Metaplastic breast cancer is difficult to diagnose, resistant to conventional treatment, and biologically aggressive. A suspicious timeline and discordance between imaging findings and histopathologic tissue diagnosis should trigger additional workup. New, large lesions or rapidly growing lesions with complex echogenicity on ultrasound warrant correlation with imageguided biopsy for a definitive diagnosis. Lesions that appear aggressive on imaging, with negative biopsy findings, may represent false negatives due to sampling bias from intratumoral heterogeneity. In such cases, it may be advisable to obtain an excisional biopsy. These tumors are known to progress even with neoadjuvant chemotherapy. Immunotherapy, however, may be effective even for metastatic disease. A multidisciplinary approach and a high index of suspicion may, therefore, confer survival benefits in circumstances where the imaging phenotype does not fit with the timeline or pathologic diagnosis. This report describes five cases of metaplastic breast cancer diagnosed at our institution to highlight the importance of a timely and accurate diagnosis of this rare but aggressive breast malignancy.
Breast tissue can be the host of not only many benign and malignant tumors but can also be a metastatic site for various tumors such as leukemia, lung cancer, and melanoma. This report describes an unusual case of a 43-year-old female who presented with a new palpable breast lump and several similar extramammary lumps on her skin. A melanoma panel, consisting of S100, HMB45, and Melan-A stains, was included in the pathology evaluation due to diagnostic suspicion of the radiologist and revealed metastatic melanoma. This case highlights the importance of detailed history and relevant physical exam as well as clinical and imaging correlation. It serves as a reminder to radiologists to include metastatic melanoma in the differential of suspicious subcutaneous breast masses, especially in patients with multiple subcutaneous lumps in the body or abnormal skin findings.
A 34-year-old female at 17 weeks gestation presented to the emergency room complaining of a painful, raised left breast mass that had been enlarging over the past couple of weeks. The patient reported fevers and chills. On examination, there was a 7 cm firm, immobile, tender mass at the 12 o'clock position of the left breast. The skin overlying the breast mass was red and warm, with small areas of excoriation ( Figure 1). Laboratory findings demonstrated a white blood cell count of 14 × 10 3 /µL (normal range 4.5-11 × 10 3 /µL) and sedimentation rate of >136 mm/h (normal range 0-20 mm/h). An ultrasound of the left breast and axilla demonstrated multiple enlarged left axillary lymph nodes and edema with skin thickening in the left breast at the site of palpable concern, without a focal mass ( Figure 2). An ultrasound-guided core needle biopsy of a left axillary lymph node revealed no malignant cells.Subsequently, the patient noticed redness of the upper inner left breast and developed a new erythematous rash with similar rash in the bilateral legs and upper extremities. A repeat ultrasound of the left breast was performed, again demonstrating nonspecific edema.An ultrasound-guided core biopsy was performed of the left breast and showed acute and chronic inflammation (Figure 3). Tissue culture was positive for Corynebacterium. A skin punch biopsy of the left tibia demonstrated septal panniculitis, consistent with erythema nodosum (Figure 4). The patient began oral prednisone and oral antibiotics for 7 days, with significant improvement in her symptoms. Erythema nodosum (EN) is characterized by the rapid onset of tender, erythematous subcutaneous nodules most commonly localized to the pretibial lower extremities, but can involve the trunk and upper extremities. EN is likely due to a hypersensitivity reaction in F I G U R E 1 Erythematous raised, excoriated rash involving the left breast [Color figure can be viewed at wileyonlinelibrary.com] F I G U R E 2 Targeted ultrasound of the left breast shows skin thickening (white arrow) and diffuse hypoechogenicity of the subcutaneous tissue (red arrow) [Color figure can be viewed at wileyonlinelibrary.com]
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