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Inflammatory breast cancer: CT evaluation
CLINICAL IMAGING 1992;16:183-186
INFLAMMATORY CT EVALUATION
BREAST CANCER:
GERALDINE T. MOGAVERO, MD, ELLIOT K. FISHMAN, AND JANET E. KUHLMAN, MD
Eleven patients with inflammatory breast carcinoma were examined by computed tomography (CT) prior to treatment with radiation and chemotherapy. Determination was made of skin thickening of the affected breast, presence of diffuse breast tumor infiltration or mass, calcification, adenopathy; and metatases. A11 affected breasts demonstrated increased skin thickness relative to the nonaffected breast, ranging from 0.7 cm-3 cm. Each could further be characterized as having diffuse infiltration of the breast tissue (5), a focal mass lesion (41, or a combination of mass with associated infiltration (2). Two of the breast masses showed diffuse calcification. Only one patient had disease confined to breast tissue at the time of study. Nine patients presented with adenopathy; 7 axillary, 3 internal mammary, 2 supraclavicular, and 1 hilar. Bilateral adenopathy was noted in two patients. Distant metaslases to lung, bone, or stomach were observed in 7 of 11 patients. Distant metastases and degree of adenopathy was not related to skin thickness, degree of tumor infiltration, or presence of a defined mass. Inflammatory breast cancer presents with a spectrum of computed tomography appearances. Computed tomography aids in the assessment of local disease, adenopathy, and distant metastases.
From the Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins Medical Institutions, Baltimore, Maryland. Address reprint requests to: Elliot K. Fishman, MD, Department of Radiology, Johns Hopkins Hospital, 600 N. Wolfe Street, Baltimore, MD 21205. Received July 1991: accepted November 1991. 0 1992 by Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas, 0899-7071/92/$5.00
New York, NY 10010
183
MD,
KEY WORDS:
Inflammatory breast cancer; Breast; Cancer
Computed tomography;
INTRODUTION Inflammatory breast cancer comprises approximately 1% of all breast cancer cases. Initially described by Bell in 1814 (1) and more completely characterized by Lee and Tannenbaum in 1924 (2), inflammatory breast cancer has a unique clinical presentation, pathology, and prognosis. The diagnosis is clinical, with patients presenting with breast edema, erythema, wheals, and tenderness to palpation (3, 4). Absence of fever and leukocytosis separates the clinical entity from mastitis. On pathologic examination, the specimen often demonstrate dermal lymphatic invasion. Additionally, at the time of initial presentation, an increased percentage of patients have distant metastases compared to the total population of breast cancer patients. Accordingly, patients with inflammatory breast cancer have carried a poorer prognosis, with the best results achieved with combination chemotherapy and high-dose radiotherapy (3). Because both treatment and prognosis vary with disease extent at the time of detection, many patients are initially staged by radiographic evaluation. Chest radiography, as well as radionuclide scans of the skeleton, liver, and spleen have all proved useful in evaluation of distant metastases (5). The value of computed tomography(CT) in the evaluation of breast cancer has been addressed by previous authors (6,~). However, the value of computed tomography in the evaluation of inflammatory breast cancer has not been addressed. We, therefore, decided to explore the appearance of inflammatory breast cancer by computed tomography, its use in staging of inflammatory breast carcinoma, and its impact on treatment at our institution.
184
MOGAVEROETAL.
