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MR mammography of a primary squamous cell carcinoma of the breast: a case report
The Breast (2003) 12, 212–214 0960-9776/03/$ - see front matter r 2003 Elsevier Science Ltd. All rights reserved. doi:10.1016/S0960-9776(03)00008-0
SHORT REPORT
MR mammography of a primary squamous cell carcinoma of the breast: a case report Mireille Van Goethem,1 Katrien Schelfout,1 Werner Jacobs,2 Inge Verslegers,1 Isabelle Biltjes,1 Hendrik De Raeve2 and Arthur De Schepper1 1
Department of Radiology, University Hospital Antwerp, Edegem, Belgium and 2Department of Anatomopathology, University Hospital Antwerp, Edegem, Belgium
S U M M A R Y . A case of a primary squamous cell carcinoma of the breast in a patient with synchronous contralateral
invasive ductal adenocarcinoma is reported. To our knowledge, no dynamic MR mammography of this pathology is described in the literature. On MR, it presented as a mainly non-enhancing, partially cystic mass with an enhancing irregular peripheral rim. In the differential diagnosis of a mass with unsharp margins and an irregular border of the cystic or the non-enhancing area on MR mammography, a primary squamous cell carcinoma must be included. r 2003 Elsevier Science Ltd. All rights reserved. Keywords: Primary squamous carcinoma of the breast; Enhanced MR mammography; Mammography; Ultrasound; Bilateral breast cancer
with enhancement was seen in the upper outer quadrant (Fig. 3). A second round, non-homogeneous mass with sharp borders and posterior enhancement was seen in the axillary tail. Doppler examination showed marked vascularisation in both masses. In the right breast, a lobulated, non-homogeneous mass of 1.6 cm with sharp margins, posterior attenuation and abnormal vascularisation at the periphery was seen. MR mammography was performed 2 months after interruption of hormonal substitution therapy (10 days after the primary diagnosis). T2-weighted images showed masses in both breasts with an intensity equal to that of the glandular breast tissue and with an irregular hyperintense centre in the mass of the upper outer quadrant of the left breast (Fig. 4). The contrast enhanced examination confirmed the presence of enhancing lesions in both breasts (Fig. 5). The mass in the upper outer quadrant of the left breast was irregular with spicules and showed fast and significant enhancement of a thin and irregular peripheral rim and a large centre without enhancement. The diameter of the enhancing mass was 4 cm on MR examination. The mass in the axillary tail showed a large centre without enhancement surrounded by a rim with continuous enhancement. The diameter on MR mammography was 2 cm. In the right breast, the stellate mass
CASE REPORT A 74-year-old woman presented with a mass in the left breast that had become palpable recently. Clinical examination confirmed a large mass measuring 4 5 cm in the outer upper quadrant of the left breast. The overlying skin was ecchymosed. The tumour had irregular margins and was not fixed to the fascia or skin. There was one palpable enlarged axillary lymph node. Mammography showed two opacities in the upper outer quadrant of the left breast (Fig. 1): an irregular mass with unsharp margins with a maximal diameter of 4.8 cm and a round mass with smooth margins with a diameter of 2.7 cm. In the right breast an oval mass with spicules measuring 1.2 cm 1.7 cm was detected (Fig. 2). Ultrasound examination revealed two masses in the left breast. One oval, non- homogeneous, ill-circumscribed mass of 3.1 cm 4.5 cm 4.1 cm with a hyperechogenic border and areas with posterior attenuation as well as Address correspondence to: Dr Mireille Van Goethem, Meirstraat 61, 2890 St. Amands, Belgium. Tel.: +32 3 8896120/+32 3 8213533; Fax: +32 3 8214532; E-mail: [email protected] Received: 26 August 2002 Accepted: 9 January 2003
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Primary squamous cell carcinoma
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Fig. 3 Ultrasound of the left breast shows a great non-homogeneous mass with irregular borders and abnormal vascularisation in the outer upper quadrant (pure squamous cell carcinoma).
Fig. 1 Mammography oblique view of the left breast. Two masses are seen: the greatest mass is round, highly dense and has irregular margins (pure squamous cell carcinoma), the second in the axillary tail is round, is mainly well circumscribed and its density is equal to the glandular tissue (involved lymph node).
Fig. 4 MR mammography, T2: in the left breast, a round mass with intensity mainly equal to the glandular tissue and a central region of high intensity is seen (pure squamous cell carcinoma).
