Teaching Case

A 35-year-old woman presented complaining about painful right breast mass for two months. She was treated with antibiotics without improving. At physical examination, the right breast was enlarged, red and warm. There was nipple retraction. An underlying large breast mass and two fixed ipsilateral axillary lymph nodes were also palpable.

Even though mammography is mandatory, the right one couldn’t be performed due to severe breast pain. Ultrasonography revealed a diffuse hypoechoic area (Fig. 1a). There were thickening of the skin and nipple retraction. Four axillary adenopathies were also detected (Fig. 1b). Contralateral breast/axilla were normal.
Findings were suspicious of malignancy so a core-needle biopsy of the breast, a skin punch-biopsy and a fine-needle-aspiration of an adenopathy were performed.
The anatomopathological result was an infiltrated ductal carcinoma with phenotype of neoplastic cells:HER2 -, ER 32%, PR 0% and Ki67 44%. Fine needle aspiration of the axillary adenopathy and skin punch were also positive for malignancy.
MRI showed an irregular heterogeneous, asymmetric nonmass enhancement in the right breast, (Fig. 2). It had kinetic curve type 2 (Fig. 3). In addition, there was thickening of the right pectoral muscle, probably because there was oedema in the prepectoral space (Fig. 4).
CT-body showed multiple osseous metastases. Final-TNM-staging was T4dN2M1.

A. Background
Inflammatory breast cancer (IBC) is a rare and aggressive form of breast cancer characterised by diffuse dermatologic erythema and oedema (peau d’orange). Diagnosis is based on the clinical presentation and the presence of invasive breast carcinoma on biopsy [1].
B. Clinical Perspective
Usual clinical presentation consists in pain and rapidly progressing tender, firm and enlarged breast. The skin is red, warmed and thickened “peau d’orange”[2]. Nipple involvement and a palpable lump may or may not be present [1]. The clinical problem is that many patients with those symptoms may be treated with antibiotics for presuming diagnosis of mastitis. However, the absence of clinical improvement after 1-2 weeks should always be further investigated through imaging and biopsy [3].
C. Imaging Perspective
Mammography shows a diffuse increased breast density with or without a mass, calcifications and/or parenchymal distortion. Ultrasonography may show ill-defined mass or areas of parenchymal distortion. MRI has a high sensitivity for parenchymal lesions and thickening of the skin (2). In addition, approximately 30% of patients have metastases so it is mandatory to rule out distant disease [1, 2]. CT scans of the chest, abdomen, and pelvis (optimally with intravenous contrast administration), and a bone scan have to be obtained [1]. In addition, 18F-FDG PET/CT significantly contributed the accurate staging and management of breast cancer, and it is the technique of choice to rule out metastases. Nonetheless, in our case we did not perform PET-CT because it was not available.
Final diagnosis is made by all the following criteria: rapid onset of typical symptoms, duration of history < 6 months, erythema occupying at least one-third of the breast and pathologic confirmation of invasive carcinoma [1]. Skin punch biopsy showing tumour embolism within the dermal lymphatics supports the diagnosis but it is not a diagnostic criterium [2].
D. Outcome
IBC is an aggressive form of locally advanced breast cancer. Conservation therapy and sentinel node biopsy are inappropriate. Treatment consists in neoadjuvant chemotherapy followed by mastectomy and post-mastectomy radiation. It was the treatment of our patient. Nevertheless, prognosis is poor with a median disease-free survival of less than 2.5 years and an overall survival of 30-40% at 5 years [2].
E. Take Home Message,
We should take into account IBC as a differential diagnosis in a presumed mastitis that does not improve with antibiotics after 1-2 weeks of treatment.