MATERIALS
AND METHODS
Eleven patients who presented with inflammatory breast carcinoma between 1984 and 1989 were examined by computed tomography prior to treatment with radiation and chemotherapy. The diagnosis of inflammatory breast cancer was reached by a combination of breast biopsy or biopsy of metastasis and clinical and mammographic findings. Using a Siemens Somatom DR3, DRH or Plus CT scanner, the thorax was scanned from the lung apices through the liver using consecutive 8 mm sections at IO-mm intervals in ten patients and 8 mm sections at g-mm intervals in one patient. Nine out of 11 scans were performed after administration of intravenous contrast material and each scan was assessed with lung (ww 1350, WC - 400) and mediastinum (ww 420, WC 36) windows. The remaining two scans were performed without intravenous contrast because of either previous adverse reaction to contrast or lack of intravenous access. All patients were female, between the age of 26 and 81 (mean = 52). One patient had bilateral inflammatory breast cancer. Determination was made of skin thickness of both breasts, presence of diffuse breast tumor infiltration or tumor mass, calcification within the mass, metastases; and adenopathy. Adenopathy was defined as presence of nodes measuring greater than or equal to 1 cm in size. The skin thickness of the affected breast was measured at its greatest width. Given the limitations of resolution, results were then placed into three groupings, less than or equal to 0.7 cm, 0.8-1.0 cm, and greater than 1.0 cm. The skin thickness of the nonaffected breast was calculated on the same section as the previously obtained measurement. RESULTS All patients demonstrated increased skin thickness of the affected breast relative to the nonaffected breast, ranging from 0.7 cm-3.0 cm (Table 1). The average skin thickness of the nonaffected breast was 0.2 cm, varying from an almost imperceptible line to 0.3 cm (Figures l-3). Each patient could further be characterized as having diffuse tumor infiltration of the breast tissue (5), a focal mass lesion (4), or a combination of mass with associated infiltration (2) (Figures 4-5). Tumor infiltration of the breast tissue was felt to be present when the CT attenuation of the abnormal breast was increased relative to the normal breast and subcutaneous fat. Edema of the breast tissue was also defined by enlargement or swelling of the underlying breast tissue. Two of the breast masses showed diffuse calcification (Figure 3).
CLINICALIMAGING VOL. 16,N0.
3
Only one patient had disease confined to the breast tissue at the time of study. Nine patients presented with adenopathy; 7 axillary, 3 internal mammary, 2 supraclavicular, and 1 hilar. In all cases with unilateral adenopathy, the adenopathy noted was on the ipsilateral side to the breast lesion. Bilateral adenopathy was noted in three patients, including the patient with bilateral breast cancer. One patient demonstrated ipsilateral supraclavicular nodes with bilateral axillary nodes, the second had bilateral hilar adenopathy, and the patient with bilateral inflammatory breast cancer had bilateral axillary and supraclavicular nodes. Distant metastases and degree of adenopathy were not related to skin thickness, degree of infiltration or presence of a well-defined mass. Patients with distant metastases had skin thickening that varied from 0.7 cm-38 cm. Additionally, widespread disease was found in both patients characterized as having diffuse tumor infiltration and as having focal tumor masses. However, conclusions drawn from a population of 11 patients is limited, and a larger series of patients is needed for evaluation to determine the validity of these conclusions.
DISCUSSION Inflammatory breast cancer has long been considered a diagnosis based on physical examination (1, 2). Rather than presenting with either a palpable mass or a suspicious lesion on mammography, most patients with inflammatory breast cancer have symptoms of erythema, edema and pain. Mammography, if revealing any abnormality, may demonstrate increased breast density, skin thickening, and lymphatic vessel prominence (8). In our expereince, evidence of skin thickening was easily demonstrated by computed tomography. Although the smallest amount of skin thickening within our patient population was 7 mm (Figure l),computed tomography may be able to detect even more subtle change, given the ability to readily compare and contrast skin thickness with the unaffected breast. All patients showed some form of tumor infiltration of breast tissue by computed tomographic criterion. These changes were not distinctive, however. Although three patients had defined tumor masses (Figure 2), five patients had diffuse infiltration without a focal lesion (Figure 4). Two other patients had a combination of a focal mass with a more diffuse associated reaction (Figure 5).Therefore, while computed tomography demonstrated both skin thickening and tumor infiltration in all patients, the nature
JULY-SEPTEMBER
TABLE 1. CT Findings Patient
6 7 8 9 10 11
no.
