Cribriform carcinoma mimicking breast abscess - case report. Diagnostic and therapeutic management.

The authors presents a case of cribriform breast carcinoma in a cyst that clinically imitated an abscess. The case concerns a 71-year-old female patient treated for ankylosing spondylitis, with a positive family history of breast cancer. The patient presented at the surgical clinic for incision of an abscess of the mammary gland localized in the lower inner quadrant that was a consequence of previous trauma to the right breast. The abscess was incised and the serosanguineous contents were evacuated. The wound was drained and antibiotics (Dalacin with Metronidazol) were administered for the period of 10 days. During the treatment, a cutaneous fistula was formed. At the incision site, a hard thickening was palpable (tumor). Core needle biopsy of the clinically palpable tumor was performed and the purulent material from the fistula was collected for a culture test. Complete blood count did not reveal leucocytosis. In accordance with the obtained sensitivity report, the patient was started on antibiotics again. Breast ultrasound performed upon the completion of the antibiotic therapy, in the right breast, revealed two solidcystic oval lesions with thick echogenic walls and blurred margins. Both masses contained dense levels of fluid material and solid polycyclic structures. On sonoelastography, the lesions were heterogeneous with a high Young's modulus. In the right axillary fossa, ultrasound examination revealed three abnormal lymph nodes enlarged to 31 mm length, which were rounded, hypoechoic and without visible sinuses. Histopathology of the core needle biopsy performed at admittance and after the antibiotic therapy indicated a breast abscess (presence of fibrinous and partly fibrinopurulent material). The mass was finally resected to confirm histopathology. The resected material revealed the presence of an invasive, moderately differentiated cribriform carcinoma, which developed within a cyst, with a 40% necrotic component. Eighteen months after the commencement of treatment, the patient remains under oncological supervision and continues hormonal therapy. There are no signs of relapse or foci of distant metastases. The occurrence of breast carcinoma within an abscess emphasises the need for comprehensive assessment and correlation of the clinical picture with imaging and histopathological findings. It also highlights the necessity to include breast abscess in the differential diagnosis of rare forms of carcinomas.

Cribriform carcinoma of the breasts is a rare form of breast neoplasm. Its early detection and implementation of appropriate treatment is of crucial significance for improved prognosis of such patients. Despite screening tests and continuously perfected diagnostic methods, the establishment of adequate diagnosis is in certain cases still problematic.

A palpable mass is the most common symptom of breast cancer. Infrequently, sanguineous discharge from the nipple, its retraction or indrawn skin of the breasts may be encountered. In very few cases of breast carcinoma signs of mastitis or enlarged lymph nodes in the axillary fossae are observed without abnormal focal lesions in the breasts(.

Breast carcinoma which imitates an abscess is very rare and accounts for less than 1% of all cases of breast carcinomas – this is frequently inflammatory carcinoma(. Such a manifestation of a neoplasm may provoke a late diagnosis and treatment.

The differential diagnosis of focal lesions in the breasts is problematic due to their diversified presentation, both radiological and clinical. The abovementioned clinical signs may also appear in the case of benign lesions, which are much more common than malignant ones. The consequential delay in diagnosis is unfavorable for the prognosis.

The paper presents a patient with symptoms of breast abscess, who was finally diagnosed with infiltrating cribriform carcinoma.

Case report

A 71-year-old female patient presented at the surgical clinic for incision of an abscess of the mammary gland localized in the lower inner quadrant (LIQ) that appeared as a consequence of a trauma to the right breast.

The medical history was significant for a 20-year history of treatment for ankylosing spondylitis as well as a positive family history for breast cancer – the patient's daughter suffered from the same neoplasm at the age of 45. The patient was not a smoker.

In the regional surgical clinic, the abscess was incised and over 500 ml of serosanguineous contents was evacuated. The wound was drained and antibiotics (Dalacin with Metronidazol) were administered for the period of 10 days. During treatment, a cutaneous fistula was formed. At the incision site, a hard thickening was palpable (tumor).

After 4 weeks the patient was referred to the surgical outpatient clinic at the Oncological Centre – Institute for further diagnosis. Core needle biopsy (CNB) of the clinically palpable tumor was performed and the purulent material from the fistula was collected for a culture test. The culture was positive for Staphylococcus aureus (MRSA+++) and Enterococcus faecalis (+++). Complete blood count (CBC) did not reveal leucocytosis. In accordance with the obtained sensitivity report, the patient was started on antibiotics (amoxicillin with clavulanic acid) once again for a period of 10 days.

Histopathology of the CNB indicated breast abscess (presence of fibrinous and partly fibrinopurulent material) (fig. 1).

Fig. 1

Microscopic presentation of purulent inflammatory granulation

Due to breast tenderness and the presence of active fistula, mammography (MMG) was not performed.

