Inflammatory breast carcinoma and its differential

diagnosis: a pictorial review

Poster No.: C-1011

Congress: ECR 2017
Type: Educational Exhibit
Authors: L. S. Missumi, R. A. E. K. Matsumoto, N. de Barros; São Paulo/BR
Keywords: Cancer, Biopsy, Ultrasound, MR, Mammography, Breast
DOI: 10.1594/ecr2017/C-1011

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Page 1 of 16
Learning objectives

The objective of the study is to describe the epidemiological, clinical aspects and imaging
findings of inflammatory breast carcinoma (IBC), emphasizing the differences between
IBC and its differential diagnosis, such as locally advanced breast carcinoma (LABC) and
other inflammatory benign pathologies.

Background

Inflammatory breast carcinoma is a rare and aggressive type of breast cancer, accounting
for 2% - 5% of all breast cancer, with a 5-year survival rate of 25% - 50% [1]. Overweight
and obesity are well-known risks factors for any molecular subtype of IBC. Other
modifiable risk factors, such as age at first pregnancy, breastfeeding and smoking history
are associated with specific IBC subtypes [2].

Clinically, IBC presents as a rapid onset of breast swelling with erythema and edema of
the skin. Diagnostic criteria for IBC are [3]:

• rapid onset of breast erythema,

• edema and/or peau d'orange and/or warm breast
• with or without an underlying palpable mass
• duration of history of no more than 6 months
• erythema occupying at least one-third of the breast
• pathological confirmation of invasive carcinoma.

At pathologic analysis, the presence of many lymphovascular tumor emboli in a skin

punch biopsy is the hallmark of this disease. Although, it is found in less than 75% of the
cases [4], and it is not necessary to diagnosis confirmation.

Findings and procedure details

INFLAMMATORY BREAST CARCINOMA

The imaging findings are related to the onset of inflammatory skin changes and tumor
growth.

Page 2 of 16
On mammogram, the most common IBC findings are: enlargement of the breast,
increased breast density, global asymmetry, skin thickening and enlarged lymph nodes.
Sometimes masses and architectural distortion can be found [1]. ( Fig. 1 on page 5
and Fig. 2 on page 6 )

On ultrasonography, IBC generally presents with similar findings as mammogram (skin

thickening, parenchymal edema and axillary lymphadenopathy), but it plays an important
role because it can auxiliate tumor identification and guide a core biopsy, that is
mandatory for diagnosis [5]. ( Fig. 2 on page 6 )

MRI is also important because it can assess the extent of the disease of the affected
breast and shows possible occult disease on contralateral breast. Moreover, it is the most
accurate imaging method to identify and guide percutaneous procedures of the primary
breast lesion, when sonography is negative. Besides diagnosis and staging, MRI can be
used to follow-up treated patients and verify neoadjuvant therapy response [1].

Common findings of IBC, on MRI, are extensive or segmental non mass-like

enhancement and diffuse skin thickening. When presented as a mass with irregular
or spiculated margins, it may have adjacent satellites lesions or associated suspicious
enhancement. Kinetic analysis typically shows initial rapid enhancement with washout or
plateau curves [1]. ( Fig. 2 on page 6 and Fig. 3 on page 6 )

Although sometimes the imaging findings are characteristics and do not raise any
diagnostic difficulty, it is common to face a suspicious mass with skin thickening and
IBC is not the correct diagnosis. The main differential diagnosis are benign inflammatory
lesions and locally advanced breast carcinoma.

DIFFERENTIAL DIAGNOSIS - CLUES TO THE CORRECT DIAGNOSIS

Due to its clinical presentation, IBC can be misdiagnosed as a benign inflammatory

pathology, such as acute and chronic mastitis and idiopathic granulomatous mastitis (
Fig. 4 on page 7, Fig. 5 on page 8, Fig. 6 on page 9, Fig. 7 on page 10
and Fig. 8 on page 11 ). Here, other clinical aspects are relevant to raise the possibility
of inflammatory / infectious pathologies. Since IBC is not an infectious process, fever and
leukocytosis are not expected. Besides, IBC shows no response to antibiotic treatment,
revealing the importance of investigating mastitis that don't get better with this treatment
[3]. Enhancement of the pectoral muscles and thickened Cooper's ligaments are also
relevant to raise the diagnostic possibility of IBC instead of a non-neoplastic inflammatory
process.