INFLAMMATORY
1992
Side left left left left left right right left right right right left
in 11 Patients Skin thickness 0.7 cm 0.7 cm 0.7 cm 0.7 cm 1.0 cm 1.0 cm 1.0 cm 1.0 cm 1.0 cm 1.0 cm 1.2 cm 3.0 cm
with Inflammatory Mass
BREAST
CANCER:
185
CT EVALUATION
Breast Cancer Diffuse
infiltration
Both
Adenopathy
Distant
metastases
x X
x x x
X
X
X
X
X
X
X
X X
x x x
X
X
X
X
X
X
X
x
X
x
X
of infiltration and edema within the breast tissue appeared different in each patient. The degree of adenopathy varied widely between patients. Whereas two patients did not have adenopathy demonstrated by computed tomography, other patients revealed diffuse adenopathy involving axillary nodes, internal mammary nodes, hilar nodes, and supraclavicular nodes. The two patients without adenopathy also demonstrated the lowest amount of skin thickening. Two additional patients with the same skin-thickness measurements, however, had adenopathy, one with internal mammary adenopathy and the other with unilaterally enlarged axillary nodes. Three of these four patients with 0.7 cm skin FIGURE 2. An 81-year-old
woman with a small focal left breast mass (arrow). Skin thickening also noted.
FIGURE 1. A 46-year-old
woman with minimal left breast skin thickening (arrows) measuring less than 6.7 cm compared with normal skin thickness of right breast. FIGURE
3. A 65-year-old woman with a large calcified left breast mass, marked skin thickening, and left axillary lymph nodes.
186
MOGAVERO ET AL.
CLINICAL IMAGING VOL. 16. NO. 3
FIGURE 4. A 67-year-old
woman with diffuse infiltration of right breast tissue. On additional scans, patient was noted to have unilateral mammary nodes as well as lung metastases.
thickening also showed widespread disease, with stomach, bone, and lung metastases. Therefore, measurement of skin thickening was not a good indicator of disease extent in this limited series.
Similarly, the pattern of infiltration was not correlated to breast cancer progression. Well-contained as well as extensive disease was found in patients with diffuse tumor infiltration and patients with defined tumor masses. Also, the presence of calcification within the breast lesion was not associated with advanced disease.
FIGURE 5. A 4%year-old woman with left breast infiltration characterized as a combination of focal mass with associated diffuse tumor infiltration. Additionally, minimal skin thickening of the breast and a right pleural effusion are demonstrated.
CT plays an important role in accurately staging the extent of disease in inflammatory breast cancer and can be used to monitor response to therapy.
REFERENCES 1. Bell C. A System of Operative Longman, 1814, p. 136. 2.
CONCLUSION Computed tomography evaluation of patients with inflammatory breast cancer reveals distinct differences between the affected and nonaffected breast. Although all patients exhibited skin thickening of the affected breast, nodal involvement and metastases did not correlate with the amount of thickening. Additionally, three patterns of breast tissue tumor infiltration were identified by computed tomography-diffuse infiltration, discrete mass, and a combination of mass plus infiltration. Patients grouped by appearance had varying degrees of tumor spread.
Surgery, Volume 2. London:
Lee BJ, Tannenbaum NE. Inflammatory carcinoma breast. Surg Gynecol Obstet 1924;39:580-595.
of the
3. Sherry MM, Johnson DH, Page DL, Greco FA, Hainsworth,
Inflammatory
carcinoma
of
the
breast.
Am
J
JD. Med
1985;79:355-364. 4. Grace WR, Cooperman
AM. Inflammatory Clin North Am 1985;65(1):151-160.
breast cancer. Surg
5. Burton G, Cox EB, Leight GS, et al. Inflammatory
breast carci-
noma. Arch Surg 1987;122:1329-1332. 6. Lindfors
KK, Meyer JE, Busse PM, Kopans DB, Munzenrider JE, Sawicka JM. CT evaluation of local and regional breast cancer recurrence. AJR 1985;145:833-837.
7. Shea WJ, de Geer G, Webb WR. Chest wall after mastectomy.
Radiology 1987;162:162-164. carcinoma 1962;88:1109-1116.
