7). 3. 1/3–2/3. Progesterone. receptor. Intermediate. (5/7). 2. 1/3–2/3. C-erbB2. Negative (1+). Ki-67. Positive in 5%. of tumor cells. Operation. Second Operation (Sep. 2004) Left breast wide. excision.. Pathology Report. No residual carcinoma with foreign body. reaction.. . 1. Post-lumpectomy status.. Adjuvant Therapy. Postoperative radiation therapy.. Tamoxifen 20 mg/day for 2 years.. Treatments After Recurrence. 240. 241. Local Recurrence. 816. Operation. ­. 242. 243. Pathology Report. . 1. Ductal Carcinoma In Situ. . (a) Size of tumor: 2.0 cm (pTis).. . (b) Nuclear grade: low.. . (c) Necrosis: absent.. . (d) Architectural pattern: cribriform.. . (e) Surgical margins:. • Deep margin: 7 mm.. • Superficial margin: 6 mm.. . (f) Microcalcification:. present,. tumoral/. non-tumoral.. . (g) Pathologic stage (AJCC 2010): pTisNx.. . 2. Sclerosing adenosis.. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (7/8). 3. 1/3–2/3. C-erbB2. Equivocal (2+). Ki-67. Positive in 17%. of tumor cells. . . . Y. Kim et al.. 817. . . Adjuvant Therapy. Tamoxifen. 20. mg/day. for. 0.3. year. (self-cessation).. 36. " +610,Case 35,Patient History,Local Recurrence,"Patient History and Progress. Female/53 years old, peri-menopause.. Screen detected mass lesion on left breast. subareola.. No family history.. No comorbidities.. BRCA 1 and 2 mutation: Not detected.. 35.2. " +599,Case 35,Courses of Treatment,Metastatic Breast Cancer,35.1. . Courses of Treatment. Right breast cancer → Operation → Adjuvant. therapy → Bone metastasis.. Primary Treatment. Strong (8/8). 3. >2/3. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Negative (1+). Ki-67. Positive in. 16% of tumor. cells. Oncotype Dx test: 23 (Recurrence Score).. Adjuvant Therapy. Post-operative radiation therapy to right breast. zoladex for 2 years +Tamoxifen 20 mg/day for. 5 years.. Treatments After Recurrence. See Figs. 112 and 113.. Sep. 2017 PET-CT: R/o metastasis to C2. vertebra.. Palliative Therapy. Bilateral salpingo-oophorectomy.. Radiation therapy to C-spine + Letrozole &. Palbociclib & zometa (2017-11-03~).. Metastatic Breast Cancer +611,Case 35,Patient History,Metastatic Breast Cancer,"Patient History and Progress. Female/51 years old, pre-menopause.. No family history.. S/p. hysterectomy. &. Left. salpingo-­. oophorectomy (benign), s/p total hip replacement. arthroplasty.. 35.2. " +612,Case 36,Courses of Treatment,Carcinoma In Situ,"36.1. . Courses of Treatment:. Operation. Operation. 169. 170. Pathology Report. Lobular carcinoma in situ. . 1. Size of tumor: 0.5 cm.. . 2. Nuclear grade: low.. . 3. Necrosis: absent.. . 4. Architectural pattern: solid.. . 5. Skin: no involvement of tumor.. . 6. Surgical margins:. . (a) superior margin: 10 mm,. . (b) inferior margin: 5 mm,. E. S. Lee et al.. 131. . . a. b. . . Carcinoma In Situ. 132. . (c) medial margin: 20 mm,. . (d) lateral margin: 10 mm,. . (e) deep margin: 2 mm,. . (f) superficial margin: 2 mm.. . 7. Microcalcification:. present,. tumoral/non-. tumoral.. 37. " +619,Case 36,Important Radiologic,Carcinoma In Situ,Important Radiologic. Findings. 167. 168. 36.3.  +624,Case 36,Patient History,Carcinoma In Situ,"Patient History and Progress. Female/47 years old, pre-menopause.. Screen detected mass lesion on right breast. 11 o’clock direction.. No family history.. No comorbidities.. 36.2. " +613,Case 36,Courses of Treatment,HR(+) HER2(+) Breast Cancer,"36.1. . Courses of Treatment. Operation  +  Adjuvant chemotherapy (#4. cycles of docetaxel and cyclophosphamide and. trastuzumab) + Post-operative radiation ther­. apy + Trastuzumab + Tamoxifen 20 mg/day.. 215. Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 1.5 cm (pT1c).. 2. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. b. . 3. Intraductal component: present, intratu­. moral/extratumoral (5%) (nuclear grade:. high, necrosis: absent, architectural pattern:. solid, extensive intraductal component:. absent).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) superior margin: 10 mm,. . (b) inferior margin: 10 mm,. . (c) medial margin: 5 mm,. . (d) lateral margin: 5 mm,. . (e) deep margin: <1 mm from invasive duc­. tal carcinoma (slide 2),. . (f) superficial margin: 2 mm.. 6. Lymph nodes: no metastasis in two axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/2).. 7. Arteriovenous invasion: absent.. 8. Lymphovascular invasion: absent.. 9. Tumor border: infiltrative.. . 10. Microcalcification:. present,. tumoral/. non-tumoral.. . 11. Pathological TN category (AJCC 2017):. pT1cN0(sn).. Result. Intensity. Positive. %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Weak (3/8). 2. <1%. C-erbB2. Equivocal (2+). Ki-67. Positive in 54%. of tumor cells. SISH. Tumor. heterogeneity. S. Park et al.. 427. © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023. E. S. Lee (ed.), A Practical Guide to Breast Cancer Treatment,. https://doi.org/10.1007/978-981-19-9044-1_7" +620,Case 36,Important Radiologic,HR(+) HER2(+) Breast Cancer,Important Radiologic. Findings. 211 212 213. 214. 36.3.  +625,Case 36,Patient History,HR(+) HER2(+) Breast Cancer,"Patient History and Progress. Female/42 years old, pre-menopause.. Self-detected palpable mass lesion on left. breast 5:30 o’clock direction.. No family history.. S/P Right pneumonectomy (lung cancer).. BRCA 1 and 2 mutation: Not examination.. 36.2. " +614,Case 36,Courses of Treatment,HR(+) HER2(-) Breast Cancer,"36.1. . Courses of Treatment. Operation  +  Post-operative radiation ther­. apy + Tamoxifen 20 mg/day.. Operation. Right breast conserving surgery, sentinel lymph. micropapillary/cribri­. form, extensive intraductal component:. present).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) superior margin: 10 mm.. . (b) inferior margin: 25 mm.. . (c) medial margin: 10 mm.. . (d) lateral margin: 20 mm.. . (e) deep margin: <1 mm from invasive duc­. tal carcinoma (slide 1).. . (f) superficial margin: 5 mm.. 6. Lymph nodes: no metastasis in two axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/1,. non-sentinel LN: 0/1). pT1bN0(sn).. Result. Intensity. Positive. %. Estrogen. receptor. Strong (7/8). 3. 1/3–2/3. Progesterone. receptor. Strong (7/8). 3. 1/3–2/3. C-erbB2. Negative (1+). Ki-67. Positive in 9% of. tumor cells. HR(+) HER2(−) Breast Cancer" +621,Case 36,Important Radiologic,HR(+) HER2(-) Breast Cancer,"Important Radiologic. Findings. See Figs. 199, 200, 201, 202 and 203.. 36.3. " +626,Case 36,Patient History,HR(+) HER2(-) Breast Cancer,"Patient History and Progress. Female/50 years old, pre-menopause.. Screen detected mass lesion on right breast 10. o’clock direction.. No family history.. s/p endometrial curettage.. 36.2. " +615,Case 36,Courses of Treatment,HR(−) HER2(+) Breast Cancer,"36.1. . Courses of Treatment. Neoadjuvant chemotherapy (#6 cycles of. docetaxel and carboplatin and trastuzumab. and pertuzumab)  +  Operation  +  Post-­. operative radiation therapy + Trastuzumab.. 245. Pathology Report. . 1. No residual tumor with foamy histiocytic. collection.. . (a) Post-chemotherapy status.. . (b) Lymph nodes: no metastasis in four axil­. lary lymph nodes (ypN0(sn)) (sentinel. LN: 0/4).. . (c) Microcalcification:. present,. tumoral/. non-tumoral.. . 2. Intraductal papilloma.. Result. Intensity. Positive %. Estrogen. receptor. Negative. (0/8). 0. 0. Progesterone. receptor. Negative. (0/8). 0. 0. C-erbB2. Positive. (3+). Ki-67. Positive in. 22% of. tumor cells. Y. Kwon et al.. 565. F. i. g. 243. (mSUV = 1.3). HR(−) HER2(+) Breast Cancer. 566. . . 37. " +622,Case 36,Important Radiologic,HR(−) HER2(+) Breast Cancer,Important Radiologic. Findings. 243. 244. 36.3.  +627,Case 36,Patient History,HR(−) HER2(+) Breast Cancer,"Patient History and Progress. Female/63 years old, post-menopause.. Screen detected mass lesion on left breast 2. o’clock direction.. No family history.. Hypertension, chronic renal failure, ventricu­. lar premature contraction.. S/P cholecystectomy (due to stone).. 36.2. " +616,Case 36,Courses of Treatment,HR(−) HER2(−) Breast Cancer,"36.1. . Courses of Treatment. Neoadjuvant chemotherapy (#4  cycles of. doxorubicin and ­. cyclophosphamide + #4 cycles. of docetaxel)  +  Operation  +  Post-operative. radiation therapy.. Operation. 267. Pathology Report. . 1. No residual tumor with foamy histiocytic. collection.. . (a) Post-chemotherapy status.. . (b) Lymph nodes: no metastasis in two axil­. lary lymph nodes (ypN0(sn)) (sentinel. LN: 0/2).. . (c) Related slides: S21–10541, S21–10544.. . 2. Adenomyoepithelial. hyperplasia. with. microcalcification.. Result. Intensity. Positive. %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Negative (0). Ki-67. Positive in 66%. of tumor cells. E. S. Lee et al.. 707. . . . HR(−) HER2(−) Breast Cancer. 708. 37. " +623,Case 36,Important Radiologic,HR(−) HER2(−) Breast Cancer,Important Radiologic Findings. 260 261 262. 263. HR(−) HER2(−) Breast Cancer. 704. . . . ­. E. S. Lee et al.. 705. . HR(−) HER2(−) Breast Cancer. 706. . After Neoadjuvant Chemotherapy. 264 265. 266. 36.3.  +628,Case 36,Patient History,HR(−) HER2(−) Breast Cancer,"Patient History and Progress. Female/46 years old, pre-menopause.. Self-detected palpable mass lesion on left. axillary.. Family history of breast cancer, aunt. (maternal).. Hepatitis B virus carrier.. BRCA 1 and 2 mutation: Not detected, RET. VUS (variant of uncertain).. 36.2. " +617,Case 36,Courses of Treatment,Local Recurrence,"36.1. . Courses of Treatment. Right breast DCIS → Operation → Left breast. recurrence (DCIS).. Primary Treatment. 244. Operation. 245. Pathology Report. Ductal Carcinoma In Situ. . 1. Post mammotome biopsy status.. Local Recurrence. 818. . a. b. . . 2. Size of tumor: 0.2 cm, residual.. . 3. Nuclear grade: low.. . 4. Necrosis: absent/present.. . 5. Architectural pattern: cribriform.. . 6. Surgical margins:. . (a) Superior margin: (see note).. . (b) Inferior margin: 7 mm.. . (c) Medial margin: 4 mm from ductal carci­. noma in situ.. . (d) Lateral margin: 8 mm.. . (e) Deep margin: 2 mm.. . (f) Superficial margin: 2 mm.. . 7. Microcalcification: absent.. Note: 1. The superior margin of the lumpec­. tomy specimen (slide 4) is close to ductal carci­. noma in situ (<1 mm), but this margin submitted. for frozen diagnosis (Fro 1) is free of tumor.. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (1+). Ki-67. Positive in 29%. of tumor cells. Treatments After Recurrence. 246. Operation. 247. 248. Pathology Report. Ductal Carcinoma In Situ. . 1. Size of tumor: 3.5 cm (pTis).. . 2. Nuclear grade: low.. . 3. Necrosis: absent.. . 4. Architectural pattern: papillary/cribriform/. solid.. . 5. Skin: no involvement of tumor.. . 6. Surgical margins:. . (a) Deep margin: 2 mm.. . (b) Superficial margin: 2 mm.. . 7. Microcalcification:. present,. tumoral/. non-tumoral.. . 8. Pathological TN category (AJCC 2017): pTis.. Axillary Tail: Ductal Carcinoma In Situ. . 1. Size of tumor: 0.3 cm.. . 2. Nuclear grade: low.. . 3. Necrosis: absent.. . 4. Architectural pattern: cribriform.. . 5. Surgical margin: involvement of superficial. margin.. Y. Kim et al.. 819. . a. b. . Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (0). Ki-67. Positive in 51%. of tumor cells. Adjuvant Therapy. Tamoxifen 20 mg/day for 5 years.. 37. " +629,Case 36,Patient History,Local Recurrence,"Patient History and Progress. Female/48 years old, pre-menopause.. Screen detected mass lesion on right breast 10. o’clock direction.. Outside result of biopsy: Papillary carcinoma. in situ.. No family history.. s/p bilateral breast augmentation.. BRCA 1 and 2 mutation: Not detected.. 36.2. " +618,Case 36,Courses of Treatment,Metastatic Breast Cancer,Courses of Treatment. Right breast cancer → Operation → Adjuvant. therapy → Lung metastasis.. Primary Treatment. Estrogen. receptor. Strong (7/7). 3. >2/3. Progesterone. receptor. Intermediate. (5/7). 2. 1/3–2/3. Result. Intensity. Positive %. C-erbB2. Equivocal. (2+). Ki-67. Positive in. 10% of tumor. cells. SISH. Negative. Adjuvant Therapy. Adjuvant chemotherapy #8 cycles (Doxorubicin. & cyclophosphamide #4 → Docetaxel #4).. Post-operation radiation to right breast +. Tamoxifen 20 mg/day for 5 years.. Treatments After Recurrence. Strong (8/8). 3. >2/3. Progesterone. receptor. Intermediate. (6/8). 2. 1/3–2/3. C-erbB2. Negative (0). Ki-67. Positive in. 22% of tumor. cells. Palliative Therapy. Clinical trial: Capecitabine #19: Progressive. disease.. Nov. 2018 Bilateral salpingo-oophorectomy.. Palliative therapy: Letrozole +Palbociclib. (Dec. 2018) ~. 37.  +630,Case 36,Patient History,Metastatic Breast Cancer,mellitus.. 36.2.  +631,Case 37,Courses of Treatment,Carcinoma In Situ,"37.1. . Courses of Treatment:. Operation. Operation. 173. 174. Pathology Report. Lobular carcinoma in situ. . 1. Size of tumor: 2.0 cm.. . 2. Nuclear grade: low.. . 3. Necrosis: absent.. . 4. Architectural pattern: solid.. . 5. Skin: no involvement of tumor.. . 6. Surgical margins:. . (a) superior margin: positive (Fro 1),. . (b) inferior margin: 4 mm,. . (c) medial margin: positive (Fro 3),. . (d) lateral margin: positive (Fro 4),. . (e) deep margin: <1 mm (slide 6),. . (f) superficial margin: 10 mm.. . 7. Microcalcification: absent.. Result. Intensity. Positive %. Estrogen. receptor. Weak (4/8). 2. 1–10%. Progesterone. receptor. Weak (4/8). 2. 1–10%. C-erbB2. Negative (1+). Ki-67. Positive in 8%. of tumor cells. . E. S. Lee et al.. 133. . a. b. . a. b. . ­. Carcinoma In Situ. 134. 38. " +637,Case 37,Important Radiologic,Carcinoma In Situ,Important Radiologic. Findings. 171. 172. 37.3.  +641,Case 37,Patient History,Carcinoma In Situ,"Patient History and Progress. Female/46 years old, pre-menopause.. Screen detected mass lesion on left breast. 12 o’clock direction.. Outside result of biopsy: Lobular carcinoma. in situ.. No family history.. No comorbidities.. 37.2. " +632,Case 37,Courses of Treatment,HR(+) HER2(-) Breast Cancer,"Courses of Treatment. Operation + Adjuvant chemotherapy (#4. cycles of docetaxel & cyclophosphamide)  +. Post-operative radiation therapy + Tamoxifen. 20 mg/day.. Operation. Left breast conserving surgery, sentinel lymph. ductal component: present).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) superior margin: 10 mm.. . (b) inferior margin: 15 mm.. . (c) medial margin: 10 mm.. . (d) lateral margin: (see note).. . (e) deep margin: 4 mm.. . (f) superficial margin: <1 mm from ductal. 10. Microcalcification:. present,. tumoral/. non-tumoral.. . 11. Pathological TN category (AJCC 2017):. pT2N0(sn).. Note: 1. The lateral margin of the lumpec­. tomy specimen (slide 6) is close to ductal. carcinoma in situ (<1 mm) but this margin. submitted for frozen diagnosis (Fro 9) is free. of tumor.. Y. Kim et al.. 3. 10%–1/3. C-erbB2. Negative (1+) IDC. Positive (3+) DCIS. Ki-67. Positive in 47% of tumor cells. 38. " +638,Case 37,Important Radiologic,HR(+) HER2(-) Breast Cancer,"Important Radiologic. Findings. See Figs. 205, 206, 207 and 208.. 37.3. " +642,Case 37,Patient History,HR(+) HER2(-) Breast Cancer,"4–5 o’clock direction.. No family history.. Hypertension,. s/p. Lumbar. spine. disc. operation.. 37.2. " +633,Case 37,Courses of Treatment,HR(−) HER2(+) Breast Cancer,"37.1. . Courses of Treatment. Neoadjuvant chemotherapy (#6 cycles of. docetaxel and carboplatin and trastuzumab. and pertuzumab)  +  Operation  +  Post-­. operative radiation therapy + Trastuzumab.. 253. Pathology Report. Ductal Carcinoma In Situ. 1. Post-chemotherapy status.. 2. Size of tumor: 0.5 cm (ypTis).. 3. Nuclear grade: high.. 4. Necrosis: present.. 5. Architectural pattern: solid/comedo.. 6. Skin: no involvement of tumor.. 7. Surgical margins:. . (a) superior margin: 10 mm,. . (b) inferior margin: 10 mm,. . (c) medial margin: 30 mm,. HR(−) HER2(+) Breast Cancer. 570. . . (d) lateral margin: 20 mm,. . (e) deep margin: 2 mm,. . (f) superficial margin: 2 mm.. 8. Lymph nodes: no metastasis in two axillary. lymph nodes (ypN0(sn)) (sentinel LN: 0/2).. 9. Microcalcification:. present,. tumoral/. non-tumoral.. . 10. Pathological TN category (AJCC 2017):. ypTisN0(sn).. Result. Intensity. Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in. 39% of tumor. cells. 38. " +639,Case 37,Important Radiologic,HR(−) HER2(+) Breast Cancer,Important Radiologic. Findings. 246 247. 248. Y. Kwon et al.. 567. . . . HR(−) HER2(+) Breast Cancer. 568. 37.3. . After Neoadjuvant. Chemotherapy. 249 250 251. 252. . Y. Kwon et al.. 569. . . . 37.4.  +643,Case 37,Patient History,HR(−) HER2(+) Breast Cancer,"Patient History and Progress. Female/63 years old, post-menopause.. Self-detected nipple discharge on left breast.. No family history.. S/P Total hysterectomy, s/p right lung lobec­. tomy (benign), diabetes mellitus.. 37.2. " +634,Case 37,Courses of Treatment,HR(−) HER2(−) Breast Cancer,"37.1. . Courses of Treatment. Neoadjuvant chemotherapy (#4  cycles of. doxorubicin and cyclophosphamide  +  #4. cycles of docetaxel)  +  Operation  +  Post-. operative radiation therapy  +  Adjuvant. capecitabine.. Operation. 276. Pathology Report. Invasive Ductal Carcinoma. 1. Post-chemotherapy status.. 2. Size of invasive component: up to 0.3  cm,. multifocal (ypT1a).. 3. Size of intraductal component: 2.0 cm.. 4. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 2/3, 3/HPF).. 5. Intraductal component: present, intratu­. moral/extratumoral (80%) (nuclear grade:. high, necrosis: present, architectural pattern:. papillary/micropapillary/cribriform/solid/. comedo, extensive intraductal component:. absent/present).. 6. Skin: no involvement of tumor.. 7. Surgical margins:. . (a) Superior margin: 20 mm.. . (b) Inferior margin: 5 mm.. . (c) Medial margin: (see note).. . (d) Lateral margin: 5 mm.. . (e) Deep margin: 2 mm.. . (f) Superficial margin: 2 mm.. 8. Lymph nodes:. . (a) metastasis in two out of six axillary lymph. nodes (ypN1a) (sentinel LN: 1/1, axillary. LN: 0/4, intramammary LN: 1/1),. . (b) perinodal extension: present,. . (c) size of metastatic carcinoma: 4 mm.. 9. Arteriovenous invasion: absent.. HR(−) HER2(−) Breast Cancer. 710. . . ­. . E. S. Lee et al.. 711. . 10. Lymphovascular invasion: present, intratu­. moral/peritumoral.. . 11. Tumor border: infiltrative.. . 12. Microcalcification:. present,. tumoral/. non-tumoral.. . 13. Pathological TN category (AJCC 2017):. ypT1aN1a.. Result. Intensity. Positive %. Estrogen. receptor. Weak (3/8). 1. 1%–10%. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Negative (1+). Ki-67. Positive in 29%. of tumor cells. . . HR(−) HER2(−) Breast Cancer. 712. 38. " +640,Case 37,Important Radiologic,HR(−) HER2(−) Breast Cancer,Important Radiologic. Findings. 268 269 270. 271. . . . ­. ­. E. S. Lee et al.. 709. . After Neoadjuvant. Chemotherapy. 272 273 274. 275. 37.3.  +644,Case 37,Patient History,HR(−) HER2(−) Breast Cancer,"Patient History and Progress. Female/46 years old, pre-menopause.. Self-detected palpable mass lesion on right breast.. Family history of breast cancer, aunt (maternal).. s/p myomectomy.. BRCA 1 and 2 mutation: Not detected.. 37.2. " +635,Case 37,Courses of Treatment,Local Recurrence,"37.1. . Courses of Treatment. Left breast DCIS→ Operation → Adjuvant ther­. apy → Left breast recurrence (DCIS).. Primary Treatment. 249 250. 251. Operation. 252. Local Recurrence. 820. Pathology Report. Ductal Carcinoma In Situ. . 1. Size of tumor: 3.0 cm (pTis).. . 2. Nuclear grade: low.. . 3. Necrosis: present.. . 4. Architectural pattern: micropapillary/cribri­. form/comedo.. . 5. Skin: no involvement of tumor.. . 6. Surgical margins:. . (a) Nipple margin: positive for atypical duc­. tal hyperplasia (Fro 1) (see note 1).. . (b) Superior margin: (see note 2).. . (c) Inferior margin: 20 mm.. . (d) Medial margin: 5 mm.. . (e) Lateral margin: 15 mm.. . (f) Deep margin: 2 mm.. . (g) Superficial margin: 2 mm.. . 7. Microcalcification:. present,. tumoral/. non-tumoral.. . 8. Pathologic stage (AJCC 2010): pTis.. Note: 1. Atypical ductal hyperplasia is present. only in the permanent section of Fro 1.. 2. The superior margin of the lumpectomy. specimen (slide 1) is positive for ductal carci­. noma in situ, but this margin submitted for frozen. Result. Intensity. Positive %. Estrogen. receptor. Intermediate. (6/8). 2. 1/3–2/3. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in 36%. of tumor cells. Adjuvant Therapy. Postoperative radiation therapy.. Tamoxifen 20 mg/day for 5 years.. Treatments After Recurrence. 253. 254. Operation. 255. Pathology Report. Ductal Carcinoma In Situ. . 1. Post-lumpectomy status.. . 2. Size of tumor: 0.5 cm (rpTis).. . 3. Nuclear grade: high.. . 4. Necrosis: absent.. . 5. Architectural. pattern:. micropapillary/. cribriform.. . 6. Skin and nipple: Paget’s disease.. . 7. Surgical margins:. . (a) Superior margin: 5 mm.. . (b) Inferior margin: 5 mm.. . (c) Medial margin: 5 mm.. . (d) Lateral margin: 5 mm.. . (e) Deep margin: 2 mm.. . (f) Superficial margin: 2 mm.. Local Recurrence. 822. . . . 8. Microcalcification:. present,. tumoral/. non-tumoral.. . 9. Pathological TN category (AJCC 2017):. rpTis(Paget).. Result. Intensity. Positive %. Estrogen. receptor. Negative (2/8). 1. <1%. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in 58%. of tumor cells. 38. " +645,Case 37,Patient History,Local Recurrence,"Patient History and Progress. Female/43 years old, pre-menopause.. Screen detected mass lesion on left breast 7. o’clock direction.. Outside result of biopsy: ductal carcinoma in. situ.. No family history.. No comorbidities.. BRCA 1 and 2 mutation: Not detected.. 37.2. " +636,Case 37,Courses of Treatment,Metastatic Breast Cancer,"37.1. . Courses of Treatment. Right breast cancer → Operation → Adjuvant. therapy → Lung metastasis.. Primary Treatment. Estrogen. receptor. Intermediate. (6/8). 2. 1/3–2/3. Progesterone. receptor. Intermediate. (6/8). 2. 1/3–2/3. C-erbB2. Positive (3+). Ki-67. Positive in. 27% of tumor. cells. Metastatic Breast Cancer. 920. Adjuvant Therapy. Adjuvant chemotherapy #8 cycles (Doxorubicin. & cyclophosphamide #4 → Docetaxel & trastu­. zumab #4).. Post-operative radiation therapy to right. breast.. Concurrent Trastuzumab # 4 + Tamoxifen. 20 mg/day for 85 days.. Treatments After Recurrence. See Figs. 117 and 118.. Feb. 2014 PET>R/O metastasis to lung, lymph. node, and right pleural effusion.. Palliative Therapy. Palliative therapy: Letrozole & trastuzumab (Feb." +646,Case 37,Patient History,Metastatic Breast Cancer,"Patient History and Progress. Female/59 years old, post-menopause.. No family history.. Hypertension, s/p right vertebral artery, tran­. sient ischemic attack.. 37.2. " +647,Case 38,Courses of Treatment,Carcinoma In Situ,"38.1. . Courses of Treatment. Neoadjuvant chemotherapy #6 cycles (Docetaxel. and. Carboplatin. and. Trastuzumab. and. Pertuzumab) + Operation + Postoperative radia­. tion therapy + Tamoxifen 20 mg/day for 5 years. + Trastuzumab for 1 year.. Operation. 180. 181. Pathology Report. Right.. Lobular carcinoma in situ. . 1. Post-chemotherapy status.. . 2. Size of tumor: 1.5 cm.. . 3. Nuclear grade: low.. . 4. Necrosis: absent.. . 5. Architectural pattern: solid.. . 6. Surgical margins:. . (a) superior margin: (see note),. . (b) inferior margin: 4 mm,. . (c) medial margin: 20 mm,. . (d) lateral margin: (see note),. . (e) deep margin: <1 mm (MG2),. . (f) superficial margin: 2 mm.. . 7. Microcalcification: present, non-tumoral.. Note: 1. The superior and lateral margins of. the lumpectomy specimen (slides MG1and 5). are close to lobular carcinoma in situ (1 mm). but these margins submitted for frozen diagno­. sis (Fro 1 and Fro 4) are free of tumor.. Left.. Ductal carcinoma in situ. . 1. Post-chemotherapy status.. . 2. Size of tumor: up to 0.5 cm (ypTis).. . 3. Nuclear grade: high.. . 4. Necrosis: present.. . 5. Architectural pattern: papillary/cribriform/. solid/comedo.. . 6. Skin: no involvement of tumor.. . 7. Surgical margins:. . (a) superior margin: 17 mm,. . (b) inferior margin: 10 mm,. . . ­. E. S. Lee et al.. 135. . ­. . ­. . a. b. . Carcinoma In Situ. 136. a. b. c. d. . ­. . (c) medial margin: 40 mm,. . (d) lateral margin: 10 mm,. . (e) deep margin: 3 mm,. . (f) superficial margin: 14 mm.. . 8. Lymph nodes: no metastasis in five axillary. lymph nodes (ypN0(sn)) (sentinel LN: 0/5).. . 9. Microcalcification: present.. Result. Intensity. Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in. 15% of tumor. cells. 39. " +653,Case 38,Important Radiologic,Carcinoma In Situ,Important Radiologic. Findings. 175 176 177 178. 179. 38.3.  +657,Case 38,Patient History,Carcinoma In Situ,"Patient History and Progress. Female/51 years old, pre-menopause.. Screen detected mass and microcalcification. on upper outer left breast.. No family history.. No comorbidities.. BRCA 1 and 2 mutation: Not detected, POLE. VUS (variant of uncertain).. 38.2. " +648,Case 38,Courses of Treatment,HR(+) HER2(-) Breast Cancer,38.1. . Courses of Treatment. Operation  +  Post-operative radiation ther­. apy + Letrozole 2.5 mg/day.. HR(+) HER2(−) Breast Cancer. extensive intraductal component: present).. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) superior margin: 20 mm.. . (b) inferior margin: 7 mm.. . (c) medial margin: 15 mm.. . (d) lateral margin: 10 mm.. . (e) deep margin: 2 mm.. . (f) superficial margin: 5 mm.. 7. Lymph nodes: no metastasis in one axillary. lymph node (pN0(sn)) (sentinel LN: 0/1). Y. Kim et al.. %. Estrogen. receptor. Strong (7/8). 2. >2/3. Progesterone. receptor. Weak (3/8). 1. 1–10%. C-erbB2. Negative (1+). Ki-67. Positive in 19%. of tumor cells. HR(+) HER2(−) Breast Cancer +654,Case 38,Important Radiologic,HR(+) HER2(-) Breast Cancer,"Important Radiologic. Findings. See Figs. 210, 211, 212, 213 and 214.. 38.3. " +658,Case 38,Patient History,HR(+) HER2(-) Breast Cancer,"Patient History and Progress. Female/57 years old, post-menopause.. Screen detected mass lesion on left breast 2. o’clock direction.. No family history.. Diabetes mellitus, dyslipidemia, s/p cataract. operation.. 38.2. " +649,Case 38,Courses of Treatment,HR(−) HER2(+) Breast Cancer,"38.1. . Courses of Treatment. Operation  +  Adjuvant chemotherapy (#4. cycles of docetaxel and cyclophosphamide) +. Post-operative. radiation. therapy. +. Trastuzumab.. 258. Y. Kwon et al.. 571. . . . HR(−) HER2(+) Breast Cancer. 3. Intraductal component: present, intratu­. moral/extratumoral (60%) (nuclear grade:. high, necrosis: present, architectural pattern:. cribriform/solid/comedo, extensive intra­. ductal component: present).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) superior margin: 10 mm,. . (b) inferior margin: 15 mm,. . (c) medial margin: 5 mm,. . (d) lateral margin: 10 mm,. . (e) deep margin: 10 mm,. . (f) superficial margin: 7 mm.. Y. Kwon et al.. 573. 6. Lymph nodes: no metastasis in nine axillary. lymph nodes (pN0) (sentinel LN: 0/4, axil­. lary LN: 0/5).. 7. Arteriovenous invasion: absent.. 8. Lymphovascular invasion: absent.. 9. Tumor border: infiltrative.. . 10. Microcalcification: present, non-tumoral.. . 11. Pathological TN category (AJCC 2017):. pT1cN0.. Result. Intensity Positive %. Estrogen. receptor. Negative. (0/8). 0. 0. Progesterone. receptor. Negative. (0/8). 0. 0. C-erbB2. positive. (3+). Ki-67. Positive. in 59%. of tumor. cells. HR(−) HER2(+) Breast Cancer. 575" +655,Case 38,Important Radiologic,HR(−) HER2(+) Breast Cancer,Important Radiologic. Findings. 254 255 256. 257. 38.3.  +659,Case 38,Patient History,HR(−) HER2(+) Breast Cancer,"Patient History and Progress. Female/55 years old, post-menopause.. Self-detected palpable mass lesion on right. breast.. Family history of breast cancer, sister.. Dyslipidemia.. BRCA 1 and 2 mutation: Not detected,. MUTYH. and. RAD50 VUS. (variant. of. uncertain).. 38.2. " +650,Case 38,Courses of Treatment,HR(−) HER2(−) Breast Cancer,38.1. . Courses of Treatment. Neoadjuvant chemotherapy (#4  cycles of. doxorubicin and cyclophosphamide  +  #4. cycles of docetaxel)  +  Operation  +  Post-. operative radiation therapy.. Operation. ­. 285. 286. Pathology Report. No residual tumor with stromal degeneration. . 1. Post-chemotherapy status.. . 2. Lymph nodes: no metastasis in one axillary. lymph node (ypN0(sn)) (sentinel LN: 0/1).. . 3. Microcalcification: present.. Result. Intensity. Positive. %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Negative (1+). Ki-67. Positive in 62%. of tumor cells. HR(−) HER2(−) Breast Cancer. 714. . . . E. S. Lee et al.. 715. . . HR(−) HER2(−) Breast Cancer. 716. . E. S. Lee et al.. 717 +656,Case 38,Important Radiologic,HR(−) HER2(−) Breast Cancer,Important Radiologic. Findings. 277 278 279. 280. . . . ­. E. S. Lee et al.. 713. . After Neoadjuvant. Chemotherapy. 281 282 283. 284. 38.3.  +660,Case 38,Patient History,HR(−) HER2(−) Breast Cancer,"Patient History and Progress. Female/52 years old, post-menopause.. Self-detected palpable mass lesion on right. breast.. No family history.. s/p bilateral salpingo-oophorectomy.. BRCA 1 mutation carrier.. 38.2. " +651,Case 38,Courses of Treatment,Local Recurrence,"38.1. . Courses of Treatment. Right breast IDC→ Operation → Adjuvant ther­. apy → Right breast DCIS.. Primary Treatment. Operation. Jun. 2012 Right breast conserving surgery, senti­. nel lymph node biopsy (outside).. Pathology Report. Invasive Ductal Carcinoma. . 1. Size of tumor: 0.9 cm (pT1b).. . 2. Lymph nodes: no metastasis in four axillary. lymph nodes (pN0(sn)).. . 3. Pathological TN category: pT1bN0.. Result. Intensity. Positive %. Estrogen. receptor. Positive (6/8). Progesterone. receptor. Positive (6/8). C-erbB2. Equivocal (2+). Adjuvant Therapy. Adjuvant chemotherapy #6 cycles of cyclophos­. phamide and methotrexate and fluorouracil.. Postoperative radiation therapy.. Tamoxifen 20 mg/day for 5 years.. Treatments After Recurrence. 256. Operation. 257. Pathology Report. Ductal Carcinoma In Situ. . 1. Size of tumor: 0.3 cm (pTis).. . 2. Nuclear grade: low.. . 3. Necrosis: absent.. . 4. Architectural pattern: cribriform/solid.. . 5. Skin: no involvement of tumor.. . 6. Surgical margins:. . (a) Superior margin: 5 mm.. . (b) Inferior margin: 2 mm (slides 3 and 4).. . ­. . Local Recurrence. 824. . (c) Medial margin: 10 mm.. . (d) Lateral margin: 10 mm.. . (e) Deep margin: 2 mm.. . (f) Superficial margin: 2 mm.. . 7. Microcalcification:. present,. tumoral/. non-tumoral.. . 8. Pathological TN category (AJCC 2017): pTis.. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (1+). Ki-67. Positive in 8%. of tumor cells. Adjuvant Therapy. Postoperative radiation therapy.. Tamoxifen 20 mg/day.. 39. " +661,Case 38,Patient History,Local Recurrence,"Patient History and Progress. Female/47 years old, pre-menopause.. Screen detected mass lesion on right breast 12. o’clock direction.. Outside result of Lumpectomy: Invasive duc­. tal carcinoma.. No family history.. Y. Kim et al.. 823. 38.2. " +652,Case 38,Courses of Treatment,Metastatic Breast Cancer,"Courses of Treatment. Both breasts cancer → Operation → Adjuvant. therapy → Liver metastasis.. Primary Treatment. See Figs. 119 and 120.. Operation. Dec. 2008 Bilateral breast conserving surgery,. axillary lymph node dissection.. Pathology:. Right breast> Invasive ductal carcinoma, stage. pT2N2a, size of tumor: 4.5 cm, lymph node: 6/9. (12 mm).. Result. Intensity Positive %. Estrogen. receptor. Weak(2/7). 1. <10%. Progesterone. receptor. Negative. (0/7). 0. 0. Result. Intensity Positive %. C-erbB2. Positive. (3+). Ki-67. Positive in. 15% of. tumor cells. Left breast> Ductal carcinoma in situ, stage. pTisN0, size of tumor: 2.0 cm, lymph node: 0/7.. Metastatic Breast Cancer. receptor. Negative (0/7). 0. 0. C-erbB2. Positive(3+). Ki-67. Positive in 5%. of tumor cells. Adjuvant Therapy. Adjuvant chemotherapy #8 cycles (Doxorubicin. & cyclophosphamide #4 → Docetaxel #4).. Post-operative radiation therapy to right breast. & supraclavicular lymph node + Letrozole for. 5 years, concurrent Trastuzumab #18.. Treatments After Recurrence" +662,Case 38,Patient History,Metastatic Breast Cancer, +663,Case 39,Courses of Treatment,Carcinoma In Situ,"39.1. . Courses of Treatment. Operation + Tamoxifen 20 mg/day for 6 months.. Operation. 184. 185. Pathology Report. Lobular carcinoma in situ. . 1. Size of tumor: 2.0 cm.. . 2. Nuclear grade: low.. . 3. Necrosis: absent.. E. S. Lee et al.. 137. . 4. Architectural pattern: solid.. . 5. Skin: no involvement of tumor.. . 6. Surgical margins:. . (a) superior margin: <1 mm (slide 2),. . (b) inferior margin: <1 mm (slide 5),. . (c) medial margin: 1 mm (slide 4),. . (d) lateral margin: <1 mm (slide 6),. . (e) deep margin: <1 mm (slide 3),. . (f) superficial margin: 2 mm.. . 7. Microcalcification:. present,. tumoral/non-. tumoral.. Result. Intensity. Positive %. Estrogen. receptor. Strong (7/8). 3. 1/3–2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (1+). Ki-67. Positive in 6%. of tumor cells. . . a. b. . Carcinoma In Situ. 138. a. b. . ­. . ­. . 40. " +667,Case 39,Important Radiologic,Carcinoma In Situ,Important Radiologic. Findings. 182. 183. 39.3.  +669,Case 39,Patient History,Carcinoma In Situ,"Patient History and Progress. Female/47 years old, pre-menopause.. Screen detected mass lesion on right breast 12. o’clock direction.. Outside result of biopsy: lobular carcinoma in. situ.. No family history.. Hypertension.. 39.2. " +664,Case 39,Courses of Treatment,HR(+) HER2(-) Breast Cancer,"Courses of Treatment. Operation. +. Adjuvant. chemotherapy. (#4  cycles of docetaxel & cyclophospha­. mide) + Tamoxifen 20 mg/day.. Operation. Right nipple–areolar complex sparing mastec­. tomy with immediate implant reconstruction, left. breast mass excision (Figs. 220, 221 and 222).. Pathology Report. [Right]. Invasive Lobular Carcinoma. 1. Size of tumor: 2.5 cm (pT2).. Y. Kim et al.. 295. 2. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 6/10 HPF). 3. In situ component: present, intratumoral/. extratumoral (70%).. 4. Skin: no involvement of tumor.. 5. Surgical margins: (see note).. . (a) deep margin: <1 mm from invasive lobu­. lar carcinoma (slides 1 and 9).. . (b) superficial margin: <1 mm from invasive. lobular carcinoma (slide 1).. 6. Lymph nodes: no metastasis in one axillary. lymph node (pN0(sn)) (sentinel LN: 0/1). 7. Arteriovenous invasion: absent.. 8. Lymphovascular invasion: absent.. 9. Tumor border: infiltrative.. . 10. Microcalcification:. present,. tumoral/. non-tumoral.. . 11. Pathological TN category (AJCC 2017):. pT2N0(sn).. Note: 1. Lobular carcinoma in situ is pres­. ent only in the permanent sections of Fro 9. and Fro 10.. Result. Intensity. Positive. %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Equivocal (2+). (SISH negative). Ki-67. Positive in 5% of. tumor cells. [Left]" +668,Case 39,Important Radiologic,HR(+) HER2(-) Breast Cancer,"Important Radiologic. Findings. See Figs. 216, 217, 218 and 219.. 39.3. " +670,Case 39,Patient History,HR(+) HER2(-) Breast Cancer,No comorbidities.. 39.2.  +665,Case 39,Courses of Treatment,Local Recurrence,"39.1. . Courses of Treatment. Left breast IDC→ Operation → Adjuvant ther­. apy → Left breast recurrence (IDC).. Primary Treatment. 258 259 260. 261. Operation. 262. Pathology Report. Invasive Ductal Carcinoma. 1. Size of invasive tumor: 3 cm (pT2).. 2. Size of intraductal component: 4.5 cm.. 3. Histologic grade: 1/3 (tubule formation: 3/3,. nuclear pleomorphism: 1/3, mitotic count:. 1/3, 7/10HPF).. 4. Intraductal component: present, intratu­. moral/extratumoral (30%) (nuclear grade:. low, necrosis: absent, architectural pattern:. cribriform, extensive intraductal component:. present).. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . ­. . Y. Kim et al.. 825. . . . Local Recurrence. 826. . (a) Deep margin: 13 mm.. . (b) Superficial margin: 16 mm.. 7. Lymph nodes:. . (a) Metastasis in 1 out of 10 axillary lymph. nodes (pN1mi) (sentinel LN: 1/3, axil­. lary LN: 0/7).. . (b) Perinodal extension: absent.. . (c) Size of metastatic carcinoma: 2 mm.. 8. Vascular invasion: absent.. 9. Lymphatic invasion: absent.. . 10. Tumor border: infiltrative.. . 11. Microcalcification: absent.. . 12. Pathologic stage (AJCC 2010): pT2N1mi.. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (0). Ki-67. Positive in 26%. of tumor cells. Adjuvant Therapy. Tamoxifen 20  mg/day for 2.6  years with. goserelin.. Treatments after Recurrence. 263. 264. Operation. 265. Pathology Report. Invasive Ductal Carcinoma. 1. Post-nipple-sparing mastectomy status.. 2. Size of tumor: 0.3 cm, residual (see note).. 3. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 7/10HPF).. 4. Intraductal component: present, intratu­. moral/extratumoral (10%) (nuclear grade:. low, necrosis: absent, architectural pattern:. cribriform, extensive intraductal component:. absent).. 5. Skin and nipple: no involvement of tumor.. 6. Surgical margins:. . (a) Superior margin: 10 mm.. . (b) Inferior margin: 5 mm.. . (c) Medial margin: 20 mm.. . (d) Lateral margin: 5 mm.. . (e) Deep margin: 2 mm.. . (f) Superficial margin: 2 mm.. 7. Arteriovenous invasion: absent.. 8. Lymphovascular. invasion:. present,. intratumoral.. 9. Tumor border: infiltrative.. . 10. Microcalcification:. present,. tumoral/. non-tumoral.. Note: 1. In the previous biopsy specimen. (S18–12629), invasive ductal carcinoma mea­. sures at least 0.4 cm in greatest dimension.. . . Y. Kim et al.. 827. . . Result. Intensity. Positive %. Estrogen. receptor. Intermediate. (5/8). 2. 10%-1/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (1+). Ki-67. Positive in 14%. of tumor cells. Adjuvant Therapy. Postoperative radiation therapy.. Letrozole 2.5 mg/day for 5 years.. 40. " +671,Case 39,Patient History,Local Recurrence,"Patient History and Progress. Female/42 years old, post-menopause.. Bloody discharge from left nipple.. No family history.. 39.2. " +666,Case 39,Courses of Treatment,Metastatic Breast Cancer,Courses of Treatment. Right breast cancer → Neoadjuvant chemother­. apy → Operation → Adjuvant therapy → Left. breast and lung metastasis.. Primary Treatment. Estrogen. receptor. Negative(0/7). 0. 0. Progesterone. receptor. Negative(0/7). 0. 0. C-erbB2. Equivocal (2+). Ki-67. Positive in. 10% of tumor. cells. SISH. Negative. Adjuvant Therapy. Post-operative radiation to right breast.. Treatments After Recurrence. (0/8). 0. 0. Progesterone. receptor. Negative(0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in. 43% of tumor. cells +672,Case 39,Patient History,Metastatic Breast Cancer,"Patient History and Progress. Female/51 years old, peri-menopause.. No family history.. BRCA 1 & 2 mutation: Not detected.. Hepatitis B virus carrier, hypertension.. 39.2. " +673,Case 4,Courses of Treatment,Benign and Proliferative,"4.1. . Courses of Treatment. → 2021-12-14 Excision, Lt.. Benign and Proliferative Case Series. 22. . 4.3.1. . Pathology Report. Diagnosis. • Breast, left, excision:. –. – Intraductal papilloma.. 5. " +681,Case 4,Important Radiologic,Benign and Proliferative,Important Radiologic. Findings. 6. 4.3.  +687,Case 4,Patient History,Benign and Proliferative,"Patient History and Progress. Female/60 years old, post-menopause.. Screen detected mass lesion on left breast. 12 o’clock direction.. Family history of pancreatic cancer, mother.. Hypertension, dyslipidemia (taking medication).. 4.2. " +674,Case 4,Courses of Treatment,Carcinoma In Situ,"4.1. . Courses of Treatment. Operation + Postoperative radiation therapy (left. side) + Tamoxifen 20 mg/day for 5 years.. 4.3.1. . Operation. 19. 20. 4.3.2. . Pathology Report. Right.. . Lobular carcinoma in situ. . 1. Size of tumor: 0.2 cm.. . 2. Nuclear grade: low.. . 3. Necrosis: absent.. . 4. Architectural pattern: solid.. . 5. Surgical margins:. . (a) superior margin: 5 mm,. . (b) inferior margin: 5 mm,. . . (d) lateral margin: 10 mm,. . (e) deep margin: 2 mm,. . (f) superficial margin: 2 mm.. . 6. Microcalcification:. present,. tumoral/. non-tumoral.. . Lobular carcinoma in situ. . 1. Post-excision status.. . 2. Size of tumor: 0.2 cm, residual.. . 3. Nuclear grade: low.. . 4. Necrosis: absent.. . 5. Architectural pattern: solid.. . 6. Surgical margins:. . (a) superior margin: 5 mm,. . (b) inferior margin: 5 mm,. . ­. . . ­. . Carcinoma In Situ. 60. d. . (c) medial margin: 10 mm,. . (d) lateral margin: 30 mm (see Note 1),. . (e) deep margin: 10 mm,. . (f) superficial margin: 5 mm.. . 7. Microcalcification: present, non-tumoral.. Note: 1. Atypical ductal hyperplasia is pres­. ent only in the permanent section of Frozen 10.. Left.. . E. S. Lee et al.. 61. Ductal carcinoma in situ, pathological TN cat­. egory (AJCC 2017): pTis. . 1. Size of tumor: 0.5 cm (pTis).. . 2. Nuclear grade: low.. . 3. Necrosis: absent.. . 4. Architectural. pattern:. micropapillary/. cribriform.. . 5. Surgical margins:. . (a) superior margin: 5 mm,. . (b) inferior margin: 5 mm,. . (c) medial margin: 5 mm,. . (d) lateral margin: 5 mm,. . (e) deep margin: 2 mm,. . (f) superficial margin: 2 mm.. . 6. Microcalcification:. present,. tumoral/non-. tumoral.. Result. Intensity. Positive %. Estrogen. receptor. Strong (7/8). 2. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (1+). Ki-67. Positive in 8%. of tumor cells. . Ductal carcinoma in situ. . 1. Post-excision status.. . 2. Size of tumor: 0.4 cm, residual.. . 3. Nuclear grade: low.. . 4. Necrosis: absent.. . 5. Architectural. pattern:. micropapillary/. cribriform.. . 6. Surgical margins:. . (a) superior margin: 5 mm (see Note 1),. . (b) inferior margin: 5 mm,. . (c) medial margin: (see Note 2),. . (d) lateral margin: 30 mm,. . (e) deep margin: 2 mm,. . (f) superficial margin: 2 mm.. . 7. Microcalcification: present, tumoral.. Note: 1. Atypical ductal hyperplasia is. present only in the permanent section of Fro 1. 2. The medial margin of the lumpectomy. specimen (slide 4) is close to ductal carci­. noma in situ (2 mm) but this margin submit­. ted for frozen diagnosis (Fro 3) is free of. tumor. F. i. g. . 20_1" +682,Case 4,Important Radiologic,Carcinoma In Situ,Important Radiologic. Findings. 15 16 17. 18. 4.3.  +688,Case 4,Patient History,Carcinoma In Situ,"Patient History and Progress. Female/46 years old, pre-menopause.. Self-detected palpable mass on right breast 8. and 9 o’clock direction.. No family history.. No comorbidities.. BRCA 1 and 2: No detected mutation,. RAD51C VUS (variant of uncertain).. 4.2. " +675,Case 4,Courses of Treatment,HR(+) HER2(+) Breast Cancer,"4.1. . Courses of Treatment. Operation  +  Adjuvant chemotherapy (#4. cycles of doxorubicin and cyclophospha­. mide). +. Post-operative. radiation. ther­. apy + Letrozole 2.5 mg/day.. 23. 4.3.1. . Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 0.6 cm (pT1b).. 2. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 2/3, 10/10 HPF).. HR(+) HER2(+) Breast Cancer. 310. . ­. . 3. Intraductal component: present, extratumoral. (50%) (nuclear grade: high, necrosis: pres­. ent, architectural pattern: micropapillary/. cribriform/comedo, extensive intraductal. component: present).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) superior margin: 10 mm,. . (b) inferior margin: 5 mm,. . (c) medial margin: 15 mm,. . (d) lateral margin: 25 mm,. . (e) deep margin: 1.5 mm from ductal carci­. noma in situ (slide 3),. . (f) superficial margin: 8 mm.. 6. Lymph nodes: no metastasis in two axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/2).. 7. Arteriovenous invasion: absent.. 8. Lymphovascular invasion: absent.. 9. Tumor border: infiltrative.. . 10. Microcalcification:. present,. tumoral/. non-tumoral.. . 11. Pathological TN category (AJCC 2017):. pT1bN0(sn).. Result. Intensity. Positive. %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Intermediate. (5/8). 2. 10% to. 1/3. C-erbB2. Positive (3+). Ki-67. Positive in 27%. of tumor cells. S. Park et al.. 311. . . HR(+) HER2(+) Breast Cancer. 312. a. b. . 5. " +683,Case 4,Important Radiologic,HR(+) HER2(+) Breast Cancer,Important Radiologic. Findings. 19 20 21. 22. 4.3.  +689,Case 4,Patient History,HR(+) HER2(+) Breast Cancer,"Patient History and Progress. Female/56 years old, post-menopause.. Screen detected mass lesion on right breast 12. o’clock direction.. No family history.. S/P Thyroid radiofrequency ablation.. 4.2. " +676,Case 4,Courses of Treatment,HR(+) HER2(-) Breast Cancer,"high, necrosis: present, architectural pattern:. solid/comedo, extensive intraductal compo­. nent: absent).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) superior margin: 10 mm,. . (b) inferior margin: (see note),. . (c) medial margin: 10 mm,. . (d) lateral margin: 15 mm,. . (e) deep margin: 2 mm,. . (f) superficial margin: 2 mm.. 6. Lymph nodes:. . (a) metastasis in one out of five axillary. lymph nodes (pN1a(sn)) (sentinel LN:. 1/1, axillary LN: 0/4),. . (b) perinodal extension: present,. . (c) size of metastatic carcinoma: 23 mm.. 7. Arteriovenous invasion: absent.. 8. Lymphovascular. invasion:. present,. intratumoral.. 9. Tumor border: infiltrative.. . 10. Microcalcification:. present,. tumoral/. non-tumoral.. . 11. Pathological TN category (AJCC 2017):. pT1cN1a(sn).. Result. Intensity. Positive %. Estrogen receptor. Strong (8/8). 3. >2/3. Progesterone receptor. Negative (0/8). 0. 0. C-erbB2. Equivocal (2+) (SISH negative). Ki-67. Positive in 6% of tumor cells. Y. Kim et al." +684,Case 4,Important Radiologic,HR(+) HER2(-) Breast Cancer,"Important Radiologic. Findings. See Figs. 15, 16, 17 and 18.. HR(+) HER2(−) Breast Cancer" +690,Case 4,Patient History,HR(+) HER2(-) Breast Cancer,Dyslipidemia.. 4.2.  +677,Case 4,Courses of Treatment,HR(−) HER2(+) Breast Cancer,"4.1. . Courses of Treatment. Neoadjuvant chemotherapy (#6 cycles of. docetaxel and carboplatin and trastuzumab and. pertuzumab) + Operation + Post-operative radia­. tion therapy.. 4.4.1. . Operation. 35. 4.4.2. . Pathology Report. . 1. No residual tumor with stromal fibrosis.. . (a) Post-chemotherapy status.. . (b) Lymph nodes: no metastasis in nine axil­. lary lymph nodes (ypN0) (sentinel LN:. 0/4, non-sentinel LN: 0/5).. . 2. Fibroadenomatous change.. Note: Histologic mapping has been done.. Result. Intensity. Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in 35%. of tumor cells. . HR(−) HER2(+) Breast Cancer. 446. . 5. " +685,Case 4,Important Radiologic,HR(−) HER2(+) Breast Cancer,Important Radiologic. Findings. 27 28 29. 30. . Y. Kwon et al.. 443. . ­. . F. ig. 30. 34. . ­. . ­. ­. . Y. Kwon et al.. 445. 4.4.  +691,Case 4,Patient History,HR(−) HER2(+) Breast Cancer,"Patient History and Progress. Female/58 years old, post-menopause.. Self-detected mass lesion on left breast 3:30. o’clock direction.. No family history.. No comorbidities.. 4.2. " +678,Case 4,Courses of Treatment,HR(−) HER2(−) Breast Cancer,"4.1. . Courses of Treatment. Operation + adjuvant chemotherapy (#4 cycles. of docetaxel and cyclophosphamide)  +  Post-­. operative radiation therapy.. 4.3.1. . Operation. 26. 4.3.2. . Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 1.5 cm (pT1c).. 2. Histologic grade: 3/3 (tubule formation: 2/3,. nuclear pleomorphism: 3/3, mitotic count:. 3/3, 40/10HPF).. 3. Intraductal component: absent.. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) Superior margin: 16 mm.. . (b) Inferior margin: 20 mm.. . (c) Medial margin: 18 mm.. . (d) Lateral margin: 26 mm.. . (e) Deep margin: 6 mm.. . (f) Superficial margin: 8 mm.. 6. Lymph nodes: no metastasis in one axillary. lymph node (pN0(sn)) (sentinel LN: 0/1).. 7. Arteriovenous invasion: absent.. 8. Lymphovascular invasion: absent.. 9. Tumor border: infiltrative.. . 10. Microcalcification: present, non-tumoral.. . 11. Pathological TN category (AJCC 2017):. pT1cN0(sn).. Result. Intensity. Positive. %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Negative (1+). Ki-67. Positive in 25%. of tumor cells. HR(−) HER2(−) Breast Cancer. 588. . 5. " +686,Case 4,Important Radiologic,HR(−) HER2(−) Breast Cancer,Important Radiologic. Findings. 22 23 24. 25. HR(−) HER2(−) Breast Cancer. 586. . . . E. S. Lee et al.. 587. . 4.3.  +692,Case 4,Patient History,HR(−) HER2(−) Breast Cancer,"Patient History and Progress. Female/52 years old, post-menopause.. Self-detected palpable mass lesion on left. breast 1–2 o’clock direction.. No family history.. Hyperthyroidism.. 4.2. " +679,Case 4,Courses of Treatment,Local Recurrence,"4.1. . Courses of Treatment. Left breast Invasive cribriform carcinoma →. Operation → Adjuvant therapy → Left chest. wall recurrence (IDC).. 4.2.1. . Primary Treatment. 22 23. 24. Operation. ­. 25. 26. Pathology Report. Invasive Cribriform Carcinoma. 1. Size of invasive component: 1.5  cm and. 0.5 cm (pT1c).. 2. Size of intraductal component: 7.0 cm.. Local Recurrence. 726. . . . . 3. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 6/10HPF).. 4. Intraductal component: present, intratu­. moral/extratumoral (90%) (nuclear grade:. low, necrosis: present, architectural pattern:. papillary/cribriform/solid/comedo, extensive. intraductal component: present).. