Inflammatory breast cancer combined with breast abscess in the same breast

Clinical History

A 73-year-old woman presented in our hospital complaining of rapid (within a week) enlargement of her right breast (double in size comparing with the left one) and sensation of burning. The physical examination revealed edema, erythema of almost the entire breast, ulceration of the skin and areola and serous-bloody discharge.

Imaging Findings

A digital mammography was performed revealing a diffused density increase of the right breast with multiple air-fluid levels but without the appearance of a detectable mass. The air-fluid levels led to the suspicion that the most possible diagnosis was the abscess.
The bacteriological culture of the discharge from the ulcerated breast revealed the presence of Staphylococcus aureus.
After the antibiotic therapy (two weeks later) another digital mammography was performed in which the air-fluid levels were significantly reduced. The inflammatory aspect of the breast remained intense so the possibility of inflammatory breast cancer had to be excluded before the continuation of the treatment of the abscess.
For that reason random biopsies were taken and the result was infiltrated ductal carcinoma with phenotype of neoplasmatic cells: keratin 7+, keratin LMW+, Keratin HMW focally +, p63 focally +, ER-, PR-, c-erb-2(+3) positive.
The patient received chemotherapy followed by further surgical operation.

Discussion

A breast abscess is defined as an inflammatory mass that drains purulent material either spontaneous or on incision. The most common organisms responsible for developing an abscess are Staphylococcus aureus, Staphylococcus epidermidis and Proteus mirabilis. Mastitis and some abscesses may respond to antibiotic treatment with aspiration if needed.Unfortunately, even with adequate treatment, a significant proportion of breast abscesses recur, especially the non-puerperal ones. Although the ideal treatment for abscesses is incision and drainage, in post-menopausal women in whom the diagnosis of carcinoma is suspected, total excision of the mass is necessary for accurate histological diagnosis.
Experienced clinicians are aware of the need to exclude inflammatory breast cancer (IBC). IBC accounting for about 1-5% of all breast cancers is the most aggressive form. It is characterised by diffuse erythema and edema (peau d'orange) of the breast with or without an underlying palpable mass. Rapid enlargement of the breast,two to three times its original size, is pathognomonic of IBC. It is the rapid progression of the disease with associated erythema affecting more than one third of the skin that distinguishes true IBC from a neglected locally advanced breast cancer that has developed inflammatory changes. The frequent absence of an underlying discrete breast mass should increase suspicion for IBC. Disease presentations may also include flattening, erythema, crusting, blistering or retraction of the nipple. Fixed palpable ipsilateral axillary lymph nodes, synonymous with metastatic disease are frequently observed.
The advent of digital mammography with its improved contrast resolution has enabled the depiction of skin thickening, trabecular and stromal thickening and diffuse increased breast density, abnormalities that are associated with IBC. These changes reflecting lymphatic infiltration and obstruction by tumour may be subtle and detected only when the affected breast is compared with the contralateral one. A mass lesion or a group of suspicious calcifications are less common. US frequently permits the identification of a focal mass to facilitate image-guided biopsy and has an important role in staging IBC and assesment of regional lymph nodes. On sonography , visible breast masses are irregular, solid, and hypoechoic with ill-defined margins and posterior acoustic shadowing. Patients without discrete masses visible may demonstrate extensive areas of parenchymal architectural distortion. MRI shows the extent of tumour involvement most clearly.
Great strides have been made in the local management of IBC. By utilising a combination of neoadjuvant chemotherapy followed by mastectomy and adjuvant chemotherapy with accelerated hyperfractionated radiation, physicians can expect to obtain 5-year local control rates on the order of 70% for most patients with IBC.
Unfortunately skin changes are often non-specific , resulting in significant delay in diagnosis due to the use of prolonged courses of antibiotics or even drainage for presumed benign inflammatory processes. Advances in imaging techniques such as mammography, sonography, MRI have improved the early diagnosis and staging of IBC. A physician has to keep in mind that to avoid misdiagnosis, patients with skin changes of the breast persisting greater than 10-14 days despite antibiotic treatment should always be further investigated with advanced imaging techniques and biopsy.

Differential Diagnosis List

Final Diagnosis

Inflammatory breast cancer and abscess in the same breast

URL:	https://www.eurorad.org/case/8841
DOI:	10.1594/EURORAD/CASE.8841
ISSN:	1563-4086