Page 3 of 16
Besides benign diseases, locally advanced breast carcinoma (LABC) can mimic the
image findings of IBC ( Fig. 9 on page 11 ). Clinically, LABC affects older patients,
has a longer onset of symptoms, a slower progression and less chance of metastasis
at initial presentation and a lower rate of locoregional recurrences [1]. LABC comprises
large tumors (> 5 cm) or T4 (TNM staging) and/or N2/N3 (TNM) axillary involvement.
Regarding management aspects, IBC and LABC have similar initial approach, with
systemic neoadjuvant chemotherapy. (Fig. 10 on page 12) After that, LABC can
undergo breast conserving surgery, in contrast to IBC, where mastectomy is the surgical
procedure of choice. The confirmation of diagnosis is made after surgery, when a
pathological analysis of the entire breast is made.

Sometimes it is difficult to distinguish IBC and LABC but MRI might help, once
some findings are more frequent, but not exclusive, on IBC than LABC: nonmasslike
enhancement (instead of a mass being the index lesion), diffuse breast involvement skin
thickening, skin edema, skin enhancement and prepectoral or intramuscular pectoral
edema [1]. ( Fig. 11 on page 13 and Fig. 12 on page 13 ) T2W hyperintensity of
the skin can be one of the earliest imaging findings that could identify skin involvement.
MRI can also help as an excellent tool to monitor response to chemotherapy.

IBC LABC MASTITIS

Mass ++ ++++ +
Non-mass like +++ ++ +++
enhancement
Diffuse breast ++++ ++ ++
involvement
Skin ++++ ++ +++
enhancement /
edema
Calcifications ++ ++++ +
Axillary ++++ +++ +
lymphadenopathy
Other - Often with no - Skin changes - Lactation context
particularities palpable mass are usually due
to central necrosis - Usually
- Rapid onset of and lymphatic stasis retroareolar
symptoms from rapid tumor
growth
- Enhancement of - Local skin - Washout curves on
pectoralis major edema and skin kinetic analysis are
muscle enhancement uncommon

Page 4 of 16
 - Enhancement of - Mass with - Pre pectoral
Cooper's ligaments heterogeneous or and intramuscular
rim enhancement edema rare
- More than #
of the skin breast
thickened

STAGING

T4 Tumor of any size with direct extension to

the chest wall and/or to the skin (ulceration
or skin nodules)
T4a Extension to chest wall, not including only
pectoralis muscle adherence/invasion
T4b Ulceration and/or ipsilateral satellite
nodules and/or edema (including peau
d'orange) of the skin, which do not meet
the criteria for inflammatory carcinoma
T4c Both T4a and T4b
T4d Inflammatory carcinoma

Images for this section:

Fig. 1: Patient with a complaint of palpable breast mass for 3 months, has a previous
negative mammography (not shown). Current mammography shows global asymmetry
and trabecular thickening (green arrow), associated with skin and nipple thickening (blue
arrow). Follow-up post neoadjuvant chemotherapy of left breast shows reduction of global
asymmetry and skin thickening. Inflammatory breast carcinoma.

Page 5 of 16
© DEPARTMENT OF RADIOLOGY - HOSPITAL DAS CLINICAS DA FACULDADE DE
MEDICINA DA UNIVERSIDADE DE SAO PAULO

Fig. 2: Inflammatory breast carcinoma. Mammography reveals an oval, obscured mass

with equal density to the fibroglandular tissue on upper outer quadrant of left breast. MRI
shows a mass with irregular shape and margin, rim enhancement and liquefied central
area on left breast, associated with skin thickening of the lateral quadrants of the breast
and nipple retraction. Kinetic analysis reveals a plateau curve. This lesion was biopsied
and an invasive ductal carcinoma was diagnosed.

© DEPARTMENT OF RADIOLOGY - HOSPITAL DAS CLINICAS DA FACULDADE DE

MEDICINA DA UNIVERSIDADE DE SAO PAULO

Page 6 of 16
Fig. 3: Inflammatory breast carcinoma. Patient noticed erythema and induration of left
breast for 2 months. MRI shows round mass (yellow arrow) with irregular margins and
rim enhancement pattern with liquefied central area (asterisk) on the central portion of
the left breast, associated with diffuse skin thickening (blue arrow), nipple retraction and
enhancement, pectoralis major muscle edema (orange arrow) and retraction. This lesion
has a washout curve on kinetic analysis.

© DEPARTMENT OF RADIOLOGY - HOSPITAL DAS CLINICAS DA FACULDADE DE

MEDICINA DA UNIVERSIDADE DE SAO PAULO

Page 7 of 16
Fig. 4: Mammography shows two focal asymmetries located at subareolar region and
upper outer quadrant of right breast, associated with diffuse skin thickening, more evident
around the areola. US image shows ill defined areas, with heterogeneous echotexture
and thick component, the larger one on the upper lateral quadrant of the right breast is
in contact to the skin and is compatible with the focal asymmetry on mammography. US
guided core needle biopsy demonstrated chronic granulomatous inflammatory process.

