**4.4 Luminal B HER2 ve breast cancer case presentation**

60-years-old female patient presented with left breast lump. Family history: Negative (**Figure 4**).

#### **Figure 3.**

*U/S breast showing irregular shaped lesion with speculated margin measuring 3.3 cm in its maximum dimension showing posterior acoustic shadowing.*

#### **Figure 4.**

*U/S of fibroglandular breast showing hypoechoic focal lesion, irregular in shape with speculated margin and not surrounded by desmoplastic reaction, mixed posterior acoustic shadowing and enhancement. The parenchyma showed distortion and few calcific foci.*

#### **Histopathological examination result:**

Invasive duct carcinoma grade III

#### **Immunohistochemical results revealed:**

ER: positive PR: negative *Correlation between Ultrasound Findings and Molecular Subtypes of Breast Cancer DOI: http://dx.doi.org/10.5772/intechopen.108812*

HER2: positive Ki-67: 30%

### **4.5 Triple negative breast cancer case presentation**

47-years-old female patient presented with left breast mass. Family history: Negative (**Figure 5**).

**Histopathological examination result:** Invasive ductal carcinoma grade III.

## **Immunohistochemistry results:**

ER: negative PR: negative HER2: negative Ki-67: 30%

#### **4.6 Triple negative breast cancer case presentation**

45-year-old female patient presented with right breast mass. Family history: Negative (**Figure 6**).

**Histopathological examination result:** Invasive ductal carcinoma grade III.

#### **Immunohistochemistry results:**

ER: negative PR: negative HER2: negative Ki-67: 50%

#### **Figure 5.**

*U/S showed fibroglandular breast with hypoechoic oval shaped lesion with circumscribed margin, measuring 4.3x3.6 cm in its maximum dimensions showing posterior acoustic enhancement with edge attenuation. The lesion is not surrounded by desmoplastic reaction.*

#### **Figure 6.**

*U/S breast showing hypoechoic oval shaped lesion with circumscribed margin, measuring 2.2x1.5 cm in its maximum dimensions showing mixed posterior acoustic shadowing and enhancement. The lesion is not surrounded by desmoplastic reaction. No associated parenchymal distortion or calcification noted.*

## **4.7 HER2 breast cancer case presentation**

52-years-old female patient presented with right breast lump. Family history: Positive (**Figure 7**). **Histopathological examination result:** Invasive ductal carcinoma grade III.

#### **Figure 7.**

*U/S of breast showing hypoechoic irregular shaped lesion. The lesion was associated with parenchymal distortion and other satellite lesions. The largest measuring 1.2 x 2.1 cm in its maximum dimensions.*

*Correlation between Ultrasound Findings and Molecular Subtypes of Breast Cancer DOI: http://dx.doi.org/10.5772/intechopen.108812*

#### **Immunohistochemistry revealed:**

ER: negative PR: negative HER2: positive.

The current study comprised 40 female patients with breast cancer. When analyzing the main four breast cancer subtypes. The present results showed the percentage rates of the subtypes-as: LA 34%. LB 40%, HER2 15%, and TNBC 11%.

The result of the present work showed LB subtype represented 40% and the cases followed by LA subtype 34%. While [6] in their study showed that LA subtype was 37.8°(.o and LB subtype was 36.8%.

The differences between the current work and [6] did not rank to valuable statistical difference.

The mean age of the patients was 50 +/ 10 with a range from 45 to 65:years. Correlation between each subtype.with age and density had been done. The significance of the correlation of subtype of the lesion and density of the breast was related to the age groups.

Since dense fibroglandular breast was associated with younger age group and fatty breast was associated with older age group was described by [7].

In the present study, LA subtype included 14 patients with 8 patients > 50 years and 6 patients <50 years. The result was not consistent with [8] study which had reported that most of LA patients' age was above 50 years.

LB subtype represented 16 patients of the current study with 10 patients> =50 years and 6 patients <50 years. The result was congruent with [8] which showed a higher percentage of the studied LB patients were less than 50 years of age.

HER2 subtype included 15 patients of our study with 6 patients>50 years and 9 patients<50 years. This was consistent with [6]. They found that HER2 breast cancer lesions were significantly associated with advanced age.

TNBC subtype included 4 patients, 3 of them were > 50 years and one patient <50 years. Which indicates that TNBC was more associated with younger age group. The same results had been founded by [6, 9] studies that showed the majority of TNBC lesions were encountered with younger age group.

