Japanese Journal of Clinical Oncology 30:279-282 (2000)
© 2000 Foundation for Promotion of Cancer Research
Primary Squamous Cell Carcinoma of the Breast During Lactation: a Case Report
1Second Department of Surgery, 2Department of Emergency and Critical Care Medicine and 3Second Department of Pathology, Gunma University School of Medicine, Maebashi, Gunma, Japan
 |
ABSTRACT |
|---|
 TOP ABSTRACT INTRODUCTIONCASE REPORTDISCUSSIONREFERENCES |
|---|
A case of primary squamous cell carcinoma of the breast during lactation is reported. The patient was a 32-year-old woman, in post-partum lactating 18 months after delivery, who was referred to our hospital following detection of a lump in her left breast during physical examination in mass screening for breast cancer. The tumor, palpated in the upper outer quadrant of the left breast, was firm, well-defined and 2.8 x 2.6 cm in size. Ultrasonograms identified an irregular-shaped hypoechoic lesion and mammograms revealed a well-defined, circumscribed tumor. Based on these findings, breast cancer was suspected and an excisional biopsy was performed. The resected specimen was a firm, solid and circumscribed tumor with central hemorrhage. Microscopic findings demonstrated that the tumor consisted of an invasive ductal carcinoma with marked squamous metaplasia, such as keratinization and squamo-columnar junction. Breast-conserving surgery was performed and no lymph node involvement was noted. Both estrogen and progesterone receptors of the tumor were negative. Generally, the size of both squamous cell carcinoma and carcinoma during the lactation period tends to be larger than ordinary carcinomas. In this case, the cancerous lesion was detected at a relatively early stage. Although the cancerous lesion was detected at a relatively early stage and no lymph node involvement was noted, lung metastases occurred within 12 months of the surgery. Malignant potential is generally considered to be high in cases of squamous cell carcinoma of the breast with lactation and thus intensive treatment potentially resulting in severe side effects was considered to be necessary for this patient.
|
INTRODUCTION |
|---|
|
TOPABSTRACTINTRODUCTIONCASE REPORTDISCUSSIONREFERENCES |
|---|
Primary squamous cell carcinoma (SCC) of the breast is rare, particularly during the gestational period; only six cases of this combination have been reported previously (1–5). These six cases include three in the lactating period (1,2,5). We report here a patient with primary SCC of the breast during the lactation period. Both SCC of the breast and breast cancer during the lactation period tend to be larger than ordinary carcinomas. Despite SCC of the breast during lactation, the cancerous lesion was detected at a relatively early stage. Although the cancerous lesion was detected at a relatively early stage, lung metastases occurred within 12 months of the surgery.
|
CASE REPORT |
|---|
|
TOPABSTRACTINTRODUCTIONCASE REPORTDISCUSSIONREFERENCES |
|---|
In March 1998, a 32-year-old female noticed a lump in her left breast. The patient’s second child had been born in August 1996 and she was still lactating. During a mass screening for breast cancer in September 1998, a tumor in the breast of the patient was detected and she was referred to our hospital. Neither past nor family histories were noteworthy. Menarche occurred when the patient was 11 years old and the patient was married and had her first child at the age of 27.
Bulging was noted in the upper outer quadrant of the left breast. Skin retraction overlying the tumor was not remarkable. The tumor was firm, well-defined, relatively mobile with an irregular surface and 2.8 x 2.6 cm in size. A soft lymph node was palpable in her left axilla.
Ultrasonograms identified an irregularly shaped hypoechoic lesion with a heterogeneous internal echo and relatively obvious margin (Figure 1).
|
Mammograms showed a well-defined and circumscribed contour of the tumor despite a relatively dense breast due to lactation. Neither spicula nor calcification was observed (Figure 2).
|
Based on these findings, breast cancer was suspected and an excisional biopsy was performed to establish whether breast-conserving therapy was possible. Since this case was suspected to be lactating breast cancer, more detailed pathological analyses, such as whether intraductal component spread had occurred or not and whether cancerous lesion was completely resected or not, were necessary for breast-conserving therapy in contrast to ordinary types of breast cancer.
A specimen resected by excisional biopsy was firm, solid, circumscribed and 2.8 x 2.5 x 2.2 cm in size with hemorrhage. No cystic changes were observed (Figure 3).
|
Microscopic examination demonstrated that a necrotic mass occupied a large part of the tumor and that the remaining portion of the tumor consisted of an invasive ductal carcinoma with marked squamous metaplasia, i.e. keratinization or squamo-columnar junction (intercellular bridges) (Figure 4). The size and pleomorphism of cancer cells varied and numerous mitoses were detected. Neither lymphatic permeation nor vessel invasion of cancer cells were observed. The cancerous lesion was restricted and no intraductal component was detected. Lobular enlargement was microscopically observed in the non-carcinomatous area. Secretory change and secretion were visible in the acinar lumens. These findings corresponded to a normal lactating mammary gland (Figure 5).
