Inflammatory Breast Carcinoma

by Nishtha Raval, Rend Al-Khalili, MD, and Kevin Rice, MD

63 F with one month history of enlarging right breast with redness and tenderness. What is the diagnosis? • Xray of the Week

Figure 1. A) Mammogram MLO view. Focal asymmetries involving most of the anterior and mid right breast with diffuse skin thickening, trabecular coarsening and increased overall density of the right breast. Abnormally enlarged right axillary lymph nodes are also visualized.

Figure 2. A. Bone scan shows diffuse uptake in the markedly enlarged right breast secondary to increased blood pool activity and impaired washout. B. Mammogram CC view. Focal asymmetries involving most of the anterior and mid right breast with diffuse skin thickening, trabecular coarsening and increased overall density.

Discussion:

63-year-old woman presented to a clinic with a one month history of progressively enlarging right breast with redness and tenderness. Physical examination revealed an enlarged, erythematous, indurated right breast with a peau d’orange appearance. Multiple fixed underlying breast masses were palpated in the upper breast. In addition, there were multiple enlarged right axillary lymph nodes. A mammogram demonstrated focal asymmetries involving most of the anterior and mid right breast with diffuse skin thickening, trabecular coarsening, increased overall density, and enlarged right axillary lymph nodes. Ultrasound guided biopsy yielded invasive ductal carcinoma with lymphatic invasion. Bone scan showed diffuse uptake in the markedly enlarged right breast secondary to increased blood pool activity and impaired washout.

Inflammatory breast cancer (IBC) is a rare subtype of breast cancer that accounts for 2%–5% of all breast cancers [1-3]. Both tissue diagnosis of malignancy and clinical evidence of inflammatory disease are required to confirm the diagnosis of IBC [3].

Around 3-6 months and most commonly within 3 months into the disease progression, changes of the skin and development of an underlying mass will be appreciated and are used to validate the diagnosis. The key feature that differentiates IBC from Locally Advanced Breast Cancer (LABC) is the onset of symptoms, as symptoms of non-IBC LABC typically develop over a more protracted period [3]. Skin punch biopsy may be performed but is not required for diagnosis.

On examination, edema and erythema span sat least one-third of the breast tissue, and peau d’orange is present in some cases [3]. Once the clinical picture and baseline laboratory tests for tumor markers like cancer antigen 15-3 and CEA confirm the diagnosis, local imaging with mammogram and ultrasound will help guide management as standards of care [1]. Because of the inflamed breast tissue causing added pain during the process of mammography, visualization of the breast tissue and the lesion of concern is often limited, but will demonstrate findings such as microcalcifications, trabecular thickening/coarsening, and diffusely increased breast density [1]. However, if the lesion is not visualized on imaging, this does not preclude the diagnosis of IBC [1]. Ultrasound has a higher rate of detection and greater sensitivity, and will often reveal a solid mass, skin thickening, and/or parenchymal changes as well as accompanying axillary lymph node involvement [1]. PET/CT scan is especially useful for visualizing lymph node metastasis, as well as monitoring treatment response [1]. MRI has taken an increasingly important role in characterizing IBC and separating it from other similarly presenting pathologies, such as acute mastitis [4,5]. Diffuse subcutaneous pre-pectoral edema is one key to diagnosing IBC seen on MRI, as well as skin thickening occupying at least one-third of the breast [5]. Inflammatory breast cancer tends to affect older, non-lactating women whereas mastitis is typically seen in younger women who are lactating [2]. It can often be difficult to clinically differentiate inflammatory breast cancer from mastitis given their similar presentation; however, improvement after a trial of antibiotics suggests mastitis [2].

References:

1. Chow CK. Imaging in inflammatory breast carcinoma. Breast Dis. 2005;22:45-54. doi:10.3233/bd-2006-22106

2. Dahlbeck SW, Donnelly JF, Theriault RL. Differentiating inflammatory breast cancer from acute mastitis. Am Fam Physician. 1995;52(3):929-934.Papalouka V, Gilbert FJ. Inflammatory breast cancer-importance of breast imaging. Eur J Surg Oncol. 2018;44(8):1135-1138. doi:10.1016/j.ejso.2018.05.008

3. Menta A, Fouad TM, Lucci A, et al. Inflammatory Breast Cancer: What to Know About This Unique, Aggressive Breast Cancer. Surg Clin North Am. 2018;98(4):787-800. doi:10.1016/j.suc.2018.03.009

4. Papalouka V, Gilbert FJ. Inflammatory breast cancer-importance of breast imaging. Eur J Surg Oncol. 2018;44(8):1135-1138. doi:10.1016/j.ejso.2018.05.008

5. Uematsu T. MRI findings of inflammatory breast cancer, locally advanced breast cancer, and acute mastitis: T2-weighted images can increase the specificity of inflammatory breast cancer. Breast Cancer. 2012;19(4):289-294. doi:10.1007/s12282-012-0346-1

Nishtha Raval is a fourth year medical student at Georgetown University School of Medicine with aspirations to become a Diagnostic Radiologist. She completed her

undergraduate education at Georgetown and studied Healthcare Management and

Policy. She is passionate about leadership and mentorship in Radiology, as well as how we can go about improving health outcomes in our healthcare system through quality improvement. Nishtha has been involved in several campus leadership positions and currently serves on the Medical Student Subcommittee as the Mentorship Program Co-Lead for the American College of Radiology. In her spare time, she enjoys trying new restaurants, painting, and spending time with her family.

Dr. Rend Al-Khalili is an Assistant Professor of Radiology at MedStar Georgetown University Hospital, specialized in Breast Imaging. She completed her diagnostic radiology residency training at Rutgers University Hospital and her breast imaging subspeciality training at Columbia University Medical Center. Besides training residents and fellows, she is very passionate about providing educational opportunities for medical students and has won multiple teaching awards in her career. At Georgetown University, she serves as the medical student clerkship course director for breast imaging. Dr. Al-Khalili has strong interest in research and has published in many aspects of breast Imaging with particular focus on education. She is a reviewer for many radiology journals including the Breast Journal, American Journal of Roentgenology (AJR) and Journal of Breast Imaging (JBI) where she also served on the Editorial Board. Dr. Al-Khalili currently serves as the co-chair of the Young Physician Committee of the Society of Breast Imaging as well as the Members-in-Training Education Chair for the DC chapter of the American College of Radiology.

Kevin M. Rice, MD is the president of Global Radiology CME and is a radiologist with Cape Radiology Group. Formerly the Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016 and , Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator. He was once again a semifinalist for a "Minnie" for 2021's Most Effective Radiology Educator by AuntMinnie.com.

Follow Dr. Rice on Twitter @KevinRiceMD

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