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CASE REPORT
Year : 2022  |  Volume : 15  |  Issue : 5  |  Page : 773-775  

Malignancy mimicking mastitis


Department of Pathology, Lady Hardinge Medical College, New Delhi, India

Date of Submission06-Dec-2020
Date of Decision11-Feb-2021
Date of Acceptance11-Apr-2021
Date of Web Publication25-May-2022

Correspondence Address:
Dr. Neha Suman
Department of Pathology, Lady Hardinge Medical College, Shaheed Bhagat Singh Marg, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_690_20

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  Abstract 


Inflammatory breast carcinoma is a rare rapidly progressive form of breast carcinoma. The nature of lesion often mimics inflammatory lesions such as mastitis which leads to the delay in diagnosis and treatment. Here, we report a case of a young lactating female patient who presented with features of mastitis. However, fine-needle aspiration cytology and further histopathological examination of the core biopsy revealed it as carcinoma. The patient was then advised neoadjuvant chemotherapy. Thus, the awareness and recognition of this rare entity, which mimic various inflammatory and nonmalignant causes, are of utmost importance.

Keywords: Fine-needle aspiration cytology, inflammatory breast carcinoma, mastitis


How to cite this article:
Shukla S, Suman N. Malignancy mimicking mastitis. Med J DY Patil Vidyapeeth 2022;15:773-5

How to cite this URL:
Shukla S, Suman N. Malignancy mimicking mastitis. Med J DY Patil Vidyapeeth [serial online] 2022 [cited 2022 Dec 1];15:773-5. Available from: https://www.mjdrdypv.org/text.asp?2022/15/5/0/345909




  Introduction Top


Inflammatory carcinoma of the breast (IBC) is a rare rapidly progressive form of breast cancer, characterized by erythema, warmth, and a classic “peau d' orange” appearance of the breast. In addition, there are tenderness and diffuse rapid enlargement of the affected breast. The term “inflammatory breast carcinoma” was first coined by Lee and Tannenbaum in 1924.[1] It shares its clinical pictures with benign conditions such as mastitis and dermatitis, often resulting in misdiagnosis and treatment.


  Case Report Top


A 23-year-old nursing mother presented to the surgery outpatient department with complaints of redness, swelling, and heaviness of right breast for the past 3 months. No history of trauma was present. On local examination, the right breast was enlarged as compared with the left breast. The overlying skin was tense, erythematous, and warm. Characteristic peau 'd orange appearance was present. The whole breast was swollen, firm, and tender along with slight retraction of nipple, however, no definite lump was palpable [Figure 1]. A small lymph node (1 cm × 1 cm) was palpable in the right axilla. Ultrasonography of right breast showed multiple oval-shaped hypoechoic areas with echogenic hilum in right axilla suggestive of acute mastitis with ductal ectasia and right-sided lymphadenopathy. The patient was treated with antibiotics for 1 week, however, there was no improvement. Mammography was done and it was suggestive of heterogeneously enhancing lesion with increased vascularity in the right breast, BIRADS IV. Left breast was within normal limits. Contrast-enhanced computed tomography (CECT) of chest showed heterogenous right breast mass with inflammatory changes and necrotic axillary lymph nodes, suggestive of carcinoma [Figure 2]. Then, fine-needle aspiration cytology (FNAC) was suggested. The aspiration was done with a 23G needle fitted to a 10 cc syringe from right breast swelling and enlarged right axillary lymph node. Both yielded blood-mixed granular material. The smears were stained with Wright-Giemsa stain and Papanicolaou stain. The microscopy revealed cellular smears comprising of pleomorphic ductal cells in clusters and singly in a hemorrhagic background. There were no bare bipolar nuclei or myoepithelial cells in the smears [Figure 3]. A cytological diagnosis of ductal carcinoma, no special type with metastasis to right axillary lymph node was made. A Trucut biopsy confirmed the diagnosis of inflammatory carcinoma of right breast (invasive ductal carcinoma, no special type) [Figure 4]. The tumor was triple negative on immunohistochemistry with a Ki-67 proliferation index of 60%. The patient was advised for neoadjuvant chemotherapy but was lost to follow-up.
Figure 1: Diffusely enlarged right breast with redness and pitting of the overlying skin and retracted nipple

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Figure 2: Contrast-enhanced computed tomography chest showing the heterogenous right breast mass

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Figure 3: Fine-needle aspiration cytology aspirate from right breast showing pleomorphic ductal cells in clusters and singly in a hemorrhagic background (papanicolaou; ×400). Inset shows malignant cells in lymph node aspirate (wright Giemsa; ×400)

