Inflammatory breast carcinoma; a diagnosis not to be missed

Transcription

1 Inflammatory breast carcinoma; a diagnosis not to be missed Poster No.: C-0093 Congress: ECR 2015 Type: Educational Exhibit Authors: A. Elías Mas, C. Julià, A. Collado, N. Arcalis, J. L. Fernandez, J. A. Goday Arno, J. Bartrina Rosell; Barcelona/ES Keywords: Breast, Oncology, Soft tissues / Skin, Mammography, Ultrasound, Diagnostic procedure, Education, Cancer, Inflammation, Neoplasia DOI: /ecr2015/C-0093 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 37

2 Learning objectives Our objectives are to review and illustrate the clinical, radiological and pathological findings of inflammatory breast carcinoma and to discuss its main differential diagnosis. Background Inflammatory breast carcinoma (IBC) is a rare form of invasive breast cancer. It accounts for 1% to 6% of all breast cancers, with the average age of onset between 45 and 54 years (2). Clinical findings This disease entity has typical clinical symptoms, characterized by erythema (redness of the skin of at least one-third of the breast), warmth, cutaneous thickening, increased volume and induration of the breast (dermal ridging) and "orange peel" appearance of the affected breast. These changes are sometimes accompanied by breast tenderness or pain, palpable mass or masses and diffuse rapid breast enlargement. (fig 5 and 15) Pathological findings Pathologically, IBC is usually poorly differentiated infiltrating ductal carcinoma but any subtype of primary breast carcinoma may be present. Dermal lymphatic vessels must be involved; presence of tumor emboli within dilated lymphatic vessels and a surrounding lymphocytic reaction in the dermis is the pathologic hallmark of IBC. Although infiltration of dermal lymphatics confirms a diagnosis of IBC, dermal vascular or lymphatic invasion may be inconspicuous and the disease may only be evident clinically. Both tissue diagnosis of malignancy and clinical findings of inflammatory disease are required to confirm diagnosis of IBC. Primary versus secondary IBC The definition of inflammatory carcinoma of the breast differs between studies and has often included locally advanced breast carcinoma with secondary inflammatory changes, Page 2 of 37

3 which usually presents as a large mass with localized skin changes adjacent to the underlying mass. A history of rapid onset of clinical signs within 3 months of presentation is the key feature that differentiates primary inflammatory carcinoma of the breast from locally advanced carcinoma with secondary lymphatic invasion, which typically develops over a more protracted period. Primary IBC has a different clinical manifestation and a different prognosis than locally advanced breast cancer. IBC typically has a rapid onset of classic symptoms, younger age at diagnosis, poorer tumor grade, grows and spreads quickly, and is associated with a higher rate of distant metastases at presentation. (5, 9) When locally advanced breast cancer enlarges or is located more superficially within the breast, it may involve the skin and cause secondary erythema and skin induration, symptoms that mimic the classic characteristics of IBC. Skin biopsy results often cannot differentiate the two forms of breast cancer. (9) TNM staging system In the TNM staging system of the American Joint Committee on Cancer and the International Union Against Cancer, inflammatory carcinoma of the breast is classified as T4 and as at least stage IIIB, and locally advanced carcinoma of the breast is also classified at least stage IIIB. Treatment Trimodality treatment that includes preoperative chemotherapy, mastectomy, and radiation therapy is the therapeutic mainstay and has been shown to improve prognosis in IBC. Findings and procedure details We describe the clinical history, findings at physical examination, mammographic and ultrasonographic findings of a series of patients diagnosed with inflammatory breast carcinoma as well as other entities that can lead to a misdiagnose (i.e.mastitis). (fig 1 to 28) Mammographic findings Page 3 of 37

4 Common mammographic abnormalities that are present in patients with inflammatory carcinoma of the breast are: - skin thickening - diffusely increased density - trabecular thickening - axillary lymphadenopathy - architectural distortion - focal asymmetric density - diffuse enlargement of the breast Less common manifestations of this disease are: - nipple retraction - mammographic masses - malignant-appearing calcifications Mammographically visible masses and malignant-appearing calcifications are most frequently seen in "secondary" inflammatory carcinoma than in "primary" inflammatory carcinoma. (fig 1, 2, 3, 6, 7, 9, 10, 12, 13, 16, 17 and 18) Ultrasonographic findings At ultrasound, common abnormalities that are present in patients with inflammatory carcinoma of the breast are (4): - skin thickening (skin thickness of at least 2 mm or skin of the involved breast thicker than that of the contralateral breast). Page 4 of 37