Breast ultrasound (US) in the LIQ of the right breast, performed after the completion of the antibiotic therapy, revealed two solid-cystic oval lesions with thick hyperechoic walls. The cysts measured 58×34×40 mm and 28×21×20 mm. Both masses contained levels of dense fluid material (fig. 2) and polycyclic solid structures (fig. 3). The margins were indistinct.

Fig. 2

Solid-cystic oval lesion with the dimensions of 58×34×40 mm and dense fluid contents

Fig. 3

Solid-cystic lesion with thickened hyperechoic wall. In the region of the polycyclic solid structure and in the wall of the lesion, color Doppler (CDUS) shows tortuous arterial vessels

The polycyclic structures of the cystic mass, and the walls adjacent to them showed increased vascularity, along with a tortuous arterial supply on color Doppler (fig. 3).

Additionally, on sonoelastography, performed by means of shear wave method, the focal lesions and adjacent tissues presented themselves as heterogeneous structures of high Young's modulus (average values ranging from 69–218 kPa, max. 149–300 kPa) (fig. 4).

Fig. 4

Solid-cystic lesion on sonoelastography. The lesion and adjacent tissues present themselves as heterogeneous structures of high Young's modulus (average values ranging from 69 to 218 kPa, max. 149–300 kPa)

Skin thickening was not observed. US examination of the right axillary fossa revealed three abnormal lymph nodes which were enlarged to 31 mm in length, rounded, hypoechoic and without visible sinuses. Based on the standards of the Polish Ultrasound Society(, the lesion was assigned to category 4 in BIRADS-US classification.

Due to ineffective treatment implemented so far, a repeated histopathological verification was conducted.

US-guided CNB of the solid component of the change and fine needle biopsy (FNAB) of the enlarged lymph node in the axillary fossa was performed. The histopathological analysis demonstrated the presence of necrotic material and hyaline tissue. The cytological examination of the lymph node revealed only inflammatory cells.

In the view of persisting clinical symptoms of the abscess and suspicious US presentation, it was decided to remove the entire lesion for the purposes of histopathological verifi- cation. The analysis revealed the presence of invasive, moderately differentiated cribriform carcinoma (G2), which developed within a cyst, with a 40% necrotic component (figs. 5, 6). Immunohistochemical tests demonstrated positive expression of estrogen and progesterone receptors (ER and PgR). The reaction to HER2- (HER2 – human epidermal growth factor receptor type 2) protein was negative [ER 90%, PgR 70%, HER 2 (-)].

Fig. 5

Microscopic presentation of the fragment of cribriform carcinoma tissue

Fig. 6

Microscopic presentation of purulent inflammatory granulation and cribriform carcinoma tissue

The patient was treated surgically with a Madden's modified radical mastectomy. In the sample of the mammary gland, no neoplastic cells were found. Metastases were detected in 3/18 axillary lymph nodes (fig. 7).

Fig. 7

Oval, hypoechoic lymph node measuring 31×15 mm without a visible sinus, localized in the right axillary fossa (histopathological examination revealed neoplastic cells)

Following the surgery, the patient was referred to an oncologist- chemotherapist and a radiotherapist in order to plan adjuvant therapy. She underwent radiotherapy of the region of the scar that remained after the right-side mastectomy. Due to numerous internal conditions, she received hormonal therapy (Atrozol). In a follow-up US examination performed 18 months after the surgery, no metastases were found.

Discussion

Invasive cribriform carcinoma (ICC) accounts for merely 0.8–3.5% of invasive breast carcinomas(. It was first described by Page et al.( in 1983 as a type of invasive ductal carcinoma with a relatively good prognosis. On palpation, ICC may present itself as a tumorous mass but is frequently clinically silent(. In the presented case, the lesion was palpable and presented clinical symptoms of an abscess with a fistula. The data reported in the literature related to ICC mainly concern small groups of patients. Stutz et al.( described eight cases of cribriform carcinoma detected by means of imaging examinations. Only four of them were visualized on MMG examination and their US images were not typical of breast carcinoma. On MMG, the lesions had spiculated margins and contained microcalcifications. The literature does not report on any case of cribriform carcinoma visualized in magnetic resonance imaging (MRI). Furthermore, EUSOMA guidelines (European Society of Breast Cancer Specialists) state that MRI is not recommended for the differentiation between mastitis and inflammatory carcinoma prior to the commencement of the therapy. MRI might be considered if upon the conclusion of the treatment of the alleged mastitis, inflammatory carcinoma is still suspected(.

Lim et al.( demonstrated the US features of cribriform carcinoma based on three cases: the lesions were oval or shaped irregularly, had low echogenicity, rich vascularity, were well-circumscribed and had microlobulated outlines.

These features were confirmed by the case presented here: the lesion was oval, presented low echogenicity, had solidcystic structure and blurred margins. The solid components of the lesion showed increased perfusion.

