A 50 year old lady presented with the history of a lump in the left breast for one year duration. The lump was painless and slowly increasing in size. There was no family history of breast cancer or any history of taking oral contraceptives or estrogen therapy. There was no history of nipple discharge. Physical examination was unremarkable. The rest of the systemic examination revealed no abnormality. Local examination of the left breast showed 6.0x3.0 cm large, hard, irregular, non- tender mobile lump involving mainly the lower outer quadrant. There was puckering of the overlying skin with retracted nipple. Two lymph nodes were palpated in her left axilla and both were slightly tender. Contralateral breast and axilla were normal. The patient was referred for fine needle aspiration cytology (FNAC) with the clinical diagnosis of carcinoma of the left breast with axillary lymph nodes involvement. FNAC from the breast mass showed clusters, acinar pattern and dissociative population of pleomorphic cells having large nuclei with irregular nuclear membrane, anisonucleosis, prominent nucleoli and moderate amount of cytoplasm. FNAC from the clinically significant axillary lymph nodes showed the presence of similar sheets and groups of malignant tumor cells against clear lymphoid background. Diagnosis offered on cytology was ductal carcinoma of the left breast with metastasis to the left axillary lymph nodes. The preoperative workup consisted of a complete haemogram, ESR, chest X- ray and ultrasound examination of the abdomen. Complete haemogram showed mild microcytic hypochromic anemia while other investigations were within normal limits. The patient subsequently underwent modified radical mastectomy of the left breast with axillary lymph nodes clearance and the specimen was sent for histopathology examination.
The mastectomy specimen measured 16x15x4 cm and the axillary tail was 8.0 cm in length. The overlying skin showed puckering whereas nipple was retracted. On slicing, the specimen revealed an irregular yellowish gray mass measuring 3.5x2.5x1.5cm in size. It was firm in consistency with infiltrating margins. On sectioning there was a gritty sensation. The axillary tail revealed 14 lymph nodes ranging from 0.5cm to 1.0cm in diameter, and all were sampled.
Representative samples were fixed in 10% neutral buffered formalin, dehydrated and embedded in paraffin. Sections were stained in haematoxylin and eosin. Microscopic examination of the tumor showed sheets, clusters and duct- like arrangement of tumor cells of having large vesicular nucleus containing prominent nucleoli embedded within dense collagenous stroma. Of the fourteen lymph nodes, thirteen showed tuberculous lymphadenitis in the form of numerous well formed caseating granulomas composed of epithelioid cells, Langhans' giant cells surrounded by lymphocytes, two of the lymph nodes showed coexistent carcinomatous deposits along with well defined caseating granulomas and reactive hyperplasia in one. Ziehl Neelsen stain for acid- fast bacilli was positive (Figure 1, Figure 2) Sections from resected margins, deep resection plane and nipple and areola did not show any evidence of infiltration by tumor. The surrounding breast was normal. The final diagnosis offered on histopathology was infiltrating ductal carcinoma, grade II (Nottingham modification of Scarff Bloom Richardson System) of the left breast with metastasis in left axillary lymph nodes harbouring tuberculous lymphadenitis.
Since preoperatively tuberculosis was not suspected, Mantoux test, culture, serology or polymerase chain reaction were not performed. On the basis of histopathological report, the patient was put on anti- tuberculous therapy along with adjuvant chemotherapy with cyclophosphamide, methotrexate and 5- fluorouracil (CMF) and responded well to treatment.