8. Berger SM. Inflammatory
of the breast. Radiology
INFLAMMATORY CT EVALUATION
BREAST CANCER:
GERALDINE T. MOGAVERO, MD, ELLIOT K. FISHMAN, AND JANET E. KUHLMAN, MD
Eleven patients with inflammatory breast carcinoma were examined by computed tomography (CT) prior to treatment with radiation and chemotherapy. Determination was made of skin thickening of the affected breast, presence of diffuse breast tumor infiltration or mass, calcification, adenopathy; and metatases. A11 affected breasts demonstrated increased skin thickness relative to the nonaffected breast, ranging from 0.7 cm-3 cm. Each could further be characterized as having diffuse infiltration of the breast tissue (5), a focal mass lesion (41, or a combination of mass with associated infiltration (2). Two of the breast masses showed diffuse calcification. Only one patient had disease confined to breast tissue at the time of study. Nine patients presented with adenopathy; 7 axillary, 3 internal mammary, 2 supraclavicular, and 1 hilar. Bilateral adenopathy was noted in two patients. Distant metaslases to lung, bone, or stomach were observed in 7 of 11 patients. Distant metastases and degree of adenopathy was not related to skin thickness, degree of tumor infiltration, or presence of a defined mass. Inflammatory breast cancer presents with a spectrum of computed tomography appearances. Computed tomography aids in the assessment of local disease, adenopathy, and distant metastases.
From the Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins Medical Institutions, Baltimore, Maryland. Address reprint requests to: Elliot K. Fishman, MD, Department of Radiology, Johns Hopkins Hospital, 600 N. Wolfe Street, Baltimore, MD 21205. Received July 1991: accepted November 1991. 0 1992 by Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas, 0899-7071/92/$5.00
New York, NY 10010
183
MD,
KEY WORDS:
Inflammatory breast cancer; Breast; Cancer
Computed tomography;
INTRODUTION Inflammatory breast cancer comprises approximately 1% of all breast cancer cases. Initially described by Bell in 1814 (1) and more completely characterized by Lee and Tannenbaum in 1924 (2), inflammatory breast cancer has a unique clinical presentation, pathology, and prognosis. The diagnosis is clinical, with patients presenting with breast edema, erythema, wheals, and tenderness to palpation (3, 4). Absence of fever and leukocytosis separates the clinical entity from mastitis. On pathologic examination, the specimen often demonstrate dermal lymphatic invasion. Additionally, at the time of initial presentation, an increased percentage of patients have distant metastases compared to the total population of breast cancer patients. Accordingly, patients with inflammatory breast cancer have carried a poorer prognosis, with the best results achieved with combination chemotherapy and high-dose radiotherapy (3). Because both treatment and prognosis vary with disease extent at the time of detection, many patients are initially staged by radiographic evaluation. Chest radiography, as well as radionuclide scans of the skeleton, liver, and spleen have all proved useful in evaluation of distant metastases (5). The value of computed tomography(CT) in the evaluation of breast cancer has been addressed by previous authors (6,~). However, the value of computed tomography in the evaluation of inflammatory breast cancer has not been addressed. We, therefore, decided to explore the appearance of inflammatory breast cancer by computed tomography, its use in staging of inflammatory breast carcinoma, and its impact on treatment at our institution.
184
MOGAVEROETAL.