Fig. 2 Detail of mammography oblique view of the right breast. Two masses are seen: one round mass with course calcifications (fibroadenoma), one stellate mass next to the other mass (carcinoma).
seen on mammography and ultrasound showed significant and fast enhancement. Pathological examination of a core biopsy of the two lesions in the left breast revealed a well-differentiated carcinoma with squamous
differentiation representing either a squamous metaplasia in a ductal adenocarcinoma or a primary squamous carcinoma of the breast. The dermis overlying the tumour showed diffuse extravasation of red blood cells. Core biopsy of the stellate mass in the right breast revealed an infiltrating ductal adenocarcinoma. Tumorectomy and axillary dissection was proposed for the right breast and mastectomy with axillary lymph node dissection for the left breast. In the left breast, a primary squamous carcinoma with a diameter of 4 cm 3.7 cm was diagnosed. The tumour was composed of fields of eosinophilic cells with central
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Fig. 5 (a) MR mammography, subtraction image. Right breast: mainly peripheral enhancing mass, very irregular borders (invasive ductal carcinoma). Left breast: big mass of which the greatest part does not enhance. Only an irregular rim of strong and early enhancement is seen (pure squamous cell carcinoma). (b) Time–intensity curves show strong and early enhancement in the strongest enhancing region of the masses in the left and right breast (curve 1 (full line) and 2 (interrupted line)). A linear time course with persisting enhancement is seen in the centre of the mass in the right breast (curve 3 (dotted line)). The morphology of the masses suggests malignant lesions.
keratinisation. Extensive areas of necrosis were seen. Between the tumour fields, there was a desmoplastic stroma containing a chronic inflammatory infiltrate. The second mass was an involved lymphnode. DISCUSSION The patient we presented had a synchronous bilateral carcinoma of the breast with two tumours with a different histopathology. Bilateral breast cancer accounts for 5–10% of breast cancers.1 Bilateral carcinomas are mostly histopathologically different and present with different clinical symptoms and as morphologically different masses on mammography and ultrasound.2,3 Primary squamous cell carcinoma of the breast is very rare, occurring in less than 1% of all primary invasive
breast carcinomas.4 Squamous metaplasia in a breast carcinoma is more frequent. It is identified in 74% of breast carcinomas, and in 710% of medullary carcinomas.5 Other squamous cell carcinomas occurring in the breast include metastatic carcinoma from the oral cavity, bronchus, oesophagus, renal pelvis, bladder, ovary and cervix.6 The tumour must be distinguished from lesions involving the epidermis and/or the nipple region, which should be considered as squamous carcinoma of the skin or dermal appendages.5 Many of the pure squamous cell carcinomas within the breast are partially or largely cystic,4,5 with cysts filled with keratin debris. Least often they are solid and present with uniformly keratinising features. Clinical examination and mammography are nonspecific in cases of primary squamous carcinoma of the breast. On ultrasound and MR mammography, we can recognise the cystic areas that are present in most of these types of carcinomas. Contrast MR mammography shows an irregular, significantly enhancing rim. However, the necrosis and debris are not always seen as typical cysts on ultrasound. Cystic lesions that are not completely anechoic and present with an irregular wall on ultrasound and an irregular strongly enhancing rim on MR mammography should be seen as suspect for malignancy. Time– intensity curves cannot differentiate between benign and malignant lesions as not all malignant lesions have a ‘wash-out’ effect. If a mainly non-enhancing mass with only a thin enhancing irregular border is seen on MR mammography, pure squamous cell carcinoma must be included in the differential diagnosis. Other tumours with central necrosis or cysts (papillary carcinoma, phylloides tumour, colloid carcinoma) may present with the same morphology on MR mammography. MR mammography can help in determining the extent of the mass and may detect multifocal or multicentral cancer.
References 1. Brenner H, Engelsmann B, Stegmaier C. Clinical epidemiology of bilateral breast cancer. Cancer 1993; 72: 3629–3634. 2. Robidoux M A, Norris E L, Paragamul C. Mammographic appearance of cancer in the opposite breast: comparison with the first cancer. AJR 1996; 166: 29–31. 3. Dawson P, Path F. Pathology update: Bilateral and multifocal breast cancer. Cancer Control J 2000; 3: 3. 4. Tavassoli F A. Pathology of the Breast. East Norwalk, CT: Appleton & Lange, 1992; 354. 5. Page D, Anderson T. Infiltrating carcinomas/major histological types and Uncommon types of invasive carcinoma. In: Sakamoto G ed. Diagnostic Histopathology of the Breast. New York, NY: Churchill Livingstone, 1987; 216, 240. 6. Hajdu S I, Urban J A. Cancer metastatic to the breast. Cancer 1982; 29: 1691–1696.
