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Image of the Month—Diagnosis
Arch Surg. 2010;145(2):208.
Answer: Inflammatory Breast Carcinoma
An incisional biopsy was performed and, on final pathologic review of the specimen, the patient was found to have infiltrating ductal carcinoma consistent with the inflammatory type. The tumor was strongly estrogen receptor/progesterone receptor–positive and HER2/neu–negative. Metastatic workup revealed multiple distant metastases to the brain, liver, and adrenal glands. Chemotherapy and adjuvant hormonal therapy were started.
Inflammatory breast cancer is a rare but aggressive subtype of breast cancer, which historically was considered to be uniformly fatal. Treatment with local therapy, surgery, radiation therapy, or both surgery and therapy results in few long-term survivors. Inflammatory breast cancer accounts for approximately 5% of all cases of breast cancer.1 In general, women with inflammatory breast cancer present at a younger age, are more likely to have metastatic disease at diagnosis, and have shorter survival times than women with noninflammatory breast cancer. According to the latest revision of the American Joint Committee on Cancer staging guidelines, inflammatory carcinoma is classified as T4d, which means that all patients with inflammatory carcinoma have stage IIIB, IIIC, or IV disease, depending on the nodal status and presence of distant metastases.2
Inflammatory breast carcinoma is not associated with a particular histologic subtype and can occur in association with infiltrating ductal or lobular, small cell, medullary, and large cell carcinomas. The characteristic pathologic finding is dermal lymphatic invasion by carcinoma, which can lead to obstruction of the lymphatic drainage, causing the clinical picture of erythema and edema. However, the diagnosis of inflammatory carcinoma is made based on clinical findings, and the absence of dermal lymphatic invasion does not exclude the diagnosis.3 Patients with the clinical features of inflammatory carcinoma should be treated aggressively even if they do not have pathologic evidence of dermal lymphatic invasion. In many centers, surgery is used as part of a combined modality approach to the treatment of inflammatory breast cancer. Nevertheless, its value is controversial given the high risk of metastatic relapse and poor overall prognosis.4-5
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The Editor welcomes contributions to the Image of the Month. Manuscripts should be submitted via our online manuscript submission and review system (http://manuscripts.archsurg.com). Articles and photographs accepted will bear the contributor's name. Manuscript criteria and information are per the Instructions for Authors for Archives of Surgery (http://archsurg.ama-assn.org/misc/ifora.dtl). No abstract is needed, and the manuscript should be no more than 3 typewritten pages. There should be a brief introduction, 1 multiple-choice question with 4 possible answers, and the main text. No more than 2 photographs should be submitted. There is no charge for reproduction and printing of color illustrations.
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AUTHOR INFORMATION
Correspondence: Alexey Markelov, MD, Department of Surgery, Easton Hospital, 250 S 21st St, Easton, PA 18045 (Dr.markelov{at}gmail.com).
Accepted for Publication: March 31, 2009.
Author Contributions: Study concept and design: Markelov and Kohli. Acquisition of data: Markelov and Kohli. Analysis and interpretation of data: Markelov and Kohli. Drafting of the manuscript: Markelov and Kohli. Critical revision of the manuscript for important intellectual content: Markelov and Kohli. Statistical analysis: Markelov and Kohli. Administrative, technical, and material support: Markelov and Kohli. Study supervision: Markelov and Kohli.
Financial Disclosure: None reported.
REFERENCES
1. Levine PH, Steinhorn SC, Ries LG, Aron JL. Inflammatory breast cancer: the experience of the Surveillance, Epidemiology, and End Results (SEER) program. J Natl Cancer Inst. 1985;74(2):291-297.
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2. Singletary SE, Allred C, Ashley P; et al. Revision of the American Joint Committee on Cancer staging system for breast cancer. J Clin Oncol. 2002;20(17):3628-3636.
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3. Hance KW, Anderson WF, Devesa SS, Young HA, Levine PH. Trends in inflammatory breast carcinoma incidence and survival: the Surveillance, Epidemiology, and End Results program at the National Cancer Institute. J Natl Cancer Inst. 2005;97(13):966-975.
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4. De Boer RH, Allum WH, Ebbs SR; et al. Multimodality therapy in inflammatory breast cancer: is there a place for surgery? Ann Oncol. 2000;11(9):1147-1153.
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5. Smoot RL, Koch CA, Degnim AC; et al. Single-center experience with inflammatory breast cancer, 1985-2003. Arch Surg. 2006;141(6):567-573.
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SECTION EDITOR: CARL E. BREDENBERG, MD
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Image of the Month—Quiz Case
Alexey Markelov and Harjeet Kohli
Arch Surg. 2010;145(2):207.
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