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) Deep margin: <1 mm from ductal carci­. noma in situ (slides 4 and 15).. . (b) Superficial margin: positive for ductal. carcinoma in situ (slides 5 and 10).. 7. Lymph nodes: no metastasis in two axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/2). 8. Arteriovenous invasion: absent.. 9. Lymphovascular invasion: absent.. . 10. Tumor border: infiltrative.. . 11. Microcalcification: present, tumoral.. . 12. Pathologic stage (AJCC 2010): pT1c(m). N0(sn).. Y. Kim et al.. 727. a. b. c. d. . . Invasive Lobular Carcinoma. . 1. Size of tumor: 0.4 cm.. . 2. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 2/10HPF).. . 3. In situ component: present, extratumoral (30%).. . 4. Arteriovenous invasion: absent.. . 5. Lymphovascular invasion: absent.. . 6. Tumor border: infiltrative.. Result. Intensity Positive %. Estrogen. receptor. Strong (7/8). 2. >2/3. Progesterone. receptor. Strong (7/8). 2. >2/3. C-erbB2. Negative (0). Ki-67. Positive in 18%. of tumor cells. Adjuvant Therapy. Tamoxifen 20 mg/day for 1.2 years.. 4.2.2. . Treatments After Recurrence. 27. 28. Operation. 29. Pathology Report. Invasive Ductal Carcinoma. 1. Post-nipple-sparing mastectomy status.. 2. Size of tumor: 0.7 cm (rpT1b).. Local Recurrence. 728. . ­. . 3. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 2/10HPF).. 4. Intraductal component: present, intratumoral. (10%) (nuclear grade: low, necrosis: present,. architectural pattern: cribriform/comedo,. extensive intraductal component: absent).. 5. Skin and nipple: no involvement of tumor.. 6. Surgical margins: deep margin: 3 mm.. 7. Arteriovenous invasion: absent.. 8. Lymphovascular invasion: absent.. 9. Tumor border: infiltrative.. . 10. Microcalcification: present, tumoral.. . 11. Pathological TN category (AJCC 2017):. rpT1b.. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Equivocal (2+). (SISH negative). Ki-67. Positive in 15%. of tumor cells. Adjuvant Therapy. Plan for tamoxifen with goserelin.. 5. " +693,Case 4,Patient History,Local Recurrence,"Patient History and Progress. Female/41 years old, pre-menopause.. Screen detected mass lesion on left breast 1. and 2 o’clock direction.. Outside result of biopsy: Ductal carcinoma in. situ.. No family history.. No comorbidities.. BRCA 1 and 2 mutation: Not detected.. 4.2. " +680,Case 4,Courses of Treatment,Metastatic Breast Cancer,"Courses of Treatment. Right breast cancer → Operation → Adjuvant. therapy → Left breast and pleural effusion. recurrence.. 4.2.1. . Primary Treatment. Operation. Oct. 2008 Right breast conserving surgery, axil­. lary lymph node dissection.. Pathology: Invasive ductal carcinoma, stage. T1(m)N1 (2/25).. Size of tumor: 1.7  *  1.5  *  1  cm and. 0.5 * 0.4 cm, lymph node: 2/25, size of metastatic. carcinoma: 19 mm.. Result. Intensity. Positive %. Estrogen. receptor. Positive. N.A.. N.A.. Progesterone. receptor. Positive. N.A.. N.A.. C-erbB2. Negative (1+). Ki-67. Positive in. 63.51% of. tumor cells. Adjuvant Therapy. Adjuvant chemotherapy #6 cycles  →  Post-­. operative radiation therapy + Tamoxifen 20 mg/. day for 5 years.. 4.2.2. . Treatments After Recurrence. Left breast and pleural effusion recurrence.. 0. Progesterone. receptor. Negative. (0/8). 0. 0. C-erbB2. Negative (0). Ki-67. Positive in. 74% of. tumor cells. Clinical. stage:. cT4N3M1. (pleural. effusion).. Palliative Chemotherapy. Palliative chemotherapy #12 cycles (paclitaxel. #12 & Cisplatin #9): controlled disease.. Palliative Operation. Feb. 2022 Left total mastectomy, sentinel lymph. node biopsy (palliative operation).. Pathology: No residual tumor with foamy his­. tiocytic collection.. . 1. Post-chemotherapy status. . 2. Lymph nodes: no metastasis in one axillary. lymph node (pN0(sn)). (sentinel LN: 0/1). Palliative radiation therapy.. Post-operative radiation therapy." +694,Case 4,Patient History,Metastatic Breast Cancer,"BRCA 1 mutation: detected.. s/p Appendectomy, s/p myomectomy.. 4.2. " +695,Case 40,Courses of Treatment,Carcinoma In Situ,"40.1. . Courses of Treatment:. Operation. Operation. 189. 190. Pathology Report. Lobular carcinoma in situ. . 1. Post-stereotactic excision status.. . 2. Size of tumor: 1.0 cm, residual.. . 3. Nuclear grade: low.. E. S. Lee et al.. 139. . 4. Necrosis: absent.. . 5. Architectural pattern: solid.. . 6. Skin: no involvement of tumor.. . 7. Surgical margins:. . (a) superior margin: 10 mm,. . (b) inferior margin: 10 mm,. . (c) medial margin: 10 mm,. . (d) lateral margin: 20 mm,. . (e) deep margin: 2 mm,. . (f) superficial margin: 2 mm.. . 8. Microcalcification:. present,. tumoral/non-. tumoral.. . a. b. . a. b. . Carcinoma In Situ. 140. . . ­. Result. Intensity. Positive %. Estrogen. receptor. Strong (7/8). 3. 1/3–2/3. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Equivocal (2+). Ki-67. Positive in 1%. of tumor cells. 41. " +698,Case 40,Important Radiologic,Carcinoma In Situ,Important Radiologic. Findings. 186 187. 188. 40.3.  +699,Case 40,Patient History,Carcinoma In Situ,"Patient History and Progress. Female/47 years old, post-menopause.. Screen detected mass and microcalcification. on right breast 10 o’clock direction.. No family history.. No comorbidities.. 40.2. " +696,Case 40,Courses of Treatment,Local Recurrence,"40.1. . Courses of Treatment. Right breast DCIS→ Operation → Right breast. recurrence (microinvasive ductal carcinoma).. Primary Treatment. 266. Local Recurrence. 828. . . Operation. 267. Pathology Report. Ductal Carcinoma In Situ. . 1. Size of tumor: 0.3 cm (pTis).. . 2. Nuclear grade: low.. . 3. Necrosis: absent.. . 4. Architectural pattern: solid/cribriform.. . 5. Surgical margins:. . (a) Superior margin: 7 mm.. . (b) Inferior margin: 6 mm.. . (c) Medial margin: 1 mm from ductal carci­. noma in situ (slide 1).. . (d) Lateral margin: 45 mm.. . (e) Deep margin: <1 mm from ductal carci­. noma in situ (slide 1).. . 6. Microcalcification:. present,. tumor/. non-tumor.. . 7. Pathologic stage (AJCC 2010): pTisNx.. Result. Intensity. Positive %. Estrogen. receptor. Intermediate. (6/8). 2. 1/3–2/3. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in 25%. of tumor cells. Treatments After Recurrence. 268 269. 270. Operation. ­. 271. Pathology Report. Microinvasive Ductal Carcinoma. 1. Size of invasive component: <0.1  cm. (pT1mi).. 2. Size of intraductal component: 0.6 cm.. Y. Kim et al.. 829. . . ­. . Local Recurrence. 830. 3. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 6/10HPF).. 4. Intraductal component: present, intratu­. moral/extratumoral (99%) (nuclear grade:. low, necrosis: present, architectural pattern:. cribriform/solid/comedo, extensive intra­. ductal component: present).. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) Deep margin: 2 mm.. . (b) Superficial margin: 2 mm.. 7. Lymph nodes: no metastasis in one axillary. lymph node (pN0(sn)) (sentinel LN: 0/1).. 8. Arteriovenous invasion: absent.. 9. Lymphovascular invasion: absent.. . 10. Tumor border: infiltrative.. . 11. Microcalcification:. present,. tumoral/. non-tumoral.. . 12. Pathologic stage (AJCC 2010): pT1miN0(sn).. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Equivocal (2+). Ki-67. Positive in 22%. of tumor cells. Adjuvant Therapy. Anastrozole 1 mg/day for 3.3 years, then tamoxi­. fen 20 mg/day.. 41. " +700,Case 40,Patient History,Local Recurrence,"Patient History and Progress. Female/60 years old, post-menopause.. Screen detected mass lesion on right breast 12. o’clock and 9 o’clock direction.. Outside result of biopsy: right breast 12. o’clock, Atypical ductal hyperplasia.. Right breast 9:30 o’clock, Fibrocystic change.. Family history of breast cancer, older sister. and younger sister.. Hepatitis C virus carrier, Facet Joint Syndrome. lumbosacral region, Dyspnea disorder.. BRCA 1 VUS (variant of uncertain).. 40.2. " +697,Case 40,Courses of Treatment,Metastatic Breast Cancer,"Courses of Treatment. Right breast cancer → Neoadjuvant chemother­. apy → Operation → Adjuvant therapy → Lung. metastasis.. Primary Treatment. 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (0). Ki-67. Positive in. 76% of tumor. cells. Neoadjuvant Chemotherapy. Neoadjuvant chemotherapy #8 cycles (Doxorubicin. & cyclophosphamide #4 → Docetaxel #4).. Y. Kwon et al.. 925. Operation. Apr. 2015 Right breast conserving surgery, axil­. lary lymph node dissection.. Pathology: Invasive ductal carcinoma, stage. ypT1cN1mi.. Size of tumor: 1.4 cm, lymph node 2/9 (2 mm).. Adjuvant Therapy. Post-operative radiation to right breast +. Tamoxifen 20 mg/day for 2 years.. Treatments After Recurrence" +701,Case 40,Patient History,Metastatic Breast Cancer, +702,Case 41,Courses of Treatment,Carcinoma In Situ,"41.1. . Courses of Treatment. 194. 195. Operation + Tamoxifen 20 mg/day for 5 years.. Operation. 194. 195. Pathology Report. . Ductal carcinoma in situ, pathological TN cat­. egory (AJCC 2017): pTis. . 1. Size of tumor: 1.5 cm (pTis).. . 2. Nuclear grade: low.. . 3. Necrosis: absent.. . 4. Architectural pattern: solid.. . 5. Skin: no involvement of tumor.. . 6. Surgical margins:. . (a) superior margin: 5 mm,. . (b) inferior margin: 5 mm,. . (c) medial margin: <1 mm from ductal carci­. noma in situ (slide 3),. . (d) lateral margin: 10 mm,. . (e) deep margin: 2 mm,. . (f) superficial margin: 2 mm.. . 7. Microcalcification:. present,. tumoral/non-. tumoral.. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (1+). Ki-67. Positive in. 16% of tumor. cells. . E. S. Lee et al.. 141. Ductal carcinoma in situ. . 1. Post-excision status.. . 2. Size of tumor: 1.5 cm, residual.. . 3. Nuclear grade: low.. . 4. Necrosis: present.. . 5. Architectural. pattern:. cribriform/solid/. comedo.. . 6. Skin: no involvement of tumor.. . 7. Surgical margins:. . (a) inferior margin: (see Note 1),. . (b) medial margin: (see Note 2).. . 8. Microcalcification: present, non-tumoral.. Note: 1. The inferior margin of the lumpec­. tomy specimen (slides 2 and 3) is close to. ductal carcinoma in situ (<1  mm) but this. margin submitted for frozen diagnosis (Fro 1). is free of tumor.. . ­. a. b. . Carcinoma In Situ. 142. a. b. c. d. . 2. The medial margin of the lumpectomy speci­. men (slide 1) is positive for ductal carcinoma. in situ but this margin submitted for frozen. diagnosis (fro 2) is free of tumor.. 42. " +705,Case 41,Important Radiologic,Carcinoma In Situ,Important Radiologic. Findings. 191 192. 193. 41.3.  +706,Case 41,Patient History,Carcinoma In Situ,"Patient History and Progress. Female/46 years old, pre-menopause.. Screen detected mass lesion on left breast. 2 o’clock direction.. Outside result of biopsy: R/O Atypical ductal. hyperplasia or ductal carcinoma in situ.. No family history.. No comorbidities.. 41.2. " +703,Case 41,Courses of Treatment,Local Recurrence,"41.1. . Courses of Treatment. Left breast IDC → Operation → Adjuvant ther­. apy → Right breast recurrence (DCIS).. Primary Treatment. 272 273. 274. Operation. 275. Pathology Report. Invasive Ductal Carcinoma. 1. Size of invasive tumor: 1.2 cm (pT1c).. 2. Size of ductal carcinoma in situ: 3.5 cm.. 3. Histologic grade: 2 (tubule formation: 2/3,. nuclear pleomorphism: 3/3, mitotic count:. 1/3, 3/10HPF).. . ­. Y. Kim et al.. 831. 4. Intraductal component: present, intratumoral. and extratumoral (80%) (nuclear grade: high,. necrosis: present, architectural pattern: pap­. illary and cribriform, extensive intraductal. component: present).. 5. Skin: no involvement of tumor.. 6. Nipple: involvement of lactiferous duct by. ductal carcinoma in situ.. 7. Surgical margins:. . (c) Deep margin: 2 mm.. . (d) Superficial margin: 12 mm.. 8. Lymph nodes: no metastasis in 4 axillary. lymph nodes (pN0) (sentinel LN: 0/1, axil­. lary LN: 0/3).. 9. Vascular invasion: absent.. . 10. Lymphatic invasion: absent.. . 11. Tumor border: infiltrative.. . 12. Microcalcification: present, tumoral.. . 13. Pathologic stage (AJCC 2010): pT1cN0.. Result. Intensity. Positive %. Estrogen. receptor. Strong (7/7). 3. >2/3. Progesterone. receptor. Intermediate. (5/7). 3. 10%-1/3. C-erbB2. Negative (0). Ki-67. Positive in 35%. of tumor cells. a. b. . . . Local Recurrence. 832. Adjuvant Therapy. Adjuvant chemotherapy #6 cycles of fluorouracil. and doxorubicin and cyclophosphamide.. Tamoxifen 20 mg/day for 2.3 years.. Treatments After Recurrence. 276 277. 278. Operation. 279. Pathology Report. . 1. Ductal Carcinoma In Situ, residual involving. sclerosing adenosis.. . (a) Size of tumor: 3.5 cm.. . (b) Nuclear grade: low.. . (c) Necrosis: present.. . (d) Architectural pattern: papillary/cribri­. form/comedo.. . (e) Skin and nipple: no involvement of tumor.. . (f) Surgical margins:. • Deep margin: 3 mm.. • Superficial margin: 6 mm.. . (g) Lymph nodes: no metastasis in two axil­. lary lymph nodes (pN0(sn)) (sentinel LN:. 0/1, axillary LN: 0/1).. . (h) Microcalcification:. present,. tumoral/. non-tumoral.. . 2. Sclerosing adenosis with microcalcification.. Result. Intensity. Positive %. Estrogen. receptor. Negative (2/8). 1. <1%. Progesterone. receptor. Negative (2/8). 1. <1%. C-erbB2. Equivocal (2+). (SISH negative). Ki-67. Positive in 20%. of tumor cells. Adjuvant Therapy. Anastrozole 1 mg/day.. . Y. Kim et al.. 833. . . . Local Recurrence. 834. 42. " +707,Case 41,Patient History,Local Recurrence,"Patient History and Progress. Female/62 years old, post-menopause.. Screen detected mass lesion on left breast sub­. areolar and retraction of left nipple.. No family history.. No comorbidities.. 41.2. " +704,Case 41,Courses of Treatment,Metastatic Breast Cancer,"Courses of Treatment. Left breast cancer → Operation → Adjuvant. therapy → Lung, liver, and bone metastasis.. Primary Treatment. Strong (7/8). 3. 1/3–2/3. Progesterone. receptor. weak (4/8). 2. 1–10%. C-erbB2. Positive. (+3). Ki-67. Positive in. 19% of. tumor cells. Adjuvant Therapy. Adjuvant chemotherapy # 8 cycles (Doxorubicin. & cyclophosphamide #4 → Docetaxel &. Trastuzumab #4).. Post-operative radiation to left breast +. Tamoxifen 20 mg/day for 2.5 years.. Concurrent Trastuzumab # 14.. Treatments After Recurrence. See Figs. 128 and 129.. Oct. 2018 PET-CT> R/O multiple metastasis. in both lungs, bone, and liver.. Palliative Therapy. Palliative therapy # 23 cycles (Docetaxel &. Trastuzumab & Pertuzumab)." +708,Case 41,Patient History,Metastatic Breast Cancer,"Patient History and Progress. Female/52 years old, peri-menopause.. No family history.. S/p Tuberculosis.. 41.2. " +709,Case 42,Courses of Treatment,Carcinoma In Situ,"42.1. . Courses of Treatment. Operation + Postoperative radiation therapy.. Operation. 200. 201. Pathology Report. Ductal carcinoma in situ, pathological TN cat­. egory (AJCC 2017): pTisNx. . 1. Size of tumor: 1.5 cm (pTis).. . 2. Nuclear grade: low.. . 3. Necrosis: absent.. . 4. Architectural pattern: papillary/cribriform.. . 5. Skin: no involvement of tumor.. . 6. Surgical margins:. . (a) superior margin: 10 mm,. . (b) inferior margin: 20 mm,. . (c) medial margin: 5 mm,. . (d) lateral margin: 5 mm,. . (e) deep margin: 2 mm,. . (f) superficial margin: 2 mm.. E. S. Lee et al.. 143. . ­. . . ­. . a. b. . Carcinoma In Situ. 144. a. b. . . . . 7. Lymph nodes: not submitted (pNx).. . 8. Microcalcification:. present,. tumoral/. non-tumoral.. Result. Intensity Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Intermediate. (5/8). 2. 10%-1/3. C-erbB2. Negative (1+). Ki-67. Positive in 7%. of tumor cells. 43. " +712,Case 42,Important Radiologic,Carcinoma In Situ,Important Radiologic. Findings. 196 197 198. 199. 42.3.  +713,Case 42,Patient History,Carcinoma In Situ,"Patient History and Progress. Female/57 years old, post-menopause.. Screen detected microcalcification on left. breast 6 o’clock direction.. Outside result of biopsy: Ductal carcinoma in. situ.. No family history.. Diabetes mellitus.. 42.2. " +710,Case 42,Courses of Treatment,Local Recurrence,"42.1. . Courses of Treatment. Left breast ILC → Operation → Adjuvant ther­. apy → Right breast recurrence (IDC).. Primary Treatment. 280. Operation. Aug. 2017 Left nipple-areolar complex sparing. mastectomy with transverse rectus abdominis. muscles flap reconstruction (outside).. Pathology Report. Invasive Lobular Carcinoma. . 1. Size of invasive tumor: 0.2 cm (pT1a).. . 2. Pathologic stage: pT1aNx.. Result. Intensity. Positive %. Estrogen. receptor. Positive. Progesterone. receptor. Negative. C-erbB2. Negative (1+). Ki-67. Positive in 5%. of tumor cells. Adjuvant therapy.. Tamoxifen 20 mg/day for 0.7 year.. Treatments After Recurrence. 281 282. 283. Operation. ­. 284. Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 0.8 cm (pT1b).. 2. Histologic grade: 1/3 (tubule formation: 1/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 5/10HPF)/. . . Y. Kim et al.. 835. 3. Intraductal component: absent.. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) Superior margin: 15 mm.. . (b) Inferior margin: 15 mm.. . (c) Medial margin: 10 mm.. . (d) Lateral margin: 20 mm.. . (e) Deep margin: 2 mm.. . (f) Superficial margin: 2 mm.. 6. Lymph nodes: no metastasis in one axillary. lymph node (pN0(sn)) (sentinel LN: 0/1).. 7. Arteriovenous invasion: absent.. 8. Lymphovascular invasion: absent.. 9. Tumor border: infiltrative.. . 10. Microcalcification: present, tumoral.. . 11. Pathological TN category (AJCC 2017):. pT1bN0(sn).. Result. Intensity. Positive %. Estrogen. receptor. Intermediate. (5/8). 1. 1/3–2/3. Progesterone. receptor. Weak (4/8). 2. 1–10%. C-erbB2. Equivocal (2+). (SISH negative). Ki-67. Positive in 2%. of tumor cells. Adjuvant Therapy. Postoperative radiation therapy.. Letrozole 2.5 mg/day with leuprolide.. . . . Local Recurrence. 836. 43. " +714,Case 42,Patient History,Local Recurrence,"Patient History and Progress. Female/52 years old, pre-menopause.. Screen detected mass lesion on right breast 10. o’clock direction.. Outside result of biopsy: Invasive ductal. carcinoma.. Family history of breast cancer, younger sister. at her 44 years old.. s/p Left breast Nipple sparing mastectomy. (invasive lobular carcinoma).. BRCA 1 and 2 mutation: Not detected.. 42.2. " +711,Case 42,Courses of Treatment,Metastatic Breast Cancer,. Courses of Treatment. Left breast cancer → Operation → Adjuvant. therapy → Lung metastasis.. Primary Treatment. Progesterone. receptor. Strong (7/7). 3. >2/3. C-erbB2. Equivocal (2+). Ki-67. Positive in 5%. of tumor cells. FISH. Negative. Adjuvant Therapy. Adjuvant chemotherapy # 6 cycles (Fluorouracil-5. & Doxorubicin & Cyclophosphamide).. Post-operation radiation to left breast +. Tamoxifen 20 mg/day for 5 years.. Treatments After Recurrence. 2022) ~. Y. Kwon et al. +715,Case 42,Patient History,Metastatic Breast Cancer,"Patient History and Progress. Female/57 years old, post-menopause.. No family history.. Arrhythmia (taking on medicine).. 42.2. " +716,Case 43,Courses of Treatment,Brief Overview of Breast Cancer Treatment,"Brief Overview of Breast Cancer Treatment. 150. . (b) Multicentric or multifocal lesions or with. an extensive intraductal component of. 25% or greater and tumor size that is sig­. nificantly reduced after neoadjuvant. therapy.. . (c) A lesion significantly reduced in size. after neoadjuvant therapy that is a T1 or. partial T2 tumor located deep in the breast. parenchyma.. Nipple–areolar complex (NAC) spar­. ing mastectomy has also begun to improve. the cosmetic effect. The risk of cancer. cell infiltration or recurrence in the nip­. ple–areola complex is an issue that. requires consideration. Selecting target. patients based on preoperative findings is. very important. Patients with inflamma­. tory breast cancer and stage III locally. advanced breast cancer are generally not. recommended for this surgery.. . 2. Surgical technique.. Several incision techniques are used: the. peri-areolar incision, a separate dilated inci­. sion around the areola, a separate previous. biopsy site incision, a modified oval incision. that includes the nipple and areola area and. the previous biopsy site, and an incision using. the inframammary fold. Surgeons should. carefully choose the type of skin incision, tak­. ing into account various factors. When per­. forming. a. nipple–areola. complex. and. skin-­. sparing mastectomy, a radial incision. that minimizes the blockage of blood flow in. the areola can be used. The first priority is that. the tumor must be completely resected. The. technique for removing the skin during a skin-­. sparing mastectomy, similar to a classical. mastectomy, avoids the breast tissue and. removes skin from the subcutaneous tissue. and dermis to the surface of the superficial. fascia. With the skin flap lifted, the breast tis­. sue is detached from the chest wall together. with the pectoralis major fascia from top to. bottom. After the skin flap is completely lifted. and most of the mastectomy is done, the. breast is detached from the pectoralis major. muscle and pulled outward to facilitate access. for sentinel lymph node biopsy or axillary. lymph node dissection. It is necessary to. remove as much breast tissue as possible and. satisfy the two conditions so that necrosis. does not occur in the remaining nipple. The. best technique to use depends on the patient’s. skin thickness, areola size, presence or. absence of inverted nipples, vascular distribu­. tion, breast size, age, and breast tightness.. Surgeons must accumulate techniques through. a lot of experience [23, 24].. . 3. Breast reconstruction.. Immediate breast reconstruction is per­. formed by various methods depending on the. characteristics of the patient. An artificial. implant can be inserted, or the patient’s own. tissue can be used. For implant placement, a. tissue expander is placed between the pectora­. lis major and pectoralis minor muscles under. the resected breast to gradually increase the. volume. Another method to make a breast that. uses autologous tissue is a myocutaneous flap. surgery. The skin and muscles are transferred. from the patient’s back (latissimus dorsi flap),. lower abdomen (deep inferior epigastric artery. perforator flap or transverse rectus myocutane­. ous flap), or buttocks or thighs [25–29].. . 4. Local recurrence.. When the indications are carefully. selected, performing breast reconstruction. immediately after a skin-sparing mastectomy. has a better cosmetic effect than other options. and has a similar local recurrence rate. Local. recurrence is not difficult to detect because it. recurs mostly on the chest wall. Therefore,. skin-­. sparing mastectomy is oncologically. safe and cosmetically superior to traditional. mastectomy when performed selectively.. There are not many reports of long-term fol­. low-up for nipple–areola complex and skin-. sparing mastectomy, and an excision of. nipple–areola complex might be performed. during surgery depending on the results of. frozen section tests. Therefore, it is impor­. tant to fully explain all the possibilities to the. patient and proceed with surgery only after. that consultation.. J. Y. You et al.. 151. 1.3. . Axillary Lymph Node Surgery. 1.3.1. . Sentinel Lymph Node Biopsy. and Intraoperative Evaluation. of the Sentinel Lymph Node. . 1. Method using dye.. Among the dyes, isosulfan blue is the most. widely used. In combination with albumin, it. selectively enters the lymph vessels and stains. them and the sentinel lymph nodes blue.. Methylene blue, indigo carmine, Paten blue V,. indocyanine green, etc., have also been used. and shown similar success rates. Among the. methods for injecting dye for a sentinel lymph. node biopsy, an intradermal injection around. the areola is reported to have a higher detec­. tion rate of sentinel lymph nodes than a sub­. cutaneous injection, intradermal injection,. subareolar injection, or tumor site parenchy­. mal injection. Some researchers argue that. parenchymal injections around the tumor. have a high detection rate. Gently massage the. breast for about 5 min after injecting the dye. to allow it to enter the lymph vessels well.. Precise timekeeping is important because. starting a biopsy too early after the injection. might not result in staining, and waiting until. too late to start could result in staining of non-­. sentinel lymph nodes with excessive stain.. The time it takes for the dye to reach the sen­. tinel lymph nodes becomes shorter as the. tumor becomes closer to the axilla. It has been. reported that massaging the breast after injec­. tion increases the sensitivity of finding the. sentinel lymph nodes [30].. After that, the clavipectoral fascia is found. by making a 2–3-cm skin incision in front of. the midaxillary line about 1  cm below the. axillary hair line, and the axillary adipose tis­. sue can be found. Look for stained lymph ves­. sels in the area where the pectoral node is. located along the margin of the pectoralis. major muscle. If no lymph node is found. there, look for lymph nodes at levels I and II,. such as the external breast lymph node and the. sub-shoulder central lymph node. All sentinel. lymph nodes can only be found only by trac­. ing both the proximal and distal parts of the. stained lymph vessels and looking for the sen­. tinel lymph nodes. After the sentinel lymph. nodes are removed, the axilla should be re-­. examined, and any suspicious palpable lymph. nodes should be removed and included in the. sentinel lymph nodes. It is important to be. careful not to cut or damage the stained lymph. vessels because they play a role in the area. where the sentinel lymph nodes can be found.. . 2. Method using radioactive isotopes.. Among the radioactive isotopes, colloidal. radioisotopes are most commonly used. because they move quickly into the lymph. vessels and are transported to the sentinel. lymph nodes, where they remain long enough. to be found during surgery.. Currently, 99mTc-sulfur, 99mTc-human. serum albumin, 99mTc-antimony sulfur col­. loid, 99mTc-dextran, 99mTc-tin, etc. are used.. Other ideal radio colloids should be inexpen­. sive, free from radiation exposure, and easy to. handle. Radioactive isotopes can be injected. around the tumor, subcutaneously, intrader­. mally, subareolar, and around the areola, but. many studies have shown that subareolar or. around the areola injections are effective for. sentinel lymph node detection. Preoperatively,. sentinel lymph node locations can be deter­. mined by taking frontal and lateral lymphos­. cintigraphy images 15  min after injection.. That also has the advantage of locating senti­. nel lymph nodes outside the axilla before sur­. gery. Conversely, some reports indicate that it. does not help the detection rate or false nega­. tive rate of the sentinel lymph nodes [31].. Before starting surgery, a gamma-ray. detector is used to confirm and display the. exact locations of the sentinel lymph nodes.. A minimal incision window is made at that. location, and a gamma-ray detector is used to. find hotspots with high radiation doses and. remove those sentinel lymph nodes. There is. no dispute that the stained lymph nodes. should be considered as sentinel lymph. nodes when dyes are used, but there is no. standard for how many nodes should be con­. sidered sentinel lymph nodes when radioiso­. topes are used. One standard is that the. Brief Overview of Breast Cancer Treatment. 152. absolute value of the radiation dose be 25 or. more for 10 s, but another is that the radia­. tion dose be 10 times or more than that of the. surrounding tissue. Furthermore, once the. sentinel lymph node with the highest radia­. tion dose is excised, there is an increased risk. of false negatives if the remaining lymph. nodes, which exhibit a radiation dose of 10%. or more of that value, are not removed by. measuring the radiation dose as a sentinel. lymph node. There is also a report that the. standard can be lowered even further. Breast. cancer usually shows the highest amount of. metastasis to the sentinel lymph nodes with. the highest radiation dose. But once metasta­. sized tumor cells have completely replaced. the lymph nodes, the lymph nodes might. have very low or undetectable radiation. doses, so all suspicious lymph nodes should. be removed at the time of biopsy. The greater. the number of sentinel lymph nodes resected,. the higher the accuracy. According to the. NSABP B-32 study, the false negative rate. was 17.7% in one node, 10% in two nodes,. 6.9% in three nodes, 3.3% in four nodes, and. 1% in five nodes.. . 3. Combination of dyes and radioactive isotopes.. It has been reported that combining dyes. and radioactive isotopes for sentinel lymph. node biopsy increases the meaningful sentinel. lymph node detection rate and average num­. ber of sentinel lymph nodes and lowers the. false negative rate. Therefore, for surgeons. who are not experienced with these proce­. dures, it is easy to use both formulations. together to shorten the learning curve [32].. . 4. Side effects and complications.. Isosulfan blue dyes rarely cause urticaria. and anaphylaxis. The administration of ste­. roids and antihistamines improves urticaria in. a short time. Hypotensive anaphylaxis, how­. ever, requires aggressive and immediate treat­. ment and 24-h intensive observation. In. addition, the use of isosulfan blue during sur­. gery can interfere with the measurement of. intraoperative oxygen saturation by pulse. oximetry, causing it to be measured as lower. than the actual value. Other side effects that. stain the epidermis can occur, but they usually. disappear in a few weeks to a few months [17,. 18].. It is well known that sentinel lymph node. biopsy has fewer complications than axillary. lymphadenectomy. When only the sentinel. lymph node procedure is performed, effects. such as postmastectomy pain syndrome,. lymphedema, axillary pain, abnormal sensa­. tion in the surgical site, upper extremity. movement on the affected side, cosmetic. aspects of the axillary wound, postoperative. wound infection, and seroma were held at sat­. isfactory levels.. . 5. Sentinel lymph node evaluation.. With the advent of sentinel lymph nodes, a. thorough and detailed examination of the axil­. lary lymph nodes has become possible.. According to the American Society of. Pathology’s draft recommended method, the. sentinel lymph nodes are first cut in half in the. longitudinal direction and then cut at intervals. of 1.5–2  mm to make continuous sections. [32]. It is recommended to make three sec­. tions for each block. If metastases are found,. the pathologist should record whether they are. macrometastases or micrometastases found. by immunohistochemical staining or reverse. transcription polymerase chain reactions. Due. to controversy over the significance of senti­. nel lymph node metastases found by immuno­. histochemical. staining,. the. American. Pathology Society does not recommend the. basic use of immunohistochemical staining.. According to the ACOSOG Z0010 trial,. sentinel node metastases deemed positive by. H&E staining had a significant effect on the. 5-year overall survival rate, but sentinel node. metastases deemed positive by immunohis­. tochemical staining did not affect the sur­. vival rate. The clinical significance of. micrometastasis is also still controversial.. Some results show that micrometastases. found by H&E staining indicate a difference. in disease-free survival, but other reports. persist that this is not [33, 34].. According to the seventh edition of the. AJCC, isolated tumor cells or isolated clusters. J. Y. You et al.. 153. of tumor cells (ultra-micrometastases) are. defined as a cell colony size of 0.2 mm or less,. single tumor cells, or fewer than 200 colonies. in a single histological cross-section, and they. are classified as pN0.. 1.3.2. . Axillary Lymph Node Dissection. The presence or absence of axillary lymph node. metastasis is one of the most important single. prognostic factors in breast cancer. Axillary. lymph node dissection is a local axillary treat­. ment used to stage breast cancer and determine. the direction of advanced treatment.. . 1. Indications.. . (a) A sentinel lymph node biopsy shows. metastasis.. . (b) Contraindications for sentinel lymph. node biopsy or if no sentinel lymph node. is found.. . (c) Inflammatory breast cancer or surgery. after neoadjuvant chemotherapy.. . (d) Cases of locoregional recurrence of axil­. lary lymph nodes after sentinel lymph. node resection.. . 2. Surgical anatomy.. The axilla is divided into three levels, I, II,. and III, depending on the positional relation­. ship with the pectoralis minor muscle. Level I. is the lateral portion of the pectoralis minor. muscle, including the lateral border, and con­. tains the lateral lymph nodes, the subscapu­. laris, and the lateral axillary veins. Level II is. situated between the lateral and medial bor­. ders of the pectoralis minor muscle, essentially. just inferior to the pectoralis minor. This. region is where the central lymph node group. is located. The common axillary dissection. involves a level I and II lymphadenectomy.. Level III is the area inside the medial border of. the pectoralis minor and contains the subcla­. vian lymphoid group. Dissection is not gener­. ally considered except in cases in which the. lymph nodes of level III are palpable, or when. a level III dissection is required because metas­. tasis to level I or II is clinically clear. Rotter’s. nodes mean the lymph nodes located between. the pectoralis major and pectoralis minor.. . 3. Preoperative considerations and surgical. steps.. The patient’s arms should be placed on the. arm supports, with the affected arm at 90° or. less, and the skin of the axilla is prepared for. standard methods. From preparation for sur­. gery until the end of surgery, the arm should. not be hyperextended. It is important to place. a pad on the arm struts to prevent shoulder. dislocation and brachial plexus tension during. surgery. To prevent infection, a wide range of. antibiotics, including against Gram-positive. bacteria, is given intravenously just before. surgery. During anesthesia, avoid the use of. long-acting muscle relaxants to make it easier. to recognize the motor nerves during surgery.. When performing a modified radical mas­. tectomy, use the mastectomy line without a. separate skin incision. In mastectomy, surgery. is performed through a new axillary incision. line. The anterior edge of the skin incision. extends to the lateral aspect of the pectoralis. major muscle, while the posterior edge. reaches the anterior border of the latissimus. dorsi muscle. In most cases, the incision is. made parallel to the wrinkles of the skin, but. in some cases, it can be made vertically or. diagonally to the chest wall. The cutaneous. flap is bordered by the axillary vein above, the. chest wall below, the lateral edge of the pecto­. ralis major muscle in the anterior, and the. anterior edge of the distribution muscle in the. posterior. At this time, attention should be. paid to the external thoracic nerve that runs. along the posterior side of the pectoralis major. muscle and the internal thoracic nerve that. runs in a Y shape on the inferolateral sides of. the pectoralis major muscle.. The surgeon dissects along the pectoralis. minor muscle. When the axillary vein is iden­. tified, the fat layer covering it should be sepa­. rated from top to bottom. At this time, thorough. removal of the tissue around the vein induces. lymphedema. When the axillary vein is. exposed, the lower part of the vein is separated. from the inside to the outside, and the upper. part of the vein is not dissected. Rather than. separating just below the vein, separating it at. Brief Overview of Breast Cancer Treatment. 154. intervals of about 5 mm can prevent side holes. from forming in the vein. When separating and. ligating the branches of the axillary vein, the. anterior thoracic branch of the axillary vein is. ligated, and the thoracic vein just below is. checked. Axillary lymph node dissection. involves en bloc resection to prevent damage. to the axillary lymphatic vessels and pro­. gresses in stages from medial to lateral. At this. time, the thoracic neurovascular bundle is the. first deep branch to be found. Detachment. along the lateral and anterior sides of the latis­. simus dorsi muscle can prevent damage to the. thoracodorsal nerve. The thoracodorsal nerve. is located mainly inside the vein, slightly pos­. terior, and can be pressed lightly to check the. contraction of the latissimus dorsi muscles and. the movement of the shoulder. Along with this,. the long thoracic nerve must be found and pre­. served. The long thoracic nerve returns inferi­. orly and posteriorly along the thoracic wall. from the fat layer at the intersection of the. axillary vein and the thoracic wall, with the. subscapular lymphatic group sample pulled. downward and outward. Pressing it lightly. allows the surgeon to check the movement of. the serratus anterior. If it is not found along the. chest wall, check that it is not pulled outward. along the axillary tissue being exfoliated. If it. has been pulled outward, it should be sepa­. rated and placed on the chest wall. To safely. preserve the long thoracic nerve, the surgeon. should keep an eye on it and immediately dis­. sect the anterior nerve, taking care not to dis­. sect the inside of the nerve. Then, the surgeon. dissects downward until the nerve enters the. serratus anterior muscle, taking special care. not to injure the nerves at this point because. they run slightly outward just before entering. the serratus anterior. It can be confirmed that. the intercostal brachial nerve enters the chest. wall through the third intercostal nerve during. the separation of the long thoracic nerve. It. runs about 1  cm below the axillary vein.. Intermediate axillary adipose tissue is sepa­. rated until the nerves are free. Preservation of. the intercostal brachial nerve is not essential if. the axilla is lymph node positive when viewed. with the naked eye.. . 4. Postoperative management and complications.. When the 24-h drainage volume is 30 mL. or less, the axillary drainage tube can be. removed, and most of the time, it is removed. 4–7 days after surgery. During this time, oral. antibiotics are not usually required. Arm. movements should begin the day after surgery. and should be managed carefully until the. range of movement returns to normal.. Excessive exercise can increase drainage.. Lymphedema can appear at various times. after surgery and must be diagnosed early in. the condition and treated appropriately.. Axillary cord syndrome, often known as. Mondor’s disease, involves a string of tender. subcutaneous tissues extending from the lat­. eral axilla to the upper and medial aspects of. the arm, manifesting in a cord-like structure. beneath the skin. It typically occurs 1–8 weeks. after axillary dissection and appears when the. axillary veins and lymphatic vessels were. damaged proximally during surgery. It gener­. ally improves spontaneously and must be dis­. tinguished from lymphedema.. When the thoracic nerve is injured, the. abduction of the arm is restricted, and when. the long thoracic nerve is injured, the wing. scapula and shoulders are affected. When the. intercostobrachial nerve is injured, paresthe­. sia of the upper medial part of the arm, axil­. lary, and superior laterality of the chest. appears. Complications such as upper arm. movement range limitation can occur, but. movement can be recovered by steady exer­. cise and rehabilitation.. 2. . Local Therapy: Radiotherapy. 2.1. . History. Radiation began to be used in the treatment of. cancer shortly after Roentgen discovered X-rays.. Since then, radiation therapy has played an impor­. tant role in improving the local remission rate and. survival rate in breast cancer. Radiation therapy is. also given to patients with distant metastases to. relieve symptoms. After the Curie couple discov­. ered a radioisotope called radium, radium needles. J. Y. You et al.. 155. were primarily used to treat breast cancer, but in. the 1930s, low-energy external radiation therapy. was used. However, much of the radiation from. low-energy radiation therapy was absorbed into. the skin and did not sufficiently irradiate the. actual cancer tissue, which caused acute skin. damage and chronic sequelae. In 1951, a radiation. therapy device using cobalt was put into operation. to reduce the amount of radiation absorbed by the. skin. Thus, medical linear accelerators that gener­. ate high-energy X-rays and electron beams have. been developed since the early 1950s, and they. now play a major role in radiation therapy for. breast cancer. Linear-­. accelerated radiotherapy. equipment began to be used after the development. of computer-based three-dimensional radiother­. apy technology in the 1990s [35, 36].. Subsequently, intensity-modulated radiation ther­. apy technology was developed, and now, respira­. tory gated radiation that treats patients according. to their breathing has also been developed. Thanks. to these advancements, side effects can be mini­. mized and the target can be irradiated uniformly,. thereby enhancing clinical effectiveness. In addi­. tion to radiation using electromagnetic waves. such as X-rays and γ-rays, medium-particle radio­. therapy devices for neutrons, protons, and carbon. ions have also been developed, but they are still. used in a limited manner for breast cancer.. Recently, breast conserving surgery has become. widespread, and radiation therapy is an important. part of that breast cancer treatment. In recent. years, the convenience and accessibility of radia­. tion therapy have become the main concerns.. Therefore, various methods for optimizing radio­. therapy, such as reducing the number of sessions. and performing partial radiotherapy, have been. developed and tested [37–39].. 2.2. . Radiation Therapy After. Breast-Conserving Surgery. 2.2.1. . Range of Radiation Therapy. and Radiation Dose. The scope of radiation therapy for patients who. undergo axillary lymph node dissection at the. same time as breast conservation surgery includes. the remaining total breast tissue, adjacent skin. and subcutaneous tissue, and chest wall. It can be. found by dividing up to 50 Gy over 25–28 days.. The divided survey dose is thus 1.8–2 Gy and is. administered once a day, 5 times a week.. Subsequently, an electron beam is directed to the. site of the surgical scar and previous tumor loca­. tion, or brachytherapy is performed within the. tissue. In some cases, additional irradiation is. performed by three-dimensional modeling treat­. ment using a photon beam and electron beam.. Radiation therapy is usually available as outpa­. tient treatment, and each treatment takes about. 15 min. The total duration of radiation therapy is. usually 6 weeks. If there is a tumor in the resec­. tion margin, the recurrence rate is high. In that. situation, additional irradiation of 15–20  Gy is. applied to the primary lesion site, for a total irra­. diation dose of 60–65 Gy. To evaluate the useful­. ness of additional irradiation, an EORTC study. was conducted in patients with lesions of 3 cm or. smaller and confirmed tumor-free excision.. According to that study, 5-year survival did not. change with additional radiation therapy of. 16 Gy, but the local recurrence rate was signifi­. cantly reduced. However, the researchers reported. that the additional radiation had a negative effect. on the cosmetic results [40, 41]. At the same. time, the effect of an additional 10 Gy of irradia­. tion was studied in France. That study reported. that the local recurrence rate was significantly. reduced without causing a difference in the cos­. metic results [42].. The standard treatment to date has been radia­. tion therapy to the whole breast, but partial treat­. ment has been attempted in some studies. Holland. et al. (1985) [43] reported that in the case of a. tumor of 2 cm or smaller, the probability that a. new tumor would be found at a site 2 cm or more. away from the primary tumor was 28%. Therefore,. they reported that the entire breast had to be. treated. However, according to reports since 1990,. most local recurrences occur around the surgical. site, even when radiotherapy is not administered. after surgery, and the recurrence rate in other. lesions is not significantly different from the inci­. dence of secondary tumors in the contralateral. breast. This suggests the possible feasibility of. Brief Overview of Breast Cancer Treatment. 156. partial treatment ([44, 45], Veronesi et  al. [5]).. Furthermore, such conservative treatment can be. retried if cancer recurs in the breast after local. treatment. Unlike whole breast therapy, partial. treatment can be completed within 1 week using. methods such as external radiation therapy, inter­. stitial. brachytherapy,. balloon. intracavitary. brachytherapy, or low-energy radiation therapy.. Therefore, it has the advantage of having little. effect on the timing of systemic anticancer che­. motherapy. Most studies conducted to date report. that local recurrence rates and survival rates do. not differ from those with existing treatments.. However, the follow-up period is still short, so it. is difficult to conclude the usefulness of partial. radiotherapy.. 2.2.2. . Timing of Radiation Therapy. . 1. Timing of radiotherapy after surgery.. It has never been established when radia­. tion therapy should be started after surgery. It. usually takes 4–6 weeks for the surgical scar. to heal. Delaying radiation therapy for more. than 8 weeks after surgery does not increase. the local recurrence rate compared with radia­. tion therapy given within 4 weeks after sur­. gery. One study by Vujovic et al. reported that. for axillary lymph node-negative patients,. delaying radiation therapy for more than. 16 weeks did not affect the local recurrence. rate. However, that is not the case for patients. aged 40  years or younger who have close. resection margins (≤ 2 mm) or benign resec­. tion margins. In those cases, the local recur­. rence rate tended to increase, though not in a. statistically significant way, when radiation. therapy was given 8 or 12 weeks or more after. surgery. In general, patients who are not eli­. gible for systemic anticancer chemotherapy. should receive radiation therapy within. 8 weeks after surgery [46].. . 2. Timing of systemic chemotherapy and radia­. tion therapy.. For patients who are not eligible for sys­. temic chemotherapy, radiation therapy begins. after surgical scarring, generally 3–4  weeks. after surgery. The order of treatment for. patients who must receive both systemic che­. motherapy and radiation therapy is still con­. troversial. An analysis of 11 studies with 1927. patients showed a high local recurrence rate of. 16% in the group of patients who received. chemotherapy first and radiation therapy later.. The local recurrence rate in the group of. patients who received radiation therapy first. was 6% [47]. However, a large retrospective. study reported that delaying radiation therapy. did not increase local recurrence rates. A. study of 718 axillary lymph node-positive. patients reported no difference in the local. recurrence rate between the group who. received radiation therapy immediately after. breast-conserving surgery and the group who. received radiation therapy after 3 or 6 chemo­. therapy sessions.. 2.2.3. . Irradiation Method. The breast and surrounding tissues are irradiated. through an internally and externally symmetrical. tangential irradiation field. The treatment should. be designed so that the whole target volume. receives radiation in as uniform a dose as possi­. ble while minimizing the amount of lung tissue. contained in the treatment area. When designing. the internally and externally symmetrical tan­. gential irradiation field, sufficiently treat the. chest wall. At the same time, when treating lung. tissue on the left side, the volume of radiation to. which normal organs, such as the heart, are. exposed should be minimized. Because the fre­. quency of radiation pneumonia is proportional to. the volume of exposed lung tissue, it is important. to reduce the exposed area. Recently, 3-dimen­. sional treatment plans using CT images to adjust. the irradiation intensity have been proposed.. Intensity-modulated radiation therapy, which. irradiates tumors intensively, has been intro­. duced, and makes it possible to reduce the. amount of radiation applied to normal tissues.. It can also be helpful to fix the patient’s body. and induce postural changes to facilitate the set­. ting of the radiation field. Various fixation devices. are used to consistently maintain the patient’s. therapeutic posture for each fractionated irradia­. tion. For breast treatment, low-density cradle-­. type fixing devices are commonly used.. J. Y. You et al.. 157. 2.3. . Radiation Therapy After. Radical Total Mastectomy. 