SHORT REPORT
MR mammography of a primary squamous cell carcinoma of the breast: a case report Mireille Van Goethem,1 Katrien Schelfout,1 Werner Jacobs,2 Inge Verslegers,1 Isabelle Biltjes,1 Hendrik De Raeve2 and Arthur De Schepper1 1
Department of Radiology, University Hospital Antwerp, Edegem, Belgium and 2Department of Anatomopathology, University Hospital Antwerp, Edegem, Belgium
S U M M A R Y . A case of a primary squamous cell carcinoma of the breast in a patient with synchronous contralateral
invasive ductal adenocarcinoma is reported. To our knowledge, no dynamic MR mammography of this pathology is described in the literature. On MR, it presented as a mainly non-enhancing, partially cystic mass with an enhancing irregular peripheral rim. In the differential diagnosis of a mass with unsharp margins and an irregular border of the cystic or the non-enhancing area on MR mammography, a primary squamous cell carcinoma must be included. r 2003 Elsevier Science Ltd. All rights reserved. Keywords: Primary squamous carcinoma of the breast; Enhanced MR mammography; Mammography; Ultrasound; Bilateral breast cancer
with enhancement was seen in the upper outer quadrant (Fig. 3). A second round, non-homogeneous mass with sharp borders and posterior enhancement was seen in the axillary tail. Doppler examination showed marked vascularisation in both masses. In the right breast, a lobulated, non-homogeneous mass of 1.6 cm with sharp margins, posterior attenuation and abnormal vascularisation at the periphery was seen. MR mammography was performed 2 months after interruption of hormonal substitution therapy (10 days after the primary diagnosis). T2-weighted images showed masses in both breasts with an intensity equal to that of the glandular breast tissue and with an irregular hyperintense centre in the mass of the upper outer quadrant of the left breast (Fig. 4). The contrast enhanced examination confirmed the presence of enhancing lesions in both breasts (Fig. 5). The mass in the upper outer quadrant of the left breast was irregular with spicules and showed fast and significant enhancement of a thin and irregular peripheral rim and a large centre without enhancement. The diameter of the enhancing mass was 4 cm on MR examination. The mass in the axillary tail showed a large centre without enhancement surrounded by a rim with continuous enhancement. The diameter on MR mammography was 2 cm. In the right breast, the stellate mass
CASE REPORT A 74-year-old woman presented with a mass in the left breast that had become palpable recently. Clinical examination confirmed a large mass measuring 4 5 cm in the outer upper quadrant of the left breast. The overlying skin was ecchymosed. The tumour had irregular margins and was not fixed to the fascia or skin. There was one palpable enlarged axillary lymph node. Mammography showed two opacities in the upper outer quadrant of the left breast (Fig. 1): an irregular mass with unsharp margins with a maximal diameter of 4.8 cm and a round mass with smooth margins with a diameter of 2.7 cm. In the right breast an oval mass with spicules measuring 1.2 cm 1.7 cm was detected (Fig. 2). Ultrasound examination revealed two masses in the left breast. One oval, non- homogeneous, ill-circumscribed mass of 3.1 cm 4.5 cm 4.1 cm with a hyperechogenic border and areas with posterior attenuation as well as Address correspondence to: Dr Mireille Van Goethem, Meirstraat 61, 2890 St. Amands, Belgium. Tel.: +32 3 8896120/+32 3 8213533; Fax: +32 3 8214532; E-mail: [email protected] Received: 26 August 2002 Accepted: 9 January 2003
212
Primary squamous cell carcinoma
213
Fig. 3 Ultrasound of the left breast shows a great non-homogeneous mass with irregular borders and abnormal vascularisation in the outer upper quadrant (pure squamous cell carcinoma).
Fig. 1 Mammography oblique view of the left breast. Two masses are seen: the greatest mass is round, highly dense and has irregular margins (pure squamous cell carcinoma), the second in the axillary tail is round, is mainly well circumscribed and its density is equal to the glandular tissue (involved lymph node).
Fig. 4 MR mammography, T2: in the left breast, a round mass with intensity mainly equal to the glandular tissue and a central region of high intensity is seen (pure squamous cell carcinoma).