5 - parenchymal echogenicity changes owing to edema and thickening of Cooper ligaments. - dilated lymphatic channels (branching anechoic tubular structures in the subcutaneous fatty tissues) - axillary lymphadenopathy (hypoechoic smoothly or irregularly outlined mass with a longto-short axis ratio of less than 1.5 and absence of the echogenic hilus) - solid masses (usually lobulated or irregular with posterior acoustic shadowing and less commonly seen smooth contours without posterior acoustic shadowing). Less common ultrasonographic manifestations of this disease are: - pectoral muscle invasion - focal areas of parenchymal acoustic shadowing without a mass configuration - multifocality (the mass being within the same quadrant or within 5 cm of the primary lesion) - multicentricity (the mass being in different quadrants or beyond 5 cm from the primary lesion) - skin invasion (interruption of the deep echogenic line of the skin, the dermis, or the subcutaneous fat interface) Most importantly, ultrasound can identify the biopsy target and guide percutaneous core biopsy. (fig. 4, 8, 11, 14, 19 and 20) Differential diagnosis Inflammatory breast carcinoma is not the only disease process that presents with mammographic or physical signs of breast tissue inflammation. In fact, the differential for these findings remains vast, and correlation with patient history in conjunction with physical and radiologic examination findings remains crucial in these situations. Inflammation of the breast tissue may be seen: - after surgery Page 5 of 37

6 - postradiation therapy - after trauma - due to infection (i.e., mastitis) - secondary to various dermatologic disorders or dermatoses as nephrogenic systemic fibrosis - due to breast edema. It may be secondary to other systemic conditions such as superior vena cava syndrome, subclavian vein thrombosis, congestive heart failure, and lymphoma. There are rare reports of breast edema of congestive heart failure which were difficult to differentiate from inflammatory carcinoma. The differential becomes more difficult when congestive heart failure is associated with unilateral breast edema. - Metastatic lesions (rare) (fig 21 to 28) In the differential diagnosis, clinical history is very important. When the clinical suspicion is mastitis and there is no response or an incomplete response to antibiotic treatment within 1-2 weeks, or in the absence of clinical symptoms and abnormal laboratory values, i.e., fever or an elevated white blood cell count, one should immediately indicate a biopsy to definitively exclude a diagnosis of IBC. Images for this section: Page 6 of 37

7 Fig. 1: 50-year-old woman with inflammatory carcinoma of the left breast who presented with 1-week history of breast erythema, ridging, peau d'orange, slight nipple inversion and poorly defined 13 cm palpable mass in the centro-mammary area. No fever or pain was present. Craniocaudal and mediolateral oblique mammograms (fig 1 and 2) show diffusely increased density, diffuse skin thickening and regional pleomorphic microcalcifications suggestive of malignancy, better seen on the close-up image (photographic enlargement, fig 3) of left breast. Sonographic image of the left breast (fig 4) demonstrates multiple (at least 4) irregular hypoechoic masses, the largest one at the 2-o'clock position measuring 3,2 x 2,5 cm, and enlarged axillary lymph nodes. USguided core biopsy demonstrated invasive carcinoma. Since this patient presented with a history of rapid onset of clinical signs, we suspected primary inflammatory carcinoma, but the presence of multiple large masses and malignant-appearing calcifications are less commonly seen in primary IBC. Page 7 of 37

8 Fig. 2: 50-year-old woman with inflammatory carcinoma of the left breast who presented with 1-week history of breast erythema, ridging, peau d'orange, slight nipple inversion and poorly defined 13 cm palpable mass in the centro-mammary area. No fever or pain was present. Craniocaudal and mediolateral oblique mammograms (fig 1 and 2) show diffusely increased density, diffuse skin thickening and regional pleomorphic microcalcifications suggestive of malignancy, better seen on the close-up image (photographic enlargement, fig 3) of left breast. Sonographic image of the left breast (fig 4) demonstrates multiple (at least 4) irregular hypoechoic masses, the largest one at the 2-o'clock position measuring 3,2 x 2,5 cm, and enlarged axillary lymph nodes. USguided core biopsy demonstrated invasive carcinoma. Since this patient presented with a history of rapid onset of clinical signs, we suspected primary inflammatory carcinoma, but the presence of multiple large masses and malignant-appearing calcifications are less commonly seen in primary IBC. Page 8 of 37