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Figure 4: Biopsy from right breast showing invasive ductal carcinoma, no special type, Grade 2 (H and E; ×400)

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  Discussion Top


IBC is a rare and aggressive form of breast carcinoma. The incidence reported is 2.5% of diagnosed breast carcinomas.[2] It is characterized by rapid onset of breast warmth, erythema, and edema (peau d' orange) often without a well-defined mass. Furthermore, there is early involvement of the axillary lymph nodes. The typical presentation of rapid swelling with the characteristic peau d' orange is attributed to involvement of dermal lymphatics. However, the diagnosis of IBC is not solely based on dermal lymphatics involvement.[3],[4]

The clinical presentation often mimics mastitis which leads to delay in diagnosis and proper treatment as happened in the present case. The other differential diagnosis of IBC includes dermatitis and breast edema by venous congestion.[5]

The unique description of IBC was provided by Taylor and Meltzer in 1938: “The redness, which may vary from a faint blush to a flaming red, spreads diffusely over the breast, which becomes hot, pitted, and edematous, presenting an “orange-skin” appearance. Meanwhile, cancer spreads rapidly throughout the entire breast in the form of a diffuse ill-defined induration. The breast may swell to two or three times its original volume within a few weeks.”[6]

The distinct clinical and/or pathological criteria for IBC include rapid onset of breast erythema, edema and/or peau d' orange, and/or warm breast, with or without an underlying palpable mass, erythema occupying at least one-third of the breast with duration of history no more than 6 months, imaging studies, and pathologic confirmation by FNAC or biopsy of invasive carcinoma.[7]

Contralateral spread or simultaneous involvement of the other breast occurs in approximately 1%–5% of patients with IBC. Hence, thorough examination of the other breast for asymmetry or trabecular and/or cutaneous thickening is also important.[8]

Higher frequency of negative hormone receptors status has been reported in IBC which has been associated with a more aggressive clinical course and decreased survival.[9]

Thus, cytology/histological confirmation remains the mainstay in the diagnosis of this extremely rare but potentially dangerous malignancy.


  Conclusion Top


The treatment of inflammatory breast cancer may be inadvertently delayed as it usually mimics various benign conditions. Proper diagnostic workup including FNAC and biopsy, therefore, can be of tremendous help in early diagnosis of such cases, especially ones without palpable lump.

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.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Lee BJ, Tannenbaum NE. Inflammatory carcinoma of the breast: A report of twenty-eight cases from the breast clinic of memorial hospital. Surg Gynecol Obstet 1924;39:580-95.  Back to cited text no. 1
    
2.
Robertson FM, Bondy M, Yang W, Yamauchi H, Wiggins S, Kamrudin S, et al. Inflammatory breast cancer: The disease, the biology, the treatment. CA Cancer J Clin 2010;60:351-75.  Back to cited text no. 2
    
3.
Sidiropoulou Z, Ramalho L, Madureira R. Inflammatory breast cancer: A case report. Breast Care (Basel) 2009;4:397-9.  Back to cited text no. 3
    
4.
Merajver SD, Sabel MS. Inflammatory breast cancer. In: Harris JR, Lippman ME, Morrow M, Osborne CK, editors. Diseases of the Breast. 3rd ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2004. p. 971-82.  Back to cited text no. 4
    
5.
Chakrabarti I, Basu A, Ghosh N. Inflammatory carcinoma of breast: The chameleon. Arch Med Health Sci 2017;5:255-7.  Back to cited text no. 5
  [Full text]  
6.
Taylor G, Meltzer A. Inflammatory carcinoma of the breast. Am J Cancer 1938;33:33-49.  Back to cited text no. 6
    
7.
Dawood S, Merajver SD, Viens P, Vermeulen PB, Swain SM, Buchholz TA, et al. International expert panel on inflammatory breast cancer: Consensus statement for standardized diagnosis and treatment. Ann Oncol 2011;22:515-23.  Back to cited text no. 7
    
8.
Kushwaha AC, Whitman GJ, Stelling CB, Cristofanilli M, Buzdar AU. Primary inflammatory carcinoma of the breast: Retrospective review of mammographic findings. AJR Am J Roentgenol 2000;174:535-8.  Back to cited text no. 8
    
9.
Zell JA, Tsang WY, Taylor TH, Mehta RS, Anton-Culver H. Prognostic impact of human epidermal growth factor-like receptor 2 and hormone receptor status in inflammatory breast cancer (IBC): Analysis of 2,014 IBC patient cases from the california cancer registry. Breast Cancer Res 2009;11:R9.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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