Fig. 2 Detail of mammography oblique view of the right breast. Two masses are seen: one round mass with course calcifications (fibroadenoma), one stellate mass next to the other mass (carcinoma).
seen on mammography and ultrasound showed significant and fast enhancement. Pathological examination of a core biopsy of the two lesions in the left breast revealed a well-differentiated carcinoma with squamous
differentiation representing either a squamous metaplasia in a ductal adenocarcinoma or a primary squamous carcinoma of the breast. The dermis overlying the tumour showed diffuse extravasation of red blood cells. Core biopsy of the stellate mass in the right breast revealed an infiltrating ductal adenocarcinoma. Tumorectomy and axillary dissection was proposed for the right breast and mastectomy with axillary lymph node dissection for the left breast. In the left breast, a primary squamous carcinoma with a diameter of 4 cm 3.7 cm was diagnosed. The tumour was composed of fields of eosinophilic cells with central
214
The Breast
Fig. 5 (a) MR mammography, subtraction image. Right breast: mainly peripheral enhancing mass, very irregular borders (invasive ductal carcinoma). Left breast: big mass of which the greatest part does not enhance. Only an irregular rim of strong and early enhancement is seen (pure squamous cell carcinoma). (b) Time–intensity curves show strong and early enhancement in the strongest enhancing region of the masses in the left and right breast (curve 1 (full line) and 2 (interrupted line)). A linear time course with persisting enhancement is seen in the centre of the mass in the right breast (curve 3 (dotted line)). The morphology of the masses suggests malignant lesions.
keratinisation. Extensive areas of necrosis were seen. Between the tumour fields, there was a desmoplastic stroma containing a chronic inflammatory infiltrate. The second mass was an involved lymphnode. DISCUSSION The patient we presented had a synchronous bilateral carcinoma of the breast with two tumours with a different histopathology. Bilateral breast cancer accounts for 5–10% of breast cancers.1 Bilateral carcinomas are mostly histopathologically different and present with different clinical symptoms and as morphologically different masses on mammography and ultrasound.2,3 Primary squamous cell carcinoma of the breast is very rare, occurring in less than 1% of all primary invasive
breast carcinomas.4 Squamous metaplasia in a breast carcinoma is more frequent. It is identified in 74% of breast carcinomas, and in 710% of medullary carcinomas.5 Other squamous cell carcinomas occurring in the breast include metastatic carcinoma from the oral cavity, bronchus, oesophagus, renal pelvis, bladder, ovary and cervix.6 The tumour must be distinguished from lesions involving the epidermis and/or the nipple region, which should be considered as squamous carcinoma of the skin or dermal appendages.5 Many of the pure squamous cell carcinomas within the breast are partially or largely cystic,4,5 with cysts filled with keratin debris. Least often they are solid and present with uniformly keratinising features. Clinical examination and mammography are nonspecific in cases of primary squamous carcinoma of the breast. On ultrasound and MR mammography, we can recognise the cystic areas that are present in most of these types of carcinomas. Contrast MR mammography shows an irregular, significantly enhancing rim. However, the necrosis and debris are not always seen as typical cysts on ultrasound. Cystic lesions that are not completely anechoic and present with an irregular wall on ultrasound and an irregular strongly enhancing rim on MR mammography should be seen as suspect for malignancy. Time– intensity curves cannot differentiate between benign and malignant lesions as not all malignant lesions have a ‘wash-out’ effect. If a mainly non-enhancing mass with only a thin enhancing irregular border is seen on MR mammography, pure squamous cell carcinoma must be included in the differential diagnosis. Other tumours with central necrosis or cysts (papillary carcinoma, phylloides tumour, colloid carcinoma) may present with the same morphology on MR mammography. MR mammography can help in determining the extent of the mass and may detect multifocal or multicentral cancer.
References 1. Brenner H, Engelsmann B, Stegmaier C. Clinical epidemiology of bilateral breast cancer. Cancer 1993; 72: 3629–3634. 2. Robidoux M A, Norris E L, Paragamul C. Mammographic appearance of cancer in the opposite breast: comparison with the first cancer. AJR 1996; 166: 29–31. 3. Dawson P, Path F. Pathology update: Bilateral and multifocal breast cancer. Cancer Control J 2000; 3: 3. 4. Tavassoli F A. Pathology of the Breast. East Norwalk, CT: Appleton & Lange, 1992; 354. 5. Page D, Anderson T. Infiltrating carcinomas/major histological types and Uncommon types of invasive carcinoma. In: Sakamoto G ed. Diagnostic Histopathology of the Breast. New York, NY: Churchill Livingstone, 1987; 216, 240. 6. Hajdu S I, Urban J A. Cancer metastatic to the breast. Cancer 1982; 29: 1691–1696.