2.3.1. . Indications. The local recurrence rate after radical mastec­. tomy has been reported to be 9–36%, varying. with the size of the primary lesion and the pres­. ence and degree of metastasis to the axillary. lymph nodes. That is, in the absence of axillary. lymph node metastasis, the local recurrence rate. is only 5%, but in the presence of metastasis, the. local recurrence rate is about 25%. The recur­. rence rate is about 10% with 3 or fewer lymph. node metastases and 36% with 4 or more lymph. node metastases. In patients with T1–2 breast. cancer and lymph node metastasis (4 or more if. the primary tumor is 2  cm or more), vascular. lymphatic invasion of the tumor, or a primary. tumor that is clinically palpable, the frequency. of lymph node metastasis is significantly. increased [48]. Therefore, patients with 4 or. more lymph node metastases or other risk fac­. tors for recurrence should receive radiation ther­. apy after mastectomy. For T3 and T4 tumors. without lymph node metastases, radiation ther­. apy is given after radical mastectomy, which. reduces the local recurrence rate to 5%. Even. when chemotherapy was performed as adjuvant. therapy, local recurrence increased as the pri­. mary disease site and number of axillary lymph. nodes affected became larger. Specifically, when. the primary lesion is 5  cm or larger and 4 or. more axillary lymph nodes have metastases, the. local recurrence rate is reported to be 30% or. more, so radiation therapy is absolutely neces­. sary [49].. 2.3.2. . Method. Radiation therapy after radical mastectomy is. usually split treatment once a day, 5 days a week,. for about 5 weeks (25–28 sessions). A total dose. of 45–50 Gy of radiation should be irradiated to. the supraclavicular lymph node on the ipsilateral. chest wall from which the tumor has been. removed. According to the US Treatment Method. Study [50], this irradiation dose has become uni­. versal, and it is the irradiation dose that is com­. monly prescribed in South Korea. The treatment. area is based on the chest wall and some axillary. lymph nodes. The supraclavicular lymph nodes. on that side can also be included as dictated by. the patient’s risk factors. Because there is no evi­. dence to recommend radiation therapy for inter­. nal mammary lymph nodes, it is performed only. when lymph node metastases are clinically diag­. nosed by CT or MRI or confirmed by pathologic. findings after surgery. Because recurrence often. occurs in the skin or subcutaneous tissue within. 3 cm above and below the wound site, it is neces­. sary to ensure that the skin is exposed to a suffi­. cient amount of radiation when the chest wall is. irradiated. Treatment with electron beams ensures. that the skin surface receives a high dose. When. treating a tangential field using X-rays, the skin is. covered with a tissue-equivalent substance for. treatment. Because the depth varies depending on. the anatomical position of the irradiation volume. and major organs such as the lungs and heart are. near the affected area, care must be taken to per­. form radiation therapy without complications.. 2.4. . Axillary Lymph Node. Radiation Therapy. Axillary lymphadenopathy is performed to stage. the disease, assess the risk, and prevent recur­. rence in the axillary lymph nodes. It is well. known that the local control rate offered by sur­. gery improves the survival rate, but side effects. such as edema, pain, paresthesia, and restricted. shoulder movement are problematic. For early-. stage breast cancer, sentinel lymph node biopsy. can significantly reduce these side effects.. Furthermore, this procedure can provide similar. outcomes to axillary lymph node dissection,. while lowering the incidence of complications.. The NSABP B-04 study at the Curie Institute. demonstrated that axillary lymph node radiation. therapy after breast conserving surgery had the. same effect as lymphadenectomy, and many ret­. rospective analyses have shown similar results. [51]. If lymph node metastasis is confirmed by. sentinel lymph node biopsy, further axillary. lymph node dissection is performed. However,. radiation therapy can be given instead of surgery. Brief Overview of Breast Cancer Treatment. 158. to reduce lymphedema of the arm. Prospective. studies, such as the AMAROS study, are under­. way to find the best treatment protocol. Some. researchers have argued that if the sentinel lymph. node are positive, radiation therapy could be a. viable option if additional axillary lymphadenop­. athy is unlikely to change the chemotherapy. treatment regimen [33, 39].. 2.5. . Breast Reconstruction. and Radiation Therapy. Many women desire breast reconstruction after. mastectomy. If patients have to undergo radiation. therapy, they will face various problems and. require close cooperation among specialists in. breast surgery, orthopedics, and radiation oncol­. ogy. Breast reconstruction uses artificial prosthe­. ses and autologous tissue. It can be performed at. the time of the initial surgery or after a certain. period of time, usually after radiation therapy.. Immediate reconstruction has advantages in terms. of skin sensation and cosmetology, but when radi­. ation therapy is used, those advantages disappear,. and it becomes difficult to establish a treatment. plan. Geometric problems arise, especially for. transplanted prostheses, and radiation is difficult. without specially planned treatments, such as. intensity-controlled radiation therapy. In many. cases, fibrosis, constriction, etc., cause poor cos­. metic results. Even when using autologous tissue,. it is generally recommended to perform recon­. struction after radiation therapy [23, 24].. 2.6. . Radiation Therapy. for Palliative Purposes. Breast cancer patients, unlike other cancer. patients, can survive for a long time even if they. have a local recurrence or distant metastasis. To. improve the patient’s quality of life, long-term. control of the pain, fractures, spinal cord com­. pression, etc., that can be caused by distant metas­. tases must be ensured. Extensive distant. metastases can cause a short survival time, but. metastasis confined to one organ, especially if the. time to metastasis is long, can permit long-term. survival. Therefore, radiation therapy more. aggressive than that required for short-term symp­. tom-relieving radiation therapy, such as palliative. radiation therapy for general cancer, is required.. 3. . Neoadjuvant Therapy. Neoadjuvant chemotherapy has two purposes:. First, in patients (N2–3 or T4) who have diffi­. culty with definitive surgery, it can induce a reac­. tion in the tumor or metastasized lymph nodes. that will facilitate local treatment such as surgery. or radiation therapy. Second, in patients who can. undergo definitive surgery (T3N1M0), it can. make breast conserving possible. In addition, it. has the advantage of revealing the susceptibility. of the tumor to chemotherapy and, at least in the­. ory, provides early treatment of micrometastases. [52]. Most studies have shown similar clinical. courses and prognoses with neoadjuvant chemo­. therapy and adjuvant chemotherapy, and both. protocols are thus widely used as standard thera­. pies. In addition, pathological complete remis­. sion (pCR) can be used as a prognostic factor for. long-term survival. Whether adjuvant chemother­. apy should be given before or after surgery. depends on the stage, histology, hormone recep­. tor, and HER2 receptor status of the invasive. breast cancer. The choice must be made by com­. prehensively judging the state of expression and. the possibility of breast preservation. Neoadjuvant. chemotherapy can be performed for locally. advanced breast cancer and (when surgery is pos­. sible) to reduce the surgical range for large breast. cancers. Patient planning for advanced chemo­. therapy requires a core biopsy of the primary. tumor. If axillary lymph node metastasis is clini­. cally suspected, a biopsy or cell aspiration cytol­. ogy of the lymph nodes is also recommended.. 3.1. . Chemotherapy. In principle, the drugs used for adjuvant chemo­. therapy can also be used for neoadjuvant chemo­. therapy. Combined therapy based on doxorubicin. J. Y. You et al.. 159. has mainly been performed, but since adjuvant. chemotherapy including taxane showed superior­. ity in the survival rate, taxane has also been used. in neoadjuvant chemotherapy. Various other ther­. apies have also been studied and reported better. pCR rate. In the NSABP B-27 study of 2300. patients, pCR rates were higher in the group that. received docetaxel after AC (doxorubicin, cyclo­. phosphamide) than in the group that did not. receive docetaxel (26% vs. 13%) [53]. In the. Aberdeen study of 162 patients, the CVAP. (cyclophosphamide, vincristine, doxorubicin,. prednisolone) response group who received. docetaxel after conversion had a higher pCR rate. than the group who continued to receive CVAP. therapy (34% vs. 16%). In the GEPARDUO. study of 913 patients, AC (doxorubicin, cyclo­. phosphamide) followed by DOC (docetaxel). sequential therapy had a better pathological com­. plete remission rate than 2-week interval (dose. dense) ADOC (doxorubicin, docetaxel) simulta­. neous combination therapy (14.3% vs. 7%) [54].. Following a neoadjuvant chemotherapy study. with taxane, phase II or III studies on nanoparti­. cle. albumin-bound. (nab)-paclitaxel. were. reported. The GeparSepto study compared epiru­. bicin/cyclophosphamide (EC) administration. after nab-paclitaxel or paclitaxel and found pCR. rates of 38% and 29%, respectively [55]. In addi­. tion, after 4 years of follow-up, invasive disease-. free survival was superior in the nab-paclitaxel. group, though there was no difference in the. overall survival rate. In contrast, the ETNA study. did not show the superiority of nab-paclitaxel,. with a pCR rate of 22.5% vs. 18.6% [56]. In dif­. ferent large studies, nab-paclitaxel did not show. consistent results, but it did show a pCR rate sim­. ilar to paclitaxel, so long-term follow-up results. need to be collected.. In a study of the number of neoadjuvant che­. motherapy treatments, the pCR rate with ED. (epirubicin, docetaxel) was higher after 6 cycles. than after 3  cycles. In the GeparTrio study of. 2000 people, 2 doses of TAC (docetaxel, doxoru­. bicin, cyclophosphamide) were administered. first, and then 4 or 6 additional doses of TAC. were administered to 1390 responders [57]. The. study reported no differences in the pCR rate. between the two groups. The 2006 International. Expert Panel recommendation is for a combina­. tion therapy that includes anthracycline or taxane. to be administered at least 6 cycles for 4–6 months. before surgery in eligible breast cancer patients.. The recent GeparQuinto study of 1509 patients. given 4 cycles of EC (epirubicin, cyclophospha­. mide) therapy compared the addition of docetaxel. monotherapy (EC-T), docetaxel + capecitabine. combination therapy (EC-TX), and docetaxel →. capecitabine sequential therapy (EC-T-X). It. reported no difference in the pCR rate or breast-­. conserving surgery, so it is not recommended to. increase the duration of anthracycline-taxane. therapy or add capecitabine.. After completing 2–3 neoadjuvant chemother­. apies, a clinical evaluation and response evalua­. tion by imaging study must be performed. Then,. the decision to continue the planned chemother­. apy, switch to a new therapy, or administer local. treatment must be made based on the results of. those assessments. If trastuzumab or hormone. therapy is indicated after surgery, it can be given. in parallel with radiation therapy.. 3.2. . Endocrine Therapy. Studies of neoadjuvant endocrine therapy in pre­. menopausal women who are hormone receptor. positive are very restrictive. Reports have shown. 3% complete pathological observation and 42%. breast preservation from combination therapy. with GnRH agonists and letrozole. According to. several studies of neoadjuvant endocrine therapy. in postmenopausal women, tamoxifen plus anas­. trozole, anastrozole alone, and letrozole mono­. therapy offer the best breast-conserving surgery. and objective response rates [58]. Based on those. studies, aromatase inhibitors are suitable neoad­. juvant endocrine therapy for postmenopausal. women with hormone receptor positive breast. cancer. The appropriate duration of neoadjuvant. endocrine therapy is 4–6  months, and co-­. administration of chemotherapy and aromatase. inhibitors is not desirable. In addition, neoadju­. vant therapy with a CDK4/6 inhibitor combined. with endocrine therapy has recently been tested. Brief Overview of Breast Cancer Treatment. 160. in clinical studies.. According to the CORALLEEN. phase 2 clinical study comparing 6  months of. ribociclib + letrozole and prior endocrine therapy. with doxorubicin/cyclophosphamide and pacli­. taxel, both therapies have the same low risk-of-­. relapse score [59].. 4. . Systemic Therapy: Adjuvant. Setting. 4.1. . Chemotherapy. 4.1.1. . Adjuvant Chemotherapy. Adjuvant chemotherapy should be determined by. the histological type of tumor, presence or. absence of hormone receptor and HER2 overex­. pression,. and. lymph. node. metastasis.. Chemotherapy and endocrine therapy should be. given sequentially, not simultaneously. CMF and. radiation therapy can be given at the same time,. but except in special cases, all other chemother­. apy is given prior to radiation therapy.. The first randomized studies of adjuvant che­. motherapy in breast cancer demonstrated that adju­. vant CMF chemotherapy significantly reduced the. treatment failure rate. Four cycles of doxorubicin. and cyclophosphamide have the same effect as six. cycles of CMF chemotherapy. There is no benefit. to be gained by increasing the dose of doxorubicin. or cyclophosphamide above the standard dose. The. comparison of 4 cycles of AC and 6 cycles of FEC. for lymph node-negative breast cancer in the. NSABP B-36 study found no difference in disease-. free survival or overall survival between the two. groups, but toxicity was higher with FEC therapy. [60]. High-dose epirubicin-­. based CEF therapy for. lymph node-positive breast cancer improved dis­. ease-free survival compared with CMF therapy. [61]. The FASG-05 study comparing two epirubi­. cin doses (high versus low doses) observed a sig­. nificant improvement in survival with high-dose. epirubicin-based CEF therapy [62].. Various studies have also been conducted on. the role of taxane in adjuvant therapy. Sequential. administration of docetaxel or paclitaxel for. lymph node-positive breast cancer showed. improved survival over FEC monotherapy. The. addition of taxane to anthracycline-based therapy. has been shown to improve the clinical course of. lymph node-positive breast cancer and reduce the. risk of recurrence in even high-risk lymph node-­. negative patients in several phase III studies [63].. The EBCTCG meta-analysis also showed a sig­. nificant reduction in breast cancer related mortal­. ity with the addition of 4-cycle taxane to treatment. with fixed doses of anthracyclines. The E1199. study by the Eastern Cooperative Oncology. Group compared schedules of paclitaxel and. docetaxel given after AC chemotherapy [64]. In a. 12-year follow-up analysis, docetaxel therapy. every 3 weeks showed a significant prolongation. of disease-free survival compared with paclitaxel. therapy every 3 weeks. Therefore, weekly pacli­. taxel or every 3-week docetaxel therapy is rec­. ommended for sequential administration after. 4 cycles of AC [65]. The USON 9735 study com­. pared docetaxel with cyclophosphamide (TC),. doxorubicin, and cyclophosphamide (AC) and. showed significantly longer disease-free survival. with TC therapy. The CALGB 9741 study com­. pared dose-­. intensive therapy with standard. sequential chemotherapy and found that dose-. dense therapy improved survival [66]. A meta-. analysis. also. reported. that. dose-dense. chemotherapy significantly improved both over­. all survival and disease-free survival. A meta-. analysis restricted to clinical trials using. equivalent doses demonstrated that dose-dense. chemotherapy significantly improved survival. without increasing chemotherapy-related side. effects. In the meta-analysis results of 26 studies. in EBCTCG, dose-dense chemotherapy signifi­. cantly lowered the 10-year recurrence rate from. 31.4% to 28.0% and lowered the 10-year breast. cancer mortality rate from 21.3% to 18%, com­. pared with the control group. From the viewpoint. of improving the survival rate, dose-dense che­. motherapy with prophylactic G-CSF assistance is. preferred [67].. 4.1.2. . Chemotherapy in Elderly. Patients. Chemotherapy may be recommended for all age. groups younger than 70  years. The benefits of. post-surgery chemotherapy are most pronounced. J. Y. You et al.. 161. in women younger than 50 and diminish with. age above that. For patients older than 70, it is. difficult to offer general clinical guidelines. because clinical trial materials for adjuvant che­. motherapy are rare. However, in the CALGB. 49907 study, patients, especially those with. ER-negative breast cancer, who were treated. with capecitabine did more poorly than those. who received AC or CMF standard therapy [68].. In other words, evidence suggests that it is better. for older breast cancer patients to receive the. same standard therapy as younger breast cancer. patients. In a random-distribution open clinical. trial comparing trastuzumab monotherapy with. trastuzumab plus chemotherapy in patients aged. 70–80  years with HER2-positive breast cancer. who underwent surgical resection, 3-year dis­. ease-free survival was reported to be 85.9% in. the trastuzumab monotherapy group and 93.8%. in the trastuzumab/chemotherapy combination. therapy group, demonstrating the noninferiority. of trastuzumab monotherapy. Therefore, in prin­. ciple, systemic adjuvant therapy for patients. aged 70 years or older should be standard ther­. apy, but decisions should be made individually. in consideration of accompanying diseases and. general condition.. 4.1.3. . Adjuvant Systemic Therapy. for histology of Breast Cancer. with Good Prognosis. For invasive cancer of good histological subtypes. such as tubular carcinoma or mucinous carci­. noma, adjuvant systemic therapy is not required. in the absence of lymph node involvement or. lymph node involvement of less than 2 mm when. the tumor is less than 1  cm. With lymph node. involvement less than 2 mm and a tumor of 1 cm. or more and less than 3 cm, endocrine therapy. can be considered if the hormone receptor is pos­. itive, and if the tumor is 3 cm or more, endocrine. therapy should be performed irrespective of the. hormone receptor status. The chemotherapy may. be considered as an alternative to endocrine ther­. apy when lymph node metastasis is 2mm or. greater, regardless of tumor size. If the hormone. receptor is negative after retesting, chemotherapy. based on common histological types can be con­. sidered [69, 70].. 4.2. . Endocrine Therapy. All breast cancer patients should be confirmed. for ER and PR expression [71]. If one of them is. positive, adjuvant endocrine therapy is given. regardless of the patient’s age, axillary lymph. node metastasis, adjuvant chemotherapy, or. HER2 overexpression. Adjuvant endocrine ther­. apy may be omitted in some cases because the. prognosis after surgery is very good if the size is. 0.5 cm or less and there is no lymph node metas­. tasis. However, in an ER-positive patient, adju­. vant endocrine therapy is recommended because. it reduces the risk of developing secondary can­. cer in the contralateral breast [72].. 4.2.1. . Endocrine Therapy for Breast. Cancer in Premenopausal. Women. For hormone receptor-positive premenopausal. women, oral administration of 20 mg of tamoxi­. fen daily is a priority, and the recommended. duration of use is at least 5 years. The SOFT and. TEXT trial found that the addition of ovarian. suppression therapy to tamoxifen significantly. improved disease-free survival and overall sur­. vival compared with the use of tamoxifen alone. [73]. In addition, ovarian suppression therapy. was used to induce menopause, and when an aro­. matase inhibitor was administered, the disease-. free. survival. rate. improved.. Therefore,. premenopausal women can undergo ovarian sup­. pression therapy for 5 years with tamoxifen and. aromatase inhibitors. Ovarian suppression ther­. apy is more beneficial if anticancer treatment is. required because of a high risk of recurrence or if. the risk of other clinicopathological recurrence is. high (35 years or younger, high tumor grade, N2. stage or higher, etc.). However, the decision must. be made in consideration of the side effects that. can occur due to ovarian suppression therapy and. drug adaptability.. If tamoxifen is used for 5  years and meno­. pause occurs, it can be replaced with an aroma­. tase inhibitor and administered for another. 5 years or more. Also, based on the ATLAS study,. 10 years of endocrine therapy plus tamoxifen for. another 5  years can be given with or without. menopause. Because aromatase inhibitors are. Brief Overview of Breast Cancer Treatment. 162. ineffective in women with ovarian action, serum. LH, FSH, and estradiol (E2) concentrations. should be checked every 3–6 months when con­. sidering aromatase inhibitor treatment in this. group of patients.. When a GnRH agonist and an aromatase. inhibitor are administered in combination to pre­. menopausal patients, it has been reported that the. administration of zoledronic acid significantly. prolongs disease-free survival. It also delays. bone density loss and helps to restore bone den­. sity after treatment is interrupted [74].. 4.2.2. . Endocrine Therapy for Breast. Cancer in Postmenopausal. Women. In general, the postmenopausal condition indi­. cates one of the followings:. –. – Bilateral oophorectomy was performed.. –. – The patient is older than 60 years.. –. – The patient is younger than 60 years but has. been amenorrheic (with FSH and E2 in the. postmenopausal. range). for. at. least. 12 months without treatment with antican­. cer drugs (tamoxifen, etc.) or ovarian func­. tion suppressants.. –. – Among patients younger than 60 years who are. taking tamoxifen and started adjuvant chemo­. therapy before menopause, when FSH and E2. were in the premenopausal range, menopause. status after chemotherapy cannot be judged as. amenorrhea. Therefore, treated amenorrheic. patients can receive an aromatase inhibitor. only if menopause is confirmed by regular fol­. low-up of FSH and E2 levels [75, 76].. For postmenopausal patients with hormone. receptor-positive breast cancer, we recommend. upfront therapy as the initial adjuvant therapy.. Initial administration of an aromatase inhibitor. instead of tamoxifen for 5 years has been shown. to reduce the risk of local recurrence, contralat­. eral breast cancer development, and distant. metastasis without affecting overall survival. In. addition, after taking tamoxifen for 2–3 years,. it can be changed to an aromatase inhibitor and. administered for a total of 5 years (switch ther­. apy as sequential with tamoxifen), or after tak­. ing tamoxifen for 5  years, the aromatase. inhibitor can be used for 5 more years (extended. therapy). Due to the absence of comparative. studies determining the optimal duration of. tamoxifen administration before initiating aro­. matase inhibitors, no specific duration can be. recommended at this time. But patients who. have been taking tamoxifen for 2–3 years are. recommended to switch to an aromatase inhibi­. tor. Based on the results of the ATLAS study, it. is possible to use tamoxifen for 5  years and. then administer the same drug for up to. 10 years. However, no studies have yet shown. whether either method is more effective than. changing to an aromatase inhibitor. The deci­. sion between tamoxifen and aromatase inhibi­. tors is best made in consultation with the. patient, considering the benefits and potential. side effects of each medication. Therefore, if. aromatase inhibitors are contraindicated or. unsuitable, tamoxifen is recommended for. 5 years. Even in those cases, tamoxifen can be. optionally used for 10 years [77].. Until now, it has not been recommended to. maintain aromatase inhibitors for more than. 5 years. Recently, a study of adjuvant endo­. crine therapies after surgery reported results. from using an initial aromatase inhibitor for. 5 years and then extending that therapy with. an additional aromatase inhibitor for up to. 10 years. Some results showed a tendency to. improve disease-free survival, but the differ­. ence was not large, and no results showed an. improvement in overall survival. However,. given the results of studies showing the long-­. term recurrence potential of breast cancer and. the effect of aromatase inhibitors in reducing. secondary breast cancer, their use can be. extended to 10 years in patients at high risk of. recurrence. Other considerations are drug. resistance and side effects [73].. To reduce the risk of osteoporosis, it is. advisable to measure bone mineral density. before using aromatase inhibitors. If necessary,. appropriate physical exercise, calcium prepara­. tions, vitamin D, and zoledronic acid can be. administered. The ABCSG-18 study reported. that subcutaneous injections of denosumab. J. Y. You et al.. 163. (60  mg every 6  months) in postmenopausal. patients taking aromatase inhibitors as adjuvant. endocrine therapy significantly delayed the. development of clinical fractures [78].. 4.2.3. . CDK4/6 Inhibitor Combination. Therapy as Adjuvant Therapy. In the MONARCHE study, patients diagnosed. with hormone receptor-positive/HER2-negative. breast cancer and having 4 or more lymph node. metastasis or high risk with 1–3 lymph node. metastasis were administered abemaciclib for a. duration of 2 years alongside adjuvant endocrine. therapy. The study reported that the drug combi­. nation improved the 2-year invasive disease-free. survival rate from 88.7% with adjuvant endocrine. therapy alone to 92.2%. In contrast, the PALLAS. study, which added 2 years of palbociclib admin­. istration to adjuvant endocrine therapy in stage. 2–3 patients, failed to show significant differ­. ences in 3-year invasive disease-free survival. [79]. Although the MONARCHE study showed. positive results, the follow-up period was rela­. tively short, so we must wait for future long-term. follow-­. up results [80]. Likewise, we have to wait. to judge the results of the NATALEE research. into ribociclib, another CDK4/6 inhibitor.. 4.3. . HER2-Targeted Therapy. Targeted treatment focuses on substances that play. crucial roles in the development and progression of. cancer, aiming to inhibit their actions and achieve. therapeutic effects. As a general rule, targeted. treatment is administered specifically to patients. with identified targets, in contrast to conventional. chemotherapy. This approach helps reduce side. effects and enhances treatment efficacy. Targeted. treatments are expected to play a major role in can­. cer treatment in the future. There are four human. epidermal growth factor receptor (HER) families:. epidermal growth factor receptor (EGFR), HER2,. HER3, and HER4. These receptors are present. throughout the cell membrane; are composed of. extracellular, cell membrane, and intracellular. regions; and have a morphological structure that. transmits signals related to cell proliferation to the. nucleus. GFR, HER3, and HER4, but not HER2,. possess a structure capable of specific binding to. the extracellular ligand of the receptor. This ligand. binding initiates the signal generation process and. its transmission into the cell. EGFR, HER2, and. HER4, but not HER3, possess a structure that. activates the intracellular tyrosine kinase domain.. Upon receptor dimerization, the phosphorylation. of intracellular tyrosine kinase enzymes trans­. mits the received signal into the nucleus. HER2 is. expressed in 20–30% of all breast cancers and can­. not bind to ligands, but it plays an important role in. amplifying and transmitting the signals generated. by forming dimers with other receptors. Therefore,. much effort has been made to develop a therapeutic. agent that can suppress the action of HER2 [81].. 4.3.1. . Trastuzumab. In current clinical practice, the representative. HER2 inhibitor used in patients with HER2-­. overexpressing breast cancer is trastuzumab, a. humanized monoclonal antibody that has four. functions. First, by binding to the extracellular. space of the HER2 receptor near the cell mem­. brane and preventing it from shedding the extra­. cellular space construct, it prevents signal. activation via the remaining HER2 construct,. p95 HER2. Second, it interferes with polymer. ­. formation between HER family receptors and. suppresses signal transduction. Third, it induces. antibody-dependent, cell-mediated cytotoxic. effects. Fourth, the bound HER2 receptor is. introduced into the cell to reduce the HER2. receptor. Trastuzumab is effective as a mono­. logic in patients with HER2-overexpressing. breast cancer. It also showed improved survival. when used as a first-line treatment along with. existing chemotherapeutic agents in patients. with metastatic breast cancer [82]. Recent clini­. cal studies have confirmed that trastuzumab. improves disease-free survival and overall sur­. vival when used in combination or sequentially. with existing chemotherapy drugs, even as post­. operative adjuvant chemotherapy [83].. 4.3.2. . Lapatinib. Lapatinib is a low molecular-weight oral tyro­. sine kinase inhibitor that competitively binds to. the intracellular ATP binding pockets of HER1. and HER2 and blocks receptor autophosphoryla­. Brief Overview of Breast Cancer Treatment. 164. tion. It regulates cell differentiation and survival. by blocking receptor activity and blocking signal. transduction of the MAPK and PI3K/AKT path­. ways below it [84]. Currently, lapatinib has been. shown to have a therapeutic effect on breast can­. cer and is being applied clinically [85]. In par­. ticular, it is effective in the treatment of p95. HER2-active breast cancer in which the extracel­. lular construct of the HER2 receptor is shed and. does not respond to treatment with trastuzumab.. Its role as a therapeutic agent for trastuzumab-. resistant cancer is well known. Currently, large-. scale clinical studies are underway on its. usefulness as a first-­. line treatment for early-stage. breast cancer and its usefulness as neoadjuvant. chemotherapy.. 4.3.3. . Pertuzumab. Pertuzumab is a monoclonal antibody that binds. to the binding site of trastuzumab (domain IV). and another site (domain II) and inhibits the. HER2–HER3 disconjugate [86]. Trastuzumab. suppresses ligand-independent HER2 signals,. whereas. pertuzumab. suppresses. ligand-­. dependent HER2 mediation signals and HER2–. HER3 signals, which are heterodimerizations. that send the strongest mitotic signaling [87].. Pertuzumab has limited efficacy as a monother­. apy, but the results of the CLEOPATRA study. show that it has a synergistic effect when used in. combination with trastuzumab. The combination. of trastuzumab and pertuzumab is currently being. clinically applied, especially in trastuzumab-­. resistant patients [88].. 4.3.4. . Trastuzumab Emtansine. (T-DM1). T-DM1 combines trastuzumab with the anti­. cancer drug DM1 (maytansine). After the. trastuzumab portion of T-DM1 binds to HER2,. the endocytosis of HER2–T-DM1 complex is. occurred, where the DM1 portion is released by. proteolytic degradation in lysosomes to exert an. tumor-suppressive effect. DM1 is a maytansine. derivative and is an anti-microtubule agent such. as vinca alkaloid. It is clinically known to sup­. press mitosis 20–100 times more than vincristine.. The EMILIA study compared T-DM1 mono­. therapy with the lapatinib and capecitabine com­. bination in HER2 overexpressing metastatic. breast cancer previously treated with taxane and. trastuzumab [89]. The excellent event-free and. overall survival of the T-DM1 monotherapy. group indicates its value as a second-line HER2. targeted treatment for patients with HER2-. overexpressing breast cancer who have failed. with trastuzumab. The ongoing MARIANNE. study is intended to confirm the effect of T-DM1. as a first-line treatment, and if it succeeds in. obtaining that result, T-DM1 might be the most. effective target treatment for HER2 overexpress­. ing metastatic breast cancer.. 4.3.5. . Pan-HER Inhibitors. Pan-HER inhibitors simultaneously block other. EGFR family members, including HER2.. Neratinib and afatinib are currently being studied. as oral, irreversible, low molecular-weight sub­. stances that simultaneously block EGFR, HER2,. and HER4 [90].. 4.4. . Immunotherapy. 4.4.1. . Antiangiogenic Agents. Angiogenesis is an essential step in tumor growth. and metastasis that involves a variety of factors,. including vascular endothelial growth factor. (VEGF). Bevacizumab is a monoclonal antibody. against VEGG-A.  As a first-line treatment for. HER2-negative breast cancer patients, the com­. bination of paclitaxel and bevacizumab showed a. significant improvement in event-free survival. compared with paclitaxel monotherapy. It was. approved in 2008 as a treatment for HER2-­. negative metastatic breast cancer. However, since. then, some meta-analyses have shown no. improvement in the survival rate, and it is found. to have a low gain compared with its toxicity,. such as hypertension, bleeding, and intestinal. perforation. In 2011, the US FDA revoked its. approval for the treatment of metastatic breast. cancer. It is still approved for use with paclitaxel. or capecitabine in Europe, but it is used in only a. J. Y. You et al.. 165. few patients because of its limited therapeutic. effect, large side effects, and high price [91, 92].. Sunitinib and sorafenib were studied as multi-­. targeted tyrosine kinase inhibitors, including. VEGFR. However, in HER2-negative metastatic. breast cancer, sunitinib monotherapy was less. effective than capecitabine monotherapy. There. was no improvement in event-free survival com­. pared with the monotherapy group when it was. combined with docetaxel as the first-line treat­. ment or administered as a combination therapy. with capecitabine to previously treated HER2-­. negative metastatic breast cancer patients.. Sorafenib in combination with capecitabine. showed improved event-free survival in patients. with advanced or metastatic HER2-negative. breast cancer compared with capecitabine alone,. but further research is needed.. 4.4.2. . PI3K/AKT/mTOR Pathway. Inhibitors. The PI3K-AKT-mTOR pathway regulates cell. proliferation and survival, making it a critical. player in tumor development and progression. [93]. It is also known to be associated with trastu­. zumab resistance and hormone therapy resistance. [94]. Everolimus acts as an allosteric inhibitor of. mTOR complex 1 with a rapamycin analog and. suppresses tumors. As a clinical study to confirm. the effects of everolimus, the BOLERO-1,2,3 trial. was advanced, and the results were reported. In. BOLERO-2, [95] the event-free survival rate of. everolimus and exemestane combination therapy. was significantly higher than that with exemes­. tane monotherapy [96, 97]. The BOLERO-3. study compared vinorelbine, trastuzumab, and. everolimus combination therapies with non-. everolimus combinations in patients who failed. with taxane and trastuzumab [98]. It found that. the event-free survival rate was improved in the. everolimus-using groups, but it was reported that. the decision should be made in consideration of. the toxicity of everolimus [99].. 4.4.3. . PARP Inhibitor. Poly-ADP-ribose polymerase (PARP) is one of. the most well-known enzymes that maintain gene. stability. PARP-1 activation is one of the early. cellular reactions that occur when a DNA strand. is destroyed, and if a DNA single strand is defec­. tive, it is detected and immediately recovered.. The BRCA1,2 gene is responsible for repairing. double-stranded DNA damage by means of. homologous recombination. If a mutation in. BRCA1 or BRCA2 causes a loss of its function,. a PARP inhibitor can be used to induce DNA. single-strand defects. In that situation, single-­. stranded DNA damage progresses from the repli­. cation process to double-stranded damage, which. eventually leads to cell death due to chromo­. somal instability because repair using homolo­. gous recombination is difficult. There are many. molecular pathological similarities between. triple-­. negative breast cancer and BRCA-deficient. breast cancer, suggesting that PARP inhibitors. (olaparib, iniparib, etc.) could play a role as tar­. geted therapeutic agents in triple-negative breast. cancer [100].. 4.5. . Bone-Directed Therapy. Bone remodeling is the process by which bone is. generated through osteoblasts and reabsorbed. through osteoclasts. Osteoblasts secrete the. RANK (receptor activator of nuclear factor kappa. B) ligand (RANKL), which activates RANK in. the cell membrane of the osteoclast precursor and. activates osteoclasts. Integrin in the osteoclast. membrane and proteins such as osteopontin. secreted from osteoblasts interact with each other. to activate osteoclasts. Osteoprotegerin secreted. by bone lining cells binds to RANKL and inhibits. RANK activity. Through this series of processes,. balance is achieved between bone resorption. (osteoblasts). and. remodeling. (osteoclasts).. Cancer cells secrete substances that allow the. stimuli necessary for their growth to occur and. thus increase the activity of osteoclasts [101].. Bisphosphonate adjuvant therapy has shown. the potential to reduce recurrence rates and. improve survival, but it is difficult to apply to all. patients. The therapeutic effect is good when it is. used as an adjunct therapy in hormone treatment. or anticancer treatment for female patients with. early-stage breast cancer who have a low estrogen. Brief Overview of Breast Cancer Treatment. 166. environment after menopause or whose ovarian. function is suppressed. The mechanism of action. of the bisphosphonates is to prevent bone resorp­. tion by activating osteoblasts and suppressing. bone metabolism. Additionally, they contribute. to reduced lifespan by inhibiting the replacement,. adhesion, and activity of osteoclasts. Furthermore,. they hinder the growth of macrophages respon­. sible for generating osteoclasts, thereby curtailing. the lifespan of osteoclasts. Indigestion is the most. common side effect, and other side effects include. heat sensation, arthralgia, myalgia, hypocalcemia,. and decreased renal function. A pretreatment den­. tal examination is essential as they can also cause. osteonecrosis of the jaw [102].. References. 1. Halsted WS. The results of operations for the cure. of cancer of the breast performed at the Johns. Hopkins hospital from June, 1889, to January,. 1894. Ann Surg. 1894;20(5):497–555. https://doi.. org/10.1097/00000658-189407000-00075.. 2. 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Abemaciclib combined with. endocrine therapy for the adjuvant treatment of HR+,. HER2-, node-positive, high-risk, early breast cancer. (monarchE). J Clin Oncol. 2020;38(34):3987–98.. https://doi.org/10.1200/JCO.20.02514.. 81. Yarden. Y,. Sliwkowski. MX.. Untangling. the ErbB signalling network. Nat Rev Mol. Cell. Biol.. 2001;2(2):127–37.. https://doi.. org/10.1038/35052073.. 82. Joensuu H, Kellokumpu-Lehtinen PL, Bono P,. Alanko T, Kataja V, Asola R, et al. Adjuvant. docetaxel or vinorelbine with or without trastuzumab. for breast cancer. N Engl J Med. 2006;354(8):809–. 20. https://doi.org/10.1056/NEJMoa053028.. 83. Untch M, Rezai M, Loibl S, Fasching PA, Huober. J, Tesch H, et al. Neoadjuvant treatment with. trastuzumab in HER2-positive breast cancer:. results from the GeparQuattro study. J Clin Oncol.. 2010;28(12):2024–31.. https://doi.org/10.1200/. JCO.2009.23.8451.. 84. Santen RJ, Song RX, McPherson R, Kumar R, Adam. L, Jeng MH, et al. The role of mitogen-activated. protein (MAP) kinase in breast cancer. J Steroid. Biochem Mol Biol. 2002;80(2):239–56. https://doi.. org/10.1016/s0960-0760(01)00189-3.. 85. Moy B, Goss PE.  Lapatinib-associated toxic­. ity. and. practical. management. recommenda­. tions. Oncologist. 2007;12(7):756–65. https://doi.. org/10.1634/theoncologist.12-7-756.. 86. Agus DB, Gordon MS, Taylor C, Natale RB, Karlan. B, Mendelson DS, et al. Phase I clinical study of. pertuzumab, a novel HER dimerization inhibitor,. in patients with advanced cancer. J Clin Oncol.. 2005;23(11):2534–43.. https://doi.org/10.1200/. JCO.2005.03.184.. 87. Holbro T, Beerli RR, Maurer F, Koziczak M, Barbas. CF III, Hynes NE. The ErbB2/ErbB3 heterodimer. functions as an oncogenic unit: ErbB2 requires. ErbB3 to drive breast tumor cell proliferation. Proc. Natl Acad Sci U S A. 2003;100(15):8933–8. https://. doi.org/10.1073/pnas.1537685100.. 88. Baselga J, Cortes J, Kim SB, Im SA, Hegg R, Im. YH, et al. Pertuzumab plus trastuzumab plus. docetaxel for metastatic breast cancer. N Engl J. Med. 2012;366(2):109–19. https://doi.org/10.1056/. NEJMoa1113216.. 89. Baselga J, Bradbury I, Eidtmann H, Di Cosimo. S, de Azambuja E, Aura C, et al. Lapatinib with. trastuzumab for HER2-positive early breast cancer. (NeoALTTO): a randomised, open-label, multicen­. tre, phase 3 trial. Lancet. 2012;379(9816):633–40.. https://doi.org/10.1016/S0140-6736(11)61847-3.. 90. Twelves C, Trigo JM, Jones R, De Rosa F, Rakhit. A, Fettner S, et al. Erlotinib in combination with. capecitabine and docetaxel in patients with meta­. static breast cancer: a dose-escalation study.. Eur J Cancer. 2008;44(3):419–26. https://doi.. org/10.1016/j.ejca.2007.12.011.. 91. Thomas ES, Gomez HL, Li RK, Chung HC, Fein. LE, Chan VF, et al. Ixabepilone plus capecitabine. for metastatic breast cancer progressing after. anthracycline and taxane treatment. J Clin Oncol.. 2007;25(33):5210–7.. https://doi.org/10.1200/. JCO.2007.12.6557.. 92. Thomas E, Tabernero J, Fornier M, Conte P,. Fumoleau P, Lluch A, et al. Phase II clinical trial of. ixabepilone (BMS-247550), an epothilone B analog,. in patients with taxane-resistant metastatic breast. cancer. J Clin Oncol. 2007;25(23):3399–406. https://. doi.org/10.1200/JCO.2006.08.9102.. 93. Serra V, Markman B, Scaltriti M, Eichhorn PJ,. Valero V, Guzman M, et al. NVP-BEZ235, a dual. PI3K/mTOR inhibitor, prevents PI3K signaling and. inhibits the growth of cancer cells with activating. PI3K mutations. Cancer Res. 2008;68(19):8022–30.. https://doi.org/10.1158/0008-5472.CAN-08-1385.. 94. Huang F, Reeves K, Han X, Fairchild C, Platero S,. Wong TW, et al. Identification of candidate molecu­. lar markers predicting sensitivity in solid tumors to. dasatinib: rationale for patient selection. Cancer Res.. 2007;67(5):2226–38. https://doi.org/10.1158/0008-. 5472.CAN-06-3633.. 95. Tabernero J, Rojo F, Calvo E, Burris H, Judson I,. Hazell K, et al. Dose- and schedule-dependent. inhibition of the mammalian target of rapamycin. pathway with everolimus: a phase I tumor pharma­. codynamic study in patients with advanced solid. J. Y. You et al.. 171. tumors. J Clin Oncol. 2008;26(10):1603–10. https://. doi.org/10.1200/JCO.2007.14.5482.. 96. Diaby V, Adunlin G, Ali AA, Tawk R. Using quality-. adjusted progression-free survival as an outcome. measure to assess the benefits of cancer drugs in ran­. domized-controlled trials: case of the BOLERO-2. trial. Breast Cancer Res Treat. 2014;146(3):669–73.. https://doi.org/10.1007/s10549-014-3047-y.. 97. Beaver JA, Park BH.  The BOLERO-2 trial: the. addition of everolimus to exemestane in the treat­. ment. of. postmenopausal. hormone. receptor-. positive advanced breast cancer. Future Oncol.. 2012;8(6):651–7. https://doi.org/10.2217/fon.12.49.. 98. Baselga J, Semiglazov V, van Dam P, Manikhas. A, Bellet M, Mayordomo J, et al. Phase II ran­. domized study of neoadjuvant everolimus plus. letrozole compared with placebo plus letrozole in. patients with estrogen receptor-positive breast can­. cer. J Clin Oncol. 2009;27(16):2630–7. https://doi.. org/10.1200/JCO.2008.18.8391.. 99. Morrow PK, Wulf GM, Ensor J, Booser DJ, Moore. JA, Flores PR, et al. Phase I/II study of trastu­. zumab in combination with everolimus (RAD001). in patients with HER2-overexpressing metastatic. breast cancer who progressed on trastuzumab-based. therapy. J Clin Oncol. 2011;29(23):3126–32. https://. doi.org/10.1200/JCO.2010.32.2321.. . 100. O’Shaughnessy J, Osborne C, Pippen JE, Yoffe M,. Patt D, Rocha C, et al. Iniparib plus chemotherapy. in metastatic triple-negative breast cancer. N Engl J. Med. 2011;364(3):205–14. https://doi.org/10.1056/. NEJMoa1011418.. . 101. Coleman RE, Rubens RD.  The clinical course. of bone metastases from breast cancer. Br J. Cancer. 1987;55(1):61–6. https://doi.org/10.1038/. bjc.1987.13.. . 102. Coscia M, Quaglino E, Iezzi M, Curcio C, Pantaleoni. F, Riganti C, et al. Zoledronic acid repolarizes. tumour-associated macrophages and inhibits mam­. mary carcinogenesis by targeting the mevalonate. pathway. J Cell Mol Med. 2010;14(12):2803–15.. https://doi.org/10.1111/j.1582-4934.2009.00926.x.. Brief Overview of Breast Cancer Treatment. 173. © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023. E. S. Lee (ed.), A Practical Guide to Breast Cancer Treatment,. https://doi.org/10.1007/978-981-19-9044-1_5" +717,Case 43,Courses of Treatment,Carcinoma In Situ,"43.1. . Courses of Treatment. Operation + Postoperative radiation therapy (left).. E. S. Lee et al.. 145. . ­. ­. . Operation. 206. 207. Pathology Report. Right.. Lobular carcinoma in situ. . 1. Size of tumor: 0.3 cm.. . 2. Nuclear grade: low.. . 3. Necrosis: absent.. . 4. Architectural pattern: solid.. . 5. Skin: no involvement of tumor.. . 6. Surgical margins:. . (a) superior margin: 5 mm,. . (b) inferior margin: 2 mm,. . (c) medial margin: 5 mm,. . (d) lateral margin: 5 mm,. . (e) deep margin: 2 mm,. . (f) superficial margin: 2 mm.. . 7. Microcalcification:. present,. tumoral/. non-tumoral.. Left.. Ductal carcinoma in situ, pathological TN cat­. egory (AJCC 2017): pTis. . 1. Size of tumor: 1.0 cm (pTis).. . 2. Nuclear grade: high.. . 3. Necrosis: present.. . 4. Architectural pattern: micropapillary/cribri­. form/comedo.. . 5. Skin: no involvement of tumor.. . 6. Surgical margins:. . (a) superior margin: 10 mm,. . (b) inferior margin: 10 mm,. . (c) medial margin: 10 mm,. . (d) lateral margin: 15 mm,. . (e) deep margin: 2 mm,. . (f) superficial margin: 2 mm.. . 7. Lymph nodes: no metastasis in one axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/1).. . 8. Microcalcification:. present,. tumoral/non-. tumoral.. Result. Intensity. Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in 8%. of tumor cells. Carcinoma In Situ. 146. a. b. . a. b. . E. S. Lee et al.. 147. © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023. E. S. Lee (ed.), A Practical Guide to Breast Cancer Treatment,. https://doi.org/10.1007/978-981-19-9044-1_4. Brief Overview of Breast Cancer. Treatment. Ji Young You, Soojin Park, and Eun Sook Lee. 1. . Local Therapy: Surgery. 