Answer: Locally Advanced Breast Cancer
The diagnosis was locally advanced breast carcinoma with direct
extension to the upper extremity and a malignant right pleural effusion.
On initial inspection, some areas of the lesion had the appearance
of deep partial and full thickness skin loss that may have resulted
from a caustic burn or acute severe radiation injury. Because the
patient did not give a history of caustic burn or radiation exposure,
the diagnoses of caustic burn injury and high-dose radiation injury
were excluded. The malodor suggested an infection that may be seen
in a necrotizing skin and soft tissue infection. It is not infrequent
that locoregionally advanced breast cancer presents with necrosis
and infection with malodorous drