Review of ultrasound appearance in inflammatory breast

cancer

Poster No.: R-0172

Congress: RANZCR ASM 2013
Type: Educational Exhibit
Authors: D. Abeywardhana, V. Nascimento, D. Dissanayake, D. Taylor, C.
Metcalf, C. Saunders, E. Wylie; Perth/AU
Keywords: Breast, Ultrasound, Diagnostic procedure, Cancer
DOI: 10.1594/ranzcr2013/R-0172

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 third-
party sites or information are provided solely as a convenience to you and do not in any
way constitute or imply RANZCR's endorsement, sponsorship or recommendation of the
third party, information, product or service. RANZCR 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 RANZCR 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, .doc documents and any other multimedia
files are not available in the pdf version of presentations.
www.ranzcr.edu.au

Page 1 of 19
Learning Objectives

To demonstrate the sonographic findings of Inflammatory breast carcinoma (IBC)

To illustrate the role of sonography in lesion localisation for needle biopsy of lesions in IBC

Background

Inflammatory breast cancer is a rare presentation of invasive breast carcinoma

accounting for 1-2% of breast cancers. It is a very aggressive malignancy presenting
either in stage III or IV disease.

A retrospective review of records of 64 patients with clinical diagnosis of IBC who

presented to the Breast Clinic at Royal Perth Hospital from 2000 - 2011 was performed.
Of these patients, only 41 patients had initial ultrasound examination and are included in
this study. Breast erythema, oedema, peau d'orange and rapid clinical deterioration were
the criteria used in clinical diagnosis of IBC.

Sonographic characterization of the breast imaging is in accordance with the BIRADS

ultrasound lexicon.

Imaging Findings OR Procedure Details

Common ultrasound findings demonstrated in this study include single or multiple

masses, skin thickening, dermal lymphatic dilatation, parenchymal oedema, axillary
lymphadenopathy, microcalcifications and increased vascularity.

The commonest sonographic finding was the presence of skin thickening (92%) similar
to other studies (2) (3). Yang l et al (4)demonstrated skin thickening in 100% of cases
in their study. Comparison with skin thickness of the contralateral breast would increase
sensitivity in evaluating this sonographic finding. 85% of patients had single or multiple
masses similar to Gunhan-Bilgen et al (2). Axillary lymphadenopathy has been detected
in 76% of patients. Parenchymal oedema was detected in 78% of study cases. Echogenic
foci consistent with microcalcifications, were documented in 17% of cases. Multiple small
anechoic spaces within the dermis correlating with dilatation of dermal lymphatics was

seen in 34%. This correlates with the pathological finding of dermal lymphatic invasion
by tumour emboli (Fig. 1). However, in other studies (2 & 3), 55% - 65% of cases had
dermal lymphatic dilatation.

Multifocality was demonstrated in 27% of cases similar to most of studies.

Page 2 of 19
Ultrasound guided core biopsy or fine needle aspiration was the preferred localisation
technique for 78% of patients in our study.

ULTRASOUND FINDING PERCENTAGE

Skin thickening 92.5
Single or multiple masses 85
Surrounding parenchymal oedema 78
Axillary lymphadenopathy 75.5
Dermal lymphatic dilatation 34
Increased vascularity 32
Multifocal abnormality 27
Microcalcifications 17

Images for this section:

Fig. 1: Right breast ultrasound shows marked skin thickening, dermal lymphatic
dilatation, subcutaneous oedema & loss of tissue planes in comparison to same region
of contralateral breast.

Page 3 of 19
Fig. 2: Left breast ultrasound demonstrates ill-defined hypo echoic mass with increased
vascularity & skin thickening.

Page 4 of 19
Fig. 3: Irregular hypo echoic mass with parenchymal oedema & skin thickening on
transverse plane ultra sound.

Page 5 of 19
Fig. 4: Irregular hypo echoic mass with loss of tissue planes, parenchymal oedema, skin
thickening & dermal lymphatic dilatation.