1.1. . History. In 1984, Halsted and Meyer reported the first radi­. cal mastectomy [1]. Under the concept that breast. cancer metastasizes locally along the lymphatic. vessels, the procedure removed the breast, the skin. of the breast, the pectoralis major muscle, and the. axillary lymph nodes. This technique became a. technically feasible but not wholly effective local. treatment for most breast cancers, especially. advanced cases, found in the early twentieth cen­. tury. However, many patients still had expired due. to breast cancer metastasis after radical mastec­. tomy, and it was found that about 25% of the breast. cancer metastasis into the internal mammary. lymph nodes. Therefore, in addition to the radical. mastectomy, an extended radical mastectomy that. included the internal mammary lymph nodes was. performed. However, even with that technique, the. survival could not be extended, and the limits of. the Halsted theory became clear. In 1948, Patey. and Dyson [2] reported that many patients would. continue to die of breast cancer after surgery. unless effective breast cancer treatments could be. developed. They designed a modified radical mas­. tectomy that preserved the pectoralis major mus­. cle. In the 1970s, radical mastectomy was the most. commonly performed procedure, but oncologists. acknowledged that local-segmental treatment. alone could not completely prevent recurrence. In. other words, the theory emerged that cancer cells. had already spread throughout the body at the time. of surgery, rather than being inadequately surgi­. cally resected. Fisher et al. found no difference in. survival between patients who received postmas­. tectomy radiation therapy and those who under­. went radical mastectomy, according to the. National Surgical Adjuvant Breast and Bowel. Project (NSABP) B-04 study [3, 4]. They pro­. posed that given the heterogeneous nature of. malignant tissues, metastasis to surrounding. organs can occur concurrently with systemic. spread via lymphatic and blood vessels. This prop­. osition marked a paradigm shift, underlining the. significance of both local and systemic treatment. modalities. Radiation therapy along with surgery. plays a decisive role in reducing the scope of sur­. gery in the local treatment of breast cancer. A mas­. tectomy under the name quadrantectomy was first. attempted by Veronesi [5]. In 1969, the World. J. Y. You (*). Division of Breast and Endocrine, Department of. General Surgery, Korea University Medical Center,. Seoul, Republic of Korea. e-mail: joliejean@korea.ac.kr. S. Park. Department of Surgery, Wonkwang University. Sanbon Hospital, Gunpo, Republic of Korea. E. S. Lee. Center for Breast Cancer, National Cancer Center,. Goyang, Kyonggi-do, Republic of Korea. e-mail: eslee@ncc.re.kr. 148. Health Organization approved a clinical study of. breast preservation surgery, and several prospec­. tive studies on breast preservation surgery were. conducted. All those studies consistently reported. no difference in survival between the group that. received radiation therapy after breast preservation. surgery and the group that underwent mastectomy. [6]. Now that its safety has been proven, breast. preservation surgery is accepted as the standard. surgery for early-stage breast cancer and is under­. gone by many patients [7–12].. Axillary lymph node surgery is almost always. performed during surgery for breast cancer. For. patients with invasive breast cancer, the purpose of. axillary lymph node surgery is the reduction of. local recurrences and prolongation of survival, as. well as obtaining disease information valuable to. prognosis, selection of postoperative adjuvant che­. motherapy, and staging. However, many patients. suffer from complications and sequelae such as. lymphedema. In addition, only about one-third of. patients who underwent axillary lymph node dis­. section were reported to have lymph node metasta­. ses. As a result, new methods have emerged that. are less invasive, have fewer complications, and. provide appropriate treatment whether or not a. patient has axillary lymph node metastases. The. sentinel lymph node is the first lymph node that. metastasizes through the lymph vessels. In 1977,. Cabanas et al. used supervised lymphadenectomy. for the first time for penile cancer [13]. In 1992,. Morton et al. [14] began using it for lymphadenec­. tomy of melanoma, laying the foundation for the. theory. The sentinel lymph node biopsy was intro­. duced to reduce possible complications during. axillary lymphadenopathy in breast cancer. Based. on the initial experience, Guiliano et al. conducted. research to standardize monitored lymph node. biopsies in breast cancer and announced that the. monitoring lymph node detection rate was 93.5%,. with a false negative rate of 0% and sensitivity and. specificity of 100% [15, 16]. A significant differ­. ence in the incidence of complications was. observed between the two procedures: a 3% inci­. dence when only sentinel lymph node resection. was performed, versus a 35% incidence when axil­. lary lymph node dissection was conducted [17,. 18]. However, no such difference was observed in. terms of local recurrence. Presently, sentinel. lymph node biopsies are extensively utilized to. evaluate the metastatic status of lymph nodes. [19–22].. 1.2. . Breast Surgery. 1.2.1. . Radical Mastectomy. . 1. Indications.. . (a) Breast cancer stage III or higher, a lesion. fixed in the pectoralis major muscle that. is resistant to chemotherapy or radiation. therapy.. . (b) Inflammatory breast cancer that do not. respond to chemotherapy or radiation. therapy.. . (c) Advanced breast cancer with a fixed. lesion in the pectoralis major that has. recurred after a partial mastectomy.. . (d) A lesion fixed to the muscle and accom­. panied by a peripheral lesion near the. clavicle and sternum.. . 2. Surgical technique.. The skin incision takes an oval shape con­. taining the primary lesion and the nipple–are­. ola complex. At this time, it is better to lift the. outer circumference of the breast to secure an. appropriate boundary. If the diagnosis was. previously confirmed by histological exami­. nation, it is advisable to include the biopsy. site in the oval display if technically possible.. The superior border of the resection is the. inferior surface of the clavicle, the lateral bor­. der is the anterior surface of the latissimus. dorsi, the medial border is the midline of the. sternum, and the inferior border is the mam­. mary fold over the extended tendon of the rec­. tus abdominis.. After retracting the skin flap, identify the. insertion point of the pectoralis major muscle. on the humerus. Subsequently, dissect the. pectoralis major muscle towards its central. and superior medial portions to expose the. underlying pectoralis minor muscle. The pec­. toralis major muscle insertion to the humerus. J. Y. You et al.. 149. rotates inward after the incision. During the. dissection, the pectoralis major nerve and. blood vessels that enter the pectoralis major. muscle are cut and ligated. Separation of the. pectoralis major from the medial edge of the. costosternal junction causes the pectoralis. major and breast to emerge away from the. chest wall. The pectoralis minor muscle is cut. with the coracoid process of the scapula and. then separated inwardly.. 1.2.2. . Modified Radical Mastectomy. . 1. Indication.. It could be applied to patients diagnosed. with breast cancer in the breast or axilla with­. out tumor infiltration in the pectoralis major. muscle or fascia.. . 2. Surgical technique.. The techniques employed for anesthesia,. surgical positioning, skin incision, and skin. flap dissection in a modified radical mastec­. tomy are similar to those used in a radical. mastectomy. The Auchincloss method is. used to pull the pectoralis minor muscle. upward and medially for level I and level II. axillary lymphadenopathy without removal. of the pectoralis minor muscle. Using the. Patty method, axillary lymph node dissec­. tion is performed by making an incision from. near the origin of the pectoralis minor mus­. cle to the region external to the pectoralis. major nerve branch to remove the pectoralis. minor muscle and level III lymph nodes.. 1.2.3. . Breast Conserving Surgery. . 1. Indications.. Breast Conserving Surgery are commonly. used techniques. If a mass is newly palpated,. there is a negative or ectopic breast cancer on. imaging study, or there is a shadow (microcal­. cification) on visual inspection that cannot be. not touched, these techniques can be per­. formed with an axillary lymphadenopathy for. breast preservation. They are suitable for non-. invasive or early stage breast cancer.. These techniques may not include lesions. in the dissected tissue. When dealing with a. tumor, it’s essential to verify the cut surface. using frozen section histology during sur­. gery. Similarly, in the case of microcalcifi­. cations, the excised tissue must be confirmed. via mammographic examination.. . 2. Surgical extent.. For palpable masses, an incision is made. directly on the skin above the mass, or an inci­. sion is made to include a portion of the skin. above the mass. It is towed by the other hand. and peeled off, but depending on the situation,. 1–2 cm of normal surrounding tissue is usu­. ally removed. If the border is unclear, espe­. cially if the mass is close to the axillary tail. side, it is better to pass through the pectoralis. major fascia and remove some of the axillary. subcutaneous fat.. In the case of a mass shadow that cannot be. touched or is suspected to be a microcalcifica­. tion, it is advisable to preliminarily select the. position under preoperative mastectomy,. ultrasound guidance, or ultrasound guidance. during surgery. The wire localization is placed. at the suspicious lesion site, and the normal. breast tissue around the lesion is excised. based on the tip of the lead wire.. . 3. Surgical technique.. The incision must be located within the. mastectomy incision line because it can be. enlarged by mastectomy after histologic. examination. The most cosmetically effective. incision is the circumareolar incision. The. tumor excision extent contains 1–2  cm of. normal surrounding tissue, excises the tumor,. and bleeding control using electrocautery.. The resected specimen is generally labeled. with a knot, clip, or stain as cranio-caudal,. medial-­. lateral, superficial-deep and then sent. for a pathological examination or imaging.. 1.2.4. . Skin-Sparing Mastectomy. . 1. Indications.. . (a) AJCC (American Joint Committee on. Cancers) stage 0, I, and II cancers for. which a primary mastectomy is required. and breast reconstruction can be per­. formed immediately." +720,Case 43,Important Radiologic,Carcinoma In Situ,Important Radiologic. Findings. 202 203 204. 205. 43.3.  +721,Case 43,Patient History,Carcinoma In Situ,"Patient History and Progress. Female/67 years old, post-menopause.. Screen detected mass lesion on left breast 4. o’clock direction.. Outside result of biopsy: Ductal carcinoma in. situ.. No family history.. Diabetes mellitus, hypertension.. 43.2. " +718,Case 43,Courses of Treatment,Local Recurrence,"43.1. . Courses of Treatment. Right breast ILC→ Operation → Adjuvant ther­. apy → Left breast recurrence (microinvasive. ductal carcinoma).. Primary Treatment. 285. 286. Operation. ­. 287. Pathology Report. Invasive Lobular Carcinoma. 1. Size of tumor: 1.5 cm (pT1c).. 2. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 2/10HPF).. 3. In situ component: present, extratumoral. (40%).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) Superior margin: 8 mm.. . (b) Inferior margin: 27 mm.. . (c) Medial margin: positive for lobular car­. cinoma in situ (Fro 6) (see note).. . (d) Lateral margin: 15 mm.. . (e) Deep margin: 2 mm.. . (f) Superficial margin: 9 mm.. 6. Lymph nodes: no metastasis in three axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/3).. 7. Arteriovenous invasion: absent.. 8. Lymphovascular invasion: absent.. 9. Tumor border: infiltrative.. . 10. Microcalcification: absent.. . 11. Pathologic stage (AJCC 2010): pT1cN0(sn).. Note: 1. Lobular carcinoma in situ is present. only in the permanent section of Fro 6.. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (0). Ki-67. Positive in 11%. of tumor cells. . . Y. Kim et al.. 837. . . . Adjuvant Therapy. Postoperative radiation therapy.. Anastrozole 1 mg/day for 5 years.. Treatments After Recurrence. 288 289 290. 291. Operation. 292. Pathology Report. Microinvasive Ductal Carcinoma. 1. Size of invasive component: <0.1  cm. (pT1mi).. 2. Size of intraductal component: 4.0 cm.. 3. Histologic grade: not applicable.. 4. Intraductal component: present, intratu­. moral/extratumoral (99%) (nuclear grade:. high, necrosis: present, architectural pattern:. micropapillary/cribriform/solid/comedo,. extensive intraductal component: present).. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) Superior margin: 5 mm.. . (b) Inferior margin: (see note).. . (c) Medial margin: (see note).. . (d) Lateral margin: 5 mm.. . (e) Deep margin: 2 mm.. . (f) Superficial margin: 2 mm.. Local Recurrence. 838. 7. Lymph nodes: no metastasis in one axillary. lymph node (pN0(sn)) (sentinel LN: 0/1).. 8. Arteriovenous invasion: absent.. 9. Lymphovascular invasion: absent.. . 10. Tumor border: infiltrative.. . 11. Microcalcification:. present,. tumoral/. non-tumoral.. . 12. Pathological TN category (AJCC 2017):. pT1miN0(sn).. Note: 1. The inferior margin of the lumpec­. tomy specimen (slide 3) is close to ductal carci­. noma in situ (<1 mm), but this margin submitted. for frozen diagnosis (Fro 3) is free of tumor.. 2. The medial margin of the lumpectomy. specimen (slide 10) is close to ductal carcinoma. in situ (2 mm), but this margin submitted for fro­. zen diagnosis (Fro 4) is free of tumor.. Result. Intensity. Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in 20%. of tumor cells. Adjuvant Therapy. Postoperative radiation therapy.. . . ­. . Y. Kim et al.. 839. 44. " +722,Case 43,Patient History,Local Recurrence,"Patient History and Progress. Female/64 years old, post-menopause.. Screen detected mass lesion on right breast 12. o’clock direction.. Outside result of biopsy: Invasive ductal. carcinoma.. Family history of breast cancer, older sister.. Diabetes mellitus, fatty liver, dyslipidemia.. BRCA 1 and 2 mutation: Not detected, ATM. VUS (variant of uncertain).. 43.2. " +719,Case 43,Courses of Treatment,Metastatic Breast Cancer,Courses of Treatment. Right breast cancer → Operation → Adjuvant. therapy → Brain metastasis.. Primary Treatment. receptor. Strong (7/7). 3. >2/3. Progesterone. receptor. Strong (7/7). 3. >2/3. C-erbB2. Negative. (1+). Ki-67. Positive in. 8% of tumor. cells. Adjuvant Therapy. Post-operation radiation to right breast +. Tamoxifen 20 mg/day for 3 years.. Concurrent Zoladex for 1 year.. Treatments After Recurrence.  +723,Case 43,Patient History,Metastatic Breast Cancer,BRCA 1 & 2 mutation: Not detected.. S/p bilateral salpingo-oophorectomy.. 43.2.  +724,Case 44,Courses of Treatment,Local Recurrence,"44.1. . Courses of Treatment. Left breast microinvasive ductal carcinoma →. Operation → Adjuvant therapy → Right breast. recurrence (IDC).. Primary Treatment. 293 294 295. 296. . . . . ­. . Local Recurrence. 840. Operation. ­. 297. Pathology Report. Microinvasive Ductal Carcinoma. 1. Size of invasive component: <0.1  cm. (pT1mic).. 2. Size of intraductal component: 1.2 cm.. 3. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 3/10HPF).. 4. Intraductal component: present, extratumoral. (99%) (nuclear grade: low, necrosis: absent,. architectural pattern: solid, extensive intra­. ductal component: present).. 5. Surgical margins:. . (a) Superior margin: 7 mm.. . (b) Inferior margin: 17 mm.. . (c) Medial margin: positive for ductal carci­. noma in situ (Fro 4) (see note).. . (d) Lateral margin: <2 mm from ductal car­. cinoma in situ (slide 6).. . (e) Deep margin: 4 mm.. . (f) Superficial margin: <1 mm from ductal. carcinoma in situ (slide 1).. 6. Lymph nodes: no metastasis in one axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/1).. 7. Venous invasion: absent.. 8. Lymphovascular invasion: absent.. 9. Tumor border: infiltrative.. . 10. Microcalcification: present, non-tumoral.. . 11. Pathologic. stage. (AJCC. 2010):. pT1micN0(sn).. Note: 1. Ductal carcinoma in situ is present. only in the permanent section of Fro 4.. Result. Intensity. Positive %. Estrogen. receptor. Weak (3/8). 1. 1–10%. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Equivocal (2+). Ki-67. Positive in 17%. of tumor cells. Operation. Second Operation (Mar. 2014) Left breast wide. excision.. Pathology Report. . 1. No residual tumor with foreign body. reaction.. . (a) Post-lumpectomy status.. . 2. Atypical ductal hyperplasia, focal (see note).. Note: Atypical ductal hyperplasia is present. only in the permanent section of Fro 1.. Adjuvant Therapy. Postoperative radiation therapy.. Tamoxifen 20 mg/day for 5 years.. Treatments After Recurrence. 298 299 300. 301. . Y. Kim et al.. 841. . ­. . . . Operation. ­. 302. Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 1.1 cm (pT1c).. 2. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 3/3, 22/10HPF).. 3. Intraductal component: present, intratumoral. (5%) (nuclear grade: low, necrosis: present,. architectural pattern: micropapillary/cribri­. form/comedo, extensive intraductal compo­. nent: absent).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) Superior margin: 15 mm.. . (b) Inferior margin: (see note).. . (c) Medial margin: 5 mm.. . (d) Lateral margin: 30 mm.. . (e) Deep margin: 5 mm.. . (f) Superficial margin: <1  mm from inva­. sive ductal carcinoma (slides 2 and 3).. 6. Lymph nodes: no metastasis in two axillary. lymph nodes (pN0(i+)(sn)) (sentinel LN:. 0/2).. 7. Arteriovenous invasion: absent.. Local Recurrence. 842. . 8. Lymphovascular. invasion:. present,. intratumoral.. 9. Tumor border: infiltrative.. . 10. Microcalcification:. present,. tumoral/. non-tumoral.. . 11. Pathological TN category (AJCC 2017):. pT1cN0(i+)(sn).. Note: 1. The inferior margin of the lumpec­. tomy specimen (slide 3) is close to invasive duc­. tal carcinoma (3 mm), but this margin submitted. for frozen diagnosis (Fro 3) is free of tumor.. 2. A few isolated tumor cells are present only. in the permanent section of Fro 6 for immunohis­. tochemical staining (pN0(i+)).. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Negative (2/8). 1. <1%. C-erbB2. Equivocal (2+). (SISH equivocal). Ki-67. Positive in 28%. of tumor cells. Adjuvant Therapy. Postoperative radiation therapy.. Anastrozole 1��mg/day.. 45. " +726,Case 44,Patient History,Local Recurrence,"Patient History and Progress. Female/54 years old, post-menopause.. Screen detected mass lesion on left breast 2. o’clock direction.. Outside result of biopsy: Ductal carcinoma.. No family history.. No comorbidities.. 44.2. " +725,Case 44,Courses of Treatment,Metastatic Breast Cancer,"44.1. . Courses of Treatment. Right breast cancer with bone metastasis →. Palliative therapy.. Progesterone. receptor. Negative. (0/8). 0. 0. C-erbB2. Negative. (1+). Ki-67. Positive in. 57% of. dissection.. Pathology: Invasive ductal carcinoma, stage. ypT1cN1a.. Size of tumor: 2.0  cm, lymph node: 3/7. (2 mm).. Result. Intensity Positive %. Estrogen. receptor. Strong (7/8). 3. 1/3–2/3. Progesterone. receptor. Negative(0/8). 0. 0. C-erbB2. Equivocal (2+). Ki-67. Positive in. 66% of tumor. cells. SISH. Negative. Palliative therapy: Capecitabine (Sep. 2019 ~. Dec. 2019): Progressive disease.. Progesterone. receptor. Weak (4/8). 2. 1–10%. C-erbB2. Negative. (1+). Ki-67. Positive in. 2% of tumor. cells. Palliative therapy: DS-8201aU 303 # 8:. Progressive disease (liver).. Concurrent proton therapy: radiation to liver.. Palliative therapy: Albumin-bound Paclitaxel. # 8: Progressive disease.. Palliative. therapy:. Fluorouracil-5. &. Doxorubicin & cyclophosphamide # 5.. Palliative therapy: Eribulin." +727,Case 44,Patient History,Metastatic Breast Cancer,"Patient History and Progress. Female/49 years old, post-menopause.. No family history.. S/p bilateral salpingo-oophorectomy.. 44.2. " +728,Case 45,Courses of Treatment,Local Recurrence,"45.1. . Courses of Treatment. Right breast LCIS→ Operation → Right breast. recurrence (DCIS).. Primary Treatment. 303. Operation. 304. 305. Pathology Report. . Y. Kim et al.. 843. . 1. Lobular Carcinoma In Situ. . (a) Size of tumor: up to 0.4 cm, multifocal. (pTis).. . (b) Surgical margins:. • Superior margin: 5 mm.. • Inferior margin: 5 mm.. • Medial margin: 5 mm.. • Lateral margin: (see note).. • Deep margin: 5 mm.. • Superficial margin: 5 mm.. . (c) Microcalcification: present, non-tumoral.. . (d) Pathologic stage (AJCC 2010): pTisNx.. . 2. Atypical ductal hyperplasia.. . . . Local Recurrence. 844. Note: 1. The lateral margin of the lumpectomy. specimen (slide 5) is close to lobular carcinoma. in situ (<1 mm), but this margin submitted for. frozen diagnosis (Fro 5) is free of tumor.. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (0). Ki-67. Positive in. 1% of. tumor cells. . . 1. Atypical ductal hyperplasia involving intra­. ductal papilloma. . 2. Fibroadenoma.. Treatments After Recurrence. 306. Operation. 307. Pathology Report. Ductal Carcinoma In Situ. . 1. Post-lumpectomy status.. . 2. Size of tumor: 0.3 cm (pTis).. . 3. Nuclear grade: low.. . 4. Necrosis: absent.. . 5. Architectural pattern: cribriform/solid.. . 6. Skin: no involvement of tumor.. . 7. Surgical margins:. . (a) Deep margin: 2 mm.. . (b) Superficial margin: 2 mm.. . 8. Microcalcification:. present,. tumoral/. non-tumoral.. . 9. Pathological TN category (AJCC 2017): pTis.. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (1+). Ki-67. Positive in 2%. of tumor cells. . Y. Kim et al.. 845. . 46. " +730,Case 45,Patient History,Local Recurrence,"Patient History and Progress. Female/57 years old, post-menopause.. Screen detected mass lesion on right breast 12. o’clock direction.. Outside result of biopsy: Lobular carcinoma. in situ.. Family history of breast cancer, older sister.. Panic disorder.. BRCA 1 and 2 mutation: Not detected.. 45.2. " +729,Case 45,Courses of Treatment,Metastatic Breast Cancer,"Courses of Treatment. Left breast cancer with lung and bone metas­. tasis → Palliative therapy.. See Figs. 137, 138, and 139.. Left invasive ductal carcinoma, stage IV. (metastasis in lung, bone).. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Negative. (2/8). 1. <1%. C-erbB2. Equivocal. (2+). Ki-67. Result. Intensity Positive %. Estrogen. receptor. Weak (4/8). 2. 1–10%. Progesterone. receptor. Negative. (0/8). 0. 0. C-erbB2. Negative (0). Ki-67. Positive in. 8% of tumor. cells. Palliative therapy: fluorouracil & Doxorubicin. & cyclophosphamide # 6.. Post-op radiation to left breast & subclavicu­. lar lymph node + Tamoxifen 20  mg/day (Apr.. 2015 ~ Jul. 2018).. Jul. 2018 Chest CT> increased nodule in lung,. hepatic metastasis.. Palliative therapy: Trastuzumab emtansine # 5. cycles: Progressive disease.. Palliative therapy: Lapatinib & Capecitabine #. 39 cycles: Progressive disease.. Palliative therapy: Gemcitabine & Cisplatin. (Feb. 2021) ~. 46. " +731,Case 45,Patient History,Metastatic Breast Cancer, +732,Case 46,Courses of Treatment,Local Recurrence,"46.1. . Courses of Treatment. Right breast papillary carcinoma in situ →. Operation → Adjuvant therapy → Right breast. recurrence (IDC).. Primary Treatment. Operation. 308. Pathology Report. Papillary Carcinoma In Situ in background of. multiple papilloma (see note). . 1. Size of intraductal carcinoma: 0.5  cm. (pTis).. . 2. Nuclear grade: low.. . 3. Necrosis: absent.. . 4. Architectural pattern: papillary.. . 5. Skin: no involvement of tumor.. Local Recurrence. 846. . . . 6. Surgical margins:. . (a) Superior margin: 18 mm.. . (b) Inferior margin: positive for intraductal. papilloma.. . (c) Medial margin: 15 mm.. . (d) Lateral margin: 20 mm.. . (e) Deep margin: 2 mm.. . 7. Microcalcification:. present,. tumoral/. non-tumoral.. . 8. Pathologic staging: pTis.. Note: The in situ component is mainly present. in the needle biopsy specimen.. Adjuvant Therapy. Tamoxifen 20 mg/day for 3.6 years.. Treatments After Recurrence. 309 310 311. 312. Operation. ­. 313. Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 0.8 cm (pT1b).. 2. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 6/10HPF).. 3. Intraductal component: present, intratu­. moral/extratumoral (30%) (nuclear grade:. low, necrosis: absent, architectural pattern:. papillary/cribriform, extensive intraductal. component: present).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) Nipple margin: (see note 1).. . (b) Superior margin: 5 mm.. . (c) Inferior margin: (see note 2).. . (d) Medial margin: (see note 3).. . (e) Lateral margin: 20 mm.. . (f) Deep margin: 2 mm.. . (g) Superficial margin: 2 mm.. 6. Lymph nodes: no metastasis in one axillary. lymph node (pN0(sn)) (sentinel LN: 0/1).. Y. Kim et al.. 847. . . . . ­. 7. Arteriovenous invasion: absent.. 8. Lymphovascular. invasion:. present,. intratumoral.. 9. Tumor border: infiltrative.. . 10. Microcalcification:. present,. tumoral/. non-tumoral.. . 11. Pathological TN category (AJCC 2017):. pT1bN0(sn).. Note: 1. Atypical ductal hyperplasia is present. only in the permanent section of Fro 1.. 2. The inferior margin of the lumpectomy. specimen (slide 8) is close to ductal carcinoma in. situ (2 mm), but this margin submitted for frozen. diagnosis (Fro 3) is free of tumor.. 3. The medial margin of the lumpectomy. specimen (slide 6) is close to ductal carcinoma in. situ (2 mm), but this margin submitted for frozen. diagnosis (Fro 4) is free of tumor.. Local Recurrence. 848. . ­. . Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (1+). Ki-67. Positive in 10%. of tumor cells. Adjuvant Therapy. Postoperative radiation therapy.. Anastrozole 1 mg/day.. 47. " +734,Case 46,Patient History,Local Recurrence,"Patient History and Progress. Female/69 years old, post-menopause.. Screen detected mass lesion on upper outer. portion of right breast.. No family history.. No comorbidities.. 46.2. " +733,Case 46,Courses of Treatment,Metastatic Breast Cancer,"46.1. . Courses of Treatment. Right breast cancer with bone metastasis →. Palliative therapy.. See Figs. 140 and 141.. Metastatic Breast Cancer. 934. Right invasive ductal carcinoma, Stage IV. (R/O metastasis in bone, T-spine 10).. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Equivocal (2+). Ki-67. Positive in 43%. of tumor cells. SISH. Negative. Palliative therapy: Letrozole & Palbociclib # 29.. Dec. 2021 Right breast conserving surgery,. sentinel lymph node biopsy.. Pathology: Invasive ductal carcinoma, stage. ypT1bN0 (sn).. Size of tumor: 0.9 cm, lymph node: 0/2.. Result. Intensity Positive %. Estrogen. receptor. Negative. (0/8). 0. 0. Progesterone. receptor. Negative. (0/8). 0. 0. C-erbB2. Positive. (3+). Ki-67. Positive in. 34% of. tumor cells. Palliative. chemotherapy. #4. cycles. (Doxorubicin & Cyclophosphamide).. Post-op radiation to right breast & T-spine 10.. 47. " +735,Case 46,Patient History,Metastatic Breast Cancer,"Patient History and Progress. Female/61 years old, post-menopause.. No family history.. s/p appendectomy, hypertension.. 46.2. " +736,Case 47,Courses of Treatment,Local Recurrence,"47.1. . Courses of Treatment. Right breast Infiltrating ductal carcinoma→. Operation → Adjuvant therapy → Left breast. recurrence (IDC).. Primary Treatment. 314. 315. Operation. Aug. 2003 Right breast conserving surgery, axil­. lary lymph node dissection.. Pathology Report. Infiltrating ductal carcinoma.. 1. Size of tumor: 2 cm (pT1c).. 2. Histologic grade: 2/3 (tubule formation: 2/3,. nuclear pleomorphism: 2/3, mitotic count: 2/3).. 3. Ductal carcinoma in situ: present, intratu­. moral (5%) (nuclear grade: low, necrosis:. absent, architectural pattern: solid, extensive. intraductal component: absent).. 4. Skin: no involvement of tumor.. 5. Surgical margins: clear:. . (a) Superior margin: 30 mm.. . (b) Inferior margin: 35 mm.. . (c) Medial margin: 35 mm.. . (d) Lateral margin: 25 mm.. . (e) Deep margin: 10 mm.. 6. Lymph nodes:. . (a) Metastasis in 2 out of 22 axillary lymph. nodes (pN1a) (sentinel LN: 1/2, axillary. LN: 1/20).. . (b) Perinodal extension: absent.. . (c) Size of metastatic carcinoma: 6 mm.. Y. Kim et al.. 849. 7. Vascular invasion: absent.. 8. Lymphatic invasion: absent.. 9. Tumor border: infiltrative.. . 10. Microcalcification: absent.. . 11. Pathologic staging: pT1cN1a.. Result. Intensity. Positive %. Estrogen. receptor. Intermediate. (5/7). 2. 1/3–2/3. Progesterone. receptor. Weak (2/7). 1. <10%. C-erbB2. Equivocal (2+). Ki-67. Positive in 2%. of tumor cells. Adjuvant Therapy. Adjuvant chemotherapy #6 cycles of fluorouracil. and doxorubicin and cyclophosphamide.. Postoperative radiation therapy.. Tamoxifen 20 mg/day 1.6 years, anastrozole. 1  mg/day for 1  year, tamoxifen 20  mg/day for. 2.3 years.. Treatments After Recurrence. 316 317. 318. Operation. ­. 319. Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 1.1 cm (pT1c).. 2. Histologic grade: 2/3 (tubule formation: 2/3,. nuclear pleomorphism: 2/3, mitotic count:. 2/3, 11/10HPF).. 3. Intraductal component: present, intratumoral/. extratumoral (20%) (nuclear grade: low, necro­. sis: absent, architectural pattern: cribriform,. extensive intraductal component: absent).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) Superior margin: 10 mm.. . (b) Inferior margin: 10 mm.. . Local Recurrence. 850. . . . . (c) Medial margin: 10 mm.. . (d) Lateral margin: 10 mm.. . (e) Deep margin: 2 mm.. . (f) Superficial margin: 2 mm.. 6. Lymph nodes: no metastasis in one axillary. lymph node (pN0(sn)) (sentinel LN: 0/1).. 7. Arteriovenous invasion: absent.. 8. Lymphovascular invasion: absent.. 9. Tumor border: infiltrative.. . 10. Microcalcification:. present,. tumoral/. non-tumoral.. . 11. Pathological TN category (AJCC 2017):. pT1cN0(sn).. Result. Intensity Positive %. Estrogen receptor. Weak. (4/8). 2. 1–10%. Progesterone. receptor. Weak. (4/8). 2. 1–10%. C-erbB2. Negative. (0). Adjuvant Therapy. Postoperative radiation therapy.. Anastrozole 1 mg/day.. Y. Kim et al.. 851. 48. " +738,Case 47,Patient History,Local Recurrence,"Patient History and Progress. Female/72 years old, post-menopause.. Screen detected mass lesion on right breast 1. o’clock direction.. No family history.. Diabetes mellitus.. BRCA 1 and 2 mutation: Not detected, ATM. VUS (variant of uncertain).. POLE VUS (variant of uncertain).. 47.2. " +737,Case 47,Courses of Treatment,Metastatic Breast Cancer,"47.1. . Courses of Treatment. Right breast cancer → Neoadjuvant chemother­. apy → Operation → Adjuvant therapy → Ipsilateral. breast recurrence → Lung metastasis.. Primary Treatment. receptor. Negative 0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in 5%. Operation. Aug. 2013 Left breast conserving surgery, senti­. nel lymph node biopsy.. Pathology: Ductal carcinoma in situ (resid­. ual), stage yp TisN0 (sn).. Size of tumor: up to 0.5 cm, lymph node: 0/3.. Result. Intensity. Positive %. Estrogen. receptor. Negative. (0/8). 0. 0. Progesterone. receptor. Negative. 0/8). 0. 0. C-erbB2. Positive. (3+). Ki-67. Positive in. 19% of. tumor cells. Adjuvant Therapy. Post-operative radiation to left breast & subcla­. vicular lymph node.. Concurrent Trastuzumab # 18.. Treatments After Recurrence. Ipsilateral Breast Recurrence. Progesterone. receptor. Negative 0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in. 84% of tumor. cells. Adjuvant Chemotherapy. Adjuvant chemotherapy #8 cycles (Paclitaxel &. Trastuzumab # 8).. Operation. Nov. 2016 Left simple mastectomy with implant. reconstruction.. Pathology: Invasive ductal carcinoma, stage. rpT2.. Size of tumor : 2.5 cm.. Adjuvant Therapy. Adjuvant therapy: Paclitaxel & Trastuzumab # 32. cycles.. Lung Metastasis. Clinical trial: PF-06804103 #1: withdraw due. to side effects.. Palliative therapy: Irinotecan & Cisplatin # 6:. Partial response.. Rest for 3 months.. Palliative therapy: Trastuzumab & Eribulin #2.. Radiation to lung.. Palliative therapy: Abraxane #2: Progressive. disease.. Palliative therapy: Mitomycin #2: Progressive. disease.. 48. " +739,Case 47,Patient History,Metastatic Breast Cancer,"Patient History and Progress. Female/46 years old, pre-menopause.. No family history.. 47.2. " +740,Case 48,Courses of Treatment,Local Recurrence,"48.1. . Courses of Treatment. Left breast Mucinous carcinoma → Operation. → Adjuvant therapy → Left breast recurrence. (mucinous carcinoma).. Primary Treatment. 320. 321. Operation. 322. Pathology Report. Mucinous Carcinoma. 1. Size of invasive carcinoma: 0.6 cm (pT1b).. 2. Size of intraductal carcinoma: 1.5 cm.. 3. Histologic grade: 2/3 (tubule formation: 2/3,. nuclear pleomorphism: 2/3, mitotic count:. 2/3).. 4. Ductal carcinoma in situ: present, intratu­. moral/extratumoral (50%) (nuclear grade:. low, necrosis: absent, architectural pattern:. cribriform, extensive intraductal component:. present).. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) Superior margin: 8 mm.. . (b) Inferior margin: 15 mm.. . (c) Medial margin: 1  mm from mucinous. carcinoma (slide 9) and.. . (d) Positive for atypical ductal hyperplasia. (Fro 5) (see note).. . (e) Lateral margin: 10 mm.. . (f) Deep margin: 1 mm.. 7. Lymph nodes: no metastasis in 1 axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/1).. 8. Vascular invasion: absent.. 9. Lymphatic invasion: present, intratumoral.. . 10. Tumor border: pushing.. . 11. Microcalcification:. present,. tumoral/. non-tumoral.. . 12. Pathologic staging: pT1bN0(sn).. . . ­. . Local Recurrence. 852. Note: Atypical ductal hyperplasia is focally. present only in the permanent section of Fro 5.. Result. Intensity. Positive %. Estrogen. receptor. Strong (6/7). 3. 1/3–2/3. Progesterone. receptor. Intermediate. (5/7). 2. 1/3–2/3. C-erbB2. Negative (1+). Ki-67. Positive in 10%. of tumor cells. Adjuvant Therapy. Postoperative radiation therapy.. Tamoxifen 20 mg/day for 5 years.. Treatments After Recurrence. 323 324. 325. Operation. ­. 326. 327. Pathology Report. Mucinous Carcinoma. 1. Post-lumpectomy status.. 2. Size of tumor: 1.1 cm (rpT1c).. 3. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 1/10HPF).. 4. Intraductal component: absent.. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) Deep margin: <1  mm from mucinous. carcinoma (slide 1).. . (b) Superficial margin: 14 mm.. 7. Lymph nodes: no metastasis in one axillary. lymph node (pN0(sn)) (sentinel LN: 0/1,. axillary LN: 0/0).. 8. Arteriovenous invasion: absent.. 9. Lymphovascular invasion: absent.. . 10. Tumor border: pushing.. . 11. Microcalcification: absent.. . 12. Pathologic stage (AJCC 2010): rpT1cN0(sn).. . . . Y. Kim et al.. 853. . . Result. Intensity. Positive %. Estrogen. receptor. Strong (7/8). 2. >2/3. Progesterone. receptor. Weak (4/8). 2. 1–10%. C-erbB2. Negative (0). Ki-67. Positive in 6%. of tumor cells. Adjuvant Therapy. Tamoxifen 10 mg/day for 2.2 years.. 49. " +742,Case 48,Patient History,Local Recurrence,"Patient History and Progress. Female/42 years old, pre-menopause.. Screen detected mass lesion on left breast 9. o’clock direction.. Outside. result. of. biopsy:. Mucinous. carcinoma.. No family history.. No comorbdities.. 48.2. " +741,Case 48,Courses of Treatment,Metastatic Breast Cancer,"48.1. . Courses of Treatment. Right breast cancer with mediastinum and. bone metastasis → Palliative therapy.. Progesterone. receptor. Intermediate. (5/8). 2. 10%–1/3. C-erbB2. Negative (0). Ki-67. Positive in. 54% of tumor. cells. Neoadjuvant. chemotherapy. #8. cycles. (Doxorubicin + Cyclophosphamide #4 →. Docetaxel #4).. Dec. 2014 Right breast conserving surgery.. Pathology: Invasive ductal carcinoma, stage. ypT2N2a.. Size of tumor: 3.0 × 1.5 cm, lymph node: 4/4. (10 mm).. Result. Intensity Positive %. Estrogen. receptor. Intermediate. (6/8). 2. 1/3–2/3. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Negative (0). Ki-67. Positive in 1%. of tumor cells. Post-operative radiation to right breast &. internal mammary lymph node + Tamoxifen. 20 mg/day & zoladex.. Mar. 2015 Bilateral salpingo-oophorectomy.. Tamoxifen 20 mg/day only.. Mar. 2016 PET-CT> metastasis in multiple. bone.. Palliative therapy: Letrozole (Mar. 2016 ~. Nov. 2017: Progressive disease).. Palliative therapy: Exemestane & Everolimus.. Oct. 2018 Chest CT> metastasis in liver.. Palliative therapy: Paclitaxel & Cisplatin #21:. Progressive disease.. Palliative therapy: Fulvestrant & Abemaciclib. (Feb. 2020)~. 49. " +743,Case 48,Patient History,Metastatic Breast Cancer,"Patient History and Progress. Female/45 years old, post-menopause.. No family history.. BRCA 1 & 2 mutation: Not detected.. S/p bilateral salpingo-oophorectomy.. 48.2. " +744,Case 49,Courses of Treatment,Local Recurrence,"49.1. . Courses of Treatment. Right breast IDC→ Operation → Adjuvant ther­. apy → Left breast recurrence (IDC).. Primary Treatment. 328. 329. Operation. Apr. 2004 Right breast conserving surgery, senti­. nel lymph node biopsy.. Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 1.5 cm (pT1c).. 2. Histologic grade: 2/3 (tubule formation: 2/3,. nuclear pleomorphism: 2/3, mitotic count:. 2/3).. 3. Ductal carcinoma in situ: present, intratu­. moral/extratumoral (30%) (nuclear grade:. low, necrosis: present, architectural pattern:. cribriform and comedo, extensive intraductal. component: present).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) Superior margin: 15 mm.. . (b) Inferior margin: 25 mm.. . (c) Medial margin: 20 mm.. . (d) Lateral margin: 20 mm.. . (e) Deep margin: 5 mm.. 6. Lymph nodes: no metastasis in 1 axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/1).. 7. Vascular invasion: absent.. 8. Lymphatic invasion: absent.. 9. Tumor border: infiltrative.. . 10. Microcalcification:. present,. tumoral/. non-tumoral.. . 11. Pathologic staging: pT1cN0(sn).. Result. Intensity. Positive %. Estrogen. receptor. Strong (6/7). 3. 1/3–2/3. Progesterone. receptor. Intermediate. (4/7). 2. 10%-1/3. C-erbB2. Equivocal (2+). Ki-67. Positive in 5%. of tumor cells. Adjuvant Therapy. Postoperative radiation therapy.. Treatments After Recurrence. 330 331. 332. Operation. 333. . . Y. Kim et al.. 855. . . . . ­. Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 1.6 cm (pT1c).. 2. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 4/10HPF).. 3. Intraductal component: present, intratumoral. (5%) (nuclear grade: low, necrosis: present,. architectural pattern: solid, extensive intra­. ductal component: absent).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) Superior margin: 19 mm.. . (b) Inferior margin: 11 mm.. . (c) Medial margin: 15 mm.. . (d) Lateral margin: 15 mm.. . (e) Deep margin: 4 mm.. . (f) Superficial margin: 15 mm.. 6. Lymph nodes: no metastasis in 2 axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/2).. 7. Arteriovenous invasion: absent.. Local Recurrence. 856. 8. Lymphovascular invasion: absent.. 9. Tumor border: infiltrative.. . 10. Microcalcification:. present,. tumoral/. non-tumoral.. . 11. 11) Pathological TN category (AJCC 2017):. pT1cN0(sn).. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (0). Ki-67. Positive in 12%. of tumor cells. Adjuvant Therapy. Postoperative radiation therapy.. Anastrozole 1 mg/day.. 50. " +746,Case 49,Patient History,Local Recurrence,"Patient History and Progress. Female/63 years old, post-menopause.. Self-detected mass lesion on right breast. . 2 o’clock direction.. No family history.. No comorbidities.. BRCA 1 and 2 mutation: No examination.. Local Recurrence. 854. 49.2. " +745,Case 49,Courses of Treatment,Metastatic Breast Cancer,"49.1. . Courses of Treatment. Right breast cancer with bone metastasis →. Palliative therapy.. See Figs. 148 and 149.. Right invasive ductal carcinoma, stage IV. (metastasis in bone).. Metastatic Breast Cancer. Strong(8/8). 3. >2/3. C-erbB2. Negative. (1+). Ki-67. Positive in. 75% of. tumor cells. Clinical trial: Tamoxifen 20  mg/day &. Goserelin 3.6  mg (Dec. 2014 ~ Jan. 2017):. Progressive disease.. Jan. 2017 Palliative right breast conserving. surgery & bilateral salpingo-oophorectomy.. Pathology: Invasive ductal carcinoma, stage. yp T1p.. Size of tumor: 1.4 cm.. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Weak (4/8). 3. <1%. C-erbB2. Negative. (1+). Ki-67. Positive in. 30% of. tumor cells. Palliative therapy: Letrozole & Palbociclib. (Jan. 2017) ~. Post-operative radiation to pelvic bone.. Y. Kwon et al.. 939. 50. " +747,Case 49,Patient History,Metastatic Breast Cancer,"Patient History and Progress. Female/55 years old, post-menopause.. No family history.. S/p bilateral salpingo-oophorectomy, s/p Left. pelvis cementoplasty.. 49.2. " +748,Case 5,Courses of Treatment,Benign and Proliferative,"5.1. . Courses of Treatment. →2021-12-17 Excision, Lt. (11H, 1H).. 5.3.1. . Pathology Report. • Breast, left, excision:. –. – Atypical ductal hyperplasia (#1. 1 o’clock. & #2. 11  o’clock) involving intraductal. papilloma with microcalcification.. C. W. Lee et al.. 23. . . 6. " +756,Case 5,Important Radiologic,Benign and Proliferative,Important Radiologic. Findings. 7. 8. 5.3.  +762,Case 5,Patient History,Benign and Proliferative,"Patient History and Progress. Female/48 years old, pre-menopause.. Screen detected microcalcification on upper. outer portion of left breast.. Family history of breast cancer, mother and. sister.. No comorbidities.. BRCA 1 and 2 mutation: Not detected.. 5.2. " +749,Case 5,Courses of Treatment,Carcinoma In Situ,"Courses of Treatment. Operation + Postoperative radiation therapy.. 5.3.1. . Operation. 25. 26. 5.3.2. . Pathology Report. Ductal carcinoma in situ, pathological TN cat­. egory (AJCC 2017): pTis. . 1. Size of tumor: 0.3 cm (pTis).. . 2. Nuclear grade: low.. . 3. Necrosis: absent.. . 4. Architectural pattern: cribriform.. . 5. Surgical margins:. . (a) superior margin: 5 mm,. . (b) inferior margin: 5 mm,. . (c) medial margin: <1 mm from ductal carci­. noma in situ (slide 12),. . (d) lateral margin: 10 mm,. . (e) deep margin: 2 mm,. . (f) superficial margin: 2 mm.. . 6. Microcalcification:. present,. tumoral/non-. tumoral.. Result. Intensity Positive %. Estrogen. receptor. Strong (7/8). 3. 1/3–2/3. Progesterone. receptor. Weak (4/8). 1. 10%–1/3. C-erbB2. Negative (0). Ki-67. Positive in. <1% of tumor. cells. E. S. Lee et al.. 63. . . . . Carcinoma In Situ. 64. . 6. " +757,Case 5,Important Radiologic,Carcinoma In Situ,Important Radiologic. Findings. 21 22 23. 24. 5.3.  +763,Case 5,Patient History,Carcinoma In Situ,"Screen detected mass lesion on left breast 11,. 3 and 2 o’clock direction.. Outside result of biopsy:. Left breast 11 o’ clock: Intraductal prolifera­. tive lesion.. Left breast 3 o’ clock: Adenosis and fibrocys­. tic change.. Left breast 2 o’clock: Fibrocystic change.. No family history.. No comorbidities.. 5.2. " +750,Case 5,Courses of Treatment,HR(+) HER2(+) Breast Cancer,"5.1. . Courses of Treatment. Operation  +  Adjuvant chemotherapy (#4. cycles. of. docetaxel. and. cyclophospha­. mide). +. Post-operative. radiation. ther­. apy + Trastuzumab + Tamoxifen 20 mg/day.. 28. 5.3.1. . Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 1.5 cm (pT1c).. 2. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 3/3, 3/HPF).. S. Park et al.. 313. . ­. . 3. Intraductal component: present, intratu­. moral/extratumoral (20%) (nuclear grade:. high, necrosis: present, architectural pattern:. solid/comedo, extensive intraductal compo­. nent: present).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) superior margin: 10 mm,. . (b) inferior margin: (see note),. . (c) medial margin: 5 mm,. . (d) lateral margin: (see note),. . (e) deep margin: <1 mm from invasive duc­. tal carcinoma (slide 4),. . (f) superficial margin: 2 mm.. 6. Lymph nodes: no metastasis in one axillary. lymph node (pN0(sn)) (sentinel LN: 0/1).. 7. Arteriovenous invasion: absent.. 8. Lymphovascular. invasion:. present,. intratumoral.. 9. Tumor border: infiltrative.. . 10. Microcalcification:. present,. tumoral/. non-tumoral.. . 11. Pathological TN category (AJCC 2017):. pT1cN0(sn).. Note: 1. The inferior and lateral margins of the. lumpectomy specimen (slides 9 and 10, respec­. tively) are close to ductal carcinoma in situ. (<1 mm) but these margins submitted for frozen. diagnosis (Fro 3 and Fro 5, respectively) are free. of tumor.. Result. Intensity. Positive. %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Intermediate. (6/8). 3. 10%-. 1/3. C-erbB2. Equivocal (2+). Ki-67. Positive in 39%. of tumor cells. SISH. Positive. HR(+) HER2(+) Breast Cancer. 314. . . S. Park et al.. 315. a. b. . 6. " +758,Case 5,Important Radiologic,HR(+) HER2(+) Breast Cancer,Important Radiologic. Findings. 24 25 26. 27. 5.3.  +764,Case 5,Patient History,HR(+) HER2(+) Breast Cancer,"Patient History and Progress. Female/53 years old, peri-menopause.. Screen detected mass lesion on right breast 12. o’clock direction.. No family history.. Hypothyroidism, dyslipidemia, s/p cold knife. conization of cervix.. 5.2. " +751,Case 5,Courses of Treatment,HR(+) HER2(-) Breast Cancer,"Courses of Treatment. Operation. +. Adjuvant. chemotherapy. (#4  cycles of docetaxel & cyclophospha­. mide). +. Post-operative. radiation. ther­. apy + Letrozole 2.5 mg/day.. 5.3.1. . Operation (1st, Dec. 2020). Right breast conserving surgery, sentinel lymph. low, necrosis: present, architectural pattern:. micropapillary/cribriform/comedo,. exten­. sive intraductal component: absent).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) superior margin: (see note 2),. . (b) inferior margin: 5 mm,. . (c) medial margin: positive for invasive duc­. tal carcinoma (Fro 6),. . (d) lateral margin: (see note 3),. . (e) deep margin: positive for invasive ductal. carcinoma (slide 1),. . (f) superficial margin: 2 mm.. 1. <1%. C-erbB2. Negative (1+). Ki-67. Positive in 4% of tumor cells. . (a) metastasis in two out of three axillary. lymph nodes (pN1a(sn)) (sentinel LN:. 2/3),. . (b) perinodal extension: absent,. . (c) size of metastatic carcinoma: 2.5 mm.. 7. Arteriovenous invasion: absent.. 8. Lymphovascular. invasion:. present,. intratumoral.. 9. Tumor border: infiltrative.. . 10. Microcalcification:. present,. tumoral/. non-tumoral.. . 11. Pathological TN category (AJCC 2017):. pT2N1a(sn).. Note: 1. Micrometastasis is present in the. frozen section of Fro 2.. 2. The superior margin of the lumpectomy. specimen (slide 6) is close to invasive ductal. carcinoma (<1 mm) but this margin submit­. ted for frozen diagnosis (Fro 4) is free of. tumor.. 3. The lateral margin of the lumpectomy. specimen (slide 8) is close to invasive ductal. carcinoma (<1 mm) but this margin submit­. ted for frozen diagnosis (Fro 7) is free of. tumor.. Y. Kim et al.. nuclear pleomorphism: 2/3, mitotic count:. 1/3).. . 4. Intraductal component: absent.. . 5. Surgical margins: 9 mm.. . 6. Arteriovenous invasion: absent.. . 7. Lymphovascular. invasion:. present,. extratumoral.. . 8. Tumor border: infiltrative.. . 9. Microcalcification: present, non-tumoral.. HR(+) HER2(−) Breast Cancer. 188. 6. " +759,Case 5,Important Radiologic,HR(+) HER2(-) Breast Cancer,"Important Radiologic. Findings. See Figs. 20, 21, 22 and 23.. 5.3. " +765,Case 5,Patient History,HR(+) HER2(-) Breast Cancer,o’clock direction.. No family history.. No comorbidities.. 5.2.  +752,Case 5,Courses of Treatment,HR(−) HER2(+) Breast Cancer,"5.1. . Courses of Treatment. Operation + Post-operative radiation therapy.. 5.3.1. . Operation. 40. 5.3.2. . Pathology Report. . 1. Invasive ductal carcinoma.. . (a) Size of invasive component: 0.2  cm. (pT1a).. . (b) Size of intraductal component: 2.0 cm.. . (c) Histologic grade: 3/3 (tubule formation:. 3/3, nuclear pleomorphism: 3/3, mitotic. count: 2/3, 10/10HPF).. . (d) Intraductal component: present, intratu­. moral/extratumoral (99%) (nuclear grade:. high, necrosis: present, architectural pat­. tern: cribriform/solid/comedo, extensive. intraductal component: present).. . (e) Skin: no involvement of tumor.. . (f) Surgical margins:. • superior margin: 10 mm,. • inferior margin: 40 mm,. • medial margin: 15 mm,. • lateral margin: 15 mm,. • deep margin: 2 mm,. • superficial margin: 30 mm.. . (g) Lymph nodes: no metastasis in four axil­. lary lymph nodes (pN0(sn)) (sentinel LN:. 0/4).. . (h) Arteriovenous invasion: absent.. . (i) Lymphovascular invasion: absent.. . (j) Tumor border: infiltrative.. . (k) Microcalcification:. present,. ­. tumoral/. non-tumoral.. . (l) Pathological TN category (AJCC 2017):. pT1aN0(sn).. . 2. Intraductal papilloma.. . 3. Mucocele-like lesion.. Result. Intensity. Positive %. Estrogen. receptor. Negative. (0/8). 0. 0. Progesterone. receptor. Negative. (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in. 28% of tumor. cells. Y. Kwon et al.. 449. F. ig. 40" +760,Case 5,Important Radiologic,HR(−) HER2(+) Breast Cancer,Important Radiologic. Findings. 36 37 38. 39. Y. Kwon et al.. 447. . . . HR(−) HER2(+) Breast Cancer. 448. . 5.3.  +766,Case 5,Patient History,HR(−) HER2(+) Breast Cancer,"Patient History and Progress. Female/58 years old, post-menopause.. Screen detected mass lesion on upper inner. portion of left breast 8 o’clock.. No family history.. S/P myomectomy, dyslipidemia.. 5.2. " +753,Case 5,Courses of Treatment,HR(−) HER2(−) Breast Cancer,"5.1. . Courses of Treatment. Neoadjuvant chemotherapy (#4  cycles of. doxorubicin and cyclophosphamide + #4. cycles of docetaxel) + Operation + Post-. operative radiation therapy + Adjuvant. capecitabine (refuse).. 5.3.1. . Operation. 35. 5.3.2. . Pathology Report. Invasive Ductal Carcinoma. 1. Post-chemotherapy status.. 2. Size of tumor: 0.3 cm (ypT1a).. 3. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 2/3, 11/10HPF).. 4. Intraductal component: absent.. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) Superior margin: 13 mm.. . (b) Inferior margin: 11 mm.. . (c) Medial margin: 25 mm.. . (d) Lateral margin: 15 mm.. . (e) Deep margin: 5 mm.. . (f) Superficial margin: 6 mm.. 7. Lymph nodes: no metastasis in two axillary. lymph nodes (ypN0(sn)) (sentinel LN: 0/2).. 8. Arteriovenous invasion: absent.. 9. Lymphovascular invasion: absent.. . 10. Tumor border: infiltrative.. . 11. Microcalcification: present, non-tumoral.. . 12. Pathological TN category (AJCC 2017):. ypT1aN0(sn).. Result. Intensity. Positive. %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Negative (1+). Ki-67. Positive in 26%. of tumor cells. E. S. Lee et al.. 591. . . ­. . HR(−) HER2(−) Breast Cancer. 