INTRODUCTION

Inflammatory breast cancer (IBC) is a rare and aggres-sive form of breast cancer that is characterized by rapidprogression, younger age of onset, and poor prognosis[1]. Its diagnosis is based on clinical, radiological andhistological findings. Clinically, IBC presents with en-larged erythematous breast lesions.

This presentation mimics a wide variety of diseaseswhere radiological aid is fundamental. In the particularcase of IBC, the growth rate of the tumor highly affectsthe radiological detection level of the lesion. Subse-quently, the sensitivity of the imaging test is affectedby the doubling time and fractions of the proliferatingcells, in addition to the fraction of spontaneous cell loss[2]. In this case report, we address the limitations ofmammography and breast ultrasound (US) in detectingIBC and we underline the importance of high clinicalsuspicion in diagnostic medicine.

CASE PRESENTATION

A 42-year-old premenopausal woman, without notablepersonal or family history of neoplastic disease, pres-ented to us in April 2014 for her annual breast cancerscreening. Clinical exam was normal. Bilateral breastmammogram and US demonstrated multiple well-defined, thin wall cysts without evidence of malignancyclassified as BIRADS 2 (Fig. 1 & 2). Six weeks later, thepatient presented for cutaneous thickening of the leftbreast and development of an asymptomatic axillarymass. Her clinical exam was within normal limits,

CCAASS CCLLIINNIIQQUUEE//CCAASSEE RREEPPOORRTTINFLAMMATORY BREAST CANCER: A RACE AGAINST SCREENINGhttp://www.lebanesemedicaljournal.org/articles/65-1/case2.pdf

Tarek ASSI1, Elie EL RASSY1, Tania MOUSSA2, Samer TABCHI1, Ralph CHEBIB1

Hampig Raphael KOURIE3, Fadi EL KARAK1

Assi T, El Rassy E, Moussa T, Tabchi S, Chebib R, Kourie HR,El Karak F. Inflammatory breast cancer: a race against screening.J Med Liban 2017 ; 65 (1) : 52-54.

Assi T, El Rassy E, Moussa T, Tabchi S, Chebib R, Kourie HR,El Karak F. Le cancer du sein inflammatoire : une course contrele dépistage. J Med Liban 2017 ; 65 (1) : 52-54.

ABSTRACT • Inflammatory breast cancer (IBC) is a rare andaggressive form of breast cancer that is characterized by rapidprogression, younger age of onset, and poor prognosis. Thesefindings underline a long list of differential diagnosis whereclinical, radiological and histological inputs are essential. Onelimitation to establishing the diagnosis is a poor sensitivity ofa test with high negative predictive value. In this paper, we re-port the case of a rapid growing IBC where two imaging tech-niques failed at establishing the diagnosis.

Keywords : inflammatory breast cancer, kinetics, screening

RÉSUMÉ • Contexte : Le cancer du sein inflammatoire (CSI)est une forme agressive et rare du cancer du sein caractérisépar une progression rapide et un mauvais pronostic. Le diag-nostic de cette entité repose sur différents éléments cliniques,radiologiques et histologiques. Une limitation à l’établissementd’un diagnostic est la faible sensibilité du test de dépistage.Dans cet article, nous rapportons le cas d’un CSI avec uneprolifération rapide où deux examens radiologiques réalisésétaient faussement rassurants.

Mots-clés : cancer du sein inflammatoire, cinétique, dépistage

1Hematology & Oncology Department, 2Radiology Department, Hôtel-Dieu de France University Hospital, Faculty of Medicine,Saint-Joseph University, Beirut, Lebanon.

3Department of Oncology, Jules Bordet Institute, Free University of Brussels (ULB), Brussels, Belgium. *Correspondence: Tarek Assi, MD. Hôtel-Dieu de France Hospital. POB 166830. Beirut, Lebanon. e-mail: tarekassi@gmail.com

FIGURE 1. Breast mammography showing very dense breastswith bilateral benign calcifications without any suspicious opacity,microcalcification or cutaneous abnormality.

except for diffuse tenderness and erythema of the leftbreast with multiple left indurated axillary lymph nodes.The diagnosis of mastitis was retained. The patient re-ceived adequate dosage of amoxicillin-acid clavulanicbut failed to improve.

