Breast Growth: Cancer or Coincidence in 42-Year-Old?
Biopsy revealed acute and chronic inflammation, granulation-type tissue, and focal granuloma with suppuration, but no evidence of malignancy. With the diagnosis still unclear, the patient was asked to return within 1 month.
However, upon her return, the breast mass and positive axillary lymph node had decreased in size significantly, with ulcerated areas showing signs of healing.
The case reported by Junisha Martin, a medical student at Ross University School of Medicine in Miami, highlighted the importance of considering a wide range of potential diagnoses.
The Patient and Her History
The patient with no significant past medical history presented with an enlarging 4.5 cm mass over 2.5 months in the right breast. The patient disclosed that 2 years ago, she had experienced a lemon-sized lump in her right breast that had persisted for approximately 2 months.
The mass was accompanied by small superficial ulcerations on the overlying skin and occasional discomfort. The mass completely resolved during that time, and no medical treatment was sought. Six months later, the mass returned to the same location and increased in size, with ulcerations in the areolar region.
The patient declined to undergo mammography during that time because of the discomfort of the areolar lesion. The past surgical history consisted of three prior caesarean sections.
The patient denied any allergies, smoking, recent travel, pets at home, or use of topical creams and ointments on the affected area. The patient denied any significant family or social history.
Findings and Diagnosis
On admission, patient vitals were obtained and reported normal: temperature 36.8 °C, blood pressure 132/88 mm Hg, heart rate 84 beats/min, respiratory rate 19 breaths/min, and oxygen saturation 99% on room air. She was alert and in no acute distress on physical examination.
Physical examination revealed that the large right breast mass had decreased in size significantly. The mass now measured 3 cm from 4.5 cm and was non-tender, with minimal nipple retraction and healing ulcerations and scars with improving skin discoloration.
The patient was scheduled for an ultrasound-guided core biopsy of the right breast and right axillary lymph node due to a high suspicion of malignancy, instead of fine-needle aspiration cytology. A core biopsy of the right breast at 12:00 revealed acute and chronic inflammation, granulation-type tissue, and focal granuloma with suppuration.
Immunohistochemical tests were negative for carcinoma. A right axillary lymph node biopsy revealed sinus histiocytosis and acute non-specific lymphadenitis but no evidence of malignancy.
During the follow-up visit after 1 week, the patient reported feeling well, with mild soreness at the biopsy site. Repeated physical examinations were consistent with an enlarging areolar breast mass with skin ulcerations and nipple retraction.
The right breast was moderately tender on palpation. Due to the discordance between the pathology report and physical examination, a repeat ultrasound-guided biopsy was recommended for further management.
No medications were prescribed to the patient, and conservative measures were taken because the final diagnosis was not confirmed. Upon repeat biopsy, physical examination revealed that the large right breast mass had decreased in size significantly.
The decreasing size of the lesion (mass effect), decreasing size of the lymph node, and the nature of the ulcer now healing ruled out inflammatory breast cancer, and the physician suspected an idiopathic aetiology, instead of an inflammatory or infectious cause of this patient's presentation. A multidisciplinary approach was established for the patient, with a primary care physician and surgeon for further management if there were signs of disease progression.
Discussion
'This case illustrates the diagnostic challenges of inflammatory breast lesions with overlapping clinical presentations. While initial findings suggested inflammatory breast cancer, biopsy results were negative for malignancy, pointing towards a benign inflammatory or infectious aetiology, such as idiopathic granulomatous mastitis or cat scratch disease. The spontaneous improvement after conservative management provided further evidence against a malignant process.
This case reinforces the need for interdisciplinary collaboration, and further research into inflammatory breast pathologies is vital. Maintaining an open perspective and integrating all available data are essential when evaluating breast masses, facilitating timely diagnosis, and preventing unnecessary aggressive treatments. This case concluded without a definitive diagnosis, highlighting the importance of flexible management guided by clinical improvement in complex presentations,' the authors wrote.
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