592. . ­. . E. S. Lee et al.. 593. 6. " +761,Case 5,Important Radiologic,HR(−) HER2(−) Breast Cancer,Important Radiologic. Findings. 27 28 29. 30. E. S. Lee et al.. 589. . . . HR(−) HER2(−) Breast Cancer. 590. . 5.2.1. . After Neoadjuvant. Chemotherapy. 31 32 33. 34. 5.3.  +767,Case 5,Patient History,HR(−) HER2(−) Breast Cancer,"Patient History and Progress. Female/57 years old, post-menopause.. Screen detected a mass lesion on left breast 9. o’clock direction.. Family history of breast cancer, sister and. niece.. Family history of ovarian cancer, mother.. S/P. Hysterectomy,. s/o. bilateral. salpingo-oophorectomy.. BRCA 1 mutation carrier.. 5.2. " +754,Case 5,Courses of Treatment,Local Recurrence,"5.1. . Courses of Treatment. Left breast IDC → Operation → Adjuvant ther­. apy → Right breast recurrence (IDC).. 5.2.1. . Primary Treatment. 30 31. 32. Operation. 33. Y. Kim et al.. 729. . ­. . . . Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 2.0 cm (pT1c).. 2. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count: 2/3). 3. Ductal carcinoma in situ: present, intratumoral/. extratumoral (30%) (nuclear grade: high, necro­. sis: present, architectural pattern: comedo,. extensive intraductal component: present).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) Superior margin: 10 mm.. . (b) Inferior margin: 30 mm.. . (c) Medial margin: 30 mm.. . (d) Lateral margin: 40 mm.. . (e) Deep margin: 2 mm.. 6. Lymph nodes: no metastasis in 4 axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/4).. 7. Vascular invasion: absent.. 8. Lymphatic invasion: present, intratumoral.. 9. Tumor border: infiltrative.. . 10. Microcalcification:. present,. tumoral/. non-tumoral.. . 11. Pathologic staging: pT1cN0(sn).. Result. Intensity. Positive %. Estrogen. receptor. Negative (0/7). 0. 0. Progesterone. receptor. Negative (0/7). 0. 0. C-erbB2. Negative (1+). Ki-67. Positive in 20%. of tumor cells. Local Recurrence. 730. Adjuvant Therapy. Adjuvant chemotherapy #6 cycles of fluorouracil. and doxorubicin and cyclophosphamide.. Postoperative radiation therapy.. 5.2.2. . Treatments After Recurrence. 34 35. 36. Operation. ­. 37. Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 0.8 cm (pT1b).. 2. Histologic grade: 2 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, <1/10HPF).. 3. Intraductal component: absent.. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) Superior margin: 30 mm.. . (b) Inferior margin: 40 mm.. . (c) Medial margin: 35 mm.. . (d) Lateral margin: 35 mm.. . (e) Deep margin: 16 mm.. . (f) Superficial margin: 20 mm.. 6. Lymph nodes: no metastasis in two axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/2).. 7. Arteriovenous invasion: absent.. 8. Lymphovascular invasion: absent.. 9. Tumor border: infiltrative.. . 10. Microcalcification: present, non-tumoral.. . 11. Pathologic stage (AJCC 2010): pT1bN0(sn).. Result. Intensity. Positive %. Estrogen. receptor. Negative (8/8). 3. >2/3. Progesterone. receptor. Negative (7/8). 2. >2/3. C-erbB2. Negative (0). Ki-67. Positive in 15%. of tumor cells. . . ­. . Y. Kim et al.. 731. a. b. . . ­. . Adjuvant Therapy. Postoperative radiation therapy.. Tamoxifen 20 mg/day for 5 years.. 6. " +768,Case 5,Patient History,Local Recurrence,"Patient History and Progress. Female/69 years old, post-menopause.. Screen detected mass lesion on left breast. . 2 o’clock direction.. No family history.. No other history of disease, operation, or. medication.. BRCA 1 VUS (variant of uncertain).. 5.2. " +755,Case 5,Courses of Treatment,Metastatic Breast Cancer,"Courses of Treatment. Left breast cancer → Neoadjuvant chemother­. apy → Operation → Adjuvant therapy → Lung. and liver metastasis.. 5.2.1. . Primary Treatment. Jun. 2015 breast, left, needle biopsy:. Invasive ductal carcinoma, histologic grade 2. with apocrine differentiation.. Result. Intensity. Positive %. Estrogen. receptor. Negative. (0/8). 0. 0. Progesterone. receptor. Negative. (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in. 24% of tumor. cells. See Figs. 15 and 16.. Neoadjuvant Chemotherapy. Neoadjuvant. chemotherapy. #8. cycles. (Adriamycin. +. Cyclophosphamide. #4. →. Docetaxel #4).. Operation. Dec. 2015 Left breast conserving surgery, senti­. nel lymph node biopsy.. Pathology: Invasive ductal carcinoma, stage. ypT1cN1mi (sn).. Size of tumor: 1.5 cm, lymph node: 1/3, size. of metastatic carcinoma: 1.8 mm.. Result. Intensity. Positive %. Estrogen. receptor. Intermediate. (5/8). 2. 10%–1/3. Progesterone. receptor. Negative. (0/8). 0. 0. C-erbB2. Negative. (1+). Ki-67. Positive in. 2% of tumor. cells. Adjuvant Therapy. Post-operative radiation therapy + Letrozole. 2.5 mg/day for 4.9 years.. Metastatic Breast Cancer. 870. 5.2.2. . Treatments After Recurrence. Lung and Liver Metastasis. Nov. 2020 CT chest: metastasis to lung, liver.. Liver biopsy: Metastatic ductal cancer.. Result. Intensity. Positive %. Estrogen. receptor. Negative. (0/8). 0. 0. Progesterone. receptor. Negative. (0/8). 0. 0. Result. Intensity. Positive %. C-erbB2. Positive. (3+). Ki-67. N.A.. Palliative Therapy (Enrolled in Clinical Trial). → Clinical trial enrolled (ZW25 + Docetaxel #6. cycles → ZW25 ~)." +769,Case 5,Patient History,Metastatic Breast Cancer,5.2.  +770,Case 50,Courses of Treatment,Local Recurrence,"50.1. . Courses of Treatment. Right breast IDC → Operation → Adjuvant. therapy → Right breast recurrence (IDC).. Primary Treatment. 334 335. 336. Operation. 337. 338. Pathology Report. . . 1. Invasive Ductal Carcinoma. . (a) Size of tumor: 1.8 cm (pT1c).. . (b) Histologic grade: 2/3 (tubule formation:. 2/3, nuclear pleomorphism: 2/3, mitotic. count: 2/3, 10/10HPF).. . (c) Intraductal component: present, intratu­. moral/extratumoral (30%) (nuclear grade:. low,. necrosis:. absent,. architectural. ­. pattern: solid, extensive intraductal com­. ponent: present).. . (d) Surgical margins:. • Deep margin: 3 mm.. • Superficial margin: 10 mm.. . (e) Lymph nodes: no metastasis in one axillary. lymph node (pN0(sn)) (sentinel LN: 0/1).. . (f) Arteriovenous invasion: absent.. . (g) Lymphovascular invasion: absent.. . (h) Tumor border: infiltrative.. . (i) Microcalcification: present, non-tumoral.. . (j) Pathologic. stage. (AJCC. 2010):. pT1cN0(sn).. . 2. Intraductal Papilloma with usual ductal. hyperplasia.. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (0). Ki-67. Positive in 23.8%. of tumor cells. . Intraductal papilloma with usual ductal. hyperplasia.. Adjuvant Therapy. Letrozole 2.5 mg/day for 2.8 years.. Treatments After Recurrence. 339. 340. Operation. 341. Y. Kim et al.. 857. . . ­. . Local Recurrence. 858. . a. b. . Y. Kim et al.. 859. Pathology Report. Invasive. Ductal. Carcinoma,. clinically. recurrent. 1. Post-nipple-sparing mastectomy status.. 2. Size of tumor: 1.1 cm (rpT1c).. 3. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 6/10HPF).. 4. Intraductal component: absent.. 5. Skin: dermal involvement of tumor.. 6. Nipple: no involvement of tumor.. 7. Surgical margins:. . (a) Superior margin: 10 mm.. . (b) Inferior margin: 10 mm.. . (c) Medial margin: 10 mm.. . (d) Lateral margin: 80 mm.. . (e) Deep margin: 2 mm.. . (f) Superficial margin: 2 mm.. 8. Lymph nodes: no metastasis in one axillary. lymph node (rpN0(sn)) (sentinel LN: 0/1).. 9. Arteriovenous invasion: absent.. . 10. Lymphovascular. invasion:. present,. intratumoral.. . 11. Tumor border: infiltrative.. . . . Local Recurrence. 860. . 12. Microcalcification:. present,. tumoral/. non-tumoral.. . 13. Pathological TN category (AJCC 2017):. rpT1cN0(sn).. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Equivocal (2+). (SISH negative). Ki-67. Positive in 31%. of tumor cells. Adjuvant Therapy. Exemestane 25 mg/day.. Y. Kim et al.. 861. © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023. E. S. Lee (ed.), A Practical Guide to Breast Cancer Treatment,. https://doi.org/10.1007/978-981-19-9044-1_10" +772,Case 50,Patient History,Local Recurrence,"Patient History and Progress. Female/72 years old, post-menopause.. Screen detected mass lesion on right breast 12. o’clock and 8 o’clock direction, left breast 12. o’clock direction.. No family history.. Hypertension, hepatitis B virus carrier,. claustrophobia.. 50.2. " +771,Case 50,Courses of Treatment,Metastatic Breast Cancer,"50.1. . Courses of Treatment. Left breast cancer with lung metastasis →. Palliative therapy.. See Figs. 150 and 151.. Left invasive ductal carcinoma, stage IV. (metastasis. in. ovary,. s/p. bilateral. salpingo-oophorectomy).. Result. Intensity Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Weak (3/8). 1. 1–10%. C-erbB2. Negative (1+). Ki-67. Positive in. 52% of tumor. cells. Palliative therapy: Letrozole & Palbociclib. #11.. Jan. 2021 Left breast conserving surgery.. Pathology: Invasive ductal carcinoma, stage. ypT2N1a.. Size of tumor: 2.5  cm, lymph node: 1/7. (6 mm).. Result. Intensity Positive %. Estrogen. receptor. Negative. (02/8). 1. <1%. Progesterone. receptor. Negative. (2/8). 1. <1%. C-erbB2. Negative. (0). Ki-67. Positive in. 59% of. tumor cells. Palliative chemotherapy # 4 cycles (Docetaxel. & cyclophosphamide #4).. Post-operative radiation to left breast & sub­. clavicular lymph node + Tamoxifen 20 mg/day. • Breast cancer treatment is highly affected by. the patient’s status of illness, overall health,. and socioeconomic condition, but it is also. influenced by the insurance policy of the soci­. ety to which the patient belongs and the politi­. cal and economic situation of the country.. • South Korea receives a relatively high-level,. guideline-compliant treatment because the. entire population is under the national health. insurance system, but there is a slight gap in. E. S. Lee (*). Center for Breast Cancer, National Cancer Center,. Goyang, Kyonggi-do, Republic of Korea. e-mail: eslee@ncc.re.kr. . 942. the immediate adoption of newly developed. therapeutics such as immune checkpoint. inhibitors, antibody-drug conjugate, and many. other agents.. • For primary breast cancers, most patients are. treated well according to the guidelines, but. there is still a shortage in patients with meta­. static cancer.. • Fortunately, we are actively involved in many. global clinical trials and patients who have. metastasis and are heavily treated are benefit­. ing from many new treatments, but globally,. the health disparity is clearly an ongoing. problem.. E. S. Lee. " +773,Case 50,Patient History,Metastatic Breast Cancer,"Patient History and Progress. Female/47 years old, post-menopause.. No family history.. S/p bilateral salpingo-oophorectomy, diabetes. mellitus.. 50.2. " +774,Case 6,Courses of Treatment,Benign and Proliferative,"6.1. . Courses of Treatment. → 2021-12-31 excision, both.. Benign and Proliferative Case Series. 24. . . 6.3.1. . Pathology Report. • Breast, right, excision:. –. – Intraductal papilloma with (1) usual ductal. hyperplasia, (2) microcalcification.. • Breast, left, excision:. –. – Intraductal papilloma with (1) usual ductal. hyperplasia, (2) microcalcification.. 7. " +782,Case 6,Important Radiologic,Benign and Proliferative,Important Radiologic. Findings. 9. 10. 6.3.  +788,Case 6,Patient History,Benign and Proliferative,"Patient History and Progress. Female/48 years old, pre-menopause.. Bloody discharge from right nipple.. No family history.. Hypertension.. 6.2. " +775,Case 6,Courses of Treatment,Carcinoma In Situ,"6.1. . Courses of Treatment. Operation + Tamoxifen 20 mg/day for 5 years.. E. S. Lee et al.. 65. 6.3.1. . Operation. 28. 29. 6.3.2. . Pathology Report. . Ductal carcinoma in situ, pathological TN cat­. egory (AJCC 2017): pTis. . 1. Size of tumor: 0.3 cm (pTis).. . 2. Nuclear grade: low.. . 3. Necrosis: absent.. . 4. Architectural. pattern:. micropapillary/. cribriform.. . 5. Skin: no involvement of tumor.. . 6. Surgical margins: positive.. . 7. Microcalcification:. present,. tumoral/non-. tumoral.. Result. Intensity Positive %. Estrogen. receptor. Strong (7/8). 3. 1/3–2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Equivocal (2+). Ki-67. Positive in 2%. of tumor cells. . No residual tumor with foreign body reaction.. . 1. Post-excision status.. . ­. . Carcinoma In Situ. 66. . . ­. 7. " +783,Case 6,Important Radiologic,Carcinoma In Situ,Important Radiologic. Findings. 27. 6.3.  +789,Case 6,Patient History,Carcinoma In Situ,"Patient History and Progress. Female/42 years old, pre-menopause.. Screen detected microcalcification on left. breast upper outer.. No family history.. s/p Lt mammotome biopsy in 2018 (result:. benign).. 6.2. " +776,Case 6,Courses of Treatment,HR(+) HER2(+) Breast Cancer,"6.1. . Courses of Treatment. Operation  +  Adjuvant chemotherapy (#4. cycles of doxorubicin and cyclophospha­. mide). +. Post-operative. radiation. ther­. apy + Trastuzumab + Tamoxifen 20 mg/day.. 35. 6.3.1. . Pathology Report. . 1. Invasive ductal carcinoma.. . (a) Size of tumor: 1.5 cm (pT1c).. . (b) Histologic grade: 3/3 (tubule formation:. 3/3, nuclear pleomorphism: 3/3, mitotic. count: 3/3, 5/HPF).. HR(+) HER2(+) Breast Cancer. 316. . . . (c) Intraductal component: present, intratu­. moral/extratumoral (10%) (nuclear grade:. high, necrosis: present, architectural pat­. tern: solid/comedo, extensive intraductal. component: absent).. . (d) Skin: no involvement of tumor.. . (e) Surgical margins:. • superior margin: 10 mm,. • inferior margin: 10 mm,. • medial margin: 20 mm,. • lateral margin: 10 mm,. • deep margin: 2 mm,. • superficial margin: 2 mm.. . (f) Lymph nodes: no metastasis in seven. axillary lymph nodes (pN0) (sentinel LN:. 0/4, non-sentinel LN: 0/3).. . (g) Arteriovenous invasion: absent.. . (h) Lymphovascular invasion: absent.. . (i) Tumor border: infiltrative.. . (j) Microcalcification:. present,. tumoral/. non-tumoral.. . (k) Pathological TN category (AJCC 2017):. pT1cN0.. . 2. Intraductal papilloma with (1) myoepithelial. hyperplasia usual ductal hyperplasia.. Result. Intensity. Positive. %. Estrogen. receptor. Strong (7/8). 3. 1/3-2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Positive (3+). Ki-67. Positive in 52%. of tumor cells. S. Park et al.. 317. . F. ig. 32. . S. Park et al.. 319. a. b. . 7. " +784,Case 6,Important Radiologic,HR(+) HER2(+) Breast Cancer,Important Radiologic. Findings. 29 30 31 32 33. 34. 6.3.  +790,Case 6,Patient History,HR(+) HER2(+) Breast Cancer,"Patient History and Progress. Female/42 years old, pre-menopause.. Screen detected mass lesion on right breast 12. o’clock direction.. No family history.. Hypertension.. 6.2. " +777,Case 6,Courses of Treatment,HR(+) HER2(-) Breast Cancer,"6.1. . Courses of Treatment. Operation  +  Post-operative radiation ther­. apy + Tamoxifen 20 mg/day.. 6.3.1. . Operation. Right breast conserving surgery, sentinel lymph. moral/extratumoral (60%) (nuclear grade:. low, necrosis: present, architectural pattern:. solid/comedo, extensive intraductal compo­. nent: present).. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) superior margin: 5 mm,. . (b) inferior margin: 5 mm,. . (c) medial margin: 5 mm,. . (d) lateral margin: 5 mm,. . (e) deep margin: 2 mm,. . (f) superficial margin: 1  mm from ductal. carcinoma in situ (slide 12).. 9. Lymphovascular. invasion:. present,. intratumoral.. . 10. Tumor border: infiltrative.. . 11. Microcalcification:. present,. tumoral/. non-tumoral.. . 12. Pathological TN category (AJCC 2017):. pT1cN1a(sn).. Result. Intensity. Positive %. Estrogen receptor. Intermediate (6/8). 2. 1/3–2/3. Progesterone receptor. Intermediate (6/8). 2. 1/3–2/3. C-erbB2. Negative (1+). Ki-67. Positive in 8% of tumor cells. HR(+) HER2(−) Breast Cancer" +785,Case 6,Important Radiologic,HR(+) HER2(-) Breast Cancer,"Important Radiologic. Findings. See Figs. 26, 27, 28 and 29.. 6.3. " +791,Case 6,Patient History,HR(+) HER2(-) Breast Cancer,"Patient History and Progress. Female/51 years old, pre-menopause.. Screen detected mass lesion on right breast 2. o’clock direction.. No family history.. S/P Thyroid benign mass, excision.. 6.2. " +778,Case 6,Courses of Treatment,HR(−) HER2(+) Breast Cancer,"Courses of Treatment. Neoadjuvant. chemotherapy. (#1. cycle. of. docetaxel and carboplatin and #6 cycles of trastu­. zumab and pertuzumab)  +  Operation  +  Post-­. operative radiation therapy  +  Trastuzumab  +. Letrozole 2.5 mg.. 6.4.1. . Operation. 47. 6.4.2. . Pathology Report. . 1. No residual tumor with stromal degeneration.. . (a) Post-chemotherapy status.. a. b. . Y. Kwon et al.. 453. . (b) Lymph nodes: no metastasis in ten axil­. lary lymph nodes (ypN0) (sentinel LN:. 0/3, axillary LN: 0/7).. . 2. Atypical ductal hyperplasia, focal with. microcalcification.. Result. Intensity. Positive %. Estrogen. receptor. Negative. (0/8). 0. 0. Progesterone. receptor. Negative. (0/8). 2. 0. C-erbB2. Positive (3+). Ki-67. Positive in. 22% of. tumor cells. 7. " +786,Case 6,Important Radiologic,HR(−) HER2(+) Breast Cancer,Important Radiologic. Findings. 41 42. 43. HR(−) HER2(+) Breast Cancer. . Y. Kwon et al.. 451. 6.3. . After Neoadjuvant. Chemotherapy. 44 45. . HR(−) HER2(+) Breast Cancer. 452. 6.4.  +792,Case 6,Patient History,HR(−) HER2(+) Breast Cancer,"S/P. cholecystectomy,. hypertension,. dyslipidemia.. BRCA 1 and 2 mutation: Not detected.. 6.2. " +779,Case 6,Courses of Treatment,HR(−) HER2(−) Breast Cancer,"6.1. . Courses of Treatment. Neoadjuvant chemotherapy (#4  cycles of. doxorubicin and cyclophosphamide  +  #4. cycles of docetaxel)  +  Operation  +  Post-. operative radiation therapy  +  Letrozole. 2.5 mg + Adjuvant capecitabine.. 6.3.1. . Operation. 43. . E. S. Lee et al.. 597. . 6.3.2. . Pathology Report. Ductal Carcinoma In Situ associated with. fibroadenoma. 1. Post-chemotherapy status.. 2. Size of tumor: 3.0 cm and 2.2 cm (ypTis).. 3. Nuclear grade: high.. 4. Necrosis: present.. 5. Architectural pattern: cribriform/comedo.. 6. Nipple: involvement of lactiferous duct.. 7. Skin: no involvement of tumor.. 8. Surgical margins:. . (a) Superior margin: 80 mm.. . (b) Inferior margin: 80 mm.. . (c) Medial margin: 60 mm.. . (d) Lateral margin: 40 mm.. . (e) Deep margin: 3 mm.. . (f) Superficial margin: 10 mm.. 9. Lymph nodes:. . (a) Metastasis in three out of five axillary lymph. nodes (ypN1a(sn)) (axillary LN: 3/5),. . (b) Perinodal extension: present,. . (c) Size of metastatic carcinoma: 4 mm.. . 10. Microcalcification:. present,. tumoral/. non-tumoral.. . 11. Pathological TN category (AJCC 2017):. ypTisN1a(sn).. Result. Intensity. Positive. %. Estrogen. receptor. Negative (2/8). 1. <1%. Progesterone. receptor. Negative (2/8). 1. 0. C-erbB2. Negative. (1+)-metastasis. Equivocal (2+)-in. situ. Ki-67. Positive in 46%. of tumor cells. 7. " +787,Case 6,Important Radiologic,HR(−) HER2(−) Breast Cancer,Important Radiologic. Findings. 36 37 38. 39. . HR(−) HER2(−) Breast Cancer. 594. . . . E. S. Lee et al.. 595. . ­. . . 6.2.1. . After Neoadjuvant. Chemotherapy. 40 41. 42. HR(−) HER2(−) Breast Cancer. 596. 6.3.  +793,Case 6,Patient History,HR(−) HER2(−) Breast Cancer,"Patient History and Progress. Female/49 years old, pre-menopause.. Self-detected palpable mass lesion on left. breast.. No family history.. Panic disorder, lumbar spine disc.. 6.2. " +780,Case 6,Courses of Treatment,Local Recurrence,"6.1. . Courses of Treatment. Both breasts IDC→ Operation → Adjuvant. therapy → Left breast recurrence (IDC).. 6.2.1. . Primary Treatment. 38 39 40 41 42. 43. Operation. ­. 44. 45. Local Recurrence. 732. . . ­. . . . ­. Pathology Report. . Invasive Ductal Carcinoma. 1. Size of tumor: 1.2 cm (pT1c).. 2. Histologic grade: 1/3 (tubule formation: 2/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 6/10HPF).. Y. Kim et al.. 733. a. b. . 3. Intraductal component: present, intratu­. moral/extratumoral (40%) (nuclear grade:. low, necrosis: present, architectural pattern:. micropapillary, cribriform, and comedo,. extensive intraductal component: present).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) Superior margin: 5 mm.. . (b) Inferior margin: 4 mm from ductal carci­. noma in situ (slide 2).. . (c) Medial margin: 10 mm.. . (d) Lateral margin: 10 mm.. . (e) Deep margin: 2 mm.. 6. Lymph nodes: no metastasis in 2 axillary. lymph nodes (pN0) (sentinel LN: 0/2).. 7. Vascular invasion: absent.. 8. Lymphatic invasion: present, intratumoral.. 9. Tumor border: infiltrative.. . 10. Microcalcification:. present,. tumoral/. non-tumoral.. . 11. Pathologic stage (AJCC 2010): pT1cN0(sn).. Result. Intensity. Positive %. Estrogen. receptor. Strong (7/7). 3. >2/3. Progesterone. receptor. Strong (7/7). 3. >2/3. C-erbB2. Negative (1+). Ki-67. Positive in 20%. of tumor cells. . Invasive Ductal Carcinoma. 1. Size of invasive carcinoma: 0.3 cm (pT1a).. 2. Size of intraductal carcinoma: 3.0 cm.. 3. Histologic grade: 1/3 (tubule formation: 2/3,. nuclear pleomorphism: 1/3, mitotic count:. 1/3, 5/10HPF).. 4. Intraductal component: present, intratu­. moral/extratumoral (90%) (nuclear grade:. low, necrosis: absent, architectural pattern:. papillary and cribriform, extensive intra­. ductal component: present).. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) Superior margin: 20 mm.. . (b) Inferior margin: 15 mm.. . (c) Medial margin: Positive for ductal carci­. noma in situ (Fro 3).. . (d) Lateral margin: 10 mm.. . (e) Deep margin: 2 mm.. 7. Vascular invasion: absent.. 8. Lymphatic invasion: present, intratumoral.. 9. Tumor border: infiltrative.. . 10. Microcalcification:. present,. tumoral/. non-tumoral.. . 11. Pathologic stage (AJCC 2010): pT1a.. Result. Intensity. Positive %. Estrogen. receptor. Strong (7/7). 3. >2/3. Progesterone. receptor. Strong (7/7). 3. >2/3. C-erbB2. Negative (1+). Ki-67. Positive in 5%. of tumor cells. Operation. 46. Local Recurrence. 734. . . . . Pathology Report. No residual tumor with foreign body reaction.. . 1. Post-lumpectomy status.. . 2. No metastasis in 1 lymph node (pN0(sn)) (left. sentinel LN: 0/1).. Adjuvant Therapy. Postoperative radiation therapy.. Tamoxifen 20 mg/day for 5 years.. 6.2.2. . Treatments After Recurrence. 47 48. 49. Operation. ­. 50. Pathology Report. Invasive Ductal Carcinoma associated with. papillary carcinoma in situ. 1. Post-lumpectomy status.. 2. Size of tumor: 0.6 cm (rpT1b).. 3. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 6/10HPF).. 4. Intraductal component: present, intratu­. moral/extratumoral (30%) (nuclear grade:. low, necrosis: absent, architectural pattern:. papillary/cribriform, extensive intraductal. component: absent).. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) Superior margin: 5 mm.. . (b) Inferior margin: 10 mm.. Y. Kim et al.. 735. a. b. . . (c) Medial margin: (see note 2).. . (d) Lateral margin: 10 mm.. . (e) Deep margin: 2 mm.. . (f) Superficial margin: 2 mm.. 7. Arteriovenous invasion: absent.. 8. Lymphovascular invasion: absent.. 9. Tumor border: infiltrative.. . 10. Microcalcification:. present,. tumoral/. non-tumoral.. . 11. Pathological TN category (AJCC 2017):. rpT1b.. Note: 1. Invasive ductal carcinoma is present. only in the permanent section of Fro 4.. 2. The medial margin of the lumpectomy. specimen (slide 9) is close to invasive ductal car­. cinoma (1  mm), but this margin submitted for. frozen diagnosis (Fro 3) is free of tumor.. Result. Intensity Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. 1/3–2/3. C-erbB2. Negative. (1+) (IDC). Equivocal. (2+) (DCIS). Ki-67. Positive in 1%. of tumor cells. Operation. Second Operation (Apr. 2022) Left sentinel. lymph node biopsy.. Pathology Report. No metastasis in two axillary lymph nodes (sen­. tinel LN: 0/1, non-sentinel LN: 0/1).. . 1. Post-lumpectomy status.. Adjuvant Therapy. Letrozole 2.5 mg/day for 5 years.. 7. " +794,Case 6,Patient History,Local Recurrence,"Patient History and Progress. Female/60 years old, post-menopause.. Bloody nipple discharge on left breast.. Screen detected mass lesion on right breast 6. o’clock direction and left breast 12 o’clock. direction.. No family history.. Hypertension.. 6.2. " +781,Case 6,Courses of Treatment,Metastatic Breast Cancer,"Courses of Treatment. Right breast cancer → Neoadjuvant chemother­. apy → Operation → Adjuvant therapy →. Ipsilateral breast and chest wall recurrence →. Palliative therapy → Progression on the skin. and contralateral axillary lymph nodes.. 6.2.1. . Primary Treatment. Aug. 2017 breast, left, needle biopsy:. Invasive ductal carcinoma, histologic grade 2.. Result. Intensity. Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in. 35% of tumor. cells. Clinical stage: cT3N1M0.. See Figs. 20 and 21.. Neoadjuvant Chemotherapy. Neoadjuvant chemotherapy #6 cycles (Docetaxel. & Carboplatin & Trastuzumab & Pertuzumab).. Operation. Jan. 2018 Right breast conserving surgery, senti­. nel lymph node biopsy.. Pathology: Invasive ductal carcinoma, stage. ypT1aN1mi (sn).. Size of tumor: 0.2 cm, lymph node: 1/1, size. of metastatic carcinoma: 2 mm.. Result. Intensity. Positive %. Estrogen. receptor. Negative. (0/8). 0. 0. Progesterone. receptor. Negative. (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in. 21% of. tumor cells. Adjuvant Therapy. Post-operative radiation therapy + Trastuzumab. for 1 year.. 6.2.2. . Treatments After Recurrence. Ipsilateral breast and chest wall recurrence →. Progression on the skin and contralateral axillary. lymph nodes.. Intensity. Positive %. Estrogen. receptor. Negative. (0/8). 0. 0. Progesterone. receptor. Negative. (0/8). 0. 0. C-erbB2. Positive. (3+). Ki-67. Positive in. 40% of. tumor cells. Palliative Therapy. Clinical trial enrolled (ZW25 #20 cycles +. Docetaxel #6 cycles): Progressive disease on. skin, axillary lymph node.. → Docetaxel & Trastuzumab & Pertuzumab. #6: Progressive disease.. → Trastuzumab emtansine ~" +795,Case 6,Patient History,Metastatic Breast Cancer,6.2.  +796,Case 7,Courses of Treatment,Benign and Proliferative,"7.1. . Courses of Treatment. →2021-10-29 Rt upper, stereotactic biopsy.. 7.3.1. . Pathology Report. Diagnosis. • Breast, right upper, stereotactic biopsy:. –. – Atypical ductal hyperplasia (#1. Ca++). with microcalcification.. –. – Flat epithelial atypia (#2. no Ca++) with. microcalcification.. →2021-11-26 excision, Rt.. Diagnosis. • Breast, right, excision:. –. – Atypical. ductal. hyperplasia. with. microcalcification.. Post-stereotactic biopsy status.. C. W. Lee et al.. 25. . 8. " +804,Case 7,Important Radiologic,Benign and Proliferative,Important Radiologic. Findings. 11. 7.3.  +810,Case 7,Patient History,Benign and Proliferative,"Patient History and Progress. Female/58 years old, post-menopause.. Screen detected microcalcification on upper. portion of right breast.. No family history.. No comorbidities.. 7.2. " +797,Case 7,Courses of Treatment,Carcinoma In Situ,"7.1. . Courses of Treatment. Operation + Postoperative radiation therapy +. Tamoxifen 20 mg/day for 5 years.. 7.3.1. . Operation. 32. 33. 7.3.2. . Pathology Report. Ductal carcinoma in situ. . 1. Post-mammotome excision status.. . 2. Size of tumor: 0.3 cm, residual.. . . . Carcinoma In Situ. 68. . 3. Nuclear grade: low.. . 4. Necrosis: absent.. . 5. Architectural pattern: papillary/cribriform.. . 6. Skin: no involvement of tumor.. . 7. Surgical margins:. . (a) superior margin: 10 mm,. . (b) inferior margin: 10 mm,. . (c) medial margin: 5 mm,. . (d) lateral margin: 15 mm,. . (e) deep margin: 2 mm,. . (f) superficial margin: 2 mm.. . 8. Lymph nodes: no metastasis in one axillary. lymph node (pN0(sn)) (sentinel LN: 0/1).. . 9. Microcalcification:. present,. tumoral/. non-tumoral.. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (1+). Ki-67. Positive in. <1% of. tumor cells. 8. " +805,Case 7,Important Radiologic,Carcinoma In Situ,Important Radiologic. Findings. 30. 31. E. S. Lee et al.. 67. 7.3.  +811,Case 7,Patient History,Carcinoma In Situ,"Patient History and Progress. Female/48 years old, pre-menopause.. Screen detected mass lesion on right breast 1. and 9 o’clock direction.. Outside result of mammotome excision:. Right breast 1 o’clock, DCIS.. Right breast 9 o’clock, intraductal papilloma. with atypical ductal hyperplasia.. No family history.. No comorbidities.. 7.2. " +798,Case 7,Courses of Treatment,HR(+) HER2(+) Breast Cancer,"7.1. . Courses of Treatment. Neoadjuvant chemotherapy (#6 cycles of. docetaxel and carboplatin and trastuzumab. and pertuzumab)  +  Operation  +  Post-­. operative radiation therapy  +  Trastuzumab. emtansine + Tamoxifen 20 mg/day.. 42. 7.3.1. . Pathology Report. Invasive Ductal Carcinoma. 1. Post-chemotherapy status.. 2. Size of tumor: 1.1 cm (ypT1c).. 3. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 6/10 HPF).. HR(+) HER2(+) Breast Cancer. 320. . ­. . 4. Intraductal component: present, intratu­. moral/extratumoral (30%) (nuclear grade:. high, necrosis: absent, architectural pattern:. solid, extensive intraductal component:. present).. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) superior margin: 10 mm,. . (b) inferior margin: (see note),. . (c) medial margin: 10 mm,. . (d) lateral margin: 5 mm,. . (e) deep margin: 2 mm,. . (f) superficial margin: 2 mm.. 7. Lymph nodes: no metastasis in 13 axillary. lymph nodes (ypN0) (sentinel LN: 0/3, axil­. lary LN: 0/10).. 8. Arteriovenous invasion: absent.. 9. Lymphovascular. invasion:. present,. intratumoral.. . 10. Tumor border: infiltrative.. . 11. Microcalcification:. present,. tumoral/. non-tumoral.. . 12. Pathological TN category (AJCC 2017):. ypT1cN0.. Note: 1. The inferior margin of the lumpec­. tomy specimen (slide 7) is close to ductal carci­. noma in situ (<1 mm) but this margin submitted. for frozen diagnosis (Fro 2) is free of tumor.. Result. Intensity. Positive. %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Positive (3+). Ki-67. Positive in 6% of. tumor cells. S. Park et al.. 321. . . HR(+) HER2(+) Breast Cancer. 322. F. ig. 40. 323. a. b. . 8. " +806,Case 7,Important Radiologic,HR(+) HER2(+) Breast Cancer,Important Radiologic. Findings. 36 37 38 39 40. 41. 7.3.  +812,Case 7,Patient History,HR(+) HER2(+) Breast Cancer,"Patient History and Progress. Female/50 years old, pre-menopause.. Screen detected mass lesion on left breast 3. o’clock direction.. No family history.. Paroxysmal supraventricular tachycardia, s/p. atrial septal defect closure.. S/P thyroid lobectomy (thyroid cancer).. 7.2. " +799,Case 7,Courses of Treatment,HR(+) HER2(-) Breast Cancer,"Courses of Treatment. Operation  +  Post-operative radiation ther­. apy + Tamoxifen 20 mg/day.. 7.3.1. . Operation. Left breast conserving surgery, sentinel lymph. (a) superior margin: 10 mm,. . (b) inferior margin: (see note),. . (c) medial margin: 10 mm,. . (d) lateral margin: 5 mm,. . (e) deep margin: <1 mm from ductal carci­. noma in situ (slide 9),. . (f) superficial margin: 2 mm.. 7. Lymph nodes: no metastasis in six axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/2,. non-sentinel LN: 0/4).. 8. Arteriovenous invasion: absent.. 9. Lymphovascular. invasion:. present,. intratumoral.. . 10. Tumor border: infiltrative.. . 11. Microcalcification:. present,. tumoral/. non-tumoral.. . 12. Pathological TN category (AJCC 2017):. pT1cN0(sn).. Note: 1. The inferior margin of the. lumpectomy specimen (slide 2) is close to. ductal carcinoma in situ (3 mm) but this mar­. gin submitted for frozen diagnosis (Fro 2) is. free of tumor.. Result. Intensity. Positive %. Estrogen receptor. Strong (7/8). 2. >2/3. Progesterone receptor. Intermediate (6/8). 2. 1/3–2/3. C-erbB2. Negative (1+). Ki-67. Positive in 5% of tumor cells. HR(+) HER2(−) Breast Cancer" +807,Case 7,Important Radiologic,HR(+) HER2(-) Breast Cancer,"Important Radiologic. Findings. See Figs. 31, 32, 32, 33, 34 and 35.. 7.3. " +813,Case 7,Patient History,HR(+) HER2(-) Breast Cancer,Depression.. 7.2.  +800,Case 7,Courses of Treatment,HR(−) HER2(+) Breast Cancer,"7.1. . Neoadjuvant chemotherapy (#6 cycles of. docetaxel and carboplatin and trastuzumab and. pertuzumab) + Operation + Post-operative radia­. tion therapy.. 7.4.1. . Operation. 53. 7.4.2. . Pathology Report. No residual tumor with stromal degeneration.. . 1. Post-chemotherapy status.. . 2. Lymph nodes: no metastasis in two axillary. lymph nodes (ypN0(sn)) (sentinel LN: 0/2,. non-sentinel LN: 0/0).. Result. Intensity. Positive %. Estrogen. receptor. Negative (2/8). 1. <1%. Progesterone. receptor. Negative (2/8). 1. <1%. C-erbB2. Positive (3+). Ki-67. Positive in. 16% of tumor. cells. . HR(−) HER2(+) Breast Cancer. 456. 8. " +808,Case 7,Important Radiologic,HR(−) HER2(+) Breast Cancer,Important Radiologic. Findings. 48. 49. . . HR(−) HER2(+) Breast Cancer. 454. 7.3. . After Neoadjuvant. Chemotherapy. 50 51. 52. +814,Case 7,Patient History,HR(−) HER2(+) Breast Cancer,"Patient History and Progress. Female/58 years old, post-menopause.. Screen detected mass lesion on upper outer. portion of left breast.. No family history.. S/P Nodules of vocal cord, operation.. 7.2. " +801,Case 7,Courses of Treatment,HR(−) HER2(−) Breast Cancer,"7.1. . Courses of Treatment. Neoadjuvant chemotherapy (#4  cycles of. doxorubicin and cyclophosphamide  +  #4. cycles of docetaxel)  +  Operation  +  Post-. operative radiation therapy  +  Adjuvant. capecitabine.. 7.3.1. . Operation. 51. 7.3.2. . Pathology Report. Metaplastic Carcinoma with sarcomatous. differentiation. 1. Post-chemotherapy status.. E. S. Lee et al.. 599. . . . HR(−) HER2(−) Breast Cancer. 600. . ­. . E. S. Lee et al.. 601. 2. Size of tumor: 4.2 cm (ypT2).. 3. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 3/3, 22/10HPF).. 4. Intraductal component: present, intratumoral. (<5%) (nuclear grade: high, necrosis: pres­. ent, architectural pattern: comedo, extensive. intraductal component: absent).. 5. Skin and nipple: no involvement of tumor.. 6. Surgical margins:. . (a) Deep margin: positive for metaplastic. carcinoma (slides 3 and 5).. . (b) Superficial margin: 11 mm.. 7. Lymph nodes: no metastasis in four axillary. lymph nodes (ypN0(sn)) (sentinel LN: 0/3,. non-sentinel LN: 0/1).. 8. Arteriovenous invasion: absent.. 9. Lymphovascular. invasion:. present,. intratumoral.. . 10. Tumor border: infiltrative.. . 11. Microcalcification: present, non-tumoral.. . 12. Pathological TN category (AJCC 2017):. ypT2N0(sn).. Result. Intensity. Positive. %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Negative (0). Ki-67. Positive in 57%. of tumor cells. Lung metastasis.. Palliative chemotherapy (abraxane and. atezolizumab → gemcitabine and cisplatin).. 8. " +809,Case 7,Important Radiologic,HR(−) HER2(−) Breast Cancer,Important Radiologic. Findings. 44 45. 46. HR(−) HER2(−) Breast Cancer. 598. . . ­. 7.2.1. . After Neoadjuvant. Chemotherapy. 47 48 49. 50. 7.3.  +815,Case 7,Patient History,HR(−) HER2(−) Breast Cancer,"Patient History and Progress. Female/56 years old, post-menopause.. Self-detected palpable mass lesion on right. breast.. No family history.. No comorbidities.. BRCA 1 and 2 mutation: Not detected.. 7.2. " +802,Case 7,Courses of Treatment,Local Recurrence,"7.1. . Courses of Treatment. Left breast microinvasive ductal carci­. noma + DCIS → Operation → Adjuvant therapy. → Right breast recurrence (DCIS).. 7.2.1. . Primary Treatment. 51 52. 53. Operation. ­. 54. Local Recurrence. 736. . ­. . . . ­. Pathology Report. Microinvasive Ductal Carcinoma. 1. Size of invasive component: <0.1  cm. (pT1mi).. 2. Size of intraductal component: 4.0 cm.. 3. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 3/3, 3/HPF).. 4. Intraductal component: present, intratu­. moral/extratumoral (99%) (nuclear grade:. high, necrosis: present, architectural pattern:. micropapillary/cribriform, extensive intra­. ductal component: present).. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) Superior margin: 5 mm.. . (b) Inferior margin: 15 mm.. . (c) Medial margin: 10 mm.. . (d) Lateral margin: positive for ductal carci­. noma in situ (Fro 6) (see note).. . (e) Deep margin: 2 mm.. . (f) Superficial margin: 2 mm.. 7. Lymph nodes: no metastasis in one axillary. lymph node (pN0(sn)) (sentinel LN: 0/1).. 8. Arteriovenous invasion: absent.. 9. Lymphovascular invasion: absent.. Y. Kim et al.. 737. . 10. Tumor border: infiltrative.. . 11. Microcalcification:. present,. tumoral/. non-tumoral.. . 12. Pathological TN category (AJCC 2017):. pT1miN0(sn).. Note: 1. Ductal carcinoma in situ is present. only in the permanent section of Fro 6.. Result. Intensity Positive %. Estrogen. receptor. Strong (7/8). 3. 1/3–2/3. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in 41%. of tumor cells. Operation. 55. Pathology Report. . 1. Ductal carcinoma in situ, residual.. . (a) Status post-lumpectomy status for micro­. invasive ductal carcinoma (S19–2090).. . (b) Nuclear grade: high.. . (c) Necrosis: absent.. . (d) Architectural pattern: cribriform.. . (e) Microcalcification: absent.. . (f) Resection margin:. • Lateral: (see note).. . 2. Foreign body reaction with fat necrosis.. Note: The lateral margin of the wide excision. specimen (slide 1) is close to ductal carcinoma in. situ (<1 mm), but this margin submitted for fro­. zen diagnosis (Fro 1) is free of tumor.. Adjuvant Therapy. Postoperative radiation therapy.. Tamoxifen 20 mg/day for 3 years.. 7.2.2. . Treatments After Recurrence. 56. 57. Operation. 58. Pathology Report. Papillary Carcinoma In Situ. . 1. Size of tumor: 0.8 cm (pTis).. . 2. Nuclear grade: low.. . 3. Necrosis: absent.. . 4. Architectural pattern: papillary/solid.. . . . ­. Local Recurrence. 738. a. b. . . 5. Skin: no involvement of tumor.. . 6. Surgical margins:. . (a) Superior margin: (see note 1).. . (b) Inferior margin: 10 mm.. . (c) Medial margin: 5 mm.. . (d) Lateral margin: 20 mm.. . (e) Deep margin: 2 mm.. . (f) Superficial margin: <1  mm from ductal. carcinoma in situ (slide 2).. . 7. Microcalcification:. present,. tumoral/. non-tumoral.. . 8. Pathological TN category (AJCC 2017): pTis.. Note: 1. The superior margin of the lumpec­. tomy specimen (slide 3) is close to ductal carci­. noma in situ (3 mm), but this margin submitted. for frozen diagnosis (Fro 1) is free of tumor.. Result. Intensity Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Negative (2/8). 1. <1%. C-erbB2. Equivocal (2+). Ki-67. Positive in 2%. of tumor cells. Adjuvant Therapy. Plan for tamoxifen for 5 years.. 8. " +816,Case 7,Patient History,Local Recurrence,"Patient History and Progress. Female/42 years old, pre-menopause.. Screen detected mass lesion on left breast. . 4 o’clock direction.. Family history of breast cancer, mother.. No comorbidities.. BRCA 1 and 2 mutation: Not detected.. 7.2. " +803,Case 7,Courses of Treatment,Metastatic Breast Cancer,"Left breast cancer → Operation → Adjuvant. therapy → Ipsilateral breast and chest wall. recurrence → Chemotherapy → Progression on. the skin and contralateral axillary lymph. nodes.. 7.2.1. . Primary Treatment. Intensity. Positive %. Estrogen. receptor. Negative. (2/8). 1. <1%. Progesterone. receptor. Negative. (2/8). 1. <1%. C-erbB2. Positive. (3+). Result. Intensity. Positive %. Ki-67. Positive. in 43% of. tumor. cells. Adjuvant Therapy. Adjuvant chemotherapy #6 cycles (Cyclo­. phosphamide & Methotrexate & Fluorouracil).. Post-operative radiation therapy.. 7.2.2. . Treatments After Recurrence. Abdominal Lymph Nodes Metastasis. Mar. 2021 CT abdomen & pelvis: r/o Enlarged. lymph node in Rt. external iliac chain and para­. aortic area; cannot exclude pathologic lymph. node, such as metastasis or lymphoproliferative. disorder.. → Closed follow-up." +817,Case 8,Courses of Treatment,Benign and Proliferative,"8.1. . Courses of Treatment. →2021-11-12 excision, Lt.. Benign and Proliferative Case Series. 26. . ­. ­. C. W. Lee et al.. 27. 8.3.1. . Pathology Report. Diagnosis. • Breast, left, excision:. –. – Atypical. ductal. hyperplasia. with. micro­. calcification.. 9. " +825,Case 8,Important Radiologic,Benign and Proliferative,Important Radiologic. Findings. 12. 8.3.  +831,Case 8,Patient History,Benign and Proliferative,"Patient History and Progress. Female/54 years old, pre-menopause.. Screen detected microcalcification on upper. outer portion of left breast.. No family history.. No comorbidities.. 8.2. " +818,Case 8,Courses of Treatment,Carcinoma In Situ,"8.1. . Courses of Treatment. Operation + Postoperative radiation therapy. (right side)  +  Tamoxifen 20  mg/day for. 5 years.. 8.3.1. . Operation. 36. 37. 8.3.2. . Pathology Report. Right.. . Ductal carcinoma in situ, pathological TN cat­. egory (AJCC 2017): pTis. . 1. Size of tumor: 0.3 cm (pTis).. . 2. Nuclear grade: low.. . 3. Necrosis: absent.. . 4. Architectural pattern: papillary.. . 5. Surgical margins: positive (slide 2).. . 6. Microcalcification: present, non-tumoral.. . . E. S. Lee et al.. 69. . . Carcinoma In Situ. 70. . . . Result. Intensity. Positive %. Estrogen. receptor. Weak (4/8). 2. 1%–10%. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Equivocal. (2+). Ki-67. Positive in 2%. of tumor cells. . Atypical ductal hyperplasia involving intra­. ductal papilloma.. . 1. Post-excision status.. Left.. Intraductal papilloma.. 9. " +826,Case 8,Important Radiologic,Carcinoma In Situ,Important Radiologic. Findings. 34. 35. 8.3.  +832,Case 8,Patient History,Carcinoma In Situ,"Patient History and Progress. Female/41 years old, pre-menopause.. Detected bloody discharge in left nipple.. No family history.. No comorbidities.. ATM VUS (variant of uncertain).. 8.2. " +819,Case 8,Courses of Treatment,HR(+) HER2(+) Breast Cancer,8.1. . Courses of Treatment. Operation  +  Adjuvant chemotherapy (#4. cycles of doxorubicin and cyclophospha­. mide). +. Post-operative. radiation. ther­. apy + Trastuzumab + Letrozole 2.5 mg/day.. 47. 8.3.1. . Pathology Report. . 1. No residual tumor with foreign body. reaction.. . (a) Post-excision status.. . (b) Lymph nodes: no metastasis in one axil­. lary lymph node (pN0(sn)) (sentinel LN:. 0/1).. . 2. Intraductal papilloma.. Result. Intensity. Positive. %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Weak (4/8). 2. 1–10%. C-erbB2. Positive (3+). Ki-67. Positive in 29%. of tumor cells. a. b. . HR(+) HER2(+) Breast Cancer. 326. 9.  +827,Case 8,Important Radiologic,HR(+) HER2(+) Breast Cancer,Important Radiologic. Findings. 43 44 45. 46. . HR(+) HER2(+) Breast Cancer. 324. . . . S. Park et al.. 325. 8.3.  +833,Case 8,Patient History,HR(+) HER2(+) Breast Cancer,"Patient History and Progress. Female/61 years old, post-menopause.. Screen detected mass lesion on right breast 9. o’clock direction.. No family history.. Hypertension,. s/p. cholecystectomy,. arrhythmia.. 8.2. " +820,Case 8,Courses of Treatment,HR(+) HER2(-) Breast Cancer,"Right nipple–areolar complex sparing mastec­. tomy, sentinel lymph node biopsy, Left nipple–. areolar complex sparing mastectomy, sentinel. lymph node biopsy (Figs. 41 and 42).. 8.3.2. . Pathology Report. [Right]. Invasive Ductal Carcinoma. micropapillary/cribriform/solid/comedo,. extensive intraductal component: present).. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) nipple margin: positive for ductal carci­. noma in situ (Fro 2),. lymph nodes (pN0) (sentinel LN: 0/1, non-­. sentinel LN: 0/6).. 8. Arteriovenous invasion: absent.. 9. Lymphovascular. invasion:. present,. intratumoral.. . 10. Tumor border: infiltrative.. . 11. Microcalcification:. present,. tumoral/. non-tumoral.. . 12. Pathological TN category (AJCC 2017):. pT1cN0.. Result. Intensity. Positive. %. Estrogen. receptor. Strong (7/8). 2. >2/3. Progesterone. receptor. Strong (7/8). 2. >2/3. C-erbB2. Negative (1+). Ki-67. Positive in 26%. of tumor cells. [Left]. Invasive Ductal Carcinoma. 1. Size of tumor: 1.5 cm (pT1c).. 2. Histologic grade: 2/3 (tubule formation: 2/3,. nuclear pleomorphism: 2/3, mitotic count:. 2/3, 17/10 HPF).. 3. Intraductal component: present, intratu­. moral/extratumoral (10%) (nuclear grade:. low, necrosis: absent, architectural pattern:. cribriform/solid, extensive intraductal com­. ponent: absent).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) nipple margin: positive for ductal carci­. noma in situ (Fro 1) (see note),. . (b) deep margin: 1 mm from invasive ductal. carcinoma (slide 1).. 6. Lymph nodes: no metastasis in eight axillary. lymph nodes (pN0) (sentinel LN: 0/3, non-­. sentinel LN: 0/5).. 7. Arteriovenous invasion: absent.. 8. Lymphovascular invasion: absent.. 9. Tumor border: partly infiltrative.. . 10. Microcalcification: present, tumoral.. . 11. Pathological TN category (AJCC 2017):. pT1cN0.. Note: 1. Ductal carcinoma in situ is pres­. ent only in the permanent section of Fro 1. Result. Intensity. Positive. %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (0). Ki-67. Positive in 8% of. tumor cells. 9. " +828,Case 8,Important Radiologic,HR(+) HER2(-) Breast Cancer,"Important Radiologic. Findings. See Figs. 37, 38, 39 and 40." +834,Case 8,Patient History,HR(+) HER2(-) Breast Cancer,o’clock and left breast 2 o’clock direction.. No family history.. No comorbidities.. BRCA 1 and 2 mutation: not detected.. 8.2.  +821,Case 8,Courses of Treatment,HR(−) HER2(+) Breast Cancer,"8.1. . 8.3.1. . Operation. ­. 58. 59. 8.3.2. . Pathology Report. Invasive Ductal Carcinoma. 1. Size of invasive component: 1.1 cm (pT1c).. 2. Size of intraductal component: 3.0 cm.. 3. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 3/3, 5/HPF).. 4. Intraductal component: present, intratu­. moral/extratumoral (60%) (nuclear grade:. high, necrosis: present, architectural pattern:. solid/comedo, extensive intraductal compo­. nent: present).. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) deep margin: 2 mm,. . (b) superficial margin: 2 mm.. 7. Lymph nodes: no metastasis in four axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/1,. axillary LN: 0/3).. 8. Arteriovenous invasion: absent.. 9. Lymphovascular invasion: present, intratumoral.. . 10. Tumor border: infiltrative.. . 11. Microcalcification:. present,. tumoral/. non-tumoral.. . 12. Pathological TN category (AJCC 2017):. pT1cN0(sn).. Breast, right “accessary,” excision:. Mammary ducts and lobules in fibroadipose. tissue, suggestive of accessory breast.. Result. Intensity. Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in. 23% of tumor. cells. HR(−) HER2(+) Breast Cancer. 458. . . Y. Kwon et al.. 459. 9. " +829,Case 8,Important Radiologic,HR(−) HER2(+) Breast Cancer,Important Radiologic. Findings. 54 55 56. 57. . . Y. Kwon et al. +835,Case 8,Patient History,HR(−) HER2(+) Breast Cancer,"Patient History and Progress. Female/53 years old, peri-menopause.. Screen detected microcalcification on right. breast 1 and 10 o’clock direction.. No family history.. No comorbidities.. 8.2. " +822,Case 8,Courses of Treatment,HR(−) HER2(−) Breast Cancer,"8.1. . Courses of Treatment. Neoadjuvant chemotherapy (#4  cycles of. doxorubicin and cyclophosphamide  +  #4. cycles of paclitaxel)  +  Operation  +  Post-. operative radiation therapy.. 8.3.1. . Operation. 58. 59. 8.3.2. . Pathology Report. . Microinvasive Ductal Carcinoma. 1. Post-chemotherapy status.. 2. Size of invasive component: <0.1  cm. (ypT1mi).. 3. Size of in situ component: 1.0 cm.. 4. Histologic grade: not applicable.. 5. Intraductal component: present, extratumoral. (99%) (nuclear grade: high, necrosis: present,. architectural pattern: ­. cribriform/solid/comedo,. extensive intraductal component: present).. 6. Skin: no involvement of tumor.. 7. Surgical margins:. . (a) Superior margin: 5 mm.. . (b) Inferior margin: 5 mm.. . (c) Medial margin: 20 mm.. . (d) Lateral margin: (see note 1).. . (e) Deep margin: 5 mm.. . (f) Superficial margin: 5 mm.. 8. Lymph nodes: no metastasis in one axillary. lymph node (ypN0(sn)) (sentinel LN: 0/1).. 9. Arteriovenous invasion: absent.. . 10. Lymphovascular invasion: absent.. HR(−) HER2(−) Breast Cancer. 602. . . . E. S. Lee et al.. 603. . . . HR(−) HER2(−) Breast Cancer. 604. . . ­. E. S. Lee et al.. 605. . 11. Tumor border: infiltrative.. . 12. Microcalcification: present, non-tumoral.. . 13. Pathological TN category (AJCC 2017):. ypT1miN0(sn).. Note: 1. The lateral margin of the lumpectomy. specimen (slide 7) is close to ductal carcinoma in. situ (2 mm), but this margin submitted for frozen. diagnosis (Fro 4) is free of tumor.. . Ductal Carcinoma In Situ. . 1. Post-chemotherapy status.. . 2. Size of tumor: 0.2 cm (ypTis).. . 3. Nuclear grade: high.. . 4. Necrosis: absent.. . 5. Architectural pattern: solid.. . 6. Skin: no involvement of tumor.. . 7. Surgical margins:. . (a) Superior margin: 20 mm.. . (b) Inferior margin: 10 mm.. . (c) Medial margin: 10 mm.. . (d) Lateral margin: 10 mm.. . (e) Deep margin: 2 mm.. . (f) Superficial margin: 2 mm.. . 8. Microcalcification:. present,. tumoral/. non-tumoral.. . 9. Pathological TN category (AJCC 2017):. ypTis.. Result. Intensity. Positive. %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Negative (1+). Ki-67. Positive in 10%. of tumor cells. 9. " +830,Case 8,Important Radiologic,HR(−) HER2(−) Breast Cancer,Important Radiologic. Findings. 52 53. 54. 8.2.1. . After Neoadjuvant. Chemotherapy. 