|Year : 2017 | Volume
| Issue : 2 | Page : 255-257
Inflammatory carcinoma of breast: The chameleon
Indranil Chakrabarti, Amitabha Basu, Nilanjana Ghosh
Department of Pathology, North Bengal Medical College, Siliguri, West Bengal, India
|Date of Web Publication||15-Dec-2017|
Department of Pathology, North Bengal Medical College, Sushrutanagar, Siliguri, Darjeeling - 734 012, West Bengal
Source of Support: None, Conflict of Interest: None
Inflammatory breast carcinoma is an extremely rare, rapidly progressive breast carcinoma which is a great masquerader and often is mistaken as an inflammatory lesion. This leads to the delay in diagnosis. Here, we report such a case where the mistaken clinical diagnosis led to it being treated with antibiotics. However, fine-needle aspiration cytology of the case saved the day. Histopathological confirmation followed by multimodal therapy was rendered, and the patient responded well to the treatment. Thus, awareness and recognition of this rare entity, which mimics various inflammatory and nonmalignant causes, is of paramount importance for the doctors and patients alike.
Keywords: Fine-needle aspiration cytology, inflammatory breast carcinoma, multimodal therapy
|How to cite this article:|
Chakrabarti I, Basu A, Ghosh N. Inflammatory carcinoma of breast: The chameleon. Arch Med Health Sci 2017;5:255-7
| Introduction|| |
Inflammatory carcinoma of breast is an extremely rare but rapidly progressive form of breast carcinoma. Its overlapping clinical presentation with dermatitis and mastitis coupled with its rarity often leads to a delay in diagnosis. Rapid accurate diagnosis followed by the multimodal approach to therapy can be lifesaving for the patient.
| Case Report|| |
A 30-year-old female presented to the outpatient department with redness, swelling, sense of burning and heaviness in the right breast for the past 1 month. There was no history of trauma or associated fever. On examination, it was seen that the redness covered more than half of the right breast which was enlarged compared to her left breast. The overlying skin was tense and warm and was pitted with the characteristic peau d'orange or orange-peel appearance. The nipple also appeared retracted [Figure 1]. There was a diffuse thickening, but no definite mass was palpable. The breast was tender, and there was also a small 2 cm × 1 cm enlarged lymph node in the right axillary region. A provisional diagnosis of acute mastitis was made, and the patient was treated for 1 week with antibiotics. The patient turned up after 10 days with no improvement of her condition. She was sent for fine-needle aspiration cytology (FNAC). The aspiration was done with a 23G needle fitted to a 10 cc syringe and yielded blood-mixed granular material. The smears were stained with hematoxylin and eosin stain and Leishman stain. The microscopy revealed cellular smears comprising of pleomorphic ductal cells in clusters and singles in a hemorrhagic background. There was no bare bipolar nuclei or myoepithelial cells in the smears [Figure 2]. A cytological diagnosis of ductal carcinoma was rendered, and biopsy was suggested based on the clinical appearance to confirm the possibility of inflammatory carcinoma. The lymph node of right axilla was also aspirated and showed deposits of ductal carcinoma. The patient was advised neoadjuvant chemotherapy followed by surgical removal. The patient refused chemotherapy, and modified radical mastectomy with axillary clearance was done. The histopathology confirmed the diagnosis of inflammatory carcinoma. Only one of the six right axillary lymph nodes showed metastatic deposits. The tumor was positive for estrogen and progesterone receptors (PRs) as well as for human epidermal growth factor receptor 2 (HER2)/neu [Figure 3]. The characteristic involvement of dermal lymphatics was also present. The patient was treated with tamoxifen and was symptom free at 6-month follow-up.
|Figure 1: Photograph showing diffusely enlarged right breast with redness and pitting of the overlying skin. The nipple is also retracted|
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|Figure 2: Photomicrograph showing pleomorphic ductal cells in a hemorrhagic background (Hematoxylin and eosin stain; ×400) Inset shows the pleomorphic cells in Leishman stain (×400)|
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|Figure 3: Photomicrograph showing estrogen receptor-positive tumor cells in dermal lymphatics (×400)|
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| Discussion|| |
Inflammatory breast carcinoma (IBC) is a rare form of breast carcinoma with very few published case reports. The importance lies in the awareness of the entity as the clinical features often mimic that of the more common mastitis or dermatitis or even trauma. The other differentials include breast edema by venous congestion and even lymphoma. The situation is further complicated by the fact that there is often no palpable mass. All these lead to the delay in diagnosis and rapid spread of the tumor.
It is a poorly understood, rapidly progressive disease, and at the time of diagnosis, the most women have lymph node metastases, and roughly one-third has distant metastases. It accounts for an estimated 2% of breast cancer diagnoses in the US but for 7% of breast cancer deaths.
The unique description was provided by Lee and Tannenbaum in 1924 when they commented: “The rate of growth is startling in its rapidity and often fills the entire breast in a few weeks … the overlying skin is reddened and brawny and its blush may extend far beyond the limits of the mammary gland … the inflamed area presents a distinct raised periphery after the fashion of erysipelas. The infiltration is so marked that the examiner, with his eyes closed, can distinguish readily the sharp contrast between normal and affected tissue.”,
The characteristic appearance of rapid swelling, redness, and peau d'orange is often attributed to the involvement of dermal lymphatics although it is now said that dermal lymphatic involvement is neither required nor sufficient by itself for the diagnosis of inflammatory breast cancer.,
The presence of an enlarged draining lymph node and the absence of fever and neutrophilic leukocytosis can also tilt the balance in favor of suspecting malignancy.
The characteristic signs and symptoms of short duration (<6 months) imaging studies (ultrasonography, mammography) with microscopic confirmation either by FNAC or biopsy should comprise the diagnostic workup. Another important exercise is to thoroughly examine and investigate the other breast for asymmetry or trabecular and/or cutaneous thickening  to rule out the possibility of contralateral spread or simultaneous involvement which occurs in approximately 1%–5% of patients with primary IBC.
The treatment is usually by a multimodal approach. Neoadjuvant chemotherapy followed by surgery and radiation therapy is the most accepted approach. Targeted therapy with trastuzumab and pertuzumab for HER2/neu-positive cases and hormone therapy for estrogen receptor/PR-positive cases are recommended with good results.
Thus, the clinical suspicion of imaging studies with cytology/histological confirmation remains the mainstay in the diagnosis of this extremely rare but potentially dangerous malignancy.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]