Clinical History:

The patient in case 1 visited her 49-year-old mother and told her about the biopsy and the results. Her mother remarked, "You know, maybe I should go and see my doctor, because my aunt died of breast cancer." She sees her doctor, who palpates a large irregular firm fixed mass in the right breast as well as overlying skin with a rough, reddened appearance. Mammographically, the mass has irregular borders. A fine needle aspirate is performed of the mass and then a mastectomy is done.

Image 2.1:

Note the irregular borders of the mass in the photograph. The mass has a central irregular whitish scar. There are scattered foci of yellow to white necrosis and calcification. Axillary lymph nodes were also found to be enlarged and firm. A frozen section confirmed the diagnosis of malignancy, specimens were sent for estrogen-progesterone receptors.

Images 2.2 to 2.5:

Shown are sections of tumor with overlying breast skin. The tumor has cells of which are arranged in nests, cords, and exhibit a poor attempt at gland formation. The stroma around the tumor-cell nests is mildly desmoplastic, as seen in image 2.3. Intralymphatic tumor is seen in the dermis, accounting the clinical features of cutaneous inflammation and the "inflammatory carcinoma" pattern seen on image 2.2. Image 2.4 shows metastatic breast tumor in an axillary lymph node. Compare the histologic features of the cancerous breast tissue with the normal breast tissue on image 2.5.

Answers:

1. What is the diagnosis?

This is an infiltrating ductal carcinoma of breast with an inflammatory (dermal lymphatic) component and metastases to axillary lymph nodes.

2. Why did the skin appear to be inflamed?

This is caused by invasion of the carcinoma into the dermal lymphatics. "Inflammatory carcinoma" does not refer to a specific type or histologic subset of breast cancer, only to dermal lymphatic involvment.

3. What is the significance of the family history?

The risk of breast cancer is increased if a first degree relative, such as a mother, or aunt, has a history of breast cancer. The lifetime risk for breast cancer with affected first degree relatives is as follows:

Number	Age	Risk
One relative	less than 50 years	13 - 21%
One relative	greater than 50 years	9 - 11%
Two relatives	less than 50 years	35 - 48%
Two relatives	greater than 50 years	11 - 24%




Of course, BRCA-1 and BRCA-2 genes are the best known mechanisms for the appearance of early breast carcinoma that is familial. However, most of the important susceptibility genes have yet to be identified!


4. What issues must be addressed with informed consent for treatment?

Treatment for breast cancer is one of the classics of the importance of giving patients a choice. Though there may be variations in practice in different locations (some places where more aggressive surgery is the norm, and places where less aggressive surgery is the norm) every woman should be told about the options available, and given the benefits and burdens of each, and allowed to choose. The reason is simple: some people value preserving their appearance while others really don't care that much about appearance but are much more concerned about small differences in survival rate.