55 56. 57. 8.3.  +836,Case 8,Patient History,HR(−) HER2(−) Breast Cancer,"Patient History and Progress. Female/56 years old, peri-menopause.. Screen detected a mass lesion on right breast 7. o’clock direction and left breast 4 o’clock. direction.. No family history.. No comorbidities.. BRCA 1 and 2 mutation: Not detected.. 8.2. " +823,Case 8,Courses of Treatment,Local Recurrence,"8.1. . Courses of Treatment. Right breast IDC/Left breast intraductal papil­. loma, sclerosing → Operation → Adjuvant ther­. apy → Left breast recurrence (DCIS).. 8.2.1. . Primary Treatment. 59. 60. Operation. 61. 62. Pathology Report. . Y. Kim et al.. 739. . 1. Invasive Ductal Carcinoma involving scleros­. ing adenosis.. . (a) Size of tumor: 1.5 cm (pT1c).. . (b) Histologic grade: 2/3 (tubule formation:. 3/3, nuclear pleomorphism: 2/3, mitotic. count: 1/3, 8/10HPF).. . (c) Intraductal component: present, intratu­. moral/extratumoral (70%) (nuclear grade:. low, necrosis: present, architectural pat­. tern: cribriform/solid, extensive intra­. ductal component: present).. . (d) Skin: no involvement of tumor.. . (e) Surgical margins:. • Superior margin: 2  mm from ductal. carcinoma in situ (slide 7).. • Inferior margin: 2 mm from ductal car­. cinoma in situ (slide MG4).. • Medial margin: 2  mm from invasive. ductal carcinoma (slide 6).. • Lateral margin: 2 mm from ductal car­. cinoma in situ (slide 9).. • Deep margin: 2 mm.. • Superficial margin: 2 mm.. . (f) Arteriovenous invasion: absent.. . (g) Lymphovascular. invasion:. present,. intratumoral.. . (h) Tumor border: infiltrative.. . ­. . a. b. . ­. Local Recurrence. 740. a. b. . ­. . . ­. . (i) Microcalcification:. present,. tumoral/. non-tumoral.. . (j) Pathological TN category (AJCC 2017):. pT1c.. . 2. Intraductal papilloma.. . 3. Sclerosing adenosis with microcalcification.. Result. Intensity Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative. (1+) (IDC). Equivocal (2+). (DCIS). Ki-67. Positive in 24%. of tumor cells. . . 1. Intraductal papilloma with usual ductal. hyperplasia. . 2. Sclerosing adenosis with microcalcification.. Operation. Second Operation (Mar. 2021) Right axillary. lymph node sampling.. Pathology Report. No metastasis in eight axillary lymph nodes. (right sentinel LN: 0/2, right axillary LN: 0/6).. . 1. Post-excision status.. Adjuvant Therapy. Postoperative radiation therapy.. Tamoxifen 20 mg/day for 0.8 year.. 8.2.2. . Treatments After Recurrence. 63. 64. Y. Kim et al.. 741. a. b. . Operation. 65. Pathology Report. . 1. Ductal Carcinoma In Situ involving scleros­. ing adenosis.. . (a) Size of tumor: 0.8 cm (pTis).. . (b) Nuclear grade: low.. . (c) Necrosis: absent.. . (d) Architectural pattern: micropapillary/. cribriform.. . (e) Surgical margins:. • Superior margin: <1 mm from ductal. carcinoma in situ (slide 2).. • Inferior margin: 10 mm.. • Medial margin: 5 mm.. • Lateral margin: 10 mm.. • Deep margin: 2 mm.. • Superficial margin: 2 mm.. . (f) Microcalcification:. present,. tumoral/. non-tumoral.. . 2. Intraductal papilloma with usual ductal. hyperplasia.. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Negative (2/8). 1. <1%. C-erbB2. Equivocal (2+). Ki-67. Positive in 1%. of tumor cells. Adjuvant Therapy. Plan for tamoxifen for 5 years.. 9. " +837,Case 8,Patient History,Local Recurrence,"Patient History and Progress. Female/48 years old, pre-menopause.. Screen detected mass lesion on right breast. . 12 o’clock direction and left 6 o’clock direction.. Family history of breast cancer, maternal aunt.. No comorbidities.. BRCA 1 and 2 mutation: Not detected.. 8.2. " +824,Case 8,Courses of Treatment,Metastatic Breast Cancer,Courses of Treatment. Left breast cancer → Operation → Adjuvant. therapy → Ipsilateral axillary lymph nodes. recurrence.. 8.2.1. . Primary Treatment. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (7/8). 3. 1/3–2/3. C-erbB2. Negative (0). Ki-67. Positive in. 61% of tumor. cells. Oncotype Dx RS Score: 18.. Adjuvant Therapy. Post-operative radiation therapy + Tamoxifen. 20 mg/day for 4.8 years.. 8.2.2. . Treatments After Recurrence. Ipsilateral Axillary Lymph Nodes. Recurrence. Progesterone. receptor. Strong (7/8). 3. 1/3–2/3. C-erbB2. Negative (0). Ki-67. Positive in. 29% of tumor. cells. Neoadjuvant Chemotherapy. Neoadjuvant. chemotherapy. #8. cycles. (Adriamycin & Cyclophosphamide #4 →. Docetaxel #4).. Operation. Sep. 2021 Left axillary lymph node dissection.. Pathology: No metastasis in twelve axillary +838,Case 8,Patient History,Metastatic Breast Cancer, +839,Case 9,Courses of Treatment,Benign and Proliferative,"9.1. . Courses of Treatment. → 2021-11-12 Excision, Rt.. 9.3.1. . Pathology Report. Diagnosis. • Breast, right, excision:. –" +847,Case 9,Important Radiologic,Benign and Proliferative,Important Radiologic. Findings. 13 14. 15. 9.3.  +853,Case 9,Patient History,Benign and Proliferative,"Patient History and Progress. Female/32 years old, pre-menopause.. Screen detected mass lesion on right breast. 8 o’clock direction.. Family history of breast cancer, mother and. maternal aunt.. No comorbidities.. 9.2. " +840,Case 9,Courses of Treatment,Carcinoma In Situ,"9.1. . Courses of Treatment. Operation + Tamoxifen 20 mg/day for 5 years.. 9.3.1. . Operation. 41. 42. E. S. Lee et al.. 71. . 9.3.2. . Pathology Report. Ductal carcinoma in situ, pathological TN cat­. egory (AJCC 2017): pTisN0(sn). . 1. Size of tumor: 1.2 cm (pTis).. . 2. Nuclear grade: high.. . 3. Necrosis: present.. . 4. Architectural pattern: solid/comedo.. . 5. Skin: no involvement of tumor.. . 6. Surgical margins:. . (a) deep margin: 2 mm,. . (b) superficial margin: 2 mm.. . 7. Lymph nodes: no metastasis in one axillary. lymph node (pN0(sn)) (sentinel LN: 0/1)).. . 8. Microcalcification:. present,. tumoral/non-. tumoral.. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Equivocal. (2+). Ki-67. Positive in 9%. of tumor cells. Carcinoma In Situ. 72. . ­. 10. " +848,Case 9,Important Radiologic,Carcinoma In Situ,Important Radiologic. Findings. 38 39. 40. 9.3.  +854,Case 9,Patient History,Carcinoma In Situ,"Patient History and Progress. Female/50 years old, pre-menopause.. Screen detected microcalcification on inner. portion of left.. Outside result of biopsy: Ductal carcinoma in. situ, left.. Family history of breast cancer, maternal aunt.. No comorbidities.. BRCA 1 and 2 mutation: Not examination.. 9.2. " +841,Case 9,Courses of Treatment,HR(+) HER2(+) Breast Cancer,"9.1. . Courses of Treatment. Operation  +  Adjuvant chemotherapy (#4. cycles of doxorubicin and cyclophospha­. mide). +. Post-operative. radiation. therapy + Trastuzumab.. 51. 9.3.1. . Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 1.3 cm (pT1c).. 2. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 3/3, 4/HPF).. 3. Intraductal component: present, intratu­. moral/extratumoral (30%) (nuclear grade:. high, necrosis: present, architectural pattern:. solid/comedo, extensive intraductal compo­. nent: present).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) superior margin: 5 mm,. . (b) inferior margin: (see Note 1),. . (c) medial margin: (see Note 2),. . (d) lateral margin: 10 mm,. . (e) deep margin: 2 mm,. . (f) superficial margin: 2 mm.. . S. Park et al.. 327. 6. Arteriovenous invasion: absent.. 7. Lymphovascular. invasion:. present,. intratumoral.. 8. Tumor border: infiltrative.. 9. Microcalcification:. present,. tumoral/. non-tumoral.. . 10. Pathological TN category (AJCC 2017):. pT1c.. Note: 1. The inferior margin of the lumpec­. tomy specimen (slide 2) is close to ductal. ­. carcinoma in situ (3 mm) but this margin submit­. ted for frozen diagnosis (Fro 4) is free of tumor.. 2. The medial margin of the lumpectomy. specimen (slide 5) is close to ductal carcinoma in. %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Positive (3+). Ki-67. Positive in 71%. of tumor cells. 10. " +849,Case 9,Important Radiologic,HR(+) HER2(+) Breast Cancer,Important Radiologic. Findings. 48 49. 50. 9.3.  +855,Case 9,Patient History,HR(+) HER2(+) Breast Cancer,"Patient History and Progress. Female/44 years old, pre-menopause.. Screen detected mass lesion on left breast 7. o’clock direction.. Family history of breast cancer, two sisters.. Family history of pancreatic cancer, mother.. No other history of disease, operation, or. medication.. BRCA 1 and 2 mutation: Not detected,. RAD50 VUS (variant of uncertain).. 9.2. " +842,Case 9,Courses of Treatment,HR(+) HER2(-) Breast Cancer,"9.1. . Courses of Treatment. Operation. +. Adjuvant. chemotherapy. (#4  cycles of docetaxel & cyclophospha­. mide). +. Post-operative. radiation. ther­. apy + Tamoxifen 20 mg/day.. 9.3.1. . Operation. Left breast conserving surgery, sentinel lymph. moral/extratumoral (25%) (nuclear grade:. high, necrosis: present, architectural pattern:. solid/comedo, extensive intraductal compo­. nent: present).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) superior margin: (see note),. . (b) inferior margin: 22 m,. . (c) medial margin: 1 mm,. . (d) lateral margin: 18 mm,. . (e) deep margin: 3 mm,. . (f) superficial margin: positive for ductal. carcinoma in situ (slide 9).. 6. Lymph nodes: no metastasis in two axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/2).. 7. Arteriovenous invasion: absent.. 8. Lymphovascular. invasion:. present,. peritumoral.. 9. Tumor border: pushing.. . 10. Microcalcification:. present,. tumoral/. non-tumoral.. . 11. Pathological TN category (AJCC 2017):. pT2N0(sn).. Intraductal Papilloma with Usual Ductal. Hyperplasia. Note: 1. The superior margin of the lumpectomy. specimen (slide 1) is close to ductal carcinoma. in situ (<1 mm) but this margin submitted for. frozen diagnosis (Fro 3) is free of tumor.. Result. Intensity. Positive. %. Estrogen. receptor. Strong (7/8). 2. >2/3. Progesterone. receptor. Weak (4/8). 2. 1–10%. C-erbB2. Equivocal (2+). (SISH negative). Ki-67. Positive in 23%. of tumor cells. HR(+) HER2(−) Breast Cancer" +850,Case 9,Important Radiologic,HR(+) HER2(-) Breast Cancer,"Important Radiologic. Findings. See Figs. 43, 44, 45 and 46.. 9.3. " +856,Case 9,Patient History,HR(+) HER2(-) Breast Cancer,"Patient History and Progress. Female/55 years old, pre-menopause.. Self-detected palpable mass lesion on left. breast 11 o’clock direction.. Family history of Prostate cancer, paternal. uncle.. No comorbidities.. 9.2. " +843,Case 9,Courses of Treatment,HR(−) HER2(+) Breast Cancer,9.1. . docetaxel and carboplatin and trastuzumab and. pertuzumab after followed #4 cycles of docetaxel. and. trastuzumab. and. ­. pertuzumab). +. Operation  +  Post-operative radiation ther­. apy + Trastuzumab and pertuzumab.. 9.4.1. . Operation. 68. 9.4.2. . Pathology Report. . 1. No residual tumor with stromal fibrosis.. . (a) Post-chemotherapy status.. . (b) Lymph nodes: no metastasis in eight axillary. lymph nodes (ypN0) (sentinel LN: 0/8).. . 2. Atypical. ductal. hyperplasia. with. microcalcification.. Result. Intensity. Positive %. Estrogen. receptor. Negative (1/8). 1. <1%. Progesterone. receptor. Negative (2/8). 1. <1%. C-erbB2. Positive (3+). Ki-67. Positive in. 79% of tumor. cells. . Y. Kwon et al.. 465. 10.  +851,Case 9,Important Radiologic,HR(−) HER2(+) Breast Cancer,Important Radiologic. Findings. 60 61 62. . ­. 9.3. . After Neoadjuvant. Chemotherapy. 64 65 66. 67. Y. Kwon et al. +857,Case 9,Patient History,HR(−) HER2(+) Breast Cancer,"Patient History and Progress. Female/51 years old, pre-menopause.. Screen detected mass lesion on left breast 2. o’clock direction.. No family history.. Hypothyroidism.. 9.2. " +844,Case 9,Courses of Treatment,HR(−) HER2(−) Breast Cancer,"9.1. . Courses of Treatment. Operation  +  adjuvant chemotherapy (#4. cycles of docetaxel and cyclophosphamide) +. Operation + Post-operative radiation therapy.. 9.3.1. . Operation. 65. 9.3.2. . Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 2.3 cm (pT2).. 2. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 3/3, 8/HPF).. 3. Intraductal component: present, intratu­. moral/extratumoral (10%) (nuclear grade:. high, necrosis: absent, architectural pattern:. solid, extensive intraductal component:. absent).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) Superior margin: 10 mm.. . (b) Inferior margin: 10 mm.. . (c) Medial margin: 5 mm.. . (d) Lateral margin: 10 mm.. . (e) Deep margin: <1 mm from invasive duc­. tal carcinoma (slide 7).. . (f) Superficial margin: 2 mm.. 6. Lymph nodes: no metastasis in four axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/1,. non-sentinel LN: 0/2, intramammary LN:. 0/1).. 7. Arteriovenous invasion: absent.. 8. Lymphovascular. invasion:. present,. intratumoral.. 9. Tumor border: infiltrative.. HR(−) HER2(−) Breast Cancer. 606. . . . E. S. Lee et al.. 607. . . Result. Intensity. Positive. %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Negative (1+). Ki-67. Positive in 87%. of tumor cells. . . 1. Localized chronic granulomatous inflamma­. tion with necrosis, suggestive of mycobacte­. rial infection (see note).. . 2. Reactive hyperplasia in 5 regional lymph. nodes (LN #10: 0/2, LN #11: 0/3).. . 10. Microcalcification:. present,. tumoral/. non-tumoral.. . 11. Pathological TN category (AJCC 2017):. pT2N0(sn).. HR(−) HER2(−) Breast Cancer. 608. . ­. ­. 10. " +852,Case 9,Important Radiologic,HR(−) HER2(−) Breast Cancer,Important Radiologic Findings. 60 61 62 63. 64. 9.3.  +858,Case 9,Patient History,HR(−) HER2(−) Breast Cancer,"Patient History and Progress. Female/65 years old, post-menopause.. Screen detected mass lesion on right breast 10. o’clock direction.. No family history.. S/P right salpingectomy (due to ectopic. pregnancy).. 9.2. " +845,Case 9,Courses of Treatment,Local Recurrence,"9.1. . Courses of Treatment. Right breast mucinous carcinoma → Operation. → Adjuvant therapy → Left breast recurrence. (IDC + DCIS)/Right breast ADH.. 9.2.1. . Primary Treatment. 66 67. 68. Operation. ­. 69. Local Recurrence. 742. . . . . ­. Pathology Report. Mucinous Carcinoma. 1. Size of tumor: 1.5 cm (pT1c).. 2. Histologic grade: 1/3 (tubule formation: 2/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 7/10HPF).. 3. Intraductal component: absent.. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) Superior margin: 10 mm.. . (b) Inferior margin: 15 mm.. . (c) Medial margin: 15 mm.. . (d) Lateral margin: 20 mm.. . (e) Deep margin: 12 mm.. . (f) Superficial margin: 3 mm.. 6. Lymph nodes: no metastasis in one axillary. lymph node (pN0(sn)) (sentinel LN: 0/1).. 7. Vascular invasion: absent.. 8. Lymphatic invasion: absent.. 9. Tumor border: infiltrative.. Y. Kim et al.. 743. . 10. Microcalcification: absent.. . 11. Pathologic stage (AJCC 2010): pT1cN0(sn).. Result. Intensity Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (0). Ki-67. Positive in 13%. of tumor cells. Adjuvant Therapy. Postoperative radiation therapy.. Tamoxifen 20 mg/day for 5 years.. 9.2.2. . Treatments After Recurrence. 70 71 72. 73. a. b. . a. b. . Operation. ­. 74. 75. Pathology Report. . Atypical ductal hyperplasia involving intra­. ductal papilloma with marked cautery artifact.. . Ductal Carcinoma In Situ, residual. . 1. Size of tumor: up to 0.2 cm.. . 2. Nuclear grade: low.. . 3. Necrosis: absent.. . 4. Architectural pattern: micropapillary.. . 5. Skin: no involvement of tumor.. . 6. Surgical margins:. . (a) Superior margin: 15 mm.. . (b) Inferior margin: 5 mm.. . (c) Medial margin: 10 mm.. . (d) Lateral margin: 10 mm.. . (e) Deep margin: 5 mm.. . (f) Superficial margin: 1  mm from ductal. carcinoma in situ (slide 5).. . 7. Lymph nodes: no metastasis in one axillary. lymph node (pN0(sn)) (sentinel LN: 0/1). . 8. Microcalcification: present, tumoral.. Note: 1. In the previous biopsy specimen. (S21–18409), invasive ductal carcinoma mea­. sures at least 0.5 cm in greatest dimension.. Result. Intensity Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (1+). Ki-67. Positive in 8% of. tumor cells. Y. Kim et al.. 745. Adjuvant Therapy. Postoperative radiation therapy.. Letrozole 2.5  mg/day for 5  years with. goserelin.. 10. " +859,Case 9,Patient History,Local Recurrence,"Patient History and Progress. Female/51 years old, pre-menopause.. Screen detected mass lesion on right breast 12. o’clock direction.. Outside result of biopsy: Mucinous carcinoma.. Family history of colon cancer, father.. No comorbidities.. BRCA 1 and 2 mutation: Not detected.. 9.2. " +846,Case 9,Courses of Treatment,Metastatic Breast Cancer,. Courses of Treatment. Right breast cancer → Operation → Adjuvant. therapy → Ipsilateral axillary lymph nodes. recurrence.. 9.2.1. . Primary Treatment. Estrogen. receptor. Strong (7/8). 2. >2/3. Progesterone. receptor. Negative (2/8). 1. <1%. C-erbB2. Negative (0). Ki-67. Positive in. 23% of tumor. cells. Adjuvant Therapy. Post-operative radiation therapy + Letrozole. 2.5 mg/day for 1 year.. 9.2.2. . Treatments After Recurrence. Ipsilateral Axillary Lymph Nodes. Recurrence. See Figs. 29 and 30.. Aug. 2021 Left axillary lymph node biopsy.. Pathology: Metastatic ductal carcinoma.. Result. Intensity. Positive %. Estrogen. receptor. Negative. (2/8). 1. <1%. Progesterone. receptor. Negative. (0/8). 0. 0. C-erbB2. Negative (0). Ki-67. Positive in. 18% of tumor. Pathology: No metastasis in seven axillary. lymph nodes (right axillary lymph nodes: 0/7).. Radiotherapy. Post-operative radiation therapy (axillary and. subclavian area).. 10.  +860,Case 9,Patient History,Metastatic Breast Cancer,"Patient History and Progress. Female/57 years old, post-menopause.. No family history.. S/p. Myomectomy. &. bilateral. salpingo-oophorectomy.. 9.2. " +861,Important Radiologic Findings,Important Radiologic Findings,Benign and Proliferative,"– Atypical ductal hyperplasia, focal.Fig. 13. Fig. 13  Mammography. shows no discernable. abnormality. Benign and Proliferative Case Series. 28. 10. . 10.1. . Patient History and Progress. Female/33 years old, pre-menopause." +862,Important Radiologic Findings,Important Radiologic Findings,Carcinoma In Situ,"52Fig. 2. Fig. 2  MRI revealed. regional heterogeneous. non-mass enhancement. in the left upper inner. breast. a. b. . . 1.3. . (c) medical margin: 10 mm,Fig. 15. Fig. 15  Mammogram. shows no suspicious. mass in both breasts,. except 1 cm sized. circumscribed iso-dense. nodule in right upper. outer breast, pre-­. mammary fat layer. (white arrow). E. S. Lee et al.. 59. Fig. 20  (a–d) Gross pathology of right breast excision. specimen (first operation). (e, f) Gross pathology of right. breast wide excision specimen (second operation). (g, h). Gross pathology of left breast excision specimen (first. operation). (i, j) Gross pathology of left breast wide exci­. sion specimen (second operation). a. c. e. f. b. Fig. 20  (continued). Carcinoma In Situ. 62. . ­. 5. . 5.1. . Patient History and Progress. Female/52 years old, pre-menopause.. Fig. 45. Fig. 45  MRI shows. focal heterogeneous. non-mass enhancement. . . 7. Lymph nodes: no metastasis in one axillary. lymph node (pN0(sn)) (sentinel LN: 0/1).. . 8. Microcalcification:. present,. tumoral/non-. Fig. 53. Fig. 53  MRI shows. round homogeneous. enhancing nodule at the. corresponding area of. the mass on US. Carcinoma In Situ. 78Fig. 54. Fig. 54  Lymphoscintigraphy. shows visualized sentinel lymph. node in left axilla. . E. S. Lee et al.. 79. . ­. 13. . 13.1. Fig. 65. Fig. 65  MRI shows. focal clumped non-mass. enhancement at the. corresponding area of. the microcalcifications. on mammography. . Pathology Report. Ductal carcinoma in situ, pathological TN cat­. egory (AJCC 2017): pTisN0(sn). 1. Size of tumor: 4.0 cm (pTis).. 86Fig. 72. Fig. 72  Asymmetric. enhancement and. thickening were shown. in left nipple–areolar. complex. . . ­. E. S. Lee et al.. 87. . Fig. 101. Fig. 101  MRI shows. asymmetric strong. enhancement and. thickening of left. nipple–areolar complex. . Carcinoma In Situ. 102. . . ­. 105Fig. 109. Fig. 109  Asymmetry. was only seen on one. view, the mediolateral. oblique view. . . Pathology Report. Lobular carcinoma in situ, pathological TN. category (AJCC 2017): pTis. . 1. Size of tumor: 1.3 cm (pTis).. 112Fig. 125. Fig. 125  MRI. demonstrates an. enhancing residual mass. in the left breast. a. b. . a. b. . E. S. Lee et al.. 114Fig. 129. Fig. 129  Biopsy clip. (white arrow) was. inserted after stereotactic. VAB. On MRI, note an. artifact related to the. VAB and inserted clip. (black arrow)Fig. 130. Fig. 130  MRI. demonstrates mild BPE. without definite. abnormality. a. b. . E. S. Lee et al.. 115. a. b. Fig. 133. Fig. 133  MRI of a. woman with known left. breast cancer. MRI. shows an enhancing. malignant mass in the. left breast (black arrow).. An enhancing focus was. seen in the right breast. (white arrow). a. b. ­Fig. 139. Fig. 139  US. demonstrates. hypoechoic lesions with. echogenic calcifications. E. S. Lee et al.. 119. . c. d. . . ­Fig. 150. Fig. 150  MRI demonstrates an irregular enhancing mass. Carcinoma In Situ. 124. a. b. . . E. S. Lee et al.. 125. 33. " +863,Important Radiologic Findings,Important Radiologic Findings,HR(+) HER2(+) Breast Cancer,"HR(+) HER2(+) Breast Cancer. Soojin Park, Ran Song, Yunju Kim, Bo Hwa Choi,. Eun Sook Lee, Chan Wha Lee, and Eun-Gyeong Lee. 1. Fig. 5  PET-CT shows. (a) a hypermetabolic. mass in the left lower. outer breast. (mSUV = 9.9) and (b). hypermetabolic lymph. node in the left axilla. level I (mSUV = 3.7). . S. Park et al.. 303. Fig. 32  PET-CT shows. (a) a hypermetabolic. mass in the left upper. outer breast. (mSUV = 4.8) and (b). there was no enlarged. hypermetabolic lymph. node in the left axilla. HR(+) HER2(+) Breast Cancer. 318. . Fig. 40  PET-CT shows. (a) a hypermetabolic. mass in the left outer. breast (mSUV = 8.6). and (b) mild. hypermetabolic enlarged. lymph nodes with fatty. hilum in the left axilla. level I–II (mSUV = 2.3). . S. Park et al.. Fig. 50. Fig. 50  Breast MRI (Jan. 2021): an irregular enhancing mass in the left breast. HR(+) HER2(+) Breast Cancer. 328. a. b. . situ (<1 mm) but this margin submitted for frozen. diagnosis (Fro 4) is free of tumor.. Result. Intensity. Positive. Fig. 55  PET-CT shows. (a) a hypermetabolic. mass in the left breast. (mSUV = 12.4) and (b). hypermetabolic lymph. nodes in the left axilla. level I–II, left internal. mammary area, and (c). left supraclavicular. fossa. (d) A. hypermetabolic mass. Fig. 115  PET-CT. shows (a) focal. hypermetabolic mass in. the subareolar area of. the right breast. (mSUV = 4.3) and (b). mild hypermetabolic. lymph node in the right. axilla level I. (mSUV = 0.9). . Fig. 130  PET-CT. shows (a) a. hypermetabolic mass in. the left lower inner. breast (mSUV = 7.7). and (b) multiple. hypermetabolic lymph. nodes in the left axilla. level I–III and (c) left. internal mammary area. . Fig. 137  PET-CT. shows (a) a. hypermetabolic mass in. the right breast. (mSUV = 13.7) and (b). small lymph nodes. without significant. hypermetabolism in the. right axilla. . S. Park et al.. 383Fig. 6.141. Fig. 6.141  (continued). . . (i) Tumor border: infiltrative.. . (j) Microcalcification: present, tumoral.. . (k) Pathological TN category (AJCC 2017):. pT1cN0(sn).. . 2. Intraductal papilloma with (1) usual ductal. 388Fig. 150. Fig. 150  PET-CT. shows a hypermetabolic. mass in the right upper. outer breast. (mSUV = 14.3). . . 3. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 3/3, 25/10 HPF).. 4. Intraductal component: present, intratu­. 170Fig. 167. Fig. 167  Right. mammography (May. 2021): an irregular mass. at lower outer quadrant. HR(+) HER2(+) Breast Cancer. 398. . . . S. Park et al.. 399. 401Fig. 172. Fig. 172  Right. mammography (May. 2021): a focal. asymmetry at upper. inner quadrant. HR(+) HER2(+) Breast Cancer. 402. . . . S. Park et al.. 405Fig. 180. Fig. 180  Left. mammography (June. 2021): an irregular mass. with spiculated margins. at upper outer quadrant. 2. Histologic grade: 2/3 (tubule formation: 2/3,. nuclear pleomorphism: 3/3, mitotic count:. 2/3, 11/10 HPF).. 3. Intraductal component: present, intratu­. moral/extratumoral (20%) (nuclear grade:. high, necrosis: present, architectural pattern:. 410Fig. 187. Fig. 187  Breast MRI. (Mar. 2021): enlarged. lymph nodes at the. axilla. No abnormal. finding in both breasts. . S. Park et al.. 411Fig. 189. Fig. 189  Breast MRI. for routine surveillance. (May 2022): no. abnormal finding in both. breasts and axillae. 33. . 33.1. . Patient History and Progress. Female/50 years old, pre-menopause.. 412Fig. 190. Fig. 190  Left. mammography (Jan.. 2021): a focal. asymmetry with. microcalcifications at. the subareolar area. (white arrow). Enlarged. lymph nodes at the. axilla (black arrow). . S. Park et al.. 419Fig. 202. Fig. 202  Right. mammography (Jan.. 2021): an irregular mass. with fine pleomorphic. microcalcifications at. upper outer quadrant. HR(+) HER2(+) Breast Cancer. 420. and pertuzumab)  +  Operation  +  Post-­. operative radiation therapy + Trastuzumab +. Tamoxifen 20 mg/day.. 3/3, 5/HPF).Fig. 211. Fig. 211  Left. mammography (May. 2021): negative finding. S. Park et al.. 425. . . . HR(+) HER2(+) Breast Cancer. 426. a" +864,Important Radiologic Findings,Important Radiologic Findings,HR(+) HER2(-) Breast Cancer,"biopsy (Fig. 4).. 1.3.2. . Pathology Report. Invasive Ductal Carcinoma. Associated. with. encapsulated. papillary. carcinoma.. 1. Size of tumor: 2.5 cm (pT2).. tumor cellsFig. 1 [BB:51.259;245.417;246.379;658.808]. Fig. 1  Left mammography (Nov. 2020): an irregular. mass with nipple retraction at subareolar areaFig. 2 [BB:51.366;55.874;453.200;201.315]. Fig. 2  Left breast US (Dec. 2020): a hypervascular irregular mass at subareolar area. US-CNB = IDCFig. 3. Fig. 3  Lymphoscintigraphy shows visualized sentinel. lymph nodes in the left axilla. Y. Kim et al.. 175. F. i. g. 4 [BB:51.298;225.990;453.269;658.808]. Fig. 4  (a) Gross pathology of mastectomy specimen. (b, c) The margins get marked and sliced with different colors on. each direction. 2. . 2.1. . Patient History and Progress. Female/61 years old, post-menopause.. Screen detected mass lesion on left breast 2. o’clock direction.. No family history.. 176Fig. 5 [BB:51.259;324.143;246.379;658.808]. Fig. 5  Left CC mammography (Oct. 2018, Sept. 2020):. negative finding in 2018. A developing asymmetry at. outer breast in 2020Fig. 6. Fig. 6  Left breast US (Nov. 2020): a hypoechoic mass at. upper outer quadrant. US-CNB = IDC. Result. Intensity. Positive %. Estrogen receptor. Strong (8/8). 3. >2/3. Progesterone receptor. Strong (8/8). node biopsy (Fig. 9).. 2.3.2. . Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 0.8 cm (pT1b).. 2. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 2/3, 11/10 HPF).. 3. Intraductal component: present, intratu­. moral/extratumoral (20%) (nuclear grade:. 177Fig. 7 [BB:153.542;343.325;453.543;658.808]. Fig. 7  Breast MRI. (Dec. 2020): an irregular. enhancing mass in the. left breastFig. 8. Fig. 8  Lymphoscintigraphy shows visualized sentinel. lymph nodes in the left axilla. HR(+) HER2(−) Breast Cancer. 178Fig. 9 [BB:71.350;391.495;433.216;658.808]. a. b. Fig. 9  (a) Gross pathology of lumpectomy specimen. (b) The margins get marked and sliced with different colors on. each directionFig. 10 [BB:263.535;111.200;441.543;345.344]. Fig. 10  Right mammography (Nov. 2020): two irregular. masses at subareolar area (white arrow) and upper outer. quadrant (black arrow). 3. . 3.1. . Patient History and Progress. Female/78 years old, post-menopause.. Screen detected mass lesion on right breast 10. o’clock direction.. 179Fig. 11 [BB:51.306;528.968;453.261;658.808]. Fig. 11  Right breast US (Nov. 2020): two irregular masses at subareolar area (white arrow, US-CNB = IDC) and upper. outer quadrant (black arrow, US-CNB = IDC)Fig. 12 [BB:51.283;174.205;453.284;478.000]. Fig. 12  Breast MRI (Dec. 2020): two irregular enhancing masses at subareolar area (white arrow) and upper outer. quadrant (black arrow) of right breast. HR(+) HER2(−) Breast Cancer. 180Fig. 13. Fig. 13  Lymphoscintigraphy shows faintly visualized. sentinel lymph nodes in the right axilla. 3.3.1. . Operation. Right breast conserving surgery, sentinel lymph. node biopsy (Fig. 14).. 3.3.2. . Pathology Report. Breast, right 10 o’clock:. Invasive Ductal Carcinoma. 1. Size of tumor: 0.9 cm.. 2. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 2/3, 11/10 HPF).. 3. Intraductal component: present, intratu­. 181Fig. 14 [BB:51.281;226.048;454.531;658.808]. a. bFig. 14 [BB:51.281;226.048;454.531;658.808]. c. d. Fig. 14  (a) Gross pathology of lumpectomy specimen (10 o’ clock direction). (c) Gross pathology of lumpectomy. specimen (subareolar area). (b, d) The margins get marked and sliced with different colors on each direction. 4. . 4.1. . Patient History and Progress. Female/57 years old, post-menopause.. Screen detected mass lesion on right breast 10. o’clock direction.. No family history.. 182Fig. 15 [BB:51.259;239.246;246.379;658.808]. Fig. 15  Right mammography (Nov. 2020): a focal asym­. metry at upper outer quadrant. 4.3. . Courses of Treatment. Operation  +  Post-operative radiation ther­. apy + Letrozole 2.5 mg/day.. 4.3.1. . Operation. Right breast conserving surgery, sentinel lymph. node biopsy (Fig. 19).. 4.3.2. . Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 1.8 cm (pT1c).. 2. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 2/3, 17/10 HPF).. 3. Intraductal component: present, intratu­. moral/extratumoral (10%) (nuclear grade:. 183Fig. 16 [BB:51.366;485.768;453.200;658.808]. Fig. 16  Right breast US (Dec. 2020): an irregular hypoechoic mass at upper outer quadrant (white arrow,. US-CNB = IDC). An enlarged lymph node at the right axillary fossa (black arrow)Fig. 17 [BB:51.284;112.816;453.283;435.065]. Fig. 17  Breast MRI (Dec. 2020): an irregular enhancing mass in the right breast (white arrow) and an enlarged lymph. node at the right axillary fossa (black arrow). HR(+) HER2(−) Breast Cancer. 184Fig. 18. Fig. 18  Lymphoscintigraphy shows visualized sentinel. lymph nodes in the right axillaFig. 19 [BB:51.314;167.485;453.253;464.500]. a. b. Fig. 19  (a) Gross pathology of lumpectomy specimen. (b) The margins get marked and sliced with different colors on. each direction. Y. Kim et al.. 185. 5. . 5.1. . Patient History and Progress. Female/58 years old, post-menopause.. Screen detected mass lesion on right breast 4. node biopsy (Fig. 24).. 5.3.2. . Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 2.1 cm (pT2).. 2. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 2/3, 14/10 HPF).. 3. Intraductal component: present, intratu­. moral/extratumoral (20%) (nuclear grade:. 6. Lymph nodes:Fig. 20 [BB:51.259;100.578;246.379;450.931]. Fig. 20  Right mammography (Nov. 2020): a focal asym­. metry with fine pleomorphic microcalcifications at lower. inner quadrantFig. 21. Fig. 21  Right breast US (Dec. 2020): an irregular. hypoechoic mass. US-CNB  =  IDC with mucinous. component. HR(+) HER2(−) Breast Cancer. 186Fig. 22 [BB:153.543;383.333;453.544;658.808]. Fig. 22  Breast MRI. (Dec. 2020): a focal. non-mass enhancement. in the right breastFig. 23. Fig. 23  Lymphoscintigraphy shows visualized sentinel. lymph nodes in the right axilla. Result. Intensity. Positive %. Estrogen receptor. Strong (7/8). 2. >2/3. Progesterone receptor. Negative (2/8). 187Fig. 24 [BB:51.307;359.662;453.260;658.078]. a. b. Fig. 24  (a) Gross pathology of lumpectomy specimen (black arrow). (b) The margins get marked and sliced with dif­. ferent colors on each directionFig. 25. Fig. 25  Gross pathology of breast wide excision. specimen. 5.3.3. . Operation (2nd, Jan. 2021). Right breast wide excision (Fig. 25).. 5.3.4. . Pathology Report. Invasive Ductal Carcinoma. . 1. Post-lumpectomy status.. . 2. Size of tumor: 0.2 cm, residual.. . 3. Histologic grade: 2/3 (tubule formation: 3/3,. node biopsy (Fig. 30).. 6.3.2. . Pathology Report. Invasive Ductal Carcinoma. 1. Size of invasive component: 1.8 cm (pT1c).. 2. Size of intraductal component: 4.0 cm.. 3. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 2/3, 11/10 HPF).. 4. Intraductal component: present, intratu­. 7. Lymph nodes:Fig. 26 [BB:51.259;70.988;246.379;455.250]. Fig. 26  Right mammography (Oct. 2020): a spiculated. mass with microcalcifications at upper inner quadrantFig. 27. Fig. 27  Right breast US (Oct. 2020): an irregular. hypoechoic mass (white arrow, US-CNB  =  IDC) with. adjacent smaller masses (not shown). Y. Kim et al.. 189Fig. 28 [BB:153.542;367.733;453.543;658.808]. Fig. 28  Breast MRI. (Nov. 2020): an irregular. enhancing mass (white. arrow) with adjacent. satellite lesions (black. arrows) in the right. breastFig. 29. Fig. 29  Lymphoscintigraphy shows visualized sentinel. lymph nodes in the right axilla. . (a) metastasis in one out of four axillary. lymph nodes (pN1a(sn)) (sentinel LN:. 1/1, axillary LN: 0/3),. . (b) perinodal extension: present,. . (c) size of metastatic carcinoma: 7 mm.. 8. Arteriovenous invasion: absent.. 190Fig. 30 [BB:51.314;361.793;453.253;658.808]. a. b. Fig. 30  (a) Gross pathology of lumpectomy specimen. (b) The margins get marked and sliced with different colors on. each direction. 7. . 7.1. . Patient History and Progress. Female/42 years old, pre-menopause.. Screen detected mass lesion on left breast 2:30. and 3 o’clock direction.. No family history.. node biopsy (Fig. 36).. 7.3.2. . Pathology Report. Mucinous Carcinoma. 1. Size of invasive component: 1.8 cm (pT1c).. 2. Size of intraductal component: 3.0 cm.. 3. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 6/10 HPF).. Y. Kim et al.. 191Fig. 31 [BB:51.259;249.966;246.379;658.808]. Fig. 31  Left mammography (Nov. 2020): an irregular. palpable mass (white arrow) and another smaller mass. (black arrow) at upper outer quadrantFig. 32. Fig. 32  Left breast US (Nov. 2020): an irregular mass. (white arrow, US-CNB = Mucinous carcinoma) with adja­. cent smaller masses (black arrows). 4. Intraductal component: present, intratu­. moral/extratumoral (60%) (nuclear grade:. low, necrosis: absent, architectural pattern:. micropapillary/cribriform, extensive intra­. ductal component: present).. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . 192Fig. 33 [BB:51.280;330.033;453.287;658.808]. Fig. 33  Breast MRI (Nov. 2020): an enhancing mass (white arrow) with increased T2 signal intensity (black arrow) in. the left breastFig. 34. Fig. 34  Lymphoscintigraphy shows visualized sentinel. lymph nodes in the left axilla. Y. Kim et al.. 193Fig. 35. Fig. 35  Breast MRI for routine surveillance (Aug. 2021): no abnormal finding in both breastsFig. 36 [BB:51.307;176.273;453.260;473.250]. a. b. Fig. 36  (a) Gross pathology of lumpectomy specimen. (b) The margins get marked and sliced with different colors on. each direction. HR(+) HER2(−) Breast Cancer. 194. 8. . 8.1. . Patient History and Progress. Female/46 years old, pre-menopause.. Screen detected mass lesion on right breast 12. Fig. 37  Both mammography (Nov. 2020): irregular mass at upper inner quadrant of the right breast (white arrow) and. upper outer quadrant of the left breast (black arrow)Fig. 37 [BB:55.877;195.405;448.690;537.000]. Y. Kim et al.. 195Fig. 38 [BB:51.366;498.968;453.200;658.808]. Fig. 38  Both breast US (Nov. 2020): irregular masses at upper inner quadrant of the right breast (white arrow) and. upper outer quadrant of the left breast (black arrow). Both US-CNB = IDCFig. 39 [BB:51.283;132.357;453.284;449.078]. Fig. 39  Breast MRI (Nov. 2020): irregular enhancing masses in both breasts. HR(+) HER2(−) Breast Cancer. 196. 8.3. . Courses of Treatment. Operation  +  Post-operative radiation ther­. apy + Tamoxifen 20 mg/day.. 8.3.1. . Operation. 1. Size of invasive component: 1.5 cm (pT1c).Fig. 40. Fig. 40  Lymphoscintigraphy shows visualized sentinel. lymph nodes in both axillaFig. 41 [BB:51.315;147.568;453.253;446.000]. a. b. Fig. 41  (a) Gross pathology of right mastectomy specimen. (b, c) The margins get marked and sliced with different. colors on each direction. Y. Kim et al.. 197. 2. Size of intraductal component: 3.5 cm.. 3. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 2/3, 18/10 HPF).. 4. Intraductal component: present, intratu­. moral/extratumoral (60%) (nuclear grade:. low, necrosis: present, architectural pattern:. Fig. 41_1 [BB:51.024;525.848;250.704;658.808]. Fig. 41  (continued). F. i. g. 42 [BB:51.367;211.885;453.200;478.000]. Fig. 42  (a) Gross pathology of left mastectomy specimen. (b, c) The margins get marked and sliced with different. colors on each direction. HR(+) HER2(−) Breast Cancer. 198. . (b) deep margin: <1 mm from ductal carci­. noma in situ (slide 3),. . (c) superficial margin: <1 mm from ductal. carcinoma in situ (slide 5).. 7. Lymph nodes: no metastasis in seven axillary. node biopsy (Fig. 47).. Y. Kim et al.. 199Fig. 43 [BB:51.259;248.064;246.379;658.808]. Fig. 43  Left mammography (Dec. 2020): an irregular. mass with microcalcifications at upper inner quadrantFig. 44. Fig. 44  Left breast US (Dec. 2020): an irregular. hypoechoic mass with angular margins. US-CNB = IDC. 9.3.2. . Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 3.0 cm (pT2).. 2. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 3/3, 40/10 HPF).. 3. Intraductal component: present, intratu­. 200Fig. 45 [BB:51.271;387.653;453.296;658.808]. Fig. 45  Breast MRI (Dec. 2020): an irregular enhancing mass in the left breastFig. 46. Fig. 46  Lymphoscintigraphy shows visualized sentinel. lymph nodes in the left axilla. Y. Kim et al.. 201Fig. 47 [BB:51.314;361.830;453.253;658.808]. a. b. Fig. 47  (a) Gross pathology of lumpectomy specimen. (b) The margins get marked and sliced with different colors on. each direction. 10. . 10.1. . Patient History and Progress. Female/50 years old, pre-menopause.. Screen detected mass lesion on left breast 12. o’clock direction.. No family history.. node dissection (Fig. 52).. Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 2.7 cm (pT2).. HR(+) HER2(−) Breast Cancer. 202Fig. 48 [BB:51.256;313.199;246.381;658.808]. Fig. 48  Left mammography (Nov. 2020): an irregular. hyperdense mass at upper centerFig. 49. Fig. 49  Left breast US (Nov. 2020): an irregular. hypoechoic mass with spiculated margins. US-CNB = IDC. 2. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 3/3, 24/10 HPF).. 3. Intraductal component: present, intratu­. moral/extratumoral (20%) (nuclear grade:. high, necrosis: present, architectural pattern:. cribriform/solid/comedo, extensive intra­. ductal component: absent).. 4. Skin: no involvement of tumor.. 203Fig. 50 [BB:51.283;306.892;453.284;658.808]. Fig. 50  Breast MRI (Dec. 2020): an irregular enhancing mass in the left breast. Enlarged lymph nodes at the left axilla. (white arrow) and internal mammary chain (black arrow)Fig. 51. Fig. 51  Lymphoscintigraphy shows visualized sentinel. lymph nodes in the left axilla. HR(+) HER2(−) Breast Cancer. 204Fig. 52 [BB:51.306;362.070;453.261;658.808]. a. b. Fig. 52  (a) Gross pathology of lumpectomy specimen. (b) The margins get marked and sliced with different colors on. each direction. 11. . 11.1. . Patient History and Progress. Female/60 years old, post-menopause.. Screen detected mass lesion on upper outer. portion of left breast.. No family history.. node biopsy (Fig. 57).. Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 2.5 cm (pT2).. Y. Kim et al.. 205Fig. 53 [BB:51.259;301.002;246.379;658.808]. Fig. 53  Left CC mammography (Nov. 2016, Nov. 2020):. negative finding in 2016. A new mass at the outer breast in. 2020Fig. 54. Fig. 54  Left breast US (Dec. 2020): an irregular. hypoechoic mass at upper outer quadrant. US-CNB = IDC. 2. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 3/3, 29/10 HPF).. 3. Intraductal component: present, intratu­. moral/extratumoral (10%) (nuclear grade:. low, necrosis: absent, architectural pattern:. cribriform, extensive intraductal component:. absent).. 4. Skin: no involvement of tumor.. 206Fig. 55 [BB:51.271;279.761;453.296;658.808]. Fig. 55  Breast MRI (Dec. 2020): a rim-enhancing mass in the left breastFig. 56. Fig. 56  Lymphoscintigraphy shows visualized sentinel. lymph nodes in the left axilla. Y. Kim et al.. 207Fig. 57 [BB:51.314;360.405;453.253;658.808]. a. b. Fig. 57  (a) Gross pathology of lumpectomy specimen. (b) The margins get marked and sliced with different colors on. each direction. 12. . 12.1. . Patient History and Progress. Female/55 years old, pre-menopause.. Screen detected mass lesion on right breast 5. o’clock direction.. No family history.. node biopsy (Fig. 62).. Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 2.3 cm (pT2).. HR(+) HER2(−) Breast Cancer. 208Fig. 58 [BB:51.259;308.321;246.379;658.808]. Fig. 58  Right mammography (Nov. 2020): a spiculated. mass with architectural distortion at lower inner quadrantFig. 59. Fig. 59  Right breast US (Dec. 2020): an irregular. hypoechoic. mass. with. non-parallel. orientation.. US-CNB = IDC. 2. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 1/3, mitotic count:. 1/3, 5/10 HPF).. 3. Intraductal component: present, intratumoral/. 209Fig. 60 [BB:51.271;246.533;453.296;658.808]. Fig. 60  Breast MRI (Dec. 2020): an irregular enhancing mass in the right breastFig. 61. Fig. 61  Lymphoscintigraphy shows visualized sentinel. lymph nodes in the right axilla. HR(+) HER2(−) Breast Cancer. 210Fig. 62 [BB:51.314;361.831;453.253;658.808]. a. b. Fig. 62  (a) Gross pathology of lumpectomy specimen. (b) The margins get marked and sliced with different colors on. each direction. 13. . 13.1. . Patient History and Progress. Female/64 years old, post-menopause.. Screen detected mass lesion on left breast 10. o’clock direction.. No family history.. Left modified radical mastectomy (Fig. 67).. Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 5.2 cm (pT3).. Y. Kim et al.. 211Fig. 63 [BB:51.257;214.430;453.310;658.808]. Fig. 63  Mammography (Nov. 2020): an irregular mass. with microcalcifications at upper inner quadrant of the left. breast. Associated global asymmetry and thickening of. the nipple–areolar complex (black arrow). Enlarged. lymph nodes at the left axilla (white arrows). 2. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 2/3, 10/10 HPF).. 3. Intraductal component: present, intratumoral. (5%) (nuclear grade: high, necrosis: present,. architectural pattern: solid/comedo, exten­. 212Fig. 64. Fig. 64  Left breast US (Nov. 2020): an irregular. hypoechoic. mass. with. microcalcifications.. US-CNB = IDCFig. 65 [BB:51.273;123.597;453.294;428.000]. Fig. 65  Breast MRI (Dec. 2020): an irregular enhancing mass (white arrow) with diffuse non-mass enhancement. (black arrows) in the left breastFig. 66. Fig. 66  Lymphoscintigraphy shows visualized sentinel. lymph nodes in the left axilla. Y. Kim et al.. 213Fig. 67 [BB:51.307;226.018;453.260;658.808]. a. b. c. d. Fig. 67  (a) Gross pathology of mastectomy specimen. (b, c and d) The margins get marked and sliced with different. colors on each direction. . (a) metastasis in eight out of nine axillary. lymph nodes (pN2a) (sentinel LN: 4/4,. axillary LN: 4/5).. . (b) perinodal extension: present.. . (c) size of metastatic carcinoma: 11 mm.. 7. Arteriovenous invasion: absent.. 214Fig. 68 [BB:258.168;162.552;453.328;578.000]. Fig. 68  Left mammography (Dec. 2020): a focal asym­. metry with microcalcifications (black arrows) at outer. subareolar area. Result. Intensity. Positive %. Estrogen receptor. Strong (8/8). 3. >2/3. Progesterone receptor. node biopsy (Fig. 73).. Pathology Report. Mucinous Carcinoma. 1. Post-chemotherapy status.. 2. Size of tumor: 2.0 cm (ypT1c).. 3. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 6/10 HPF).. Y. Kim et al.. 215Fig. 69. Fig. 69  Left breast US (Dec. 2020): an oval isoechoic. mass with microcalcifications. US-CNB  =  IDC with. mucinous componentFig. 70 [BB:51.271;138.290;453.296;445.250]. Fig. 70  Breast MRI (Dec. 2020): a rim-enhancing mass in the left breastFig. 71. Fig. 71  Post-NAC breast MRI (June 2021): decreased. tumor burden after NAC. HR(+) HER2(−) Breast Cancer. 216. 4. Intraductal component: present, intratu­. moral/extratumoral (30%) (nuclear grade:. low, necrosis: absent, architectural pattern:. cribriform/solid, extensive intraductal com­. ponent: present).. 5. Skin: no involvement of tumor.. 6. Surgical margins:. nous carcinoma (slide 1).Fig. 72. Fig. 72  Lymphoscintigraphy shows visualized sentinel. lymph nodes in the left axillaFig. 73 [BB:51.306;153.023;453.261;450.000]. a. b. Fig. 73  (a) Gross pathology of lumpectomy specimen. (b) The margins get marked and sliced with different colors on. each direction. Y. Kim et al.. 217. 7. Lymph nodes: no metastasis in three axillary. lymph nodes (ypN0(sn)) (sentinel LN: 0/3).. 8. Arteriovenous invasion: absent.. 9. Lymphovascular invasion: absent.. . 10. Tumor border: infiltrative.. . node biopsy (Fig. 78).Fig. 74 [BB:258.224;447.128;453.272;658.808]. Fig. 74  Left mammography (Dec. 2020): negative. findingFig. 75. Fig. 75  Left breast US (Dec. 2020): a hypoechoic mass. with non-parallel orientation at upper outer quadrant.. US-CNB = IDC. HR(+) HER2(−) Breast Cancer. 218Fig. 76 [BB:51.283;260.893;453.284;658.808]. Fig. 76  Breast MRI (Dec. 2020): an irregular enhancing mass in the left breast. Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 0.9 cm (pT1b).. 2. Histologic grade: 2/3 (tubule formation: 2/3,. nuclear pleomorphism: 2/3, mitotic count:. 2/3, 10/10 HPF).. 3. Intraductal component: absent.. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . 219Fig. 77. Fig. 77  Lymphoscintigraphy shows visualized sentinel. lymph nodes in the left axillaFig. 78 [BB:51.306;171.022;453.261;468.000]. a. b. Fig. 78  (a) Gross pathology of lumpectomy specimen. (b) The margins get marked and sliced with different colors on. each direction. Result. Intensity. Positive %. Estrogen receptor. Strong (8/8). 3. >2/3. Progesterone receptor. Intermediate (5/8). node biopsy (Fig. 83).. Pathology Report. Invasive Ductal Carcinoma. 1. Post-mammotome excision status.. 2. Size of tumor: 0.6 cm, residual.. 3. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 1/10 HPF).. 4. Intraductal component: present, intratu­. moral/extratumoral (40%) (nuclear grade:. low, necrosis: absent, architectural pattern:. 11. Microcalcification: present, non-tumoral.Fig. 79 [BB:258.163;242.868;453.333;658.808]. Fig. 79  Left mammography (Oct. 2020): one-view. asymmetry at outer breast. Outside US-VABE = IDC (no. available image). Y. Kim et al.. 221. Note: 1. The inferior margin of the. lumpectomy specimen (slide 6) is close to. ductal carcinoma in situ (<1  mm) but this. margin submitted for frozen diagnosis (Fro. 7) is free of tumor.. Result. tumor cellsFig. 80. Fig. 80  Left breast US (Dec. 2020): an irregular. hypoechoic area at the VABE siteFig. 81 [BB:51.271;80.578;453.296;442.063]. Fig. 81  Breast MRI (Dec. 2020): some enhancing foci at the VABE site. HR(+) HER2(−) Breast Cancer. 222Fig. 82. Fig. 82  Lymphoscintigraphy shows visualized sentinel. lymph nodes in the left axillaFig. 83 [BB:51.307;165.925;453.261;462.662]. a. b. Fig. 83  (a) Gross pathology of lumpectomy specimen. (b) The margins get marked and sliced with different colors on. each direction. Y. Kim et al.. 223. 17. . 17.1. . Patient History and Progress. Female/50 years old, peri-menopause.. Screen detected mass lesion on left breast 4. node biopsy (Fig. 88).. Pathology Report. Invasive Ductal Carcinoma. 1. Size of invasive component: 0.4 cm (pT1a).. 2. Size of intraductal component: 3.0 cm.. 3. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 1/10 HPF).. 4. Intraductal component: present, extratumoral. (80%) (nuclear grade: low, necrosis: absent,. architectural pattern: cribriform/solid, exten­. pT1aN0(i+)(sn).Fig. 84 [BB:51.354;105.578;246.284;354.698]. Fig. 84  Left mammography, MLO view (Dec. 2020):. negative findingFig. 85. Fig. 85  Left breast US (Dec. 2020): a small hypoechoic. mass at lower outer quadrant. US-CNB = IDC. HR(+) HER2(−) Breast Cancer. 224Fig. 86. Fig. 86  Breast MRI (Dec. 2020): no suspicious finding in both breastsFig. 87. Fig. 87  Lymphoscintigraphy shows visualized sentinel. lymph nodes in the left axilla. Note: 1. The inferior margin of the lumpectomy. specimen (slide 3) is close to ductal carci­. noma in situ (2 mm) but this margin submit­. ted for frozen diagnosis (Fro 4) is free of. tumor.. 2. The lateral margin of the lumpectomy speci­. men (slide 5) is close to invasive ductal car­. cinoma (1 mm) but this margin submitted for. frozen diagnosis (Fro 4) is free of tumor.. 225Fig. 88 [BB:51.307;361.830;453.260;658.808]. a. b. Fig. 88  (a) Gross pathology of lumpectomy specimen. (b) The margins get marked and sliced with different colors on. each direction. 18. . 18.1. . Patient History and Progress. Female/61 years old, post-menopause.. Screen detected microcalcification of upper. outer portion on left breast.. No family history.. Left breast excision (Fig. 97).. Pathology Report. Ductal Carcinoma in Situ. . 