A breast MRI showed asymmetrical left breast en-largement with intense diffuse enhancement after con-

trast administration associated with skin thickening andenlarged axillary lymph nodes (Fig. 3). This lesion wasclassified as BIRADS V. A complementary FDG-PETCT Scan showed two moderately hyperactive lesions inthe left breast and hyperactive nodules in the left axillaryand subpectoral regions. Biopsy of the left breast le-sions revealed high-grade ductal carcinoma.

T. ASSI et al. – Inflammatory breast cancer Lebanese Medical Journal 2017 • Volume 65 (1) 53

FIGURE 2. Breast ultrasonography showing multiple bilateral simple cysts with largest cyst measuring 1.6 cm in the left breastwithout any suspicion for malignancy.

FIGURE 3. Breast MRI (A) (B) (C) & (D)* showing asymmetrical left breast enlargement with irregular mass [Arrow in (B) and (C)] andenhancement of its background associated with skin thickening [Arrow in (A)] as well as enlarged axillary lymph nodes [Arrow in (D)].

*(A): Axial T2-weighted MR image (B): Axial contrast enhanced fat-saturated T1-weighted MR image (C) & (D): Axial T2-weighted shortinversion-recovery MR image

DISCUSSION

Patients with IBC usually present with diffuse erythemaand dermal edema of the affected breast. Almost all IBCpatients have nodal involvement and one third have dis-tant metastases. Subsequently, clinical exam providescrucial information for staging and prognosis of the dis-ease since the majority of patients present with palpableaxillary or supraclavicular node metastases [1,3,4]. Bac-terial mastitis is a possible differential diagnosis due tothe fast growing aspect of the disease and its localaggressiveness. However, it is essential to note that IBCis not a true inflammatory process and systemic signsand symptoms such as fever, pain or leukocytosis are notpresent [5,6].

As a diagnostic modality, mammography has failed toestablish its place as an integral part in the diagnosticparadigm of IBC, and clinical practice guidelines do notdefine any specific criteria for the confirmation of diag-nosis. Possible indicators of IBC on mammography in-clude the detection of a mass, architectural thickening,global skin distortion and calcifications [7]. Breast US isa possible alternative for diagnosing IBC and morespecifically nodal involvement. Common abnormalitiesdetected by US are heterogeneous infiltration of breastparenchyma or edematous skin to an underlying breastmass. US is superior to mammography in detecting skinabnormalities, nodal involvement, and consequently diag-nosis of IBC [7,8]. The combination of mammography toUS seems to be highly sensitive in detecting primaryIBC and nodal metastases. Unfortunately for our patient,the results of both mammography and US were falselyreassuring.

This false negative result is highly associated to theminimal detection level of the diagnostic test. For mam-mography, the lowest detection level is 2.1 mm [6].Moreover, the doubling time for breast cancer centersappeared to be around 180 days [9].Consequently, breastcancer requires eight years of proliferation in order to bedetected on mammograms. In general, breast, prostate,and colon present a doubling time of months to years, asopposed to testicular carcinomas, pediatric tumors andmesenchymal cell, for which the doubling time is in theorder of days [9]. In the particular case of IBC, authors

usually omitted this fast-growing tumor from data analy-sis and their doubling time is not studied. But, as experi-enced in our patient, IBC may have a short doublingtime in the order of days that affects the sensitivity ofimaging tests in screening.

CONCLUSION

Our patient was diagnosed with fulminant IBC based onclinical and radiological evidence of extensive disease asso-ciated with nodal involvement only six weeks after normalclinical exam and screening for breast cancer with mam-mography and US. In this case report, we underline theimportance of a good clinical exam and the necessity of ahigh suspicion for breast cancer in patients with enlargederythematous breast lesions.

REFERENCES

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6. Yang WT, Le-Petross HT, Macapinlac H et al. Inflam-matory breast cancer: PET/CT, MRI, mammography, andsonography findings. Breast Cancer Res Treat 2008 Jun;109 (3): 417-26.

7. Günhan-Bilgen I, Ustün EE, Memifl A. Inflammatorybreast carcinoma: mammographic, ultrasonographic,clinical, and pathologic findings in 142 cases. Radiology.2002 Jun; 223 (3): 829-38.

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