9 Fig. 3: 50-year-old woman with inflammatory carcinoma of the left breast who presented with 1-week history of breast erythema, ridging, peau d'orange, slight nipple inversion and poorly defined 13 cm palpable mass in the centro-mammary area. No fever or pain was present. Craniocaudal and mediolateral oblique mammograms (fig 1 and 2) show diffusely increased density, diffuse skin thickening and regional pleomorphic microcalcifications suggestive of malignancy, better seen on the close-up image (photographic enlargement, fig 3) of left breast. Sonographic image of the left breast (fig 4) demonstrates multiple (at least 4) irregular hypoechoic masses, the largest one at the 2-o'clock position measuring 3,2 x 2,5 cm, and enlarged axillary lymph nodes. USguided core biopsy demonstrated invasive carcinoma. Since this patient presented with a history of rapid onset of clinical signs, we suspected primary inflammatory carcinoma, but the presence of multiple large masses and malignant-appearing calcifications are less commonly seen in primary IBC. Page 9 of 37

10 Fig. 4: 50-year-old woman with inflammatory carcinoma of the left breast who presented with 1-week history of breast erythema, ridging, peau d'orange, slight nipple inversion and poorly defined 13 cm palpable mass in the centro-mammary area. No fever or pain was present. Craniocaudal and mediolateral oblique mammograms (fig 1 and 2) show diffusely increased density, diffuse skin thickening and regional pleomorphic microcalcifications suggestive of malignancy, better seen on the close-up image (photographic enlargement, fig 3) of left breast. Sonographic image of the left breast (fig 4) demonstrates multiple (at least 4) irregular hypoechoic masses, the largest one at the 2-o'clock position measuring 3,2 x 2,5 cm, and enlarged axillary lymph nodes. USguided core biopsy demonstrated invasive carcinoma. Since this patient presented with a history of rapid onset of clinical signs, we suspected primary inflammatory carcinoma, but the presence of multiple large masses and malignant-appearing calcifications are less commonly seen in primary IBC. Page 10 of 37

11 Fig. 5: Inflammatory recurrence in the right breast in a 73-year-old woman who presented with 1-month history of breast erythema of the inferior aspect of right breast (fig 1). The patient had undergone lumpectomy and radiation therapy for cancer in the right breast 10 years ago. Craniocaudal and mediolateral oblique mammograms (fig. 6 and 7) show post treatment changes from prior lumpectomy and radiation therapy with new skin thickening and diffusely increased density in the right breast. In the left breast there is a nodule that has remained stable for many years. No fever or pain was present and there was no response to antibiotic treatment. Sonographic image (fig 8) of the right breast demonstrates skin thickening (3,3 mm in the right breast versus 1,5 mm in the left breast). No mass was depicted at ultrasound. Punch biopsy of the skin demonstrated invasive carcinoma. Page 11 of 37

12 Fig. 6: Inflammatory recurrence in the right breast in a 73-year-old woman who presented with 1-month history of breast erythema of the inferior aspect of right breast (fig 1). The patient had undergone lumpectomy and radiation therapy for cancer in the right breast 10 years ago. Craniocaudal and mediolateral oblique mammograms (fig. 6 and 7) show post treatment changes from prior lumpectomy and radiation therapy with new skin thickening and diffusely increased density in the right breast. In the left breast there is a nodule that has remained stable for many years. No fever or pain was present and there was no response to antibiotic treatment. Sonographic image (fig 8) of the right breast demonstrates skin thickening (3,3 mm in the right breast versus 1,5 mm in the left breast). No mass was depicted at ultrasound. Punch biopsy of the skin demonstrated invasive carcinoma. Page 12 of 37