|
|
Based on the pathological findings, breast-conserving therapy was thought to be possible and was performed, including an excision of surrounding tissues of the biopsy scar, together with axillary lymph node dissection up to level III. No lymph node involvement was detected. Three weeks after surgery, the conserved breast underwent radiotherapy with a total dose of 50 Gy. Both estrogen and progesterone receptors of the tumor were negative and 5-fluorouracil (200 mg/day) was administered orally as an adjuvant chemotherapy. Twelve months after surgery, multiple lung metastases occurred and cisplatinum-based chemotherapy was initiated. The therapy consisted of the following agents: 70 mg of cisplatinum and 30 mg of pirarubicin hydrochloride were administered by right bronchial artery infusion, 30 mg of cisplatinum and 10 mg of pirarubicin hydrochloride were administered by left bronchial artery infusion and 150 mg of etoposide were administered intravenously every 4 weeks.
|
DISCUSSION |
|---|
|
TOPABSTRACTINTRODUCTIONCASE REPORTDISCUSSIONREFERENCES |
|---|
The Japanese Breast Cancer Society has defined SCC of the breast as a special type of cancer, in which malignant cells are arranged in broad sheets or whorls, with keratin formation or intercellular bridge (6). In this case, tumor cells characterized by keratinization and intercellular bridge were observed around a necrotic mass, consistent with the SCC definition. Primary SCC of the breast is rare and its incidence is reported to be 0.1–3.6% in Western countries (7–9) and 0.17% in Japan (10). No specific clinical features of SCC of the breast have been reported. The average age of patients with SCC of the breast is slightly higher or similar to that in common breast cancer (3,11,12). The average size of breast SCC is larger than common breast cancer both in Western countries and in Japan (2,7,13–15). Komoda et al. (16) reported that SCC of the breast was characterized both by a large size with necrosis and cystic appearance in the tumor. These findings are presumably caused by rapid tumor growth. Furthermore, lymph node involvement is reported to be less frequent than might be expected given the larger tumor size (12,13,16). Indeed, no lymph node involvement was found in our case.
Toikkanen (7) reported that SCC of the breast generally resulted in an extremely aggressive clinical course. However, other physicians have found that the behavior of SCC of the breast is not significantly different from that of invasive ductal carcinoma (12,13,17).
The gestational period is classified into either pregnant or lactating periods according to the time of diagnosis, although most reports have identified both pregnant and lactating period as a gestational period in terms of breast cancer patients. In this context, the frequency of breast cancer during the gestational period is rare: 0.4–5.0% in Western countries (17,18) and 0.4–1.3% in Japan (18–20). Breast cancer associated with the gestational period is often discovered in an advanced stage, since a lactating change generally prevented physical examination of the breast. Kito et al. (21) reported that advanced breast cancer, stage III or IV , was more frequently observed in breast cancer patients during the gestational period than in non-gestational patients. Shimozuma et al. (20), however, found that the stage of breast cancer associated with gestation was compatible with non-gestational breast cancer. In our case, the mass was detected at a relatively early stage, presumably because of the late phase of lactation. The early detection of the tumor permitted breast-conserving surgery.
Postoperative adjuvant therapy for SCC of the breast has generally been carried out in the same way as therapy for more common types of breast cancer (7,22). However, SCC of the breast is reported to be resistant to both radiotherapy and standard chemotherapy, performed for invasive ductal carcinoma, i.e. cyclophosphamide, methotrexate, 5-FU and adriamycin (23). Dejager et al. (24) reported that a cisplatinum-based chemotherapeutic regimen commonly used for SCC of primary organs other than the breast was also effective for SCC of the breast. Based on these data, a cisplatinum-containing regimen was administered to our patient following the pulmonary recurrences.
Although the cancerous lesion was detected at a relatively early stage, recurrence occurred within 12 months of the surgery. Malignant potential is generally considered to be high in cases of SCC of the breast with lactation and therefore intensive treatment potentially resulting in severe side effects was considered to be necessary for this patient.
Given the unusual incidence of both gestational cases and SCC of the breast, our case of primary SCC with lactation presented here is noteworthy. Only six cases of primary SCC during the gestational period have been reported previously (1–5).
|
FOOTNOTES |
|---|
+ For reprints and all correspondence: Nana Rokutanda, Second Department of Surgery, Gunma University School of Medicine, 3–39–15 Showa-machi, Maebashi, Gunma 371-8511, Japan
|
REFERENCES |
|---|
|
TOPABSTRACTINTRODUCTIONCASE REPORTDISCUSSIONREFERENCES |
|---|
1 Kanno T, Murakami H, Yanagida S. Squamous cell carcinoma of the breast; a case report. Kanagawa Igakukai Zasshi 1975;3:65 (in Japanese).