Page 6 of 19
Fig. 5: Multiple mass lesions with parenchymal oedema & shadowing are demonstrated
in this ultrasound study.

Page 7 of 19
Fig. 6: Transverse ultrasound demonstrating skin thickening, dermal lymphatic dilatation,
parenchymal oedema & shadowing.

Page 8 of 19
Fig. 7: Marked skin thickening, parenchymal oedema & increased parenchymal
vascularity.

Page 9 of 19
Fig. 8: Lobulated hypo echoic region with micro calcifications with possible extension
along a duct is clearly visible in this ultra sound image, although demonstration of micro
calcifications could be difficult with ultra sound.

Page 10 of 19
Fig. 9: Stromal distortion with parenchymal oedema & possible micro calcifications are
demonstrated in this image.

Page 11 of 19
Fig. 10: Left breast ultrasound with marked skin thickening, sub cutaneous &
parenchymal oedema.

Page 12 of 19
Fig. 11: Right axillary lymphadenopathy with increased vascularity.

Page 13 of 19
Fig. 12: This image demonstrates marked thickening of the cortex of the right axillary
lymph node.

Page 14 of 19
Fig. 13: Asymmetrical thickened cortex of a lymph node sampled using ultrasound
guidance.

Page 15 of 19
Page 16 of 19
Fig. 14: Ultrasound guidance used for core biopsy of suspicious hypo echoic area in this
patient.

Fig. 15: Incisional biopsy of skin overlying breast showing epidermis (EPIDERMIS) and
dermis (DERMIS). Nests of tumour cells are present within lymphatics in the mid and
deep dermis (original magnification 1.0X). Upper right inset shows dilated lymphatics
containing tumour cells occurring singly or in aggregates (original magnification
22.4X). Lower right inset shows several lymphatics containing tumour cells adjacent
a venule (original magnification 8.4X). Lower left inset shows several lymphatics
containing cohesive aggregates of tumour cells (TUMOUR) (original magnification
20.0X). Haematoxylin & Eosin.

Page 17 of 19
Conclusion

The commonest sonographic findings in IBC are skin thickening, presence of a

mass, parenchymal oedema and axillary lymphadenopathy. Dermal lymphatic dilatation,
correlating with pathological finding of dermal lymphatic invasion by tumour was present
in approximately 1/3 of cases.

Ultrasound is more sensitive than mammography for detecting the primary tumour
site and extent, for facilitating accurate needle biopsy and for demonstrating axillary
lymphadenopathy.

In more than 75% of cases sonography was used to guide needle biopsies.

Personal Information

References

1) Le-Petross H, Uppendahl L, Stafford J

Sonographic Features of Inflammatory Breast Cancer.

Seminars in Roentgenology 2011; 46; 275-279.

2) Gunhan-Bilgen I, Ustun EE, Memis A

Inflammatory Breast Carcinoma:

Mammographic, Ultrasonographic, Clinical, and Pathologic Findings

in 142 Cases. Radiology RSNA 2002; 223; 829-838.

3) Lee KW, Chung SY, Yang I, Kim HD, Shin SJ, Kim JE, Chung BW,
Choi JA

Inflammatory Breast Cancer: Imaging findings. Clinical Imaging

2005; 29; 22-25.

4) Yang WT, Le-Petross HT, Macapinlac H, Carkaci S, Gonzalez

Angulo AM, Dawood S, Resetkova E, Hortobagyi GN, Cristofanilli M.

Inflammatory breast cancer: PET/CT, MRI, Mammography, and

Page 18 of 19
Sonography findings. Breast Cancer Res Treat. 2008 Jun;109(3):

417-26.

5) Anderson WF, Chu KC, Chang S

Inflammatory Breast Carcinoma and Non inflammatory Locally

Advanced Breast Carcinoma: Distinct Clinicopathologic Entities?

Journal of Clinical Oncology. 2003 21(12): 2254-2259.

Page 19 of 19