13 Fig. 7: Inflammatory recurrence in the right breast in a 73-year-old woman who presented with 1-month history of breast erythema of the inferior aspect of right breast (fig 1). The patient had undergone lumpectomy and radiation therapy for cancer in the right breast 10 years ago. Craniocaudal and mediolateral oblique mammograms (fig. 6 and 7) show post treatment changes from prior lumpectomy and radiation therapy with new skin thickening and diffusely increased density in the right breast. In the left breast there is a nodule that has remained stable for many years. No fever or pain was present and there was no response to antibiotic treatment. Sonographic image (fig 8) of the right breast demonstrates skin thickening (3,3 mm in the right breast versus 1,5 mm in the left breast). No mass was depicted at ultrasound. Punch biopsy of the skin demonstrated invasive carcinoma. Page 13 of 37

14 Fig. 8: Inflammatory recurrence in the right breast in a 73-year-old woman who presented with 1-month history of breast erythema of the inferior aspect of right breast (fig 1). The patient had undergone lumpectomy and radiation therapy for cancer in the right breast 10 years ago. Craniocaudal and mediolateral oblique mammograms (fig. 6 and 7) show post treatment changes from prior lumpectomy and radiation therapy with new skin thickening and diffusely increased density in the right breast. In the left breast there is a nodule that has remained stable for many years. No fever or pain was present and there was no response to antibiotic treatment. Sonographic image (fig 8) of the right breast demonstrates skin thickening (3,3 mm in the right breast versus 1,5 mm in the left breast). No mass was depicted at ultrasound. Punch biopsy of the skin demonstrated invasive carcinoma. Page 14 of 37

15 Fig. 9: 53-year-old woman with inflammatory carcinoma of the breast who presented with 6-week history of breast erythema, ridging, peau d'orange and nipple inversion. Craniocaudal and mediolateral oblique mammograms (fig 9 and 10) show diffusely increased density, diffuse skin thickening and an irregular distribuition in the upper outer quadrant left breast. Sonographic image of the left breast (fig 11) demonstrates skin thickening, parenchymal echogenicity changes and an irregular hypoechoic mass at the 2-o'clock position measuring 1,6 x 2 cm and enlarged axillary lymph nodes. US-guided core biopsy and punch biopsy of the skin demonstrated invasive carcinoma. Page 15 of 37

16 Fig. 10: 53-year-old woman with inflammatory carcinoma of the breast who presented with 6-week history of breast erythema, ridging, peau d'orange and nipple inversion. Craniocaudal and mediolateral oblique mammograms (fig 9 and 10) show diffusely increased density, diffuse skin thickening and an irregular distribuition in the upper outer quadrant left breast. Sonographic image of the left breast (fig 11) demonstrates skin thickening, parenchymal echogenicity changes and an irregular hypoechoic mass at the 2-o'clock position measuring 1,6 x 2 cm and enlarged axillary lymph nodes. US-guided core biopsy and punch biopsy of the skin demonstrated invasive carcinoma. Page 16 of 37

17 Fig. 11: 53-year-old woman with inflammatory carcinoma of the breast who presented with 6-week history of breast erythema, ridging, peau d'orange and nipple inversion. Craniocaudal and mediolateral oblique mammograms (fig 9 and 10) show diffusely increased density, diffuse skin thickening and an irregular distribuition in the upper outer quadrant left breast. Sonographic image of the left breast (fig 11) demonstrates skin thickening, parenchymal echogenicity changes and an irregular hypoechoic mass at the 2-o'clock position measuring 1,6 x 2 cm and enlarged axillary lymph nodes. US-guided core biopsy and punch biopsy of the skin demonstrated invasive carcinoma. Page 17 of 37

18 Fig. 12: 38-year-old woman with inflammatory carcinoma of the breast who presented with 2-month history of increased volume and induration of the left breast breast and peau d'orange. No fever or pain was present. Craniocaudal and mediolateral oblique mammograms (fig 12 and 13) show diffusely increased density and diffuse skin thickening of left breast. Sonographic image of the left breast (fig 14) demonstrates an irregular hypoechoic mass at the 6-o'clock position measuring 1,3 cm and enlarged axillary lymph nodes. US-guided core biopsy demonstrated invasive carcinoma. Page 18 of 37