Moreover, carcinoma in the presented case, existed in two foci and their surroundings revealed intense inflammatory and necrotic changes. These characteristic features are indicated by Lim et al. The authors report that the multifocal character of lesions appears in 20% of cribriform carcinomas and that they are frequently accompanied by stromal fibrosis(.

Breast carcinoma mimicking an abscess is encountered rarely and accounts for less than 1% of breast carcinomas. The literature does not present any descriptions of cribriform carcinomas with the clinical course of breast abscess. US examination is a method of choice in the cases of forming abscesses as well as in acute and subacute inflammatory processes in the breasts. It also allows for guided collection of material for pathological verification as well as for its aspiration. MMG examination, due to pain that accompanies mastitis and difficulties to interpret the image, is applied less frequently. The majority of breast abscesses are caused by secondary infections by the bacterial flora of the skin among others by: Staphylococcus aureus, Staphylococcus epidermidis or Streptococcus pyogenes and anaerobic bacteria. The differential diagnosis should include rare diseases such as Churg-Strauss syndrome, amyloidosis, Wegener's granulomatosis or sarcoidosis, which may also manifest clinical symptoms of mastitis(.

In the presented case, the clinical picture initially indicated peripheral nonpuerperal breast abscess, which usually affects elderly women. For 20 years, the patient had suffered from ankylosing spondylitis treated with sulphasalazine. Such a form of a nonpuerperal abscess reacts well to antibiotics and is rarely recurrent. Nevertheless, coexistent diseases such as diabetes and rheumatoid arthritis as well as long-term steroid therapy and history of surgeries or radiotherapy constitute additional risk factors(.

Following the analysis of numerous studies published in the last twenty years, Trop et al.( proposed an algorithm of diagnostic and therapeutic management in a breast abscess. They presented a classification of breast abscesses, their features in imaging examinations and the algorithm of management in patients with the suspicion of a breast abscess. The authors recommend performing US examination after the antibiotic therapy.

if on US examination the presence of fluid cavity is confirmed (suspicion of abscess), aspiration with 18 Ga needle should be performed; if the diameter of the fluid cavity exceeds 2 cm, it should be irrigated with saline and cultures of the material taken;

if no fluid cavity is detected, the following should be taken into account:

inflammatory breast carcinoma – perform MMG and biopsy;

mastitis – continue antibiotic therapy and repeat US examination if no clinical improvement is observed.

In the patient described herein, however, despite the fact that the procedures were carried out in accordance with the guidelines, neoplastic cells were not detected.

The above quoted authors recommend a clinical check-up after 7–14 days.

When a complete response to treatment is not achieved, the authors suggest the differentiation with inflammatory breast carcinoma and recommend repeated US examination. If the fluid cavity persists, it is recommended to perform repeated aspirations, saline irrigations and clinical check-ups every 1–2 weeks with repeated microbiological analyses. In the case of positive culture test, targeted antibiotic therapy should be started again.

If the fluid cavity persists in subsequent control examinations (after 3–5 aspirations), the authors suggest that the US be repeated once again, along with culture and sensitivity. If the fluid collection persists on US examination, they recommend repeated aspirations without limitation of puncturing, renewed microbiological verifications and eventually, drain insertion or surgical interventions.

In the case of the 71-year-old patient, as presented herein, the history of breast trauma, clinical picture and chronic inflammatory disease (ankylosing spondylitis) as well as pathological findings (CNB performed twice and FNAB of the lymph node) suggested nonpuerperal breast abscess. It was surgical intervention that, after numerous aspirations, drain insertion and antibiotic therapies, allowed for establishing the diagnosis of breast carcinoma.

The immunohistochemical and pathomorphological tests of the resected tumor demonstrated characteristic features of cribriform carcinoma. Marzullo et al.( demonstrated that cribriform carcinoma in immunohistochemical examinations shows the expression of estrogen receptors (ER) in 100% of cases and progesterone receptors (PgR) in 69% of cases as well as a negative reaction to HER- proteins. Our studies confirmed these observations. Furthermore, the patient presented herein was diagnosed with “classic” cribriform carcinoma with necrotic areas. ICC occurs in “classic” and “mixed” forms depending on the percentage of other histological patterns (< or >50%). The prognosis in the “classic” form is favorable with 5 year survival of 100%, but in the case of tumors containing <50% of ICC tissue – it is 88%(.

Conclusion

The occurrence of breast carcinoma within an abscess emphasizes the need for comprehensive assessment and correlation of the clinical picture with imaging and histopathological findings. The complex picture of the disease, which may be observed in the presented patient, caused the delay in ICC diagnosis and in the implementation of treatment, i.e. mastectomy and axillary lymph node dissection.

Positive family history, the patient's age, abnormal US findings, and finally a 3-month period of ineffective treatment indicated the possibility of a neoplastic disease.

Eighteen months after the commencement of treatment, the patient remains under oncological supervision and continues hormonal therapy. There are no signs of relapse or foci of distant metastases.