Image Quizzes

Skin changes and pain

Reviewed by Avan J. Armaghani, MD

James Cavallini / Science Source

A 51-year-old nonsmoking Black woman presents with a lump in her left breast, as well as associated skin changes and pain of approximately 3 months' duration. The patient last underwent routine screening breast imaging 2 years earlier. The patient is 5 ft 7 in and weighs 200 lb (BMI 31.3). Previous medical history is unremarkable. There is a family history of breast cancer (maternal aunt) and lung cancer (maternal uncle). Physical examination reveals a palpable abnormality in the left breast with edema, skin thickening, and peau d'orange. More than one third of the breast is erythematous. A bilateral mammography reveals an irregular mass and calcifications in the upper outer quadrant of the left breast as well as numerous additional masses and focal asymmetries involving the upper outer and lower outer quadrant of the left breast that extend into the inner left breast. A 1.6-cm mass in the upper left breast is noted, with total abnormality spanning 12.7 cm. Left axillary lymphadenopathy is also observed. Skin punch biopsy of the affected breast reveals dermal lymphatic invasion by tumor cells and tumor emboli. Left axial fine-needle aspiration biopsy reveals malignant cells.

What is the likely diagnosis?

Invasive lobular carcinoma

Medullary carcinoma

Inflammatory breast cancer

Metaplastic breast cancer

The history and findings in this case are suggestive of inflammatory breast cancer.

Breast cancer is the leading life-threatening cancer diagnosed and the second-leading cause of cancer-related deaths in women worldwide. In the United States, estimates suggest that 287,850 new cases of invasive breast cancer were diagnosed in 2022 and 43,250 women died of the disease. Globally, approximately 2.3 million new diagnoses and 685,000 breast cancer–related deaths were reported in 2020.

Inflammatory breast cancer is a rare and highly aggressive subtype of locally advanced breast cancer. In the United States, inflammatory breast cancer accounts for approximately 2%-4% of breast cancer cases. Although its incidence is rare, 7% of breast cancer caused mortality is attributed to inflammatory breast cancer. Cases of inflammatory breast cancer tend to be diagnosed at a younger age compared with noninflammatory breast cancer cases. Risk factors include African-American race and obesity.

The symptoms of inflammatory breast cancer can vary broadly, ranging from subtle skin erythema to diffuse breast involvement with skin dimpling and nipple inversion. Diagnostic criteria include erythema occupying at least one third of the breast, edema, peau d'orange, and/or warmth, with or without an underlying mass; rapid onset (< 3 months); and pathologic confirmation of invasive breast carcinoma. Histologic findings include florid tumor emboli that obstruct dermal lymphatics, which results in swelling and inflammation of the affected breast.

Inflammatory breast cancer has been associated with a poor prognosis. However, treatment advances are helping to improve outcomes. Currently, 5-year survival rates are reported to be 40%-70%, with a median survival of 2-4 years. According to 2023 guidelines from the National Comprehensive Cancer Network (NCCN), the first-line treatment of inflammatory breast cancer involves neoadjuvant chemotherapy, modified radical mastectomy, and adjuvant radiation to the chest wall and regional nodes. Endocrine treatment should also be given to patients who are ER-positive and/or PR-positive (sequential chemotherapy followed by endocrine therapy). For patients who are HER2-positive, up to 1 year of HER2-targeted therapy should be given. HER2-targeted therapies can be administered concurrently with radiation and with endocrine therapy if indicated.

Delayed reconstruction after mastectomy remains the clinical standard for inflammatory breast cancer. This is because the need to resect involved skin negates the benefit of skin-sparing mastectomy for immediate reconstruction. Moreover, high rates of local and distant recurrence warrant comprehensive regional node irradiation in a timely fashion, which may be more challenging or subject to delay after immediate reconstruction. Rarely, the extent of skin excision at the time of mastectomy prohibits primary or local closure. In such cases, reconstruction of the chest wall defect with autologous tissue is required, and concomitant immediate reconstruction may be undertaken.

Detailed guidance on the treatment of inflammatory breast cancer, in the first line and beyond, are available from the NCCN.

Avan J. Armaghani, MD, Assistant Member, Department of Breast Oncology, Moffitt Cancer Center, University of South Florida, Tampa, FL.

Avan J. Armaghani, MD, has disclosed no relevant financial relationships.

Image Quizzes are fictional or fictionalized clinical scenarios intended to provide evidence-based educational takeaways.

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