MATERIALS
AND METHODS
Eleven patients who presented with inflammatory breast carcinoma between 1984 and 1989 were examined by computed tomography prior to treatment with radiation and chemotherapy. The diagnosis of inflammatory breast cancer was reached by a combination of breast biopsy or biopsy of metastasis and clinical and mammographic findings. Using a Siemens Somatom DR3, DRH or Plus CT scanner, the thorax was scanned from the lung apices through the liver using consecutive 8 mm sections at IO-mm intervals in ten patients and 8 mm sections at g-mm intervals in one patient. Nine out of 11 scans were performed after administration of intravenous contrast material and each scan was assessed with lung (ww 1350, WC - 400) and mediastinum (ww 420, WC 36) windows. The remaining two scans were performed without intravenous contrast because of either previous adverse reaction to contrast or lack of intravenous access. All patients were female, between the age of 26 and 81 (mean = 52). One patient had bilateral inflammatory breast cancer. Determination was made of skin thickness of both breasts, presence of diffuse breast tumor infiltration or tumor mass, calcification within the mass, metastases; and adenopathy. Adenopathy was defined as presence of nodes measuring greater than or equal to 1 cm in size. The skin thickness of the affected breast was measured at its greatest width. Given the limitations of resolution, results were then placed into three groupings, less than or equal to 0.7 cm, 0.8-1.0 cm, and greater than 1.0 cm. The skin thickness of the nonaffected breast was calculated on the same section as the previously obtained measurement. RESULTS All patients demonstrated increased skin thickness of the affected breast relative to the nonaffected breast, ranging from 0.7 cm-3.0 cm (Table 1). The average skin thickness of the nonaffected breast was 0.2 cm, varying from an almost imperceptible line to 0.3 cm (Figures l-3). Each patient could further be characterized as having diffuse tumor infiltration of the breast tissue (5), a focal mass lesion (4), or a combination of mass with associated infiltration (2) (Figures 4-5). Tumor infiltration of the breast tissue was felt to be present when the CT attenuation of the abnormal breast was increased relative to the normal breast and subcutaneous fat. Edema of the breast tissue was also defined by enlargement or swelling of the underlying breast tissue. Two of the breast masses showed diffuse calcification (Figure 3).
CLINICALIMAGING VOL. 16,N0.
3
Only one patient had disease confined to the breast tissue at the time of study. Nine patients presented with adenopathy; 7 axillary, 3 internal mammary, 2 supraclavicular, and 1 hilar. In all cases with unilateral adenopathy, the adenopathy noted was on the ipsilateral side to the breast lesion. Bilateral adenopathy was noted in three patients, including the patient with bilateral breast cancer. One patient demonstrated ipsilateral supraclavicular nodes with bilateral axillary nodes, the second had bilateral hilar adenopathy, and the patient with bilateral inflammatory breast cancer had bilateral axillary and supraclavicular nodes. Distant metastases and degree of adenopathy were not related to skin thickness, degree of infiltration or presence of a well-defined mass. Patients with distant metastases had skin thickening that varied from 0.7 cm-38 cm. Additionally, widespread disease was found in both patients characterized as having diffuse tumor infiltration and as having focal tumor masses. However, conclusions drawn from a population of 11 patients is limited, and a larger series of patients is needed for evaluation to determine the validity of these conclusions.
DISCUSSION Inflammatory breast cancer has long been considered a diagnosis based on physical examination (1, 2). Rather than presenting with either a palpable mass or a suspicious lesion on mammography, most patients with inflammatory breast cancer have symptoms of erythema, edema and pain. Mammography, if revealing any abnormality, may demonstrate increased breast density, skin thickening, and lymphatic vessel prominence (8). In our expereince, evidence of skin thickening was easily demonstrated by computed tomography. Although the smallest amount of skin thickening within our patient population was 7 mm (Figure l),computed tomography may be able to detect even more subtle change, given the ability to readily compare and contrast skin thickness with the unaffected breast. All patients showed some form of tumor infiltration of breast tissue by computed tomographic criterion. These changes were not distinctive, however. Although three patients had defined tumor masses (Figure 2), five patients had diffuse infiltration without a focal lesion (Figure 4). Two other patients had a combination of a focal mass with a more diffuse associated reaction (Figure 5).Therefore, while computed tomography demonstrated both skin thickening and tumor infiltration in all patients, the nature
JULY-SEPTEMBER
TABLE 1. CT Findings Patient
6 7 8 9 10 11
no.