2 Nishimura H, Tanaka Y, Koga T, Tanaka M, Hayashi A, Isobe M, et al. Squamous cell carcinoma of the breast; a case report. Gan No Rinsho 1988;34:803–8 (in Japanese).[Medline]
3 Fujino K, Kadota T, Imai J, Tamaki K, Hiraide H, Tamakuma M, et al. Primary squamous cell carcinoma of the breast in a pregnant woman: a case report. Nihon Rinsyo Geka Igakukai Zasshi 1988;49:1285 (in Japanese).
4 Senga O, Hikita H, Kinoshita T, Hara K, Miyakawa M, Nishimura H, et al. Primary squamous cell carcinoma of the breast in a pregnant woman: report of a case. Surg Today 1993;23:541–5.[Medline]
5 Zanconati F, Zanella M, Falconieri G, Bonito LD. Gestational squamous cell carcinoma of the breast: an unusual mammary tumor associated with aggressive clinical course. Pathol Res Pract 1997;193:783–7.[Medline]
6 Japanese Breast Cancer Society. General rules for clinical and pathological recording of breast cancer. Jpn J Surg 1989;19:612–32.[Medline]
7 Toikkanen S. Primary squamous cell carcinoma of the breast. Cancer 1981;48:1629–32.[Medline]
8 Woodard BH, Brinkhous AD, McCarty KS, McCarty KS Jr. Adenosquamous differentiation in mammary carcinoma. An ultrastructual and steroid receptor study. Arch Pathol Lab Med 1980;104:130–3.[Medline]
9 Fisher ER, Gregorio RM, Fisher B, Redmond C, Vellios F, Sommers SC. The pathology of invasive breast cancer. Cancer 1975;3:1–85.
10 Izuo M, Endo K, Kuno K, Watanabe H. Results of a nationwide statistical survey on breast cancer conducted by UICC Breast Cancer Survey (TNM Classification) Committee – analysis of the cumulative 13-year data and follow-up results. Gan No Rinsho 1982;28:111–21 (in Japanese).[Medline]
11 Rostock RA, Bauer TW, Eggleston JC. Primary squamous carcinoma of the breast: a review. Breast 1984;10:27–31.
12 Eggers JW, Chesney TM. Squamous cell carcinoma of the breast: a clinicopathologic analysis of eight cases and review of the literature. Hum Pathol 1984;15:526–31.[Medline]
13 Cornog JL, Mobini J, Steiger E. Squamous carcinoma of the breast. Am J Clin Pathol 1971;55:410–7.[Medline]
14 Tsuchiya S, Takubo K, Nakagawa J, Fujiwara M, Yamada K, Kobayashi Y, et al. A case study of primary squamous cell carcinoma of the breast. Gan No Rinsho 1983;29:51–6 (in Japanese).
15 Kurihara T, Higashi Y, Suemasu K, Kanoh T, Sano Y, Kurosumi M. A clinicopathologic study of squamous cell carcinoma of the breast focusing on prognostic aspects. Gan No Rinsho 1993;39:984–90 (in Japanese).
16 Komoda T, Shiraishi Y, Tanaka S, Kobayashi S. Squamous breast cancer – Report of two cases and a review of the literature. Nihon Rinsyo Geka Igakukai Zasshi 1989;50:1551–9 (in Japanese).
17 Haagensen CD. Disease of the Breast, 3rd ed. Philadelphia: WB Saunders 1986;843–50.
18 Koyama H, Wada T. Breast cancer associated with pregnancy. Geka 1984;46:239–43 (in Japanese).
19 Sawano A, Kimura M. Breast cancer associated with pregnancy and lactation. Rinsho Geka 1986;41:1311–5 (in Japanese).
20 Shimozuma K, Tominaga T, Hayashi K, Kosaki G. Carcinoma of the breast associated with pregnancy or lactation. Nihon Ganchiryou Gakkaishi 1991;26:929–34 (in Japanese).
21 Kito H, Sowa M, Kato Y, Mukai R, Miki A, Ohkita H, et al. Carcinoma of the breast in pregnancy and lactation. Nihon Rinsyo Geka Igakukai Zasshi 1983;44:19–26 (in Japanese).
22 Bogomoletz WV. Pure squamous cell carcinoma of the breast. Arch Pathol Lab Med 1982;106:57–9.[Medline]
23 Sezai A, Mishima S, Ichiwata M, Kanazawa H, Furuichi M, Negishi N, et al. A case of giant squamous cell carcinoma of the breast and 106 reference-reported cases in Japan. Nichidai Igaku Zasshi 1997;56:27–32 (in Japanese).
24 Dejager D, Redlich PN, Dayer AM, Davis HL, Komorowski RA. Primary squamous cell carcinoma of the breast: sensitivity to cisplatinum-based chemotherapy. J Surg Oncol 1995;59:199–203.[Medline]
Received January 31, 2000; accepted April 5, 2000.
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||