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case_images: Photos of the patient before and after 6 cycles of neoadjuvant chemotherapy. (A) Before neoadjuvant chemotherapy, the skin of the left breast was mildly inflamed; the left nipple was inverted; and a hard, palpable mass was present in the left central breast. (B) After 6 cycles of chemotherapy, the size of the mass in the left breast was significantly reduced. Drawings show the lesion of interest.
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case_images: Physical examination revealed a 150x120 mm mass in the central quadrant of the left breast that caused the nipple to retract (Figure 1A).
case_images: Ultrasound (US) imaging of the left breast and left axilla. (A) Before neoadjuvant chemotherapy, US examination of the left breast mass showed a hypoechoic lesion with inhomogeneous internal echoes. (B) US of left axillary lymph nodes before neoadjuvant chemotherapy showed enlargement and cortical thickening. (C) After 6 cycles of chemotherapy, the size of the mass was significantly reduced. (D) Lymph node size was reduced and the shape nearly returned to normal after chemotherapy.
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case_images: An ultrasound (US) examination revealed a low-echoic lesion in the left breast whose size was too large to estimate (Figure 2A), while no hypoechoic mass was observed in the right breast. There were 6 enlarged lymph nodes in the left axilla with an indistinct medullary boundary (Figure 2B).
case_images: Magnetic resonance imaging (MRI) before and after chemotherapy. (A) Diffusion-weighted imaging (DWI) before chemotherapy. The signal in the left breast and inner side of the right breast showed heterogeneous enhancement. (B) Arterial phase of enhanced MRI before chemotherapy. Both breasts were composed of asymmetrically distributed dense glands. The whole left breast was markedly enhanced. (C) Time-intensity curve of dynamic contrast enhancement of left breast mass before chemotherapy (outflow type). (D) DWI after chemotherapy. The signal in the left breast and inner side of the right breast showed heterogeneous enhancement that was weaker than before chemotherapy. (E) Arterial phase of enhanced MRI after chemotherapy. Compared to before chemotherapy, the size of lesions in the left breast and upper quadrant of the right breast were significantly reduced. (F) Time-intensity curve of dynamic contrast enhancement in the left breast mass after chemotherapy (plateau type).
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case_images: Strikingly, there was an ovoid, poorly defined mass in the upper quadrant of the right breast; although visible enhancement was observed by MRI (Figure 3A-C), the color Doppler US examination result was negative. During the treatment course, the size of the tumor decreased significantly as a result of neoadjuvant chemotherapy as determined by physical examination, US, and breast MRI (Figures 1-3, 4D-F), and there were no severe adverse effects.
case_images: Images of core needle biopsy and histologic analysis by hematoxylin and eosin staining (100x magnification). (A) Left breast biopsy. (B) Right breast biopsy. (C) Epithelial membrane antigen (EMA) in left lymph node biopsy. (D, E) After chemotherapy, there were fewer cancer cells in the left breast (D), while interstitial fibrosis, nuclear enlargement, vacuolation, and number of cells with eosinophilic cytoplasm were increased. (F) Inflammatory cell infiltration after chemotherapy.
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case_images: IMPC, while cytologic detection of metastatic breast carcinoma in the left axillary lymph node yielded positive findings (Figure 4A-C). Immunohistochemistry (IHC) of the left breast showed that cancer cells were positive for estrogen receptor (ER), progesterone receptor (PR), and HER2 (2+) (Figure 5A); fluorescence in situ hybridization (FISH) revealed m17 (Figure 5C); and the Ki-67 proliferation index was 20%, with similar IHC and FISH results obtained for the right breast mass (Figure 5B, D). During the treatment course, the size of the tumor decreased significantly as a result of neoadjuvant chemotherapy as determined by physical examination, US, and breast MRI (Figures 1-3, 4D-F), and there were no severe adverse effects.
case_images: Human epidermal growth factor receptor 2 (HER2) expression detected by immunohistochemistry (IHC) (100x magnification) and fluorescence in situ hybridization (FISH) (400x magnification). (A, B) HER2 positivity of left (A) and right (B) breast cancers as detected by IHC. (C, D) Monosomy of chromosome 17 of left (C) and right (D) breast cancers detected by FISH.
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case_images: IMPC, while cytologic detection of metastatic breast carcinoma in the left axillary lymph node yielded positive findings (Figure 4A-C). Immunohistochemistry (IHC) of the left breast showed that cancer cells were positive for estrogen receptor (ER), progesterone receptor (PR), and HER2 (2+) (Figure 5A); fluorescence in situ hybridization (FISH) revealed m17 (Figure 5C); and the Ki-67 proliferation index was 20%, with similar IHC and FISH results obtained for the right breast mass (Figure 5B, D).
case_images: Timeline of patient's clinical course. Relevant events in the patient's medical history are shown in chronologic order.. Abbreviations: MRI, magnetic resonance imaging; FISH, fluorescence in situ hybridization; OFS, ovarian function suppression; CEP17, chromosome enumeration probe 17.
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case_images: At the 30-month follow-up, the patient was still alive and there was no evidence of metastasis (Figure 6).