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1
Division of Diagnostic Imaging, Box 57, The University of Texas M. D. Anderson
Cancer Center, 1515 Holcombe Blvd., Houston, TX 77030.
2
Department of Breast Medical Oncology, Box 56, The University of Texas M. D.
Anderson Cancer Center, Houston, TX 77030.
Received November 30, 1998;
accepted after revision July 27, 1999.
Address correspondence to A. C. Kushwaha.
Abstract
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MATERIALS AND METHODS. We identified the medical records of 43 women who participated in a chemotherapy protocol for primary inflammatory carcinoma of the breast between 1994 and 1997. Mammograms were available for review in 26 women (age range, 34-78 years; mean age, 56 years). Two radiologists independently reviewed the 26 mammograms obtained before patients underwent treatment. A third observer was the final arbiter when needed.
RESULTS. Mammographic findings included skin thickening in 24 patients (92%), diffusely increased density in 21 patients (81%), trabecular thickening in 16 patients (62%), axillary lymphadenopathy in 15 patients (58%), architectural distortion or focal asymmetric density in 13 patients (50%), and nipple retraction in 10 patients (38%). Malignant-appearing calcifications were seen in six patients (23%), and a mass was seen in four patients (15%).
CONCLUSION. Diffuse mammographic abnormalities such as skin thickening, increased density, trabecular thickening, and axillary lymphadenopathy are common at presentation in patients with primary inflammatory carcinoma of the breast. Mammographic masses and malignant-appearing calcifications are uncommon manifestations of this disease.
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In this study, we examined the mammographic findings at clinical presentation in patients with primary inflammatory carcinoma of the breast. We aimed to describe the mammographic characteristics of primary inflammatory carcinoma of the breast. We performed this study because our recent experience with mammography of inflammatory carcinoma differed from that of other investigators [1, 2].
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Two radiologists independently reviewed the mammograms without knowledge of the clinical findings. The mammograms were assessed for skin thickening, diffusely increased density, trabecular thickening, vascular engorgement, nipple retraction, architectural distortion, masses, calcifications, and axillary lymphadenopathy. The findings were tabulated, and a third observer served as an arbiter when the two observers did not agree on a specific mammographic finding. During the mammogram review sessions, magnifying glasses, a light, and an oval mask were used to facilitate evaluation of the skin and the subcutaneous tissues.
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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 a stage IIIB breast carcinoma, and locally advanced carcinoma of the breast is also classified as stage IIIB. Although the 5-year 50% disease-free survival for patients with primary inflammatory carcinoma of the breast and for those with other stage IIIB breast carcinoma is similar (26-28 months), the 5-year 50% overall survival is significantly worse for patients with primary inflammatory carcinoma of the breast than for those with locally advanced carcinoma of the breast (36-40 months versus 50-52 months) [3, 6]. This discrepancy is probably a result of more aggressive treatment and subsequent morbid complications from therapy. At our institution, a distinction is made between primary inflammatory carcinoma of the breast and secondary inflammatory carcinoma of the breast in all treatment protocols.
The mammographic characteristics of inflammatory carcinoma of the breast identified in this study were diffuse and often subtle. Skin thickening (Fig. 1) and diffusely increased density (Fig. 2A, 2B) were the most common findings, seen in 92% and 81% of patients, respectively. In most cases, proper use of a mask and a bright light was necessary to detect skin thickening as well as trabecular thickening and nipple retraction. Diffusely increased density, skin edema, and trabecular thickening are mammographic manifestations of the edema and lymphatic obstruction in inflammatory carcinoma of the breast. Contralateral skin thickening was seen in the medial breast of one patient. This patient had progressive disease while receiving neoadjuvant chemotherapy and died with liver metastases 6 months after the initial diagnosis of inflammatory carcinoma of the breast. The contralateral skin thickening may have represented crossed dermal metastases.
Axillary lymphadenopathy was seen in 15 patients (58%) (Fig. 2A, 2B). Architectural distortion or focal asymmetric densities were present in 13 patients (50%). We defined architectural distortion as distortion of the normal structures of the breast with no definite mass visible [7] (Fig. 2A, 2B). We defined a focal asymmetric density as asymmetry of tissue density with a similar shape on two views, but completely lacking borders and the conspicuity of a true mass [7].
In 1994, Dershaw et al. [1] reviewed the mammographic findings in inflammatory carcinoma of the breast from a group of 22 patients at Memorial Sloan-Kettering Cancer Center. In that study, 21 of 22 patients had masses or malignant-appearing calcifications identified on mammography. In 1997, Tardivon et al. [2] reviewed 92 cases: 57 patients had secondary inflammatory carcinoma of the breast and 35 patients had primary inflammatory carcinoma of the breast. These investigators did not separate the two clinical entities. In addition, these investigators identified opacities or malignant-appearing calcifications in 74% of patients.
The main difference between our study and those of Dershaw et al. [1] and Tardivon et al. [2] is the frequency with which masses and malignant-appearing calcifications were identified. In our study, masses, malignant-type calcifications, or both were present in 10 patients (38%). However, Dershaw et al. and Tardivon et al. identified masses, malignant-appearing calcifications, or both in 95% and 74% of their patients, respectively. The disparity between these findings and ours may result from their inclusion of patients in their study populations with locally advanced breast cancer who had preexisting clinical masses. In the study by Tardivon et al., 97% of patients presented with clinically palpable masses. Dershaw et al. described palpable masses in 82% of patients. In our study population, 12 patients (46%) presented with clinically palpable masses.
Our results agree with those reported in studies of inflammatory carcinoma of the breast by other investigators. For instance, in a study by Droulias et al. [8], 33 patients underwent mammography, and skin thickening was seen in all patients. On mammography, Droulias et al. found generally increased density in 27 patients (82%) and identified masses in 11 patients (33%). In the series of 12 patients described by Berger [9], increased density, skin thickening, and prominent subcutaneous lymphatic obstruction were the most common findings in inflammatory carcinoma of the breast. Berger did not discuss the frequency of masses or calcifications.
The concept of differentiating primary from secondary inflammatory carcinoma is relatively new, but this distinction is likely important for patient treatment and prognosis. In our study of primary inflammatory carcinoma, we found a lower incidence of clinically palpable masses, mammographically visible masses, and malignant-appearing calcifications than did investigators who included both primary and secondary inflammatory carcinoma cases in their studies. Our results support the concept that primary and secondary inflammatory carcinoma of the breast are two different disease processes. Further research will be necessary to determine the importance of distinguishing between primary and secondary inflammatory carcinoma.
Acknowledgments
We thank Mary Ann Waggoner for her secretarial support in preparation of
this manuscript.
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