19 Fig. 13: 38-year-old woman with inflammatory carcinoma of the breast who presented with 2-month history of increased volume and induration of the left breast breast and peau d'orange. No fever or pain was present. Craniocaudal and mediolateral oblique mammograms (fig 12 and 13) show diffusely increased density and diffuse skin thickening of left breast. Sonographic image of the left breast (fig 14) demonstrates an irregular hypoechoic mass at the 6-o'clock position measuring 1,3 cm and enlarged axillary lymph nodes. US-guided core biopsy demonstrated invasive carcinoma. Page 19 of 37

20 Fig. 14: 38-year-old woman with inflammatory carcinoma of the breast who presented with 2-month history of increased volume and induration of the left breast breast and peau d'orange. No fever or pain was present. Craniocaudal and mediolateral oblique mammograms (fig 12 and 13) show diffusely increased density and diffuse skin thickening of left breast. Sonographic image of the left breast (fig 14) demonstrates an irregular hypoechoic mass at the 6-o'clock position measuring 1,3 cm and enlarged axillary lymph nodes. US-guided core biopsy demonstrated invasive carcinoma. Page 20 of 37

21 Fig. 15: 72-year-old woman with secondary inflammatory carcinoma of the left breast who presented with 3-month history of breast erythema, ridging, peau d'orange, nipple inversion and poorly defined 3 cm palpable mass at the 9-o'clock position (fig 15). There was no response after 2 weeks of antibiotic therapy. Craniocaudal and mediolateral oblique mammograms (fig 16 and 17) show focal asymmetric density measuring 5 x 3 cm and pleomorphic microcalcifications suggestive of malignancy better seen on the closeup image (photographic enlargement, fig 18) at the inner quadrants left breast as well as increased density and diffuse skin thickening of left breast. Sonographic image of the left breast demonstrates multiple irregular hypoechoic masses (fig 19), the largest one at the 9-o'clock position measuring 3,6 cm, and enlarged axillary lymph nodes (fig 20). USguided core biopsy demonstrated invasive ductal carcinoma. Page 21 of 37

22 Fig. 16: 72-year-old woman with secondary inflammatory carcinoma of the left breast who presented with 3-month history of breast erythema, ridging, peau d'orange, nipple inversion and poorly defined 3 cm palpable mass at the 9-o'clock position (fig 15). There was no response after 2 weeks of antibiotic therapy. Craniocaudal and mediolateral oblique mammograms (fig 16 and 17) show focal asymmetric density measuring 5 x 3 cm and pleomorphic microcalcifications suggestive of malignancy better seen on the closeup image (photographic enlargement, fig 18) at the inner quadrants left breast as well as increased density and diffuse skin thickening of left breast. Sonographic image of the left breast demonstrates multiple irregular hypoechoic masses (fig 19), the largest one at the 9-o'clock position measuring 3,6 cm, and enlarged axillary lymph nodes (fig 20). USguided core biopsy demonstrated invasive ductal carcinoma. Page 22 of 37

23 Fig. 17: 72-year-old woman with secondary inflammatory carcinoma of the left breast who presented with 3-month history of breast erythema, ridging, peau d'orange, nipple inversion and poorly defined 3 cm palpable mass at the 9-o'clock position (fig 15). There was no response after 2 weeks of antibiotic therapy. Craniocaudal and mediolateral oblique mammograms (fig 16 and 17) show focal asymmetric density measuring 5 x 3 cm and pleomorphic microcalcifications suggestive of malignancy better seen on the closeup image (photographic enlargement, fig 18) at the inner quadrants left breast as well as increased density and diffuse skin thickening of left breast. Sonographic image of the left breast demonstrates multiple irregular hypoechoic masses (fig 19), the largest one at the 9-o'clock position measuring 3,6 cm, and enlarged axillary lymph nodes (fig 20). USguided core biopsy demonstrated invasive ductal carcinoma. Page 23 of 37

