- © 2003 by American Society of Clinical Oncology
Unusual Problems in Breast Cancer and a Rare Lung Cancer Case
Case 3. Simultaneous and Synchronous Bilateral Inflammatory Breast Cancer
A 69-year-old woman with no family history of malignancy presented with a 3-week onset of progressive dyspnea and simultaneous bilateral breast swelling. On physical examination, both breasts were symmetrically enlarged, indurated, warm, erythematous, and had a peau d’orange appearance with inverted nipples (Fig 1⇓). There was no discrete mass in either breast or regional lymphadenopathy. Mammography showed diffuse increased density bilaterally with extensive edema and microcalcification only in the central portion of the left breast. Computed tomography of the chest revealed diffusely thickened mammary skin, soft tissue edema both in the breasts and in the subcutaneous tissues surrounding the entire anterior chest wall, bilateral axillary adenopathy, and bilateral pleural effusions (Fig 2⇓). Bilateral breast biopsies revealed infiltrating ductal carcinoma with extensive involvement of dermal lymphatics (Figs 3A⇓ and 3B⇓). Immunochemistry showed that the lesions were estrogen and progesterone receptor–positive with overexpression of HER-2/neu. Pleural fluid cytology on the left breast revealed adenocarcinoma. Skeletal scintigraphy was positive for metastases. Computed tomography of the abdomen and pelvis, upper endoscopy, and colonoscopy were all normal.
The term bilateral breast cancer implies that, in a patient with a known unilateral breast cancer, a malignancy is detected in the contralateral breast. In a comprehensive review, 836 (3.7%) of 25,563 breast cancers were bilateral, with one third being synchronous and two thirds being metachronous.1 The reported incidence of bilateral breast cancer varies according to the length of follow-up and method of diagnosis. Bilateral primary breast cancers described as synchronous or metachronous are arbitrary regarding designation of time and have no biologic significance. There is no correlation of bilateral breast cancer with tumor size, histologic differentiation, hormonal receptor status, or the number of lymph nodes involved. There are, however, a few true risk factors, including age at the time of initial breast cancer diagnosis, family history, genetic mutation, multicentricity, and pathologically infiltrating lobular carcinoma. Inflammatory breast cancer (IBC) is the reported diagnosis in 1% to 3% of patients with newly identified invasive breast cancer. There is no consistent histologic type of breast carcinoma associated with this entity. The histologic type ranges from infiltrating ductal to medullary. The carcinoma series of Haagensen,2 which studied 40 patients, included 19 (47%) with the large-cell undifferentiated-type carcinoma. The diagnosis of IBC is based on the clinical presentation, defined by the American Joint Committee on Cancer staging manual as “diffuse brawny induration of the skin of the breast with an erysipeloid edge, usually without underlying palpable mass.” The skin over the breast is warm and thickened, with an orange peel appearance. The classic histologic finding in IBC on biopsy of affected skin is dermal lymphatic invasion by tumor cells. However, dermal lymphatic invasion is not a necessary criterion for the diagnosis of IBC. IBC is diagnosed by clinical presentation. Affected patients may present with clinical signs only without dermal lymphatic invasion, or with dermal lymphatic involvement without clinical signs, or with both clinical signs and dermal lymphatic invasion. Our patient had both the clinical and the pathologic findings of IBC.
Metastatic tumors to the breast appear as relatively small, superficially located, poorly defined, irregular nodules without calcification on mammography and ultrasonography. However, when the lesion is diffuse, the appearance is indistinguishable from that of IBC. Two cases of breast metastasis from signet ring cell gastric cancer3,4 and three case reports of metastasis from primary ovarian carcinoma mimicking bilateral IBC have been published.5–,7 In our patient, such possibilities were excluded based on history, physical examination, and histologic and radiologic findings.
A patient like ours, who presents with simultaneous and synchronous primary IBC, is exceedingly rare. Similar cases reported in the literature include that of a male patient presenting with bilateral inflammatory medullary breast carcinoma8 and a female patient with bilateral IBC who was treated with chemotherapy, radiation, and bilateral mastectomy.9
Patient presenting with bilateral inflammatory breast cancer.
Computed tomography of patient showing diffusely thickened mammary skin, soft tissue edema both in the breasts and in the subcutaneous tissues surrounding the entire anterior chest wall, bilateral axillary adenopathy, and bilateral pleural effusions.
(A, B) Bilateral breast biopsies revealing infiltrating ductal carcinoma with extensive involvement of dermal lymphatics.