In the present study, HER2 lesions were more encountered in fatty breast. However the rest of subtypes showed no significant predominance in a certain: breast density. These findings were consistent with [8] findings that showed that HER2 subtype was significantly observed in postmenopausal women; but inconsistent in TNBC subtype. In the present work TNBC showed a strong association with dense fibroglandular breast.

Oval shaped lesions with circumscribed margin were found significantly associated with TNBC lesions (69% of the cases) (p < 0.001) and least observed in LA lesions where only 11% of them showed oval circumscribed margin. In contrast–irregular. shaped lesions were significantly observed in LA subtype (88% of the cases) with a P value < 0.001. In addition 76% of LB cases and 73% of HER2 cases were associated with irregular shape (P < 0.001).

Speculated margin was observed in most of LA lesions (76% of the cases), while lobulated margin was more observed in HER2 lesions (66.7%).These findings were congruent with [9–11] findings. They showed tumors with regular shape and circumscribed margins were more often triple negative breast cancer lesions showing hormone negativity while irregular shape and non-circumscribed margins was significantly associated with luminal tumors and hormone receptor positivity.

In the present study posterior shadowing was significantly associated with luminal tumors while posterior enhancement was found to be more observed with TNBC lesions (53%). Mixed enhancement and shadowing were associated with HER2 lesions which was observed in 53.3% of our HER2 cases.

These findings were consistent with [12] had stated that posterior enhancement is an eminent feature characterizing TNBC.

Kin et al. [13] findings were typically consistent with our study regarding the posterior acoustic shadowing feature in luminal subtypes. The current our results were not associated with [14] that showed that HER2 lesions were more associated with posterior enhancement.

Desmoplastic reaction was observed in LA lesions (55.5% of LA cases) with a P value<0.001. Other subtypes showed no significant correlation with this criterion. Our finding was typically consistent with [6, 9] findings suggesting that desmoplastic reaction could denote slowly growing tumors.

All lesions were found to be more hypoechoic than isoechoic.

Hyperechoic lesions were not found at all in all the examined masses. Hypoechogenieity was significantly associated with TNBC, a result that found to be consistent with the one reported by [13].

Multiplicity of the lesion was more frequently encountered in HER2 subtype lesions and was not significantly observed in other subtype. This \_is consistent with [13] that related this finding to the associated intraductal component that is found to be clearly associated with HER2+ receptor.

In the present study calcifications was found to be clearly encountered in ER2, subtyp lesions (,67%) with much less association with other subtype (P = 0.025).

This was found to be in accordance with [15] showing that the expression of HER2 oncogene was strongly correlated with the presence of calcification upon ultrasound. Additionally [12] noticed that the presence of calcification was significantly associated with HER2+ status.

Associated parenchymal distortion was more observed in LA and HER2 subtypes. This was consistent with [15] study that showed that LB subtype was the least associated with architectural distortion. Intraductal extension in HER2 subtype might have a role in architectural distortion as stated by [13].

Tumors larger than 2 cm were frequently associated with HER2+ status. These included HER2 and LB HER2+ subtypes which both together constitute 33% of total number of cases (P = 0.036). Smaller lesions were significantly seen in hormone receptor ER and /or PR positive breast masses. These results were correlated to the findings of [8].

TNBC lesions less than 2 cm were observed in one out of four patients, while the remaining three lesions were more than or equal 2 cm, and these findings were not consistent with [8, 16]. They showed that larger lesions were more associated with TNBC subtype. Invasive ductal carcinoma was the histopathological type the most common of breast cancer in the present study. Invasive lobular breast tumor was encountered in 23% of LA subtype's masses.

#### **5. Conclusion**

The sonographic features as margin shape, posterior acoustic features were significantly associated with molecular subtypes. The histopathological grade and hormone receptor status. Being able to predict the molecular subtype. The current study recommend that the radiologist should be aware about different imaging features of

*Correlation between Ultrasound Findings and Molecular Subtypes of Breast Cancer DOI: http://dx.doi.org/10.5772/intechopen.108812*

different molecular subtypes especially the triple negative breast cancer which had the most benign looking criteria aiming for better lesion characterization and to allow the patient to benefit from earlier non invasive, cheap diagnosis and the curable on time management.