24 Fig. 18: 72-year-old woman with secondary inflammatory carcinoma of the left breast who presented with 3-month history of breast erythema, ridging, peau d'orange, nipple inversion and poorly defined 3 cm palpable mass at the 9-o'clock position (fig 15). There was no response after 2 weeks of antibiotic therapy. Craniocaudal and mediolateral oblique mammograms (fig 16 and 17) show focal asymmetric density measuring 5 x 3 cm and pleomorphic microcalcifications suggestive of malignancy better seen on the closeup image (photographic enlargement, fig 18) at the inner quadrants left breast as well as increased density and diffuse skin thickening of left breast. Sonographic image of the left breast demonstrates multiple irregular hypoechoic masses (fig 19), the largest one at the 9-o'clock position measuring 3,6 cm, and enlarged axillary lymph nodes (fig 20). USguided core biopsy demonstrated invasive ductal carcinoma. Page 24 of 37

25 Fig. 19: 72-year-old woman with secondary inflammatory carcinoma of the left breast who presented with 3-month history of breast erythema, ridging, peau d'orange, nipple inversion and poorly defined 3 cm palpable mass at the 9-o'clock position (fig 15). There was no response after 2 weeks of antibiotic therapy. Craniocaudal and mediolateral oblique mammograms (fig 16 and 17) show focal asymmetric density measuring 5 x 3 cm and pleomorphic microcalcifications suggestive of malignancy better seen on the closeup image (photographic enlargement, fig 18) at the inner quadrants left breast as well as increased density and diffuse skin thickening of left breast. Sonographic image of the left breast demonstrates multiple irregular hypoechoic masses (fig 19), the largest one at the 9-o'clock position measuring 3,6 cm, and enlarged axillary lymph nodes (fig 20). USguided core biopsy demonstrated invasive ductal carcinoma. Page 25 of 37

26 Fig. 20: 72-year-old woman with secondary inflammatory carcinoma of the left breast who presented with 3-month history of breast erythema, ridging, peau d'orange, nipple inversion and poorly defined 3 cm palpable mass at the 9-o'clock position (fig 15). There was no response after 2 weeks of antibiotic therapy. Craniocaudal and mediolateral oblique mammograms (fig 16 and 17) show focal asymmetric density measuring 5 x 3 cm and pleomorphic microcalcifications suggestive of malignancy better seen on the closeup image (photographic enlargement, fig 18) at the inner quadrants left breast as well as increased density and diffuse skin thickening of left breast. Sonographic image of the left breast demonstrates multiple irregular hypoechoic masses (fig 19), the largest one at the 9-o'clock position measuring 3,6 cm, and enlarged axillary lymph nodes (fig 20). USguided core biopsy demonstrated invasive ductal carcinoma. Page 26 of 37

27 Fig. 21: 40-year-old woman with benign inflammatory breast disorder who presented with 1-week history of breast erythema and induration of the left breast. There was no response after 2 weeks of antibiotic therapy. Craniocaudal and mediolateral oblique mammograms (fig 21 and 22) show increased density in the upper outer quadrant, diffuse skin thickening and retroareolar ductal calcifications (photographic enlargement, fig 23) of left breast. Sonographic image of the left breast (not shown) demonstrated an hypoechoic area at the 3-o'clock position measuring 1,7 x 0,9 cm. US-guided fine-needle aspiration biopsy demonstrated unspecific inflammatory changes and was negative for breast cancer. Follow up mammography of the left breast showed no changes in the mammografic findings for more than 3 years. Page 27 of 37

28 Fig. 22: 40-year-old woman with benign inflammatory breast disorder who presented with 1-week history of breast erythema and induration of the left breast. There was no response after 2 weeks of antibiotic therapy. Craniocaudal and mediolateral oblique mammograms (fig 21 and 22) show increased density in the upper outer quadrant, diffuse skin thickening and retroareolar ductal calcifications (photographic enlargement, fig 23) of left breast. Sonographic image of the left breast (not shown) demonstrated an hypoechoic area at the 3-o'clock position measuring 1,7 x 0,9 cm. US-guided fine-needle aspiration biopsy demonstrated unspecific inflammatory changes and was negative for breast cancer. Follow up mammography of the left breast showed no changes in the mammografic findings for more than 3 years. Page 28 of 37