© DEPARTMENT OF RADIOLOGY - HOSPITAL DAS CLINICAS DA FACULDADE DE

MEDICINA DA UNIVERSIDADE DE SAO PAULO

Page 8 of 16
Fig. 5: An oval mass, with obscured margins, isodense in the outer quadrants of
the right breast. On sonography, this mass correspond to an oval, hypoechoic mass,
with associated spiculated margins in its medial part. The fat tissues surrounding this
mass appear hyperechogenic, representing inflammatory changes. Histological analysis
demonstrated a chronic inflammatory process.

© DEPARTMENT OF RADIOLOGY - HOSPITAL DAS CLINICAS DA FACULDADE DE

MEDICINA DA UNIVERSIDADE DE SAO PAULO

Page 9 of 16
Fig. 6: Irregular, ill-defined, heterogeneous hypoechoic mass in the right breast.
There are some areas of posterior acoustic shadowing inside this mass, representing
calcifications. Slight skin thickening can be seen associated with this mass. A core biopsy
was performed and a chronic granulomatous inflammatory process was diagnosed.

© DEPARTMENT OF RADIOLOGY - HOSPITAL DAS CLINICAS DA FACULDADE DE

MEDICINA DA UNIVERSIDADE DE SAO PAULO

Page 10 of 16
Fig. 7: Mammography (A-D) shows an asymmetric density in the medial quadrants of
the left breast. At sonography (E-F), this area correspond to an irregular, heterogeneous
hypoechoic mass, with thickening of the adjacent skin. US-guided biopsy demonstrated
an inflammatory process

© DEPARTMENT OF RADIOLOGY - HOSPITAL DAS CLINICAS DA FACULDADE DE

MEDICINA DA UNIVERSIDADE DE SAO PAULO

Fig. 8: Mammographic images show an irregular asymmetric density in the retroareolar

region of the right breast (red arrow). On sonography, this area represent an irregular,
hypoechoic mass, with associated skin thickening (yellow arrow). There is also an
echogenic halo around the mass. US-guided biopsy was performed and an inflammatory
process was diagnosed.

© - São Paulo/BR

Page 11 of 16
Fig. 9: Patient with a complaint of palpable mass on right breast. Mammography
shows spiculated mass on upper quadrants of right breast, associated with architectural
distortion and pleomorphic calcification. Locally advanced invasive ductal carcinoma.

© DEPARTMENT OF RADIOLOGY - HOSPITAL DAS CLINICAS DA FACULDADE DE

MEDICINA DA UNIVERSIDADE DE SAO PAULO

Fig. 10: Locally advanced breast carcinoma. Patient with palpable mass on left breast
for 2 years. Mammography shows diffuse trabecular and skin thickening associated
with an irregular density (blue arrow). There is a gas density image, compatible
with skin ulceration (orange arrow) and a retraction of skin in this area (yellow
arrow). Mammography post chemotherapy (third picture) shows reduction of trabecular

Page 12 of 16
thickening and gas. Adjacent skin thickening persists. Ultrasonography guided core
needle biopsy of indistinct, complex mass resulted invasive ductal carcinoma.

© DEPARTMENT OF RADIOLOGY - HOSPITAL DAS CLINICAS DA FACULDADE DE

MEDICINA DA UNIVERSIDADE DE SAO PAULO

Fig. 11: Locally advanced NOS IDC. Mammography reveals trabecular, skin and nipple
thickening on left breast. MRI shows a diffuse heterogeneous enhancement extending
from the posterior third of the left breast to the subareolar area, combined with reduced
volume of this breast, skin thickening, nipple retraction and skin and nipple enhancement.
The kinetic analysis reveals a plateau curve.

© DEPARTMENT OF RADIOLOGY - HOSPITAL DAS CLINICAS DA FACULDADE DE

MEDICINA DA UNIVERSIDADE DE SAO PAULO

Page 13 of 16
Fig. 12: MRI shows a diffuse heterogeneous enhancement on the left breast, reduced
volume of this breast and diffuse skin thickening. A core biopsy was performed and an
NOS invasive ductal carcinoma was diagnosed. Locally advanced breast carcinoma.

© DEPARTMENT OF RADIOLOGY - HOSPITAL DAS CLINICAS DA FACULDADE DE

MEDICINA DA UNIVERSIDADE DE SAO PAULO

Page 14 of 16
Conclusion

Inflammatory breast signs presented by IBC can be misdiagnosed as a benign pathology,

such as mastitis or malignant diseases as LABC. Knowing their imaging findings on
different image methods helps making an accurate diagnosis and optimizing therapy.

Personal information

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