1. Size of tumor: 0.5 cm (pTis).. HR(+) HER2(−) Breast Cancer. 226Fig. 89 [BB:51.242;335.477;246.396;658.808]. Fig. 89  Left mammography (July 2010): regional amor­. phous microcalcifications at upper outer quadrant. . 2. Nuclear grade: low.. . 3. Necrosis: present.. . 4. Architectural. pattern:. cribriform. and. node biopsy (Fig. 98).. Pathology Report. No residual carcinoma.. . 1. Post-excisional biopsy status.. . 2. Lymph nodes: no metastasis in five axillary. lymph nodes (pN0) (sentinel LN: 0/2, axillary. LN: 0/3).. . 3. Additional pathologic findings: Flat atypia. 227Fig. 90. Fig. 90  Breast MRI (Aug. 2010): regional non-mass enhancement at the operative site (white arrow). A benign appear­. ing mass in the right breast (black arrow)Fig. 91. Fig. 91  Lymphoscintigraphy shows visualized sentinel. lymph nodes in the left axilla (Aug. 2010)Fig. 92 [BB:258.283;168.920;453.213;341.000]. Fig. 92  Left mammography (Nov. 2011): post-operative. change at upper outer quadrant. An intramammary lymph. node at upper outer quadrant (black arrow). HR(+) HER2(−) Breast Cancer. 228Fig. 93 [BB:51.259;292.408;246.379;658.808]. Fig. 93  Left mammography (Nov. 2020): newly devel­. oped irregular masses at the operative site (white arrows).. No change in the benign intramammary lymph node. (black arrow)Fig. 94. Fig. 94  Left breast US (Nov. 2020): two masses with. non-parallel orientation. US-CNB = IDC. 3. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 3/10 HPF).. 4. Intraductal component: present, intratumoral. (5%) (nuclear grade: low, necrosis: absent,. architectural pattern: solid, extensive intra­. ductal component: absent).. 5. Skin and nipple: no involvement of tumor.. 6. Surgical margins:. 229Fig. 95 [BB:71.383;255.576;433.183;658.808]. Fig. 95  Breast MRI (Nov. 2020): an irregular enhancing mass in the left breast (white arrow). No change of a benign. appearing mass in the right breast (black arrow)Fig. 96. Fig. 96  Lymphoscintigraphy shows visualized sentinel. lymph nodes in the left axilla (Jan. 2021)Fig. 97. Fig. 97  Gross pathology of breast excision specimen. HR(+) HER2(−) Breast Cancer. 230Fig. 98. Fig. 98  Gross pathology of lumpectomy specimenFig. 99 [BB:51.306;217.571;453.261;486.500]. a. b. c. d. Fig. 99  (a) Gross pathology of right mastectomy specimen. (b, c and d) The margins get marked and sliced with dif­. ferent colors on each direction. Y. Kim et al.. 231Fig. 100 [BB:51.226;392.693;453.341;658.808]. a. b. c. d. Fig. 100  (a) Gross pathology of left mastectomy specimen. (b, c and d) The margins get marked and sliced with dif­. ferent colors on each direction. 19. . 19.1. . Patient History and Progress. Female/43 years old, pre-menopause.. Screen detected mass lesion of lower inner on. left breast.. No family history.. 232Fig. 101 [BB:51.259;243.015;246.379;658.808]. Fig. 101  Left mammography (Jan. 2021): an irregular. mass at lower inner quadrantFig. 102. Fig. 102  Left breast US (Jan. 2021): a hypoechoic mass. with angular margins at lower inner quadrant.. US-CNB = IDC. 6. Lymph nodes: no metastasis in one axillary. lymph node (pN0(sn)) (sentinel LN: 0/1).. 7. Arteriovenous invasion: absent.. 8. Lymphovascular. invasion:. present,. intratumoral.. 9. Tumor border: infiltrative.. 233Fig. 103 [BB:51.280;285.793;453.287;658.808]. Fig. 103  Breast MRI (Jan. 2021): an irregular enhancing mass at lower inner quadrant of the left breast (white arrow,. proven IDC). Another irregular enhancing mass at the lower outer quadrant of the left breast (black arrow)Fig. 104. Fig. 104  MRI-directed left breast US (Jan. 2021): a. hypoechoic mass with non-parallel orientation at lower. outer quadrant. US-CNB = IDCFig. 105. Fig. 105  Lymphoscintigraphy shows visualized sentinel. lymph nodes in the left axilla. HR(+) HER2(−) Breast Cancer. 234Fig. 106 [BB:51.323;370.528;453.244;658.808]. a. bFig. 106 [BB:51.323;370.528;453.244;658.808]. Fig. 106  (a) Preoperative and (b) immediate post-operative appearance. F. i. g. 107 [BB:51.307;63.094;453.260;332.000]. Fig. 107  (a) Gross pathology of mastectomy specimen. (b, c) The margins get marked and sliced with different colors. on each direction. Y. Kim et al.. 235. 20. . 20.1. . Patient History and Progress. Female/49 years old, pre-menopause.. Screen detected mass lesion on left breast 2. node biopsy (Fig. 113).. Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 0.9 cm (pT1b).. 2. Histologic grade: 1/3 (tubule formation: 2/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 1/10 HPF).. 3. Intraductal component: present, intratu­. moral/extratumoral (40%) (nuclear grade:. low, necrosis: absent, architectural pattern:. micropapillary/cribriform/solid/comedo,. (f) superficial margin: 3 mm.Fig. 108 [BB:258.188;292.037;453.308;658.808]. Fig. 108  Left mammography (Nov. 2020): an irregular. mass at upper outer quadrantFig. 109. Fig. 109  Left breast US (Nov. 2020): an irregular mass. with non-parallel orientation. US-CNB = IDC. HR(+) HER2(−) Breast Cancer. 236Fig. 110 [BB:51.271;275.977;453.296;658.808]. Fig. 110  Breast MRI (Nov. 2021): an irregular enhancing mass in the left breastFig. 111. Fig. 111  Lymphoscintigraphy shows visualized sentinel. lymph nodes in the left axilla. 6. Lymph nodes: no metastasis in six axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/3,. non-sentinel LN: 0/3).. 7. Arteriovenous invasion: absent.. 8. Lymphovascular invasion: absent.. 9. Tumor border: infiltrative.. . 10. Microcalcification:. present,. 237Fig. 112. Fig. 112  Breast MRI for routine surveillance (Oct. 2021): No abnormal finding in both breastsFig. 113 [BB:51.306;157.023;453.261;454.000]. a. b. Fig. 113  (a) Gross pathology of lumpectomy specimen. (b) The margins get marked and sliced with different colors. on each direction. Result. Intensity. Positive %. Estrogen receptor. Intermediate (6/8). 1. >2/3. Progesterone receptor. Intermediate (6/8). Left breast conserving surgery (Fig. 118).. Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 1.2 cm (pT1c).. 2. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 2/3, 11/10 HPF).. 3. Intraductal component: present, intratu­. moral/extratumoral (20%) (nuclear grade:. low, necrosis: present, architectural pattern:. solid/comedo, extensive intraductal compo­. 8. Tumor border: infiltrative.Fig. 114 [BB:51.238;100.578;246.400;438.999]. Fig. 114  Left CC mammography (June 2019, Nov.. 2020): negative finding in 2019. A new mass at the central. breast in 2020Fig. 115. Fig. 115  Left breast US (Nov. 2020): a hypoechoic mass. with microlobulated margins at 12 o’clock direction.. Outside US-CNB = DCIS. Y. Kim et al.. 239Fig. 116 [BB:51.271;251.490;453.296;658.808]. Fig. 116  Breast MRI (Nov. 2020): an irregular enhancing mass in the left breastFig. 117. Fig. 117  Lymphoscintigraphy shows visualized sentinel. lymph nodes in the left lateral breast. 9. Microcalcification:. present,. tumoral/. non-tumoral.. . 10. Pathological TN category (AJCC 2017):. pT1c.. Result. Intensity. 240Fig. 118 [BB:51.306;361.831;453.261;658.808]. a. b. Fig. 118  (a) Gross pathology of lumpectomy specimen. (b) The margins get marked and sliced with different colors. on each direction. Operation (2nd, Jan. 2021). Left sentinel lymph node biopsy.. Pathology Report. No metastasis in two axillary lymph nodes. . 1. Post-lumpectomy status.. 22. . 22.1. Left modified radical mastectomy (Fig. 125).. Y. Kim et al.. 241Fig. 119 [BB:51.287;469.207;453.280;658.808]. Fig. 119  Mammography (June 2020): global asymmetry with edema in the left breastFig. 120 [BB:51.366;285.700;453.200;428.500]. Fig. 120  Left breast US (July 2020): irregular hypoechoic lesion with posterior acoustic shadowing involving the. entire left breast (partly shown). US-CNB = IDC. Pathology Report. Invasive Micropapillary Carcinoma. 1. Post-chemotherapy status.. 2. Size of tumor: 11.0 cm (ypT3).. 3. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 2/10HPF).. 4. Intraductal component: absent.. 5. Skin and nipple: dermal involvement of. 242Fig. 121 [BB:51.283;321.652;453.284;658.808]. Fig. 121  Breast MRI (Aug. 2020): diffuse non-mass enhancement with involvement of the skin. Enlarged lymph nodes. at the left axilla (black arrow)Fig. 122. Fig. 122  Post-NAC breast MRI (Dec. 2020): slightly decreased tumor burden in the left breast. Y. Kim et al.. 243. . 11. Microcalcification:. present,. tumoral/. non-tumoral.. . 12. Pathological TN category (AJCC 2017):. ypT3N2a.. of tumor cellsFig. 123. Fig. 123  Lymphoscintigraphy shows visualized sentinel. lymph nodes in the left axillaFig. 124. Fig. 124  Breast MRI for routine surveillance (July 2021): no abnormal finding in right breast and anterior left chest. wall. HR(+) HER2(−) Breast Cancer. 244Fig. 125 [BB:51.306;225.861;453.261;658.808]. a. b. c. d. Fig. 125  (a) Gross pathology of mastectomy specimen. (b, c and d) The margins get marked and sliced with different. colors on each direction. 23. . 23.1. . Patient History and Progress. Female/53 years old, post-menopause.. Screen detected mass lesion on right breast 7. o’clock direction.. Family history of breast cancer, younger. 245Fig. 126 [BB:51.259;290.486;246.379;658.808]. Fig. 126  Right mammography (July 2020): an irregular. mass with microcalcifications at lower center. Another. oval mass at the upper outer quadrant (black arrow).. Multiple enlarged lymph nodes at the right axilla (white. arrows)Fig. 127 [BB:258.188;397.253;453.308;658.808]. Fig. 127  Right breast US (July 2020): an irregular. hypoechoic mass with microcalcifications at lower center. (white arrows, US-CNB = IDC). Another oval isoechoic. mass at the upper outer quadrant (black arrow). 23.3. . Courses of Treatment. Neoadjuvant chemotherapy (#4  cycles of. doxorubicin & cyclophosphamide followed by. #4  cycles of docetaxel)  +  Operation  +  Post-­. operative radiation therapy  +  Letrozole. node biopsy (Fig. 131).. Pathology Report. . 1. Microinvasive ductal carcinoma. . (a) Post-chemotherapy status.. . (b) Size of invasive component: <0.1  cm. (ypT1mi).. . (c) Size of intraductal component: 1.5 cm.. 246Fig. 128 [BB:51.283;295.732;453.284;658.808]. Fig. 128  Breast MRI (July 2020): an irregular enhancing mass in the right breast (white arrow). Enlarged lymph node. at the right axilla (black arrow)Fig. 129. Fig. 129  Post-NAC breast MRI (Dec. 2020): Decreased. size of the tumor after NACFig. 130. Fig. 130  Lymphoscintigraphy shows visualized sentinel. lymph nodes in the right axilla. Y. Kim et al.. 247Fig. 131 [BB:51.306;361.830;453.261;658.808]. a. b. Fig. 131  (a) Gross pathology of lumpectomy specimen. (b) The margins get marked and sliced with different colors. on each direction. • deep margin: <1 mm from ductal car­. cinoma in situ (slide 1).. • superficial margin: 5 mm.. . (h) Lymph nodes: no metastasis in three. axillary lymph nodes (ypN0(sn)) (senti­. nel LN: 0/1, axillary LN: 0/2). . (i) Arteriovenous invasion: absent.. node dissection (Fig. 137).. Pathology Report. Invasive Ductal Carcinoma. 1. Post-chemotherapy status.. 2. Size of tumor: 2.0 cm (ypT1c).. 3. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 1/10 HPF). 4. Intraductal component: present, intratumoral/. extratumoral (5%) (nuclear grade: low, necro­. sis: absent, architectural pattern: solid, exten­. (c) medial margin: 10 mm.Fig. 132 [BB:258.171;287.331;453.325;658.808]. Fig. 132  Breast MRI (July 2020): an irregular enhancing. mass in the right breast (white arrow). Enlarged lymph. node at the right axilla (black arrow). Y. Kim et al.. 249Fig. 133 [BB:51.366;472.087;453.200;658.808]. Fig. 133  Right breast US (June 2020): an irregular mass with microcalcifications at outer center (white arrow,. US-CNB = IDC). Another irregular mass at the lower outer quadrant (black arrow). . (d) lateral margin: positive for invasive duc­. tal carcinoma (Fro 4).. . (e) deep margin: 5 mm.. . (f) superficial margin: 3 mm.. 7. Lymph nodes:. . Right breast wide excision (Fig. 138).. Pathology Report. No residual tumor with foreign body reaction.. . 1. Post-lumpectomy status.. HR(+) HER2(−) Breast Cancer. 250Fig. 134 [BB:51.283;174.330;453.284;658.808]. Fig. 134  Breast MRI (June 2020): two irregular enhancing masses in the right breast. Multiple enlarged lymph nodes. at the right axilla (circle, US-CNB = Metastatic ductal carcinoma). Y. Kim et al.. 251Fig. 135. Fig. 135  Post-NAC breast MRI (Jan. 2021): decreased size of the tumors and lymph nodes after NACFig. 136. Fig. 136  Lymphoscintigraphy shows visualized sentinel. lymph nodes in the right axilla. HR(+) HER2(−) Breast Cancer. 252Fig. 137 [BB:51.314;361.830;453.253;658.808]. a. b. Fig. 137  (a) Gross pathology of lumpectomy specimen. (b) The margins get marked and sliced with different colors. on each directionFig. 138 [BB:51.366;177.540;453.201;310.500]. a. b. Fig. 138  (a) Gross pathology of breast wide excision specimen. (b) The margins get marked and sliced with different. colors on each direction. Y. Kim et al.. 253. 25. . 25.1. . Patient History and Progress. Female/61 years old, post-menopause.. Screen detected mass lesion on left breast 12. node dissection (Fig. 144).. Pathology Report. Invasive Ductal Carcinoma. 1. Post-chemotherapy status.. 2. Size of tumor: 1.8 cm (ypT1c).. 3. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 2/3, 11/10 HPF). 4. Intraductal component: present, intratu­. moral/extratumoral (5%) (nuclear grade:. low, necrosis: present, architectural pattern:. (a) superior margin: 20 mm.Fig. 139 [BB:258.168;320.135;453.328;658.808]. Fig. 139  Left mammography (Dec. 2020): an irregular. mass with spiculated margins at upper centerFig. 140. Fig. 140  Left breast US (Dec. 2020): an irregular. hypoechoic mass with angular margins. US-CNB = IDC. HR(+) HER2(−) Breast Cancer. 254Fig. 141 [BB:51.271;237.337;453.296;658.808]. Fig. 141  Breast MRI (Dec. 2020): an irregular enhancing mass in the left breast (white arrow). Mildly enlarged lymph. node at the left axilla (black arrow, US-CNB = Metastatic ductal carcinoma). . (b) inferior margin: 10 mm.. . (c) medial margin: 10 mm.. . (d) lateral margin: 10 mm.. . (e) deep margin: 2 mm.. . 255Fig. 142. Fig. 142  Post-NAC breast MRI (June 2021): decreased. volume of the tumor after NACFig. 143. Fig. 143  Lymphoscintigraphy shows faintly visualized. sentinel lymph nodes in the left axillaFig. 144 [BB:51.315;112.022;453.252;409.000]. a. b. Fig. 144  (a) Gross pathology of lumpectomy specimen. (b) The margins get marked and sliced with different colors. on each direction. HR(+) HER2(−) Breast Cancer. 256Fig. 145 [BB:258.188;221.265;453.308;658.808]. Fig. 145  Left mammography (Dec. 2020): an irregular. mass with spiculated margins at upper outer quadrant. Result. Intensity. Positive. %. Estrogen. receptor. Intermediate. (6/8). 2. node biopsy (Fig. 149).. Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 1.7 cm (pT1c).. 2. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 2/10 HPF). 3. Intraductal component: present, intratumoral. (5%) (nuclear grade: low, necrosis: absent,. architectural pattern: solid, extensive intra­. ductal component: absent).. 257Fig. 146. Fig. 146  Left breast US (Dec. 2020): an irregular. hypoechoic. mass. with. non-parallel. orientation.. US-CNB = IDCFig. 147 [BB:51.271;93.078;453.296;425.732]. Fig. 147  Breast MRI (Dec. 2020): an irregular rim-enhancing mass in the left breastFig. 148. Fig. 148  Lymphoscintigraphy shows visualized sentinel. lymph nodes in the left axilla. HR(+) HER2(−) Breast Cancer. 258Fig. 149 [BB:51.306;361.830;453.261;658.808]. a. b. Fig. 149  (a) Gross pathology of lumpectomy specimen. (b) The margins get marked and sliced with different colors. on each direction. . (b) inferior margin: 6 mm.. . (c) medial margin: 10 mm.. . (d) lateral margin: 15 mm.. . (e) deep margin: 8 mm.. . 259Fig. 150 [BB:51.236;185.710;246.402;658.808]. Fig. 150  Left mammography (Dec. 2020): two irregular. masses at upper inner quadrantFig. 151. Fig. 151  Left breast US (Dec. 2020): two hypoechoic. masses with spiculated margins. US-CNB = IDC. 27.3. . Courses of Treatment. Operation  +  Post-operative radiation ther­. apy + Anastrozole 1 mg/day.. Operation (1st, Jan. 2021). Left breast conserving surgery, sentinel lymph. node biopsy (Fig. 154).. Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 2.1 cm (pT2).. 2. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 3/10 HPF). 3. Intraductal component: present, intratu­. moral/extratumoral (50%) (nuclear grade:. low, necrosis: present, architectural pattern:. cribriform/solid/comedo, extensive intra­. 260Fig. 152 [BB:51.279;264.180;453.288;658.808]. Fig. 152  Breast MRI (Dec. 2020): two irregular enhancing masses in the left breastFig. 153. Fig. 153  Lymphoscintigraphy shows visualized sentinel. lymph nodes in the left axilla. Intraductal Papilloma. Note: 1. Ductal carcinoma in situ is present only. in the permanent section of Fro 1.. The medial margin of the lumpectomy specimen. (slide 9) is positive for ductal carcinoma in. situ but this margin submitted for frozen diag­. nosis (Fro 3) is free of tumor. Result. Intensity Positive %. 261Fig. 154 [BB:51.306;361.830;453.261;658.808]. a. b. Fig. 154  (a) Gross pathology of lumpectomy specimen. (b) The margins get marked and sliced with different colors. on each direction. Operation (2nd, Feb. 2021). Left breast wide excision.. Pathology Report. No residual tumor with foreign body reaction.. . 1. Post-lumpectomy status.. 28. . 28.1. node biopsy (Fig. 159).. Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 2.9 cm (pT2).. 2. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 3/10 HPF). 3. Intraductal component: present, intratu­. moral/extratumoral (5%) (nuclear grade:. low, necrosis: absent, architectural pattern:. cribriform/solid, extensive intraductal com­. 262Fig. 155 [BB:51.259;235.492;246.379;658.808]. Fig. 155  Right mammography (Oct. 2020): an irregular. mass with microcalcifications at lower outer quadrantFig. 156. Fig. 156  Right breast US (Dec. 2020): an irregular. hypoechoic mass. US-CNB = IDC. 5. Surgical margins:. . (a) superior margin: 15 mm.. . (b) inferior margin: 6 mm.. . (c) medial margin: 10 mm.. . (d) lateral margin: 10 mm.. 263Fig. 157 [BB:51.271;285.075;453.296;658.808]. Fig. 157  Breast MRI (Dec. 2020): an irregular enhancing mass in the right breast (white arrow). Enlarged lymph nodes. at the right axilla (black arrow)Fig. 158. Fig. 158  Lymphoscintigraphy shows visualized sentinel. lymph nodes in the right axilla. HR(+) HER2(−) Breast Cancer. 264Fig. 159 [BB:51.307;362.070;453.260;658.808]. a. b. Fig. 159  (a) Gross pathology of lumpectomy specimen. (b) The margins get marked and sliced with different colors. on each direction. 29. . 29.1. . Patient History and Progress. Female/80 years old, post-menopause.. Screen detected mass lesion on left breast 10. o’clock direction.. No family history.. node biopsy (Fig. 164).. Pathology Report. Invasive ductal carcinoma with mucinous. component associated with mucocele-­. like. lesion.. 1. Size of tumor: 0.8 cm (pT1b).. 2. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 1/10 HPF). 3. Intraductal component: absent.. tumor cellsFig. 160 [BB:51.240;285.092;246.398;658.808]. Fig. 160  Left mammography (Dec. 2020): an irregular. mass at upper inner quadrantFig. 161. Fig. 161  Left breast US (Dec. 2020): an irregular. isoechoic. mass. with. angular. margins.. US-CNB = Mucinous carcinoma. HR(+) HER2(−) Breast Cancer. 266Fig. 162 [BB:51.271;331.592;453.296;658.808]. Fig. 162  Breast MRI (Dec. 2020): an irregular enhancing mass in the left breastFig. 163. Fig. 163  Lymphoscintigraphy shows visualized sentinel. lymph nodes in the left axilla. Y. Kim et al.. 267Fig. 164 [BB:51.306;361.830;453.261;658.808]. a. b. Fig. 164  (a) Gross pathology of lumpectomy specimen. (b) The margins get marked and sliced with different colors. on each direction. 30. . 30.1. . Patient History and Progress. Female/63 years old, post-menopause.. Screen detected mass lesion on left breast 4. o’clock direction.. No family history.. node biopsy (Fig. 169).. Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 1.1 cm (pT1c).. 2. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 6/10 HPF). HR(+) HER2(−) Breast Cancer. 268Fig. 165 [BB:51.259;311.573;246.380;658.808]. Fig. 165  Left mammography (Dec. 2020): an irregular. mass with spiculated margins at lower outer quadrantFig. 166. Fig. 166  Left breast US (Dec. 2020): an irregular. hypoechoic. mass. with. non-parallel. orientation.. US-CNB = IDC. 3. Intraductal component: present, intratu­. moral/extratumoral (10%) (nuclear grade:. low, necrosis: absent, architectural pattern:. cribriform/solid, extensive intraductal com­. 269Fig. 167 [BB:51.271;293.217;453.296;658.808]. Fig. 167  Breast MRI (Dec. 2020): an irregular enhancing mass in the left breastFig. 168. Fig. 168  Lymphoscintigraphy shows visualized sentinel. lymph nodes in the left axilla. HR(+) HER2(−) Breast Cancer. 270Fig. 169 [BB:51.306;361.830;453.261;658.808]. a. b. Fig. 169  (a) Gross pathology of lumpectomy specimen. (b) The margins get marked and sliced with different colors. on each direction. 31. . 31.1. . Patient History and Progress. Female/65 years old, post-menopause.. Screen detected mass lesion on right breast 6. o’clock direction.. Family history of breast cancer, older sister,. node biopsy (Fig. 174).. Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 2.2 cm (pT2).. 2. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 2/3, 10/10 HPF). 3. Intraductal component: present, intratu­. moral/extratumoral (5%) (nuclear grade:. Y. Kim et al.. 271Fig. 170 [BB:51.259;315.264;246.379;658.078]. Fig. 170  Right mammography (Dec. 2020): an irregular. mass at lower outer quadrant. A lymph node with cortical. thickening at the right axilla (black arrow)Fig. 171. Fig. 171  Right breast US (Dec. 2020): an irregular. hypoechoic mass. US-CNB = IDC. high, necrosis: absent, architectural pattern:. cribriform/solid, extensive intraductal com­. ponent: absent).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) superior margin: 30 mm.. . (b) inferior margin: 40 mm.. 272Fig. 172 [BB:51.271;244.278;453.296;658.808]. Fig. 172  Breast MRI (Dec. 2020): an irregular enhancing mass in the right breast (white arrow). An enlarged lymph. node at the right axilla (black arrow). Y. Kim et al.. 273Fig. 173. Fig. 173  Lymphoscintigraphy shows visualized sentinel. lymph nodes in the right axillaFig. 174 [BB:51.314;166.522;453.253;463.500]. a. b. Fig. 174  (a) Gross pathology of lumpectomy specimen. (b) The margins get marked and sliced with different colors. on each direction. HR(+) HER2(−) Breast Cancer. 274. 32. . 32.1. . Patient History and Progress. Female/70 years old, post-menopause.. Screen detected mass lesion on right breast 10. node biopsy (Fig. 179).. Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 2.0 cm (pT1c).. 2. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 1/10 HPF). 3. Intraductal component: present, intratu­. moral/extratumoral (5%) (nuclear grade:. low, necrosis: absent, architectural pattern:. cribriform/solid, extensive intraductal com­. non-sentinel LN: 0/0)Fig. 175 [BB:51.259;109.244;246.379;432.000]. Fig. 175  Right mammography (Dec. 2020): a spiculated. mass (white arrow) with an adjacent smaller mass (black. arrow) at upper outer quadrantFig. 176. Fig. 176  Right breast US (Dec. 2020): two irregular. hypoechoic masses. US-CNB = IDC. Y. Kim et al.. 275Fig. 177 [BB:51.271;314.539;453.296;658.808]. Fig. 177  Breast MRI (Dec. 2020): a bilobed rim-enhancing mass in the right breastFig. 178. Fig. 178  Lymphoscintigraphy shows visualized sentinel. lymph nodes in the right axilla. 7. Arteriovenous invasion: absent.. 8. Lymphovascular. invasion:. present,. intratumoral.. 9. Tumor border: infiltrative.. . 10. Microcalcification: present, non-tumoral.. . 276Fig. 179 [BB:51.307;361.830;453.260;658.808]. a. b. Fig. 179  (a) Gross pathology of lumpectomy specimen. (b) The margins get marked and sliced with different colors. on each directionFig. 180 [BB:258.283;95.047;453.213;312.727]. Fig. 180  Left mammography (Dec. 2020): negative. finding. 33. . 33.1. . Patient History and Progress. Female/42 years old, pre-menopause.. Screen detected mass lesion on left breast 12. o’clock direction.. No family history.. 277Fig. 181. Fig. 181  Left breast US (Dec. 2020): an irregular mass. with microlobulated margins at 12 o’clock direction.. US-CNB = IDCFig. 182. Fig. 182  Breast MRI (Dec. 2020): no discernible suspicious finding in both breastsFig. 183. Fig. 183  Lymphoscintigraphy shows visualized sentinel. lymph nodes in the left axilla. Operation. Left breast conserving surgery, sentinel lymph. node biopsy (Fig. 185).. Pathology Report. Invasive Ductal Carcinoma. 1. Size of invasive component: 0.4 cm (pT1a).. 2. Size of intraductal component: 1.3 cm.. 3. Histologic grade: 1/3 (tubule formation: 2/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 1/10 HPF). 4. Intraductal component: present, intratu­. moral/extratumoral (70%) (nuclear grade:. low, necrosis: absent, architectural pattern:. 278Fig. 184. Fig. 184  Breast MRI for routine surveillance (Feb. 2022): no abnormal finding in both breastsFig. 185 [BB:51.307;159.925;453.261;456.903]. a. b. Fig. 185  (a) Gross pathology of lumpectomy specimen. (b) The margins get marked and sliced with different colors. on each direction. 6. Surgical margins:. . (a) superior margin: 25 mm.. . (b) inferior margin: 20 mm.. . (c) medial margin: 15 mm.. . (d) lateral margin: 10 mm.. 2/3, 11/10 HPF)Fig. 186 [BB:258.283;419.528;453.213;658.808]. Fig. 186  Right mammography (Dec. 2020): negative. findingFig. 187. Fig. 187  Right breast US (Dec. 2020): a hypoechoic. mass with microlobulated margins at upper outer quad­. rant. US-CNB = IDC. HR(+) HER2(−) Breast Cancer. 280Fig. 188 [BB:51.283;345.173;453.284;658.808]. Fig. 188  Breast MRI (Jan. 2021): an irregular enhancing mass in the right breast. Negative finding in the left breastFig. 189. Fig. 189  Lymphoscintigraphy shows visualized sentinel. lymph nodes in the right axilla. 3. Intraductal component: present, intratu­. moral/extratumoral (10%) (nuclear grade:. high, necrosis: absent, architectural pattern:. cribriform/solid, extensive intraductal com­. ponent: absent).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) deep margin: <1 mm from ductal carci­. 281Fig. 190 [BB:61.355;379.833;443.212;658.808]. a. bFig. 190 [BB:61.355;379.833;443.212;658.808]. Fig. 190  (a) Preoperative and (b) immediate post-operative appearance. F. i. g. 191 [BB:61.354;83.867;443.212;339.325]. Fig. 191  (a) Gross pathology of right mastectomy specimen. (b and c) The margins get marked and sliced with differ­. ent colors on each direction. HR(+) HER2(−) Breast Cancer. 282. F. i. g. 192 [BB:51.306;389.714;453.261;658.808]. Fig. 192  (a) Gross pathology of left mastectomy specimen. (b and c) The margins get marked and sliced with different. colors on each direction. 8. Lymphovascular. invasion:. present,. intratumoral.. 9. Tumor border: infiltrative.. . 10. Microcalcification:. present,. tumoral/. 283Fig. 193 [BB:51.259;257.308;246.379;658.808]. Fig. 193  Left mammography (Jan. 2021): a focal asym­. metry at lower outer quadrantFig. 194. Fig. 194  Left breast US (Feb. 2021): an irregular. hypoechoic mass with angular margins. US-CNB = IDC. 35.3. . Courses of Treatment. Operation + Adjuvant chemotherapy (#4. cycles of docetaxel & cyclophosphamide)  +. Post-operative radiation therapy + Tamoxifen. 20 mg/day.. Operation. Left breast conserving surgery, sentinel lymph. node biopsy (Fig. 198).. Pathology Report. Invasive Ductal Carcinoma. 1. Post-chemotherapy status.. 2. Size of tumor: 1.1 cm (ypT1c).. 3. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 2/3, 11/10 HPF). 4. Intraductal component: present, intratu­. moral/extratumoral (50%) (nuclear grade:. low, necrosis: present, architectural pattern:. 284Fig. 195 [BB:71.372;292.081;433.194;658.808]. Fig. 195  Breast MRI (Feb. 2021): an oval enhancing mass with irregular margins in the left breastFig. 196. Fig. 196  Post-NAC breast MRI (June 2021): minimally. decreased volume of the tumor after NACFig. 197. Fig. 197  Lymphoscintigraphy shows visualized sentinel. lymph nodes in the left axilla. Y. Kim et al.. 285. F. i. g. 198 [BB:51.331;226.036;453.236;658.808]. Fig. 198  (a) Gross pathology of lumpectomy specimen. (b and c) The margins get marked and sliced with different. colors on each direction. . (b) perinodal extension: absent.. . (c) size of metastatic carcinoma: 6 mm.. 8. Arteriovenous invasion: absent.. 9. Lymphovascular. invasion:. present,. intratumoral.. node biopsy (Fig. 204).. Pathology Report. Invasive Ductal Carcinoma. • Associated with complex sclerosing lesion.. 1. Size of tumor: 0.9 cm (pT1b).. 2. Histologic grade: 1/3 (tubule formation: 2/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 6/10 HPF). 3. Intraductal component: present, intratumoral. (40%) (nuclear grade: low, necrosis: absent,. architectural pattern: ­. 7. Arteriovenous invasion: absent.Fig. 199 [BB:51.354;141.925;246.284;319.525]. Fig. 199  Right mammography (Dec. 2020): negative. findingFig. 200. Fig. 200  Right breast US (Dec. 2020): an irregular. hypoechoic mass with angular margins at upper outer. quadrant. US-CNB = IDC. Y. Kim et al.. 287Fig. 201 [BB:51.283;332.451;453.284;658.808]. Fig. 201  Breast MRI (Jan. 2021): an enhancing mass with irregular margins in the right breastFig. 202. Fig. 202  Lymphoscintigraphy shows visualized sentinel. lymph nodes in the right axilla. 8. Lymphovascular invasion: absent.. 9. Tumor border: infiltrative.. . 10. Microcalcification:. present,. tumoral/. non-tumoral.. . 11. Pathological TN category (AJCC 2017):. 288Fig. 203. Fig. 203  Breast MRI for routine surveillance (Feb. 2022): no abnormal finding in both breastsFig. 204 [BB:51.307;136.022;453.261;433.000]. a. b. Fig. 204  (a) Gross pathology of lumpectomy specimen. (b) The margins get marked and sliced with different colors. on each direction. Y. Kim et al.. 289. 37. . 37.1. . Patient History and Progress. Female/43 years old, pre-menopause.. Screen detected mass lesion on right breast. node biopsy (Fig. 209).. Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 2.5 cm (pT2).. 2. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 2/3, 13/10 HPF). 3. Intraductal component: present, intratu­. moral/extratumoral (40%) (nuclear grade:. high, necrosis: present, architectural pattern:. cribriform/solid/comedo, extensive intra­. carcinoma in situ (slide 8).Fig. 205 [BB:258.188;276.412;453.308;658.808]. Fig. 205  Left mammography (Dec. 2020): a focal asym­. metry with fine pleomorphic microcalcifications at lower. outer quadrantFig. 206. Fig. 206  Left breast US (Jan. 2021): an irregular. hypoechoic. mass. with. microcalcifications.. US-CNB = IDC. HR(+) HER2(−) Breast Cancer. 290Fig. 207 [BB:51.271;333.472;453.296;658.808]. Fig. 207  Breast MRI (Jan. 2021): an irregular enhancing mass in the left breastFig. 208. Fig. 208  Lymphoscintigraphy shows visualized sentinel. lymph nodes in the left axilla. 6. Lymph nodes: no metastasis in four axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/4). 7. Arteriovenous invasion: absent.. 8. Lymphovascular. invasion:. present,. intratumoral.. 9. Tumor border: infiltrative.. . 291Fig. 209 [BB:51.306;362.070;453.261;658.808]. a. b. Fig. 209  (a) Gross pathology of lumpectomy specimen. (b) The margins get marked and sliced with different colors. on each direction. Result. Intensity. Positive %. Estrogen receptor. Strong (7/8). 2. >2/3. Progesterone receptor. Intermediate (6/8). 292Fig. 210 [BB:51.259;284.932;246.379;658.808]. Fig. 210  Left mammography (Nov. 2020): an irregular. hyperdense mass at outer centerFig. 211. Fig. 211  Left breast US (Nov. 2020): a circumscribed. hypoechoic mass. Outside US-VABE = IDCFig. 212. Fig. 212  Left breast US (Jan. 2021): post-VABE changes. (black arrow) with a residual mass (white arrow). Operation. Left breast conserving surgery, sentinel lymph. node biopsy (Fig. 215).. Pathology Report. Invasive Ductal Carcinoma. 1. Post-mammotome excision status.. 2. Size of tumor: 0.5 cm, residual.. 3. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 3/10 HPF). 4. Intraductal component: present, extratumoral. (60%) (nuclear grade: low, necrosis: present,. architectural pattern: cribriform/comedo,. 293Fig. 213 [BB:51.271;352.234;453.296;658.808]. Fig. 213  Breast MRI (Jan. 2021): a residual mass in the left breastFig. 214. Fig. 214  Lymphoscintigraphy shows visualized sentinel. lymph nodes in the left axilla. 8. Arteriovenous invasion: absent.. 9. Lymphovascular invasion: absent.. . 10. Tumor border: infiltrative.. . 11. Microcalcification: present, non-tumoral.. Result. Intensity. Positive. 294Fig. 215 [BB:51.314;361.580;453.253;658.558]. a. b. Fig. 215  (a) Gross pathology of lumpectomy specimen. (b) The margins get marked and sliced with different colors. on each direction. 39. . 39.1. . Patient History and Progress. Female/47 years old, pre-menopause.. Screen detected mass lesion on right breast 11. o’clock direction.. No family history.. Intraductal papilloma.Fig. 216 [BB:51.259;304.612;246.379;658.808]. Fig. 216  Right mammography (Feb. 2021): a focal. asymmetry at upper inner quadrantFig. 217. Fig. 217  Right breast US (Feb. 2021): an irregular. hypoechoic mass with angular margins. US-CNB = IDC. HR(+) HER2(−) Breast Cancer. 296Fig. 218 [BB:51.271;334.475;453.296;658.808]. Fig. 218  Breast MRI (Feb. 2021): an irregular enhancing mass in the right breastFig. 219. Fig. 219  Lymphoscintigraphy shows visualized sentinel. lymph nodes in the right axilla. Y. Kim et al.. 297. F. ig. 220 [BB:51.306;369.268;453.261;658.808]. Fig. 220  (a) Preoperative and (b) immediate post-operative appearance. F. i. g. 221 [BB:51.307;64.557;453.260;333.000]. Fig. 221  (a) Gross pathology of right mastectomy specimen. (b and c) The margins get marked and sliced with differ­. ent colors on each direction. HR(+) HER2(−) Breast Cancer. 298Fig. 222 [BB:51.306;525.848;453.261;658.808]. a. b. Fig. 222  (a) Gross pathology of left breast mass excision specimen. (b) The margins get marked and sliced with dif­. ferent colors on each direction. Y. Kim et al.. 299. © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023. E. S. Lee (ed.), A Practical Guide to Breast Cancer Treatment,. https://doi.org/10.1007/978-981-19-9044-1_6" +865,Important Radiologic Findings,Important Radiologic Findings,HR(−) HER2(+) Breast Cancer,"Fig. 4  PET-CT shows. (a) hypermetabolic. nodule in right upper. breast (mSUV = 5.5). and (b) prominent right. axillary LN with. hypermetabolism. (mSUV = 3.1). HR(−) HER2(+) Breast Cancer. 430. 1.3. Fig. 6. Fig. 6  Breast MRI (Dec. 2020): MRI after treatment. shows complete resolution of enhancement in the right. breast. . Y. Kwon et al.. 431. 1.4. . Courses of Treatment. Neoadjuvant chemotherapy (#6 cycles of. docetaxel and carboplatin and trastuzumab and. 12Fig. 9. Fig. 9  Mammography (July 2020):. irregular hyperdense mass in left. subareolar area. Y. Kwon et al.. 433. . . ­. . ­. HR(−) HER2(+) Breast Cancer. Fig. 21  PET-CT shows (a). hypermetabolic mass in the left upper. outer breast (mSUV = 11.7), (b). enlarged hypermetabolic LNs in the left. axilla level I–II (mSUV = 5.9), (c). hypermetabolic nodule in the left. pectoralis muscle (mSUV = 4.9), and. (d) focal hypermetabolic osteolytic. lesion in L5 (mSUV = 5.0). HR(−) HER2(+) Breast Cancer. 440. Fig. 30  PET-CT shows (a) hypermetabolic mass in. LOQ of left breast (mSUV = 7.5), (b) small soft tissue. lesions in left chest wall, medial side of mass. (mSUV = 3.7) and superior aspect (2.2) (mSUV = 2.2). HR(−) HER2(+) Breast Cancer. 444. 4.3. . After Neoadjuvant. Chemotherapy. 31 32 33. Fig. 40  (a) Gross pathology of lumpectomy specimen. (b) The margins get marked and sliced with different colors on. each direction. 6. . 6.1. . Patient History and Progress. Female/66 years old, post-menopause.. Self-detected nipple retraction on left breast.. Family history of breast cancer, cousin. (maternal).. 450Fig. 41. Fig. 41  Mammography. (Aug. 2020): asymmetry. (white arrow) in the. outer portion of left. breast. Segmental fine. linear or fine-linear. branching. microcalcifications. (black arrows) in left. upper inner breast. . 46Fig. 44. Fig. 44  Mammography:. mammography after. treatment demonstrates. residual mass is. decreased in the longest. diameter and no change. in extent of. microcalcifications in. left upper inner breast. . ­. ­Fig. 51. Fig. 51  Breast MRI (June 2021): MRI. after treatment demonstrates residual. non-mass enhancement (arrow) that is. decreased in the longest diameter and in. the degree of enhancement. . Y. Kwon et al.. 455. 7.4. . Courses of Treatment. 457Fig. 56. Fig. 56  PET-CT shows. hypermetabolic lesions. in Rt. breast. (mSUV = 2.5). . 8.3. . Courses of Treatment. Operation + Adjuvant chemotherapy (#4 cycles. of Doxorubicin and Cyclophosphamide) + Opera. tion + Trastuzumab.. 63Fig. 60. Fig. 60  Mammography (Sept. 2020): indistinct hyperdense mass in the upper outer quadrant of left breast (marked by. BB marker). Several enlarged lymph nodes in Lt. Axilla. HR(−) HER2(+) Breast Cancer. 460Fig. 61. Fig. 61  Breast US (Sept. 2020): irregular. hypoechoic mass at the 2 o’clock direction. of left breastFig. 62. Fig. 62  Breast MRI (Sept. 2020): irregular. heterogeneous enhancing mass at the 2. o’clock direction of left breast. Y. Kwon et al.. 461. F. ig. 63. Fig. 63  PET-CT shows. (a) hypermetabolic mass. in the left upper outer. breast (mSUV = 23.1). with satellite nodules. and (b) hypermetabolic. LNs in the left axilla. level I–II. (mSUV = ~10.5). HR(−) HER2(+) Breast Cancer. 462. 463Fig. 66. Fig. 66  Breast MRI (Jan. 2021): MRI after treatment. shows complete resolution of enhancement in the left breastFig. 67. Fig. 67  Lymphoscintigraphy shows. visualized sentinel lymph nodes in the left. axilla. . ­. HR(−) HER2(+) Breast Cancer. 464. 9.4. . Courses of Treatment. Neoadjuvant chemotherapy (#2 cycles of. Fig. 80. Fig. 80  Breast MRI (June 2020):. segmental heterogeneous non-mass. enhancement in the upper inner quadrant of. right breast. Y. Kwon et al.. 471. . ­. HR(−) HER2(+) Breast Cancer. 472. 11.3. 473Fig. 84. Fig. 84  Breast MRI (Dec. 2020): MRI after treatment. demonstrates residual non-mass enhancement (white. arrow) that is decreased in the longest diameter and in. the degree of enhancement. . 11.4. . Courses of Treatment. Neoadjuvant chemotherapy (#4 cycles of doxoru­. bicin and cyclophosphamide  +  #4 cycles of. docetaxel and trastuzumab) + Operation + Post-­. 90Fig. 87. Fig. 87  Mammography:. irregular hyperdense mass. with microcalcifications in. the upper outer quadrant of. left breast (marked by BB. marker). HR(−) HER2(+) Breast Cancer. 476. . Fig. 90. Fig. 90  Lymphoscintigraphy shows visualized sentinel. lymph nodes in the left axilla. 12.3. . Courses of Treatment. Operation + Adjuvant chemotherapy (#4 cycles. of docetaxel and cyclophosphamide)  +  Post-­. operative radiation therapy + Trastuzumab.. Operation. 91. Pathology Report. Fig. 94. Fig. 94  Breast MRI (Oct. 2020):. multicentric irregular enhancing masses and. heterogeneous non-mass enhancement in. the upper portion of left breast. Enhancing. lesion (black arrow) in left nipple. HR(−) HER2(+) Breast Cancer. 480. 13.3. . After Neoadjuvant. Chemotherapy. tion therapy + Trastuzumab emtansine.Fig. 95. Fig. 95  Mammography. (Feb. 2021): no. significant change of. segmental fine. pleomorphic. microcalcifications in. the upper portion of left. breast. Y. Kwon et al.. 481Fig. 96. Fig. 96  Breast US (Feb. 2021): US after. treatment demonstrates residual. hypoechoic mass that is decreased in the. longest diameter. Decrease in size of. previous enlarged LNs of left axilla and. left third intercostal spaceFig. 97. Fig. 97  Breast MR (Feb. 2021): MRI after. treatment demonstrates residual non-mass. enhancement (white arrow) that is decreased. in the longest diameter and in the degree of. enhancementFig. 98. Fig. 98  Lymphoscintigraphy shows. visualized sentinel lymph node in left axilla. and left internal mammary area. HR(−) HER2(+) Breast Cancer. 482. Operation. 99. Pathology Report. Invasive Ductal Carcinoma with apocrine. differentiation. 1. Post-chemotherapy status.. 484Fig. 101. Fig. 101  Breast US (Sept. 2020): irregular. hypoechoic mass at the 12 o’clock direction. of right breastFig. 102. Fig. 102  Breast MRI (Sept. 2020): irregular. enhancing mass at the 12 o’clock direction. of right breast. Enlarged lymph nodes in. right axilla. Y. Kwon et al.. 485. . . ­. 14.3. . 108Fig. 106. Fig. 106  Breast MRI (Dec. 2020): MRI after. treatment demonstrates residual enhancing mass. (white arrow) that is decreased in the longest diameter. and in the degree of enhancement Decrease in size of. suspicious lymph nodes (black arrow) in right axilla. . . Y. Kwon et al.. 487. . Pathology Report. 112Fig. 109. Fig. 109  Mammo­. graphy (Mar. 2021): irregular hyperdense mass in the upper mid portion of right breast. Enlarged. lymph nodes in right axilla. HR(−) HER2(+) Breast Cancer. 490. . . . Y. Kwon et al.. 491. 15.3. Fig. 115. Fig. 115  Breast US (July 2021): US after treatment. demonstrates residual hypoechoic mass that is. decreased in the longest diameter. 15.4. . Courses of Treatment. Neoadjuvant chemotherapy (#6 cycles of. docetaxel and carboplatin and trastuzumab and. pertuzumab) + Operation + Post-operative radia­. tion therapy + Trastuzumab.. Operation. 120Fig. 117. Fig. 117  Mammography. (Feb. 2021): irregular. isodense mass with obscured. margin in the mid-outer. portion of left breast. Y. Kwon et al.. 495. . . . 16.3. Fig. 133. Fig. 133  Breast MRI (Aug. 2021): MRI after treatment. demonstrates residual irregular mass (white arrow) that is. decreased in the longest diameterFig. 134. Fig. 134  Lymphoscintigraphy shows. visualized sentinel lymph nodes in the left. axilla. Operation. 135. Pathology Report. Invasive Ductal Carcinoma. 1. Post-chemotherapy status.. 2. Size of tumor: 0.7 cm (ypT1b).. 3. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. Fig. 137. Fig. 137  Breast US (Apr. 2021): US irregular. hypoechoic mass at the 12 o’clock direction of. left breast. HR(−) HER2(+) Breast Cancer. 506. 19.3. . Courses of Treatment. Operation + Adjuvant chemotherapy (#4 cycles. of doxorubicin and cyclophosphamide)  +  Post-­. operative radiation therapy + Trastuzumab.. 514Fig. 155. Fig. 155  Lymphoscintigraphy shows. visualized sentinel lymph nodes in the right. axilla. Fig. 154. Fig. 154  Breast MRI (Sept. 2021): MRI after treatment. demonstrates residual enhancing mass (white arrow) that. is decreased in the longest diameter and disappearance of. enlarged lymph nodes in right axilla. 21.4. . Courses of Treatment. Neoadjuvant chemotherapy (#6 cycles of. docetaxel and carboplatin and trastuzumab and. pertuzumab) + Operation + Post-operative radia­. tion therapy + Trastuzumab and Pertuzumab.. 523Fig. 171. Fig. 171  PET-CT shows. (a) hypermetabolic lesion. in left breast, upper inner. quadrant (mSUV = ~6.6). and (b) hypermetabolic. lymph nodes in left SCN. (2.4), left axilla level II. and interpectoral area. HR(−) HER2(+) Breast Cancer. 524. 24.3. 175Fig. 174. Fig. 174  Breast MRI: MRI after treatment demonstrates. residual non-mass enhancement (white arrow) that is. decreased in the longest diameter and in the degree of. enhancement. No change of suspected metastatic lymph. nodes (black arrow) in left axilla. . . Y. Kwon et al.. 525. 24.4. . Fig. 192  PET-CT shows. (a) a hypermetabolic. breast mass, right outer. (mSUV = 5.7) and (b). hypermetabolic LNs along. right axilla, level I–III. Y. Kwon et al.. 535. 28.3. . After Neoadjuvant. ­Fig. 195. Fig. 195  Breast MRI (Oct. 2021): MRI after treatment. demonstrates residual non-mass enhancement that is. decreased in the longest diameter and in the degree of. enhancement and decrease in size of enlarged right. axillary lymph node. HR(−) HER2(+) Breast Cancer. 536. 28.4. . Courses of Treatment. Neoadjuvant chemotherapy (#6 cycles of. Fig. 206. Fig. 206  Breast MRI (Nov. 2021): MRI after treatment. shows complete resolution of enhancement in the left. breastFig. 207. Fig. 207  Lymphoscintigraphy shows. visualized sentinel lymph nodes in the left. axilla. HR(−) HER2(+) Breast Cancer. 542. Operation. 208. Pathology Report. Microinvasive Ductal Carcinoma. 1. Post-chemotherapy status.. 2. Size of tumor: <0.1 cm (ypT1mi).. 544Fig. 210. Fig. 210  Breast US (May 2021): irregular hypoechoic. mass with microcalcifications at the 1 o’clock direction of. left breast. . . 31.3. . Courses of Treatment. Operation + Adjuvant chemotherapy (#4 cycles. of doxorubicin and cyclophosphamide)  +  Post-­. operative radiation therapy + Trastuzumab.. 550Fig. 221. Fig. 221  Mammography. (Feb. 2021): irregular. hyperdense mass in the. upper outer quadrant of. left breast. Enlarged. lymph nodes in left axilla. . . ­. Y. Kwon et al.. 551. 553Fig. 226. Fig. 226  Breast US (May 2021): US. after treatment demonstrates residual. hypoechoic mass that is decreased in the. longest diameter. . 33.4. . Courses of Treatment. Neoadjuvant chemotherapy (#6 cycles of. docetaxel and carboplatin and trastuzumab and. pertuzumab) + Operation + Post-operative radia­. Fig. 240. Fig. 240  Breast MRI (Nov. 2021): MRI after. treatment demonstrates residual enhancing foci (white. arrow) that are decreased in the longest diameter and. in the degree of enhancement and a normal-appearing. axillary lymph node (black arrow)Fig. 241. Fig. 241  Lymphoscintigraphy shows. visualized sentinel lymph nodes in the right. axilla. Y. Kwon et al.. 563. a. b. . HR(−) HER2(+) Breast Cancer. 564. 5. Intraductal component: present, intratu­. Fig. 243  PET-CT. shows (a) a. hypermetabolic mass in. the left breast. (mSUV = 14.8), (b). small hypermetabolic. lesions in the left upper. outer breast. (mSUV = 1.6), and (c). small lymph nodes in. the left axilla level I–II. 572Fig. 257. Fig. 257  Lymphoscintigraphy shows. visualized sentinel lymph nodes in the right. axilla. . Pathology Report. Invasive Ductal Carcinoma with medullary. pattern. 1. Size of tumor: 1.1 cm (pT1c).. 2. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 3/3, 30/10HPF)." +866,Important Radiologic Findings,Important Radiologic Findings,HR(−) HER2(−) Breast Cancer,634Fig. 118. Fig.. 118  Mammography:. An irregular hyperdense. mass at the upper outer. quadrant of the left. breast. The other. circumscribed oval mass. at the inner portion was. identified as a cyst on. ultrasound. +867,Important Radiologic Findings,Important Radiologic Findings,Local Recurrence,"Fig. 71. Fig. 71  MRI (2021):. An enhancing mass in. the left breast (white. arrow = proven IDC).. Another enhancing mass. in the right breast (black. arrow). . . Local Recurrence. 744. Fig. 120. Fig. 120  MRI for. evaluation of left nipple. eczema (2018): Strongly. enhanced left nipple.. Punch biopsy = Paget’s. disease. a. b. . Local Recurrence. 764. Fig. 135. Fig. 135  MRI (2016):. Irregular enhancing. masses at both. subareolar areas. (white arrow = left,. black arrow = right)Fig. 136. Fig. 136  Post-NAC. MRI (2017): Decreased. size of the masses at. both subareolar areas. (white arrow = left,. black arrow = right). 4. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 4/10HPF).. 5. Intraductal component: present, extratumoral. (70%) (nuclear grade: low, necrosis: absent,. Fig. 170. Fig. 170  Mammography: oval isodense mass in right. breast. . . 6. Surgical margins: <1  mm from the nearest. margin (slide 1).. . 7. Microcalcification: present, non-tumoral.. . 8. Pathological TN category (AJCC 2017): rpTis.. Result. diagnosis (Fro 2) is free of tumor.Fig. 251. Fig. 251  MRI: irregular. heterogeneous. enhancing mass at the 6. o’clock direction of left. breast. . . Y. Kim et al.. 821. . " +868,Important Radiologic Findings,Important Radiologic Findings,Metastatic Breast Cancer,"See Fig. 1.. Feb. 2014 Left chest well excisional biopsy.. Pathology: Invasive ductal carcinoma, clini­. cally recurrent.. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. Letrozole 2.5 mg/day re-start.Fig. 1. Fig. 1  PET-CT (Feb. 2014): A hypermetabolic lesion at. the left chest wallFig. 2 [BB:51.282;105.840;453.285;300.000]. Fig. 2  Chest CT (Mar. 2022): Multiple pleural/fissural nodules in the left hemithorax. Y. Kwon et al.. 863Fig. 3 [BB:51.282;476.648;453.284;658.808]. Fig. 3  PET-CT (Mar. 2022): Multiple pleural/fissural nodules with hypermetabolism in the left hemithorax. 2. . 2.1. . Patient History and Progress. Female/55 years old, post-menopause.. Family history of breast cancer, mother.. BRCA 1 & 2 mutation: No examination.. 2.2. . See Fig. 4.. Operation. Aug. 2012 Right breast conserving surgery, axil­. lary lymph node dissection.. Pathology: Invasive ductal carcinoma, stage. pT2(m)N1a.. Size of tumor: 3.5 cm, 1.5 cm, and 0.5 cm,. Lymph node: 3/16, size of metastatic carcinoma:. 