INFLAMMATORY
1992
Side left left left left left right right left right right right left
in 11 Patients Skin thickness 0.7 cm 0.7 cm 0.7 cm 0.7 cm 1.0 cm 1.0 cm 1.0 cm 1.0 cm 1.0 cm 1.0 cm 1.2 cm 3.0 cm
with Inflammatory Mass
BREAST
CANCER:
185
CT EVALUATION
Breast Cancer Diffuse
infiltration
Both
Adenopathy
Distant
metastases
x X
x x x
X
X
X
X
X
X
X
X X
x x x
X
X
X
X
X
X
X
x
X
x
X
of infiltration and edema within the breast tissue appeared different in each patient. The degree of adenopathy varied widely between patients. Whereas two patients did not have adenopathy demonstrated by computed tomography, other patients revealed diffuse adenopathy involving axillary nodes, internal mammary nodes, hilar nodes, and supraclavicular nodes. The two patients without adenopathy also demonstrated the lowest amount of skin thickening. Two additional patients with the same skin-thickness measurements, however, had adenopathy, one with internal mammary adenopathy and the other with unilaterally enlarged axillary nodes. Three of these four patients with 0.7 cm skin FIGURE 2. An 81-year-old
woman with a small focal left breast mass (arrow). Skin thickening also noted.
FIGURE 1. A 46-year-old
woman with minimal left breast skin thickening (arrows) measuring less than 6.7 cm compared with normal skin thickness of right breast. FIGURE
3. A 65-year-old woman with a large calcified left breast mass, marked skin thickening, and left axillary lymph nodes.
186
MOGAVERO ET AL.
CLINICAL IMAGING VOL. 16. NO. 3
FIGURE 4. A 67-year-old
woman with diffuse infiltration of right breast tissue. On additional scans, patient was noted to have unilateral mammary nodes as well as lung metastases.
thickening also showed widespread disease, with stomach, bone, and lung metastases. Therefore, measurement of skin thickening was not a good indicator of disease extent in this limited series.
Similarly, the pattern of infiltration was not correlated to breast cancer progression. Well-contained as well as extensive disease was found in patients with diffuse tumor infiltration and patients with defined tumor masses. Also, the presence of calcification within the breast lesion was not associated with advanced disease.
FIGURE 5. A 4%year-old woman with left breast infiltration characterized as a combination of focal mass with associated diffuse tumor infiltration. Additionally, minimal skin thickening of the breast and a right pleural effusion are demonstrated.
CT plays an important role in accurately staging the extent of disease in inflammatory breast cancer and can be used to monitor response to therapy.
REFERENCES 1. Bell C. A System of Operative Longman, 1814, p. 136. 2.
CONCLUSION Computed tomography evaluation of patients with inflammatory breast cancer reveals distinct differences between the affected and nonaffected breast. Although all patients exhibited skin thickening of the affected breast, nodal involvement and metastases did not correlate with the amount of thickening. Additionally, three patterns of breast tissue tumor infiltration were identified by computed tomography-diffuse infiltration, discrete mass, and a combination of mass plus infiltration. Patients grouped by appearance had varying degrees of tumor spread.
Surgery, Volume 2. London:
Lee BJ, Tannenbaum NE. Inflammatory carcinoma breast. Surg Gynecol Obstet 1924;39:580-595.
of the
3. Sherry MM, Johnson DH, Page DL, Greco FA, Hainsworth,
Inflammatory
carcinoma
of
the
breast.
Am
J
JD. Med
1985;79:355-364. 4. Grace WR, Cooperman
AM. Inflammatory Clin North Am 1985;65(1):151-160.
breast cancer. Surg
5. Burton G, Cox EB, Leight GS, et al. Inflammatory
breast carci-
noma. Arch Surg 1987;122:1329-1332. 6. Lindfors
KK, Meyer JE, Busse PM, Kopans DB, Munzenrider JE, Sawicka JM. CT evaluation of local and regional breast cancer recurrence. AJR 1985;145:833-837.
7. Shea WJ, de Geer G, Webb WR. Chest wall after mastectomy.
Radiology 1987;162:162-164. carcinoma 1962;88:1109-1116.
8. Berger SM. Inflammatory
of the breast. Radiology