A 37-year-old premenopausal woman was admitted to hospital on March 28, 2019 for finding a mass in her left breast for more than 5 months. There was no past history for her. Physical examination showed a mass of about 2*2 cm can be palpated in the upper inner quadrant of her left breast (11 o'clock direction), which is hard, irregular in shape, unclear in boundary, and still movable. A 1 * 1 cm enlarged lymph node can be palpated in her left axilla, and no definite enlarged lymph node can be found in right axilla and the upper and lower clavicles of both sides. Breast ultrasound showed that the size of the left breast mass was about 2.0 * 1.7 * 0.8 cm in size, and was located at about 10–11 o'clock direction of the left breast, approximately 0.8 cm away from the skin and 2.5 cm away from the nipple, Which was diagnosed BI-RADS 4C. Multiple hypoechoic could be found in bilateral axillary, and the maximum in left side was about 1.2 * 0.5 cm(Fig. 1). Mammography showed a irregular high-density mass located in the posterior part of upper quadrant of left breast, with a range of about 2.1 * 1.9 cm, and also was diagnosed BI-RADS 4C(Fig. 2a and 2b). Breast MRI told that the size of left breast mass was about 2.1 * 1.2 * 2.2 cm, with lobulated shape and spicules of margin, which was diagnosed BI-RADS 4C(Fig. 3). Then we gave her core needle biopsy for left breast mass and fine needle aspiration for left axilla lymph node, the result showed left breast mass was malignancy and the axilla lymph node was negative. Immunohistochemistry: Invasive adenocarcinoma of left breast(whoⅡ grade), ER (+, 80%), PR (+, 70%), HER2 (2+), GATA-3 (+), E-cad (+), p120 (membrane +), calponin (part +), p63 (part +), Ki-67 (+, 30%), p53 (+, 20%), FISH examination showed negative. Chest CT: 1.3 cm GGN was discovered in the anterior basal segment of the lower lobe of right lung, with unclear boundary(Fig. 4). Bone scan: no obvious abnormality was found. Because the uncertainty of this case, we gave her MDT. During MDT discussing, There seemed to be a consensus that the lung nodule was most likely a primary lung carcinoma.
Therefore, the patient was transferred to the department of chest surgery for pulmonary surgery. Video-assisted thoracoscopic wedge-shaped resection of the right lower lobe nodule was performed on April 9, 2019. The results showed that the right lower lobe nodule was consistent with adenocarcinoma. Based on the result, the right lower lobe resection and lymph nodes dissection were performed next. Postoperative pathological examination told tumor size was about 2.5 * 2 cm and located in the lower lobe of the right lung. Lymph node examination showed: peribronchial lymph nodes (0 / 1), group 2–4 lymph nodes(0 / 2), group 7 lymph nodes(1 / 8), group 8 lymph nodes(0 / 1), group 11 lymph nodes(0 / 5), group 12 lymph nodes(0 / 2). the cutting edge was free, no nerve invasion, no pulmonary membrane involvement, no airway spread. Immunohistochemistry: CK (diffuse +), CK5 / 6 (-), P40 (-), CK7 (diffuse +), CK20 (-), napsina (+), TTF-1 (diffuse +), Ki-67 (+, 10%), p53 (+, 80%)(Fig. 5). Genetic examination showed EGFR: 21 L858R mutation, supported the diagnosis of primary adenocarcinoma of right lung. After pulmonary surgery, she was transferred to our department and then we gave her mastectomy and sentinel lymph node biopsy (0 / 5) for left breast cancer on May 5, 2019.Postoperative pathological examination told: left breast invasive adenocarcinoma (WHO gradeⅡ), tumor size is about 2.5 * 2 * 1.5 cm; ductal carcinoma in situ: about 40%; specimen margin: all negative; lymphatic vascular invasion: found; nerve invasion: not found. Immunohistochemistry: ER (+, 90%), PR (+, 90%), HER2 (2 +), E-cad (+), p120 (membrane +), AR (-), CK5 / 6 (myoepithelial loss), EGFR (-), GATA-3 (diffuse +), Ki-67 (+, 20%), p53 (+, 5%), SMA (myoepithelial loss), FISH examination showed negative(Fig. 6).
After operation, we completed 8 cycles of adjuvant chemotherapy of epirubicin 90 mg / m2 (total 130 mg), IVP / IV, GTT, D1; cyclophosphamide 600 mg / m2 (total 900 mg), IVP / IV, GTT, D1; followed docetaxel 90 mg / m2 (total 130 mg), IVP / IV, GTT, D1 three week of a cycle, and gefitinib was given to lung adenocarcinoma EGFR targeted therapy, and tamoxifen and goserellin were continued after chemotherapy for endocrine therapy. Follow-up to September 2020, no tumor recurrence and metastasis.