8 mm.. Result. Intensity Positive %. 864Fig. 4. Fig. 4  Breast MRI (Jul.. 2012): An irregular. enhancing mass in the. right breastFig. 5 [BB:153.734;304.567;453.543;503.288]. Fig. 5  Chest CT (Jun.. 2016, Apr. 2019): A new. lung nodule (white. arrow) was getting. enlarged (black arrow). in the right lung. Wedge. resection = Metastatic. ductal carcinoma from. breast. 2.2.2. . See Fig. 7.. Y. Kwon et al.. 865Fig. 6 [BB:51.307;458.701;453.260;658.808]. Fig. 6  Bone scan (Aug. 2017, Jan. 2019, Mar. 2022): An. increased uptake in the right 8th rib (black arrow) was get­. ting enlarged. Multiple developing increased uptakes in. the right ribs, thoracic vertebrae, sternum, left iliac bone,. and left femur (white arrows)Fig. 7. Fig. 7  Abdomen CT (Mar. 2022): Multiple developing. low attenuation lesions in the liver (partly shown). 3. . 3.1. . Patient History and Progress. Female/62 years old, post-menopause.. No family history.. Diabetes mellitus, rheumatoid arthritis.. 3.2. See Fig. 8.. Neoadjuvant Chemotherapy. Neoadjuvant. Chemotherapy. #8. cycles. (Adriamycin. +. Cyclophosphamide. #4. →. 866Fig. 8. Fig. 8  Breast MRI. (Sep. 2017): Irregular. enhancing mass in the. left breast (white arrow).. Enlarged LN at the left. internal mammary chain. (black arrow). Left total. mastectomy = IDCFig. 9 [BB:153.612;321.127;453.543;531.368]. Fig. 9  Bone scan (Apr.. 2020, Aug. 2020):. Multiple uptakes in the. thoracic vertebrae and. left ribs (white arrows). were getting increased. in intensity (black. arrows). Result. Intensity. Positive %. 867Fig. 10 [BB:153.613;481.928;453.543;658.808]. Fig. 10  Chest CT (Apr.. 2020): Multiple fissural. nodules (white arrows). and lung nodules (black. arrow, partly shown) in. the right lungFig. 11. Fig. 11  Chest X-ray (Sep. 2021): Large amount of pleu­. ral effusion in the right hemithorax. Pleural fluid cytology. = Positive for malignant cellsFig. 12. Fig. 12  Brain MRI (Apr. 2021): Multiple necrotic. enhancing lesions in the brain (partly shown). Metastatic Breast Cancer. 868. 4. . 4.1. . Patient History and Progress. Female/48 years old, pre-menopause.. No family history.. See Fig. 13.. May 2021 breast, left, needle biopsy:. Invasive ductal carcinoma, histologic grade 2.. Result. Intensity. Positive %. Estrogen. receptor. Negative. (0/8). 0. See Fig. 14.Fig. 13. Fig. 13  Chest CT (May 2021): Huge mass in the left. breast (black arrow, CNB = IDC) and left pleural effusion. (white arrow). Y. Kwon et al.. 869Fig. 14. Fig. 14  Post-NAC chest CT (Jan. 2022): Disappearance. of the previous left breast mass and left pleural effusion.. Left MRM = No residual tumorFig. 15. Fig. 15  Breast MRI (Jun. 2015): Multiple malignant. enhancing masses in the left breast. US-CNB = IDCFig. 16. Fig. 16  Post-NAC breast MRI (Dec. 2015): Decreased. number and size of the previous masses in the left breast.. Left BCS = IDC. 5. . 5.1. . Patient History and Progress. Female/70 years old, post-menopause.. No family history.. Hypertension.. See Figs. 17, 18, and 19.Fig. 17 [BB:153.613;329.602;453.544;514.403]. Fig. 17  Chest CT (Feb.. 2020, Nov. 2020): A. new lung nodule (white. arrow) was getting. enlarged (black arrow). in the right lungFig. 18. Fig. 18  Abdomen CT (Dec. 2020): Multiple low attenu­. ation lesions with peripheral rim enhancement in the liver. (partly shown). US-CNB = Metastatic ductal carcinomaFig. 19. Fig. 19  Abdomen CT (Feb. 2022): Disappearance of the. previous metastatic masses in the liver. Y. Kwon et al.. 871. 6. . 6.1. . Patient History and Progress. Female/47 years old, pre-menopause.. No family history.. See Fig. 22.Fig. 20. Fig. 20  Breast MRI (Sep. 2017): Conglomerated enhanc­. ing masses (black arrow) and non-mass enhancement. (white arrows) in the right breast. US-CNB = IDCFig. 21. Fig. 21  Post-NAC breast MRI (Jan. 2018): Decreased. size of the enhancing masses (black arrow) and non-mass. enhancement (white arrows) in the right breast. Right. BCS = IDC. Metastatic Breast Cancer. 872Fig. 22. Fig. 22  Breast MRI (May 2020): Multifocal parenchy­. mal non-mass enhancement (white arrow) and skin. enhancement (black arrows) in the right breast (partly. shown). US-CNB = IDC, Skin shave biopsy = IDCFig. 23. Fig. 23  Breast MRI (May 2021): Multiple enlarged. lymph nodes in the left axilla. US-CNB = Metastatic duc­. tal carcinoma. May 2020 Right chest wall skin and breast. biopsy.. Pathology:. Invasive. ductal. carcinoma,. recurrent.. Result. See Fig. 23.. 7. . 7.1. . Patient History and Progress. Female/48 years old, pre-menopause.. No family history.. 7.2. . Courses of Treatment. See Fig. 24.. Operation. Jan. 2019 Left breast conserving surgery, sentinel. lymph node biopsy.. Y. Kwon et al.. 873. Pathology: Invasive ductal carcinoma, stage. pT1bN0(sn).. Size of tumor: 0.7 * 0.5 * 0.5 cm, lymph node:. 0/2.. Result. See Fig. 25.Fig. 24. Fig. 24  Breast MRI (Jan. 2019): A round enhancing. mass in the left breast. Left BCS = Microinvasive ductal. carcinomaFig. 25 [BB:51.293;214.999;453.274;341.000]. Fig. 25  Abdominopelvic CT (Mar. 2021): Multiple enlarged lymph nodes at the paraaortic and both iliac chains. Metastatic Breast Cancer. 874. 8. . 8.1. . Patient History and Progress. Female/55 years old, post-menopause.. No family history.. 8.2. See Fig. 26.. Operation. Mar. 2016 Left breast conserving surgery, senti­. nel lymph node biopsy.. Pathology: Invasive ductal carcinoma, stage. pT2N0(sn).. Size of tumor: 2.5 cm, lymph node: 0/1.. Result. Intensity. Positive %. Estrogen. See Fig. 27.. Mar. 2021 Left axillary lymph node biopsy.. Pathology: Metastatic ductal carcinoma.. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. lymph nodes.Fig. 26. Fig. 26  Breast MRI (Mar. 2016): An irregular enhancing. mass in the left breast. Left BCS = IDCFig. 27. Fig. 27  Chest CT (Feb. 2021): Multiple enlarged lymph. nodes in the left axilla. US-CNB = Metastatic ductal. carcinoma. Y. Kwon et al.. 875. Radiation Therapy. Post-operative radiation therapy (axillary and. subclavian area) + Letrozole 2.5 mg/day~.. 9. . 9.1. See Fig. 28.. Operation. Jul. 2019 Right breast conserving surgery, senti­. nel lymph node biopsy.. Pathology: Invasive ductal carcinoma, stage. pT1c(2)N0(sn).. Size of tumor: 1.1  cm and 0.5  cm, lymph. node: 0/1.. Result. Intensity. Positive %. cellsFig. 28. Fig. 28  Breast MRI (Jul. 2019): Mixed enhancing. masses and non-mass enhancement in the right breast.. Right BCS = IDCFig. 29. Fig. 29  Breast US. (Aug. 2021): Multiple. enlarged lymph nodes in. the right axilla. US-CNB. = Metastatic ductal. carcinoma. Metastatic Breast Cancer. 876Fig. 30. Fig. 30  PET-CT (Sep. 2021): Multiple hypermetabolic. lymph nodes in the right axillaFig. 31. Fig. 31  Mammography (Oct. 2020): Interstitial injection. mammoplasty of both breasts. Palpable lump in left breast. Neoadjuvant Chemotherapy. Neoadjuvant. chemotherapy. #8. cycles. (Adriamycin & Cyclophosphamide #4 →. Docetaxel #4).. Operation. Mar. 2022 Left axillary lymph node dissection.. 877Fig. 32. Fig. 32  Breast US (Oct. 2020): A hypoechoic mass at the. palpable area of the left breast. US-VAB = IDCFig. 33. Fig. 33  Breast MRI (Oct. 2020): An oval enhancing. mass in the left breast. Left BCS = IDCFig. 34. Fig. 34  PET-CT (Mar. 2021): Hypermetabolic nodular. lesion at the op bed of the left breast. Excision = IDC. Result. Intensity. Positive %. Estrogen. receptor. Negative. (0/8). 0. 0. See Fig. 34.. Operation. Apr. 2021 Left wide excision.. Pathology: Invasive ductal carcinoma, stage. rpT1b.. Size of tumor: 1.0 cm.. Result. Intensity. Positive %. Estrogen. receptor. See Fig. 35.. Oct. 2021 Left breast biopsy.. Pathology: Invasive ductal carcinoma.. Result. Intensity. Positive %. Estrogen. receptor. Negative. (2/8). 1. See Fig. 36.. 11. . 11.1. . Patient History and Progress. Female/65 years old, post-menopause.. Family history of colon cancer, mother.. BRCA 1 & 2 mutation: Not detected.. 11.2. . metastasis.Fig. 36 [BB:153.613;107.653;453.543;280.933]. Fig. 36  Chest CT (Mar.. 2021, Mar. 2022): A. new lung nodule (white. arrow) was getting. enlarged (black arrow). in the left lung. Multiple. other developing. nodules in both lungs. (not shown)Fig. 35. Fig. 35  Breast MRI (Oct. 2021): Enhancing. masses at the op bed of the left breast (partly. shown). US-CNB = IDC. Y. Kwon et al.. 879. Primary Treatment. See Fig. 37.. Operation. Jun. 2018 Both nipple-areolar complex sparing. mastectomy with immediate implant reconstruc­. tion, sentinel lymph node biopsy.. Pathology:. Right> Invasive ductal carcinoma, stage. pT1c(2)N0(sn).. Size of tumor: 1.8  cm and 1.7  cm, lymph. node: 0/3.. Result. See Fig. 38.. Nov. 2021 Right axillary lymph node biopsy.. Pathology: Metastatic ductal carcinoma.Fig. 38 [BB:51.307;86.116;453.260;247.310]. Fig. 38  Breast US (Oct. 2021, Mar. 2022): A new irregu­. lar lymph node (white arrow) at the right axillary tail.. US-CNB = Metastatic ductal carcinoma. Grossly normal­. ized lymph node (black arrow) after chemotherapy. Right. ALND = No metastasis in four axillary lymph nodes.. Note the breast implant (*) for reconstructionFig. 37. Fig. 37  Breast MRI (May 2018): Malignant masses in. the right breast (white arrows) and left breast (black. arrow). Both NSM = Both IDC. Metastatic Breast Cancer. 880Fig. 39. Fig. 39  Breast MRI (Apr. 2014): An irregular enhancing. mass in the left breast. Left simple mastectomy = IDC. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. See Fig. 39.. Operation. Apr. 2014 Left total mastectomy, sentinel lymph. node biopsy.. Pathology: Invasive ductal carcinoma, stage. pT2N0(sn).. Size of tumor: 2.0 cm, lymph node: 0/4.. Result. Intensity. Positive %. Estrogen. See Fig. 40.. Aug. 2018 Left axillary lymph node biopsy.. Pathology: Metastatic ductal carcinoma.. Result. Intensity. Positive %. Estrogen. receptor. Strong (7/8). 3. 1/3–2/3. 881Fig. 40 [BB:51.366;528.008;453.200;658.808]. Fig. 40  Breast US (Aug. 2018, Apr. 2019): An enlarged. lymph node (white arrow) in the left axilla. US-CNB =. Metastatic ductal carcinoma. Normalized size of the. biopsy proven metastatic lymph node (black arrow) after. chemotherapy. Left ALND = No metastasis in five axil­. lary lymph nodesFig. 41. Fig. 41  Breast MRI (Jul. 2021): A new enhancing mass. in the right breastFig. 42. Fig. 42  MRI-directed right breast US (Aug. 2021): An. irregular hypoechoic mass at the corresponding area of. the MRI abnormality. US-CNB = Ductal carcinoma,. Right MRM = DCIS. Operation. Apr. 2019 Left axillary lymph node dissection.. Pathology: No metastasis in five axillary. lymph nodes.. Adjuvant Therapy. Post-operative radiation therapy (axillary and. subclavian area) + Exemestane 25 mg/day~. See Fig. 43.. Operation. Sep. 2017 Right nipple-areolar complex sparing. mastectomy with immediate implant reconstruc­. tion, sentinel lymph node biopsy.. Pathology: Invasive ductal carcinoma, stage. pT1bN0(sn).. Size of tumor: 0.7 cm, lymph node: 0/2.. Result. Intensity. Positive %. Tamoxifen 20 mg/day for 3.3 years.Fig. 43. Fig. 43  Breast MRI (Sep. 2017): Multiple irregular enhancing masses and non-mass enhancement in the right breast.. Right NSM = IDC. Y. Kwon et al.. 883. Treatments After Recurrence. See Fig. 44.. Feb. 2021 Right axillary tail biopsy.. Pathology: Metastatic ductal carcinoma.. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. 2.5 mg/day.Fig. 44. Fig. 44  Breast US (Feb. 2021): An irregular hypoechoic. mass with non-parallel orientation at the right axillary tail.. US-CNB = Metastatic ductal carcinomaFig. 45. Fig. 45  Breast MRI (Mar. 2021): An enhancing mass at. the right axillary tailFig. 46. Fig. 46  Post-NAC breast MRI (Oct. 2021): No residual. enhancing lesion after NAC. Metastatic Breast Cancer. 884. 14. . 14.1. . Patient History and Progress. Female/55 years old, post-menopause.. No family history.. See Fig. 47.. Operation. Jun. 2014 Right nipple-areolar complex sparing. mastectomy with immediate implant reconstruc­. tion, sentinel lymph node biopsy.. Pathology: DUCTAL CARCINOMA IN. SITU, stage pTisN0(sn).. Size of tumor: 6.5 cm, lymph node: 0/1.. Result. Intensity. Positive %. See Fig. 48.. Oct. 2017 Right axillary lymph node biopsy.. Pathology: Metastatic ductal carcinoma.Fig. 47. Fig. 47  Breast MRI (Jun. 2014): Segmental non-mass. enhancement in the right breast. Right NSM = DCISFig. 48 [BB:51.366;136.116;453.200;290.436]. Fig. 48  Breast US (Oct. 2017, May 2018): An enlarged. lymph node (white arrow) in the right axilla. US-CNB =. Metastatic ductal carcinoma. Decreased size of the biopsy. proven metastatic lymph node (black arrow) after chemo­. therapy. Right ALND = Metastatic ductal carcinoma in. one out of nine lymph nodes. Y. Kwon et al.. 885Fig. 49. Fig. 49  Breast MRI (Sep. 2015): An irregular enhancing. mass in the right breast. Right simple mastectomy = IDC. Result. Intensity. Positive %. Estrogen. receptor. Strong. (8/8). 3. >2/3. See Fig. 49.. Operation. Oct. 2015 Right total mastectomy, sentinel lymph. node biopsy.. Pathology: Invasive ductal carcinoma, stage. pT2N0(sn).. Size of tumor: 2.5 cm, lymph node: 0/3.. Result. Intensity. Positive %. Estrogen. 886Fig. 51. Fig. 51  MRI-directed US (Jul. 2020): A small irregular. lymph node at the corresponding area of the CT abnor­. mality. US-CNB = Metastatic ductal carcinomaFig. 52. Fig. 52  Breast MRI (Jul. 2013): Two irregular enhancing. masses in the left breast. Left SSM = IDCFig. 50. Fig. 50  Chest CT (Jun. 2020): A small irregular lymph. node in the right axilla. Jul. 2020 Right axillary lymph node biopsy.. Pathology: Metastatic ductal carcinoma.. Result. Intensity Positive %. Estrogen receptor. Strong. (8/8). 3. >2/3. See Fig. 52.. Operation. Jul. 2013 Left skin sparing mastectomy with. immediate. implant. reconstruction,. sentinel. lymph node biopsy.. Y. Kwon et al.. 887. Pathology: Invasive ductal carcinoma, stage. See Fig. 53.. Aug. 2015 Soft tissue, left axilla biopsy.. Pathology: Metastatic carcinoma.. Result. Intensity. Positive %. Estrogen. receptor. Strong (7/8). 2. >2/3. See Fig. 54.. Operation. Aug. 2021 Left axillary lymph node dissection.. Pathology: Metastatic ductal carcinoma in 4. out of 6 lymph nodes, size of metastasis: 25 mm.Fig. 53. Fig. 53  US for evaluation of a palpable mass in the left. axilla (Aug. 2015): An oval mass with heterogeneous. echogenicity in the left axilla. US-CNB = Metastatic. carcinomaFig. 54 [BB:51.301;120.157;453.266;228.638]. Fig. 54  Chest CT (Aug. 2015, Dec. 2015, Jun. 2021):. The biopsy proven metastatic carcinoma in the left axilla. had decreased (white arrow) then increased again (black. arrow) during palliative therapy. Left ALND = Metastatic. ductal carcinoma in four out of six lymph nodes. Metastatic Breast Cancer. 888Fig. 55. Fig. 55  Breast MRI (Oct. 2017): An irregular enhancing. mass in the right breast. Right BCS = IDCFig. 56. Fig. 56  Breast US (Apr. 2021): A new round lymph node. without fatty hilum in the right axilla. US-CNB =. Metastatic ductal carcinoma. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. See Fig. 55.. Operation. Oct. 2017 Right breast conserving surgery, axil­. lary lymph node dissection (Level I).. Pathology: Invasive ductal carcinoma, stage. pT1c(2)N2.. Size of tumor: 1.8  cm and 1.0  cm, lymph. node: 4/8, size of metastasis: 25 mm.. Result. Intensity. Positive %. See Fig. 56.. May 2021 Right axillary lymph node biopsy.. Pathology: Metastatic ductal carcinoma.. Y. Kwon et al.. 889Fig. 57. Fig. 57  Breast MRI (Nov. 2015): Mixed masses and non-­. mass enhancement in the left breast. Left BCS = IDCFig. 58. Fig. 58  Breast US (Nov. 2018): An irregular hypoechoic. mass in the left pectoralis muscle. US-CNB = IDC. Result. Intensity Positive %. Estrogen. receptor. Intermediate. (6/8). 1. >2/3. Progesterone. See Fig. 57.. Operation. Dec. 2015 Left breast conserving surgery, senti­. nel lymph node biopsy.. Pathology: Invasive ductal carcinoma, stage. pT1a(Pagets′)N0(sn).. Size of tumor: 0.5 cm, lymph node: 0/1.. Result. Intensity Positive %. Estrogen. receptor. 890Fig. 61. Fig. 61  Breast US (Oct. 2020): Multiple enlarged lymph. nodes in the left axilla (partly shown). US-CNB =. Metastatic ductal carcinomaFig. 59. Fig. 59  PET-CT (Dec. 2018): A hypermetabolic mass in. the left pectoralis muscleFig. 60. Fig. 60  Post-chemotherapy breast US (Mar. 2019):. Decreased size of the IDC in the left pectoralis muscle.. Left simple mastectomy = IDC. Result. Intensity Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. See Fig. 60.. Operation. 2019-03-29 Left total mastectomy, axillary. lymph node sampling.. Pathology: Invasive ductal carcinoma, stage. yp T1aN1.. Size of tumor: 0.3 cm, lymph node: 3/10, size. of metastatic carcinoma: 3 mm.. Result. Intensity. Positive %. See Fig. 61.. Nov. 2020 Left axillary lymph node biopsy.. Pathology: Metastatic ductal carcinoma.. Result. Intensity. Positive %. Estrogen. receptor. Strong (7/8). 3. 1/3–2/3. See Fig. 62.. Operation. Mar. 2017 Right nipple-areolar complex sparing. mastectomy with immediate implant reconstruc­. tion, sentinel lymph node biopsy.. Pathology: Invasive ductal carcinoma, stage. pT2N1a(sn).. Size of tumor: 2.3 cm, lymph node: 3/5, size. of metastatic carcinoma: 7 mm.. Result. Intensity. See Fig. 63.. May 2021 Right axillary lymph node biopsy.. Pathology: Metastatic ductal carcinoma.. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. cellsFig. 62. Fig. 62  Breast MRI (Mar. 2017): A heterogeneously. enhancing mass in the right breastFig. 63. Fig. 63  Chest CT (May 2021): An irregular lymph node. in the right axilla. Metastatic Breast Cancer. 892. Operation. Jun. 2021 Right axillary lymph node dissection. and bilateral salpingo-oophorectomy.. Pathology: Metastatic ductal carcinoma in. two out of two axillary lymph nodes.. Size of metastatic carcinoma: 11 mm.. Result. Chemotherapy (Capecitabine~).Fig. 64 [BB:51.486;279.720;453.081;417.000]. Fig. 64  Chest CT and PET-CT (Mar. 2022): An enlarged lymph node with hypermetabolism at level III of the right. axillaFig. 65. Fig. 65  MRI-directed US (Mar. 2022): An. enlarged lymph node at level III of the right. axilla. Y. Kwon et al.. 893. 20. . 20.1. . Patient History and Progress. Female/61 years old, post-menopause.. See Fig. 66.. Sep. 2015 Left infraclavicular lymph node biopsy.. Pathology: Metastatic ductal carcinoma.. Left breast biopsy.. Pathology: Invasive ductal carcinoma, clini­. cally recurrent.. Result. Intensity Positive %. Estrogen. receptor. Strong (8/8). See Fig. 67.. Operation. Feb. 2016 Left total mastectomy, axillary lymph. node sampling.. Pathology: Invasive ductal carcinoma, stage. ypT1c(m)N1a.. Size of tumor: up to 1.6 cm, lymph node: 1/2,. size of metastatic carcinoma: 7 mm.. Result. Intensity. Positive %. tumor cellsFig. 66. Fig. 66  Breast US (Nov. 2014): A mildly enlarged lymph. node at level II of the left axilla. Metastatic Breast Cancer. 894Fig. 67 [BB:51.366;522.008;453.200;658.808]. Fig. 67  Breast MRI (Oct. 2015): An irregular enhancing mass in the left breast (white arrow, IDC). Two mildly. enlarged lymph nodes at level II and III of the left axilla (black arrows, metastatic ductal carcinoma)Fig. 68 [BB:51.367;314.779;453.201;471.500]. Fig. 68  Chest CT (Sep. 2016, Dec. 2021): A mildly enlarged lymph node (black arrow) had become smaller (white. arrow) at level II of the left axilla. Adjuvant Therapy. Post-operative. radiation. therapy. (axilla). +Letrozole 2.5 mg/day~. See Fig. 68.. 21. . 21.1. . Patient History and Progress. Female/61 years old, post-menopause.. No family history.. 21.2. . Courses of Treatment. See Fig. 69.. Dec. 2015 Left neck lymph node aspiration. (level 4).. Pathology: Metastatic ductal carcinoma.. Palliative Therapy. Letrozole 2.5 mg/day → Progressive disease on,. lymph node, bone.. Chemotherapy #24 cycles (Paclitaxel) →. Progressive disease on brain, skull.. Whole brain radiation therapy.. Fulvestrant + abemaciclib~. See Figs. 70, 71, and 72.Fig. 69. Fig. 69  Neck US for evaluation of palpable lumps (Dec.. 2015): Multiple suspicious lymph nodes at the left lower. neckFig. 70 [BB:153.639;132.653;453.543;331.036]. Fig. 70  PET-CT (Apr.. 2019): Multifocal. hypermetabolic lesions. in the liver (white. arrow), spleen (black. arrow), and bones. Metastatic Breast Cancer. 896Fig. 71 [BB:51.366;529.448;453.200;658.808]. Fig. 71  Abdominopelvic CT (May 2019): Multiple low attenuation lesions in the liver (white arrow, partly shown) and. spleen (black arrow)Fig. 72 [BB:51.366;251.413;453.200;477.974]. Fig. 72  Brain MRI (Sep. 2020): Multiple enhancing lesions in both cerebellums, brainstem, and both cerebral hemi­. spheres (partly shown). 22. . 22.1. . Patient History and Progress. Female/69 years old, post-menopause.. No family history.. Hepatitis B carrier.. 22.2. See Fig. 73.. Y. Kwon et al.. 897Fig. 73. Fig. 73  Chest CT (Oct. 2007): Irregular. enhancing lesion (black arrow) and skin. thickening (white arrow) of the left breastFig. 74 [BB:51.328;467.359;453.239;566.000]. Fig. 74  PET-CT (Apr. 2010, Oct. 2011, Apr. 2014): An. enlarged lymph node with hypermetabolism in the right. axilla. Size and metabolism of the biopsy proved meta­. static lymph nodes had decreased (white arrow) and then. increased again (black arrow). Neoadjuvant Chemotherapy. Neoadjuvant. chemotherapy. #6. cycles. (Fluorouracil + Doxorubicin + cyclophospha­. See Fig. 74.. Apr. 2010 Right axillary lymph node biopsy.. Pathology: Metastatic apocrine carcinoma.. Result. Intensity. Positive %. Estrogen. receptor. Negative. (0/7). 0. 898Fig. 75. Fig. 75  Breast MRI for evaluation of inflammatory. change of the right breast (Feb. 2016): Diffuse non-mass. enhancement (black arrows) and skin thickening (white. arrow) of the right breastFig. 76. Fig. 76  Post-chemotherapy breast MRI (Jan. 2017):. Decreased enhancing lesions in the parenchyma and skin. of the right breast. Result. Intensity. Positive %. Estrogen. receptor. Negative (0/8). 0. 0. See Fig. 75.. Feb. 2016 Right breast biopsy.. Pathology: Invasive ductal carcinoma.. Result. Intensity. Positive %. Estrogen. receptor. Negative (0/8). 0. 0. See Fig. 76.. Operation. Jan. 2017 Right total mastectomy.. Pathology: Invasive ductal carcinoma, stage. ypT2(m).. Size of tumor: up to 2.8 cm, multifocal.. Result. Intensity. Positive %. Estrogen. receptor. 899Fig. 77 [BB:51.307;560.748;453.260;658.808]. Fig. 77  Chest CT (Jul. 2020, Sep. 2020, Apr. 2022): The amount of pleural effusion was getting increased (white. arrow). Cytology of pleural fluid = Positive for malignant cells. Newly developed pericardial effusion (black arrow)Fig. 78 [BB:51.253;322.219;453.314;507.500]. Fig. 78  Spine MRI and bone scan (Aug. 2020): Multiple bone marrow replacing lesions (white arrows) with increased. uptake (black arrows) in the vertebrae. 23. . 23.1. . Patient History and Progress. Female/39 years old, pre-menopause.. No family history.. BRCA 1 & 2 VUS (variant of uncertain).. 23.2. See Fig. 79.. Neoadjuvant Chemotherapy. Neoadjuvant. chemotherapy. #8. cycles. (Adriamycin. +. Cyclophosphamide. #4. →. See Fig. 80.. Operation. Jan. 2013 Left total mastectomy, sentinel lymph. node biopsy.. Pathology: Invasive ductal carcinoma, stage. ypT1c(m)N0(sn).. Size of tumor: up to 1.5 cm, multifocal, lymph. node: 0/4.. Result. Intensity. Positive %. See Fig. 81.Fig. 79. Fig. 79  Breast MRI (Jul. 2012): Conglomerated enhanc­. ing masses involving the entire left breastFig. 80. Fig. 80  Post-NAC breast MRI (Jan. 2013): Decreased. tumor burden in the left breastFig. 81 [BB:51.366;195.720;453.200;321.000]. Fig. 81  Chest CT and PET-CT (Apr. 2019): Pericardial effusion (white arrows) and enlarged hypermetabolic medias­. tinal lymph nodes (black arrows). Y. Kwon et al.. 901. Apr. 2019 Chest CT: pericardial effusion, met­. astatic lymph nodes.. Palliative Therapy. Clinical trial enrolled (Paclitaxel + ipatasertib/. placebo #18 cycles): Progressive disease on bone.. Chemotherapy #5 cycles (Capecitabine):. Progressive disease on bone.. See Figs. 82, 83, 84, and 85.Fig. 82 [BB:51.366;402.925;453.200;543.805]. Fig. 82  Neck US and PET-CT (Apr. 2019): Multiple small lymph nodes with irregular margins (white arrows) and. mild hypermetabolism (black arrows) at the lower neckFig. 83 [BB:61.355;72.540;443.212;352.752]. Fig. 83  Bone scan (Oct. 2019) and spine MRI (Dec. 2019): Increased uptake (black arrow) and bone marrow replacing. lesion with mild pathologic fracture (white arrow) in the T2 vertebra. Metastatic Breast Cancer. 902Fig. 84 [BB:51.306;392.408;453.261;658.808]. Fig. 84  Abdominopelvic CT (Mar. 2020, Nov. 2020): Multiple lymph nodes (white arrows) were getting enlarged. (black arrows) in the abdominopelvic cavity (partly shown)Fig. 85 [BB:51.307;190.021;453.260;322.500]. Fig. 85  Chest CT (Sep. 2020) and US (Oct. 2020): A palpable mass at the right parasternal area. US-CNB = Metastatic. ductal carcinoma. Y. Kwon et al.. 903. 24. . 24.1. . Patient History and Progress. Female/64 years old, post-menopause.. No family history.. See Fig. 86.. Operation. Nov. 2005 Right breast conserving surgery, axil­. lary lymph node dissection.. Pathology: Invasive duct carcinoma, stage. T1cN1a.. Size of tumor: 1.9 cm, lymph node: 1/8, size. of metastatic carcinoma: 8 mm.. Result. Intensity. Positive %. See Fig. 87.. Operation. Jan. 2019 Left lower lung wedge resection.. Pathology: Metastatic carcinoma, size of. tumor: 0.9 * 0.7 * 0.3 cm.. Result. Intensity Positive %. Estrogen. receptor. Strong (8/8). 3. Palbociclib #25 cycles + Letrozole 2.5 mg/day~Fig. 86. Fig. 86  Right mammography (Oct. 2005): A palpable. mass at the lower breastFig. 87. Fig. 87  Chest CT (Dec. 2018): A nodule in the LUL lung. Metastatic Breast Cancer. 904. 25. . 25.1. . Patient History and Progress. Female/46 years old, post-menopause.. Family history of breast cancer, mother.. BRCA 1 & 2 mutation: Not detected.. See Fig. 88.. Primary Treatment. Operation. Apr. 2017 Left nipple-areolar complex sparing. mastectomy with immediate implant reconstruc­. tion, sentinel lymph node biopsy.. Pathology: Invasive ductal carcinoma, stage. T1cN0(sn).. Size of tumor: 1.1 cm, lymph node: 0/1.. Result. Intensity Positive %. See Fig. 91.. Operation. Jul. 2021 Left breast wide excision, axillary. lymph. node. sampling. and. bilateral. salpingo-oophorectomy.. Pathology: Invasive ductal carcinoma, stage. rT1cN0.. Size of tumor: 1.5 cm, lymph node: 0/4.Fig. 88. Fig. 88  Breast MRI after multiple vacuum-assisted exci­. sional biopsy in the left breast (Mar. 2017): Mild BPE. without definite abnormality of both breastsFig. 89. Fig. 89  Breast MRI (Jun. 2020): A tiny enhancing focus. (white arrow) in the reconstructed left breastFig. 90. Fig. 90  Breast MRI (Jun. 2020): Increased size of the. enhancing skin lesion (black arrow) in the reconstructed. left breast. Y. Kwon et al.. 905Fig. 91. Fig. 91  MRI-directed left US (Jul. 2021): Focal skin. thickening at the corresponding area of the MRI. abnormalityFig. 92 [BB:51.306;90.578;453.261;256.419]. Fig. 92  Breast MRI (Jan. 2020): Segmental heterogeneous non-mass enhancement in the right whole breast and oval. heterogeneous enhancing lesion at the 8 o’clock direction of left breast. Result. Intensity Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. See Fig. 92.. Operation. Jan. 2014 Both total mastectomy, axillary lymph. node dissection.. Pathology:. Right> Invasive lobular carcinoma, stage. pT3N3a.. Size of tumor: 7 cm, lymph node: 15/17, size. of metastatic carcinoma: 13 mm.. Metastatic Breast Cancer. 906Fig. 93. Fig. 93  Esophagogastroduodenoscopy (May 2018):. Diffuse infiltrative mass in the stomachFig. 94. Fig. 94  Bone scan (Jun. 2018): Multifocal increased. uptake in the 6th thoracic spinal body and right ribs, sug­. gesting bony metastases. Result. Intensity Positive %. Estrogen. receptor. Strong (7/8). 2. >2/3. Progesterone. 907Fig. 95. Fig. 95  Breast US (Feb. 2008): Irregular hypoechoic. mass at the 9 o’clock direction of left breast. 27. . 27.1. . Patient History and Progress. Female/74 years old, post-menopause.. No family history.. Hypertension, diabetes mellitus, s/p cholecys­. tectomy (GB stone).. See Fig. 95.. Operation. Mar. 2008 Left breast conserving surgery, axil­. lary lymph node dissection.. Pathology: Invasive duct carcinoma, stage. T2N1a.. Size of tumor: 3 cm, lymph node: 3/7, size of. metastatic carcinoma: 15 mm.. Result. Intensity. Positive %. See Fig. 96.. Operation. Feb. 2015 Right breast conserving surgery, senti­. nel lymph node biopsy.. Pathology: Invasive duct carcinoma, stage. T1cN0(sn).. Size of tumor: 1.8 cm, lymph node: 0/1.. Result. Intensity. Positive %. Estrogen. See Fig. 97.. Left Axillary Lymph Node Metastasis. Dec. 2019 Left axillary lymph node biopsy.. Pathology: Metastatic ductal carcinoma.. Result. Intensity. Positive %. Estrogen. receptor. Strong (7/8). 2. cellsFig. 96. Fig. 96  Breast US (Feb. 2015): Irregular hypoechoic. mass with spiculated margin at the 4 o’clock direction of. right breastFig. 97 [BB:51.307;90.578;453.260;254.356]. Fig. 97  Breast US (Nov. 2019): Spiculated hypoechoic mass with echogenic halo in the left axillary area. Increased. vascularity is seen on color Doppler US. Y. Kwon et al.. 909. Neoadjuvant Chemotherapy. Neoadjuvant. chemotherapy. #4. cycles. (Adriamycin & Cyclophosphamide).. Operation. See Fig. 98.. Palliative Therapy. Letrozole 2.5 mg/day + Palbociclib~. 29. . 29.1. . Patient History and Progress. Female/41 years old, pre-menopause.. No family history.. 29.2. See Fig. 99.. Neoadjuvant Chemotherapy. Neoadjuvant. chemotherapy. #4. cycles. (Adriamycin + Cyclophosphamide) + zoladex.. Result. Intensity. Positive %. Estrogen. cellsFig. 98. Fig. 98  Liver MRI (Oct. 2020): Two tiny lesions in the. segment 2 of liver, showing hyperintensity on diffusion-­. weighted image. Metastatic Breast Cancer. 910Fig. 99 [BB:51.307;418.324;453.260;658.808]. Fig. 99  Mammography (Jul. 2007): obscured irregular isodense mass (marked by BB marker) with punctate microcal­. cifications in the right upper outer quadrantFig. 100. Fig. 100  Chest CT (Aug. 2021): Diffuse peribronchial. infiltrates and bronchial wall thickening of right main. bronchus. Adjuvant Therapy. Chemotherapy #4 cycles (Paclitaxel).. Post-operative radiation therapy +Tamoxifen. 20 mg/day for 5 years +zoladex.. Treatments After Recurrence. See Fig. 100.. Aug. 2021 Right bronchus excision.. Pathology: Metastatic ductal carcinoma.. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. See Fig. 101.. Operation. Apr. 2017 Right nipple-areolar complex sparing. mastectomy with immediate implant reconstruc­. tion, sentinel lymph node biopsy.. Pathology: Invasive duct carcinoma, stage. T1c(2)N0(sn).. Size of tumor: 1.3  cm and 0.6  cm, lymph. node: 0/2.. Result. Intensity. See Fig. 102.. Feb. 2021 PET-CT: bone metastasis at T10.. Palliative Therapy. Letrozole 2.5 mg/day + ribociclib ~. 31. . 31.1. . Patient History and Progress. Female/54 years old, post-menopause.. No family history.. See Fig. 103.. Operation. Mar. 2014 Right breast conserving surgery, senti­. nel lymph node biopsy.. Pathology: Invasive ductal carcinoma, stage. pT2N0 (sn).. Size of tumor: 2.3 cm, lymph node: 0/1.Fig. 101. Fig. 101  Breast US (Mar. 2017): 1 cm indistinct irregu­. lar hypoechoic mass at the 9 o’clock direction of right. breastFig. 102. Fig. 102  PET-CT (Feb. 2021): Hypermetabolic bone. lesion in 10th thoracic vertebral body, suggesting bony. metastasis. Metastatic Breast Cancer. 912Fig. 103. Fig. 103  Breast MRI (Mar. 2014): An irregular enhanc­. ing mass with associated non-mass enhancement at the. 5–6 o’clock direction of right breastFig. 104. Fig. 104  PET-CT (May 2020): Focal hypermetabolic. nodule in right upper lobe. Result. Intensity. Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. See Fig. 104.. Jun. 2020 Chest CT: R/O metastasis, nodule in. right lung upper lobe.. Palliative Therapy. Paclitaxel & Atezolizumab & Ipatasertib & pla­. cebo (Jun. 2020 ~ Nov. 2021).. Atezolizumab (Nov. 2021) ~. 32. . 32.1. . See Fig. 105.. Operation. Jan. 2007 Left breast conserving surgery, sentinel. lymph node biopsy.. Pathology: Invasive ductal carcinoma, stage. pT2N0 (sn).. Size of tumor: 3.2 cm, lymph node: 0/5.. Result. Intensity. Positive %. Estrogen. 913Fig. 105 [BB:153.639;259.990;453.543;658.808]. Fig. 105  Mammography. (Jan. 2007): Indistinct. irregular hyperdense. mass with fine. pleomorphic. microcalcifications at the. 12 o’clock direction of. left breast on left CC and. MLO views. Adjuvant Therapy. Adjuvant chemotherapy # 6 cycles (Fluorouracil. See Fig. 106.. Jul. 2015 Right lung, middle lobe, percutane­. ous biopsy.. Pathology: Metastatic ductal carcinoma.. Result. Intensity. Positive %. Estrogen. receptor. Strong (7/8). 3. 914Fig. 106. Fig. 106  Chest CT (Jul. 2015): A round nodule in right. middle lobe, suggesting pulmonary metastasisFig. 107. Fig. 107  Breast US (Jun. 2007): Irregular hypoechoic. mass with microcalcifications at the 9 o’clock direction of. right breast. 33. . 33.1. . Patient History and Progress. Female/52 years old, peri-menopause.. No family history.. 33.2. See Fig. 107.. Operation. Jul. 2007 Right modified radical mastectomy at. another hospital.. Pathology: Invasive ductal carcinoma, stage. pT2N3a.. Size of tumor: 2.7  ×  1.4  cm, lymph node:. 13/38.. Result. Intensity. Positive %. See Fig. 108.. Mar. 2018 PET-CT: R/O multiple bone metas­. tasis in T8, T9, L2, L4, L5, sacrum, both pelvic. bones, right proximal femur.. Palliative Therapy. Palliative chemotherapy #15 cycles (Pertuzumab. & Trastuzumab & docetaxel).. Concurrent Bretra +zoladex (Sep. 2018 ~ Mar.. 2019): Progressive disease.. Palliative chemotherapy #38 cycles (T-DM1).. May 2021 Chest CT: T8, spinal canal. 915Fig. 108 [BB:51.367;483.607;453.200;658.808]. Fig. 108  PET-CT (Mar. 2018): Multifocal increased. uptake in thoracic and lumbar spines, sacrum, both pelvic. bones and right proximal femur, suggesting multiple bony. metastases and hypermetabolic bone lesion in 9th thoracic. vertebral body, suggesting bony metastasis. 34. . 34.1. . Patient History and Progress. Female/42 years old, peri-menopause.. See Fig. 109.. Operation. Feb. 2014 Left breast conserving surgery, senti­. nel lymph node biopsy.. Pathology: Invasive ductal carcinoma, stage. pT2N1a (sn), size of tumor: 2.5 cm, lymph node:. 1/4 (2.5 mm).. Result. Intensity Positive %. Estrogen receptor. Negative. See Fig. 110.. Feb. 2021 Chest CT: Metastasis to right pleu­. ral, liver, right adrenal gland, bone.. Metastatic Breast Cancer. 916Fig. 109. Fig. 109  Breast MRI. (Feb. 2014): Irregular. heterogeneous. enhancing mass at the. 12–3 o’clock direction. of left breastFig. 110. Fig. 110  Liver CT. (Mar. 2021):. Hypoattenuating masses. in the liver, suggesting. metastases. Palliative Therapy. Palliative therapy: Zanidatamab + Docetaxel. (Mar. 2021 ~ Aug. 2021) →Zanidatamab mono. (Sep. 2021 ~ Nov. 2021).. Dec. 2021 Brain MRI> r/o tiny metastasis to. brain.. See Fig. 111.. Operation. Dec. 2013 Right breast conserving surgery, axil­. lary lymph node dissection.. Y. Kwon et al.. 917Fig. 111. Fig. 111  Breast MRI. (Dec. 2013): Segmental. heterogeneous non-mass. enhancement at the 9–10. o’clock direction of. right breastFig. 112. Fig. 112  Bone scan (Sep. 2017): Increased uptake in the. upper C-spine. Pathology: Invasive ductal carcinoma, stage. pT1bN1a.. Size of tumor: 0.8 cm, 0.5 × 0.3 cm, lymph. node: 1/6 (8 mm).. Result. Intensity. Positive %. Estrogen. receptor. 918Fig. 113 [BB:51.306;503.768;453.261;658.808]. Fig. 113  C-spine MRI (Sep. 2017): Infiltrative enhancing lesion in the C2 vertebra vertebral body and left lateral arc,. suggesting bony metastasisFig. 114. Fig. 114  Breast US (Sep. 2008): Indistinct heteroge­. neous echoic mass at the 12 o’clock direction of right. breast. 36. . 36.1. . Patient History and Progress. Female/55 years old, post-menopause.. No family history.. S/p bilateral salpingo-oophorectomy, diabetes. See Fig. 114.. Operation. Sep. 2008 Right breast conserving surgery, axil­. lary lymph node dissection.. Pathology: Invasive ductal carcinoma, stage. pT2N1a.. Size of tumor 2.3  cm, lymph node: 1/15. (5 mm).. Result. Intensity. Positive %. See Fig. 115.. Y. Kwon et al.. 919Fig. 115 [BB:51.306;467.287;453.261;658.808]. Fig. 115  CT chest (Jul. 2017): Hypodense nodule in left upper lobe, suggesting metastasis and bone metastasis, right. 4th rib. Jul. 2017 PET-CT: R/O metastasis to left lung. lobe and right 3rd rib & 4th rib.. Aug. 2017 Left lung, upper lobe, percutane­. ous biopsy: Metastatic ductal carcinoma.. Result. Intensity. Positive %. Estrogen. receptor. See Fig. 116.. Operation. May 2013 Right breast conserving surgery, axil­. lary lymph node dissection.. Pathology: Invasive ductal carcinoma, stage. pT2N1a.. Size of tumor: 2.0  cm, lymph node: 3/30. (15 mm).. Result. Intensity. Positive %. 2014) ~Fig. 116. Fig. 116  Breast US (May 2013): Irregular hypoechoic mass. with angular margin at the 11 o’clock direction of right breastFig. 117 [BB:51.307;108.078;453.260;361.999]. Fig. 117  Chest CT (Aug. 2013, Feb. 2014): Newly developed interlobular septal thickening in left lower lobe, suggest­. ing lymphangitic metastasis. Y. Kwon et al.. 921Fig. 118 [BB:51.306;494.168;453.261;658.808]. Fig. 118  Chest CT (Feb. 2014): Enlarged mediastinal LNs, suggesting metastases and right malignant pleural. effusionFig. 119. Fig. 119  Mammography (Dec. 2008): Grouped fine. pleomorphic microcalcifications in right inner breast and. the subareolar area of left breast. 38. . 38.1. . Patient History and Progress. Female/70 years old, post-menopause.. No family history.. 38.2. 922Fig. 120. Fig. 120  Breast MRI. (Dec. 2008): Irregular. heterogeneous. enhancing mass at the. 1–3 o’clock direction of. right breast and irregular. homogeneous enhancing. mass in the subareolar. area of left breastFig. 121. Fig. 121  Liver CT (Sep. 2011): Hypoattenuating mass in. the lateral segment of liver, suggesting metastasis. Result. Intensity. Positive %. Estrogen. receptor. Negative (0/7). 0. 0. Progesterone. See Fig. 121.. Aug. 2011 PET> R/O metastasis to liver.. Palliative Therapy. Palliative therapy (clinical trial): Trastuzumab &. Paclitaxel (Sep. 2011~ Mar. 2012).. Trastuzumab mono (Mar. 2012~ Oct. 2019):. Partial response (end of treatment).. 39. . 39.1. . See Fig. 122.. Jul. 2007 Outside slide review > Right infil­. trating duct carcinoma.. Neoadjuvant Chemotherapy. Neoadjuvant. chemotherapy. #4. cycles. (Doxorubicin & cyclophosphamide #4).. Y. Kwon et al.. 923Fig. 122. Fig. 122  Breast US (Jul. 2007): Microlobulated. hypoechoic mass with microcalcifications at the 12. o’clock direction of right breastFig. 123. Fig. 123  Mammography (Feb. 2021): Irregular hyper­. dense mass in the upper portion of left breast. Operation. Oct. 2007 Right breast conserving surgery, senti­. nel lymph node biopsy.. Pathology: Invasive ductal carcinoma, stage. ypT1cN0 (sn).. Size of tumor: 1.5 × 1.0 cm, lymph node 0/1.. Result. Intensity. Positive %. See Fig. 123.. Feb. 2021 Left 12 o’clock biopsy: Invasive. ductal carcinoma.. Left axillary lymph node biopsy: Metastatic. ductal carcinoma.. Result. Intensity. Positive %. Estrogen. receptor. Negative. See Fig. 124.. Mar. 2021 PET-CT> R/O metastasis to lung,. left supraclavicular lymph node & lower neck.. Palliative Therapy. Palliative therapy (clinical trial): Zanidatamab +. Docetaxel (Apr. 2021~ Sep. 2021).. Zanidatamab mono (Sep. 2021) ~. Metastatic Breast Cancer. 924Fig. 124 [BB:51.306;358.609;453.261;658.808]. Fig. 124  PET-CT (Mar. 2021): Hypermetabolic activity in the left supraclavicular lymph nodes, and left axillary. lymph nodes and nodule in right upper lobe, suggesting pulmonary metastasis. 40. . 40.1. . Patient History and Progress. Female/54 years old, post-menopause.. No family history.. S/p bilateral salpingo-oophorectomy.. 40.2. See Fig. 125.. Oct. 2014 Outside slide review> Right inva­. sive ductal carcinoma.. Right axillary lymph node, metastatic ductal. carcinoma.. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). See Fig. 126.. Jun. 2017 PET-CT> R/O metastasis in right. lung lobe.. Palliative Therapy. Clinical trial: Capecitabine # 30 cycles:. Progressive disease.Fig. 125. Fig. 125  Breast MRI (Oct. 2014): Irregular homoge­. neous enhancing mass in right upper outer quadrant.. Enlarged lymph nodes in right axillary area, suggesting. metastasisFig. 126 [BB:51.307;160.859;453.260;397.500]. Fig. 126  Chest CT (Jun. 2017, May 2019): Nodule in right lower lobe, abutting diaphragmatic pleura, showing interval. increase in size. Metastatic Breast Cancer. 926. Jun. 2019 Bilateral salpingo-oophorectomy.. Palliative therapy: Letrozole + Palbociclib. (Jul. 2019) ~. 41. . 41.1. . See Fig. 127.. Operation. Nov. 2015 Left breast conserving surgery.. Pathology: Invasive ductal carcinoma, stage. pT2N2a.. Size of tumor: 2.4  cm, lymph node: 5/12. (11 mm).. Result. Intensity Positive %. Estrogen. receptor. Feb. 2020 Brain MRI> Metastasis in brain.Fig. 127 [BB:51.259;100.578;246.379;332.179]. Fig. 127  Breast MRI (Oct. 2015): Irregular homoge­. neous enhancing mass at the 1 o’clock direction of left. breastFig. 128 [BB:258.188;110.578;453.308;238.049]. Fig. 128  Chest CT (Sep. 2018): Interlobular septal line. thickening and bronchovascular bundle thickening (black. arrow), tiny nodules (white arrows) in bilateral lungs, sug­. gesting hematolymphangitic metastasis. Y. Kwon et al.. 927Fig. 129 [BB:51.306;332.732;453.261;658.808]. Fig. 129  PET-CT (Oct. 2018): Hypermetabolic activity in the liver, suggesting hepatic metastasis and hypermetabolic. activity in the left ilium and 4th lumbar vertebral body, suggesting body metastases. Palliative Therapy. Radiation to whole brain.. Palliative therapy # 11 cycles (Lapatinib &. Capecitabine): Progressive disease.. Palliative therapy # 4 cycles (Trastuzumab. emtansine).. 42. . 42.1. See Fig. 130.. Operation. Jun. 2008 Left breast conserving surgery, sentinel. lymph node biopsy.. Pathology: Invasive ductal carcinoma, stage. pT1aN0 (sn).. Size of tumor: 0.6 cm, 0.5 × 0.3 cm, lymph. node: 0/2.. Metastatic Breast Cancer. 928Fig. 130 [BB:51.366;438.910;453.201;658.808]. Fig. 130  Mammography (May 2008): Irregular isodense mass (white arrow) and regional microcalcifications (black. arrow) in left upper outer quadrantFig. 131. Fig. 131  Chest CT (Jan. 2021): Hypoattenuating pleural. nodule (white arrow) in left lower lobe and enlargement of. left interlobar lymph node (black arrow), suggesting pleu­. ral and lymph node metastasis. Result. Intensity Positive %. Estrogen. receptor. Strong (6/7). 3. 1/3–2/3. See Fig. 131.. Mar. 2021 Pleural fluid, cytology: Metastatic. carcinoma.. Palliative Therapy. Palliative therapy: Letrozole & Ribociclib (Jan.. 2021 ~ Mar. 2021).. Palliative therapy: Letrozole & Palbociclib. (Mar. 2021 ~ Dec. 2021).. Palliative therapy: Capecitabine # 3 (Feb.. 2022 ~ Mar. 2022): Progressive disease.. Palliative therapy: Paclitaxel & Cisplatin (Apr.. 929Fig. 132. Fig. 132  Breast US (Jun. 2012): Hypoechoic mass at the. 10 o’clock direction of right breastFig. 133. Fig. 133  Brain MRI (Jun. 2015): Small acute hemor­. rhagic lesion with dense leptomeningeal enhancement in. left superior frontal gyrus, suggesting leptomeningeal. metastasis with focal cortical hemorrhage. 43. . 43.1. . Patient History and Progress. Female/54 years old, post-menopause.. Family history of breast cancer, sister.. See Fig. 132.. Operation. Jun. 2012 Right breast conserving surgery, senti­. nel lymph node biopsy.. Pathology: Invasive ductal carcinoma, stage. pT1cN0 (sn).. Size of tumor: 1.5 cm, lymph node: 0/2.. Result. Intensity. Positive %. Estrogen. See Fig. 133.. Jun. 2015 Brain MRI> R/O metastasis in. leptomeningeal.. Jun. 2015 Cerebrospinal fluid cytology:. Atypical cells.. Metastatic Breast Cancer. 930. Palliative Therapy. Jul. 2015 Bilateral salpingo-oophorectomy.. Palliative therapy: Letrozole (Jul. 2015) ~. 44. See Fig. 134.. See Fig. 135.. Right invasive ductal carcinoma, stage IV. (metastasis in bone).. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. tumor cellsFig. 134. Fig. 134  Breast MRI (Jan. 2018): Huge irregular hetero­. geneous enhancing mass in right breast. Enlarged lymph. nodes (white arrow) in the right axillary area, suggesting. metastasesFig. 135. Fig. 135  Bone scan (May 2018): Multifocal increased. uptake in sternum, lumbar vertebral bodies, and right pel­. vic bone, suggesting bony metastases. Y. Kwon et al.. 931. Palliative Therapy. Feb. 2018 Bilateral salpingo-oophorectomy.. Palliative therapy: Letrozole & Palbociclib #. 16: Progressive disease.. Jul. 2019 Palliative operation: Right nipple-­. sparing mastectomy, axillary lymph node. See Fig. 136.. Jan. 2020 Liver biopsy: Metastatic ductal. carcinoma.. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Dec. 2021 Death.Fig. 136 [BB:51.307;148.639;453.260;344.000]. Fig. 136  Abdomen CT (Jan. 2020): Hypoattenuating nodules in the liver, suggesting hepatic metastases. Metastatic Breast Cancer. 932. 45. . 45.1. . Patient History and Progress. Female/49 years old, pre-menopause.. No family history.. 45.2. PositiveFig. 137. Fig. 137  Breast MRI (Jun. 2013): Irregular heteroge­. neous enhancing mass at the 12 o’clock direction of left. breastFig. 138 [BB:51.306;111.579;453.261;347.500]. Fig. 138  Chest CT (Jun. 2013): Multiple nodules in both lungs, suggesting pulmonary metastases. Y. Kwon et al.. 933Fig. 139. Fig. 139  PET-CT (Jun. 2013): Hypermetabolic activity. in the 1st lumbar vertebral body, suggesting bony. metastasisFig. 140. Fig. 140  Breast MRI (Jan. 2019): Irregular rim enhanc­. ing mass at the 7 o’clock direction of right breastFig. 141. Fig. 141  Whole spine MRI (Jan. 2019): Ill-defined infil­. trative bony enhancing lesion in the vertebral body and. post arc of the 10th thoracic vertebra, suggesting bony. metastasis. Palliative therapy: Paclitaxel & Trastuzumab. # 24.. Dec. 2014 Left breast conserving surgery, sen­. tinel lymph node biopsy.. Pathology: Invasive ductal carcinoma, stage. ypT2N0 (sn).. Size of tumor: 2.3 cm, lymph node: 0/2.. See Fig. 142.. Feb. 2012 Outside slide review> Left invasive. ductal carcinoma.. Result. Intensity Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. of tumor cellsFig. 142. Fig. 142  Breast MRI (Feb. 2013): Irregular heteroge­. neous enhancing mass in the left upper outer quadrant. Y. Kwon et al.. 935. Neoadjuvant Chemotherapy. Neoadjuvant. chemotherapy. #8. cycles. (Doxorubicin + cyclophosphamide #4 →. Docetaxel + Trastuzumab #4).. See Fig. 143.. Apr. 2016 Left breast biopsy> Invasive ductal. carcinoma.. Result. Intensity. Positive %. Estrogen. receptor. Negative (0/8). 0. 0. See Fig. 144.. Mar. 2018 Chest CT> metastasis in lung.. Palliative therapy: Trastuzumab emtansine #. 11: Progressive disease.. Palliative therapy: Lapatinib & Capecitabine #. 16: Progressive disease.Fig. 144. Fig. 144  Chest CT (Aug. 2020): Mildly enhancing. hypoattenuating mass in right upper lobe, suggesting pul­. monary metastasisFig. 143. Fig. 143  Chest CT (Apr. 2016): Newly developed irregu­. lar enhancing mass in left breast, suggesting recurrent. tumor. Metastatic Breast Cancer. 936. Concurrent radiation to internal mammary. lymph node.. Clinical trial: Herzuma & Vinorelbine tartrate. #4: Progressive disease.. Palliative therapy: Gemcitabine & Cisplatin. #5: Progressive disease.. See Fig. 145.. Enlarged lymph nodes (white arrow) in the. right axillary area, suggesting metastases.. See Figs. 146 and 147.. Right invasive ductal carcinoma, stage IV. (R/O metastasis in bone).Fig. 145. Fig. 145  Breast MRI (May 2014): Huge irregular hetero­. geneous enhancing mass in right breastFig. 146. Fig. 146  PET-CT (May 2014): Hypermetabolic activity. in the mediastinal lymph node, suggesting metastasis. Y. Kwon et al.. 937Fig. 147. Fig. 147  Whole spine MRI (Jun. 2014): Multiple. enhancing lesions in thoracic and lumbar vertebrae, sug­. gesting bony metastases. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. 938Fig. 148. Fig. 148  Breast MRI (Nov. 2014): Irregular enhancing. mass at the 11 o’clock direction of right breastFig. 149 [BB:51.306;138.080;453.261;254.000]. Fig. 149  PET-CT (Nov. 2014): Hypermetabolic bone lesions in both pelvic bones, suggesting bony metastases. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. (May 2021)~Fig. 150. Fig. 150  Breast US (Nov. 2019): Irregular hypoechoic. mass with echogenic halo at the 11 o’clock direction of. left breastFig. 151. Fig. 151  Chest CT (Feb. 2020): Several nodules, both. lungs, suggesting pulmonary metastases. Metastatic Breast Cancer. 941. © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023. E. S. Lee (ed.), A Practical Guide to Breast Cancer Treatment,. https://doi.org/10.1007/978-981-19-9044-1_11. Treatment Roadmap. and Summaries. Eun Sook Lee. 1"