29 Fig. 23: 40-year-old woman with benign inflammatory breast disorder who presented with 1-week history of breast erythema and induration of the left breast. There was no response after 2 weeks of antibiotic therapy. Craniocaudal and mediolateral oblique mammograms (fig 21 and 22) show increased density in the upper outer quadrant, diffuse skin thickening and retroareolar ductal calcifications (photographic enlargement, fig 23) of left breast. Sonographic image of the left breast (not shown) demonstrated an hypoechoic area at the 3-o'clock position measuring 1,7 x 0,9 cm. US-guided fine-needle aspiration biopsy demonstrated unspecific inflammatory changes and was negative for breast cancer. Follow up mammography of the left breast showed no changes in the mammografic findings for more than 3 years. Page 29 of 37

30 Fig. 24: 72-year-old woman with mastitis who presented with breast enlargement, erythema, warmth and pain of the right breast 10 days after lumpectomy surgery for breast carcinoma (fig 24). Sonographic image of the right breast (fig 25) demonstrates skin thickening, subcutaneous edema and a retroareolar breast abscess measuring 5,2 x 3,7 cm. Page 30 of 37

31 Fig. 25: 72-year-old woman with mastitis who presented with breast enlargement, erythema, warmth and pain of the right breast 10 days after lumpectomy surgery for breast carcinoma (fig 24). Sonographic image of the right breast (fig 25) demonstrates skin thickening, subcutaneous edema and a retroareolar breast abscess measuring 5,2 x 3,7 cm. Page 31 of 37

32 Fig. 26: 88-year-old woman with breast edema secondary to congestive heart failure who presented with 1-week history of left breast ridging and slight erythema. Craniocaudal and mediolateral oblique mammograms (fig 26 and 27) show diffusely increased density in both breasts, more evident on the left, and skin thickening in the left breast. Sonographic image of the left breast (fig 28) demonstrates skin thickening and subcutaneous edema. No mass was depicted at ultrasound. Page 32 of 37

33 Fig. 27: 88-year-old woman with breast edema secondary to congestive heart failure who presented with 1-week history of left breast ridging and slight erythema. Craniocaudal and mediolateral oblique mammograms (fig 26 and 27) show diffusely increased density in both breasts, more evident on the left, and skin thickening in the left breast. Sonographic image of the left breast (fig 28) demonstrates skin thickening and subcutaneous edema. No mass was depicted at ultrasound. Page 33 of 37

34 Fig. 28: 88-year-old woman with breast edema secondary to congestive heart failure who presented with 1-week history of left breast ridging and slight erythema. Craniocaudal and mediolateral oblique mammograms (fig 26 and 27) show diffusely increased density in both breasts, more evident on the left, and skin thickening in the left breast. Sonographic image of the left breast (fig 28) demonstrates skin thickening and subcutaneous edema. No mass was depicted at ultrasound. Page 34 of 37

35 Conclusion Because IBC is relatively uncommon compared with other malignancies and can mimic other pathology (i.e.mastitis), it is often not included in the initial differential. However, IBC is an aggressive entity, with tendency to metastasize early. Therefore, an adequate knowledge of its distinctive clinical and radiological findings is necessary to suggest a specific radiological diagnosis. Personal information References 1. Manfrin E, Remo A, Pancione M, et al., Comparison between invasive breast cancer with extensive peritumoral vascular invasion and inflammatory breast carcinoma: a clinicopathologic study of 161 cases. Am. J. Clin. Pathol 2014; 142 (3); Ha KY, Glass SB, Laurie L,.Inflammatory breast carcinoma. Proc (Bayl Univ Med Cent). 2013; 26 (2); Il'yasova D, Siamakpour-Reihani S, Akushevich I, et al. What can we learn from the age- and race/ethnicity- specific rates of inflammatory breast carcinoma?. Breast Cancer Res. Treat. 2011; 130 (2); Günhan-Bilgen I, Ustün EE, Memi# A, Inflammatory breast carcinoma: mammographic, ultrasonographic, clinical, and pathologic findings in 142 cases. Radiology. 2002; 223 (3); Anderson WF, Chu KC, Chang S, Inflammatory breast carcinoma and noninflammatory locally advanced breast carcinoma: distinct clinicopathologic entities?. J. Clin. Oncol. 2003; 21 (12); Kushwaha AC, Whitman GJ, Stelling CB, et al., Primary inflammatory carcinoma of the breast: retrospective review of mammographic findings. AJR Am J Roentgenol. 2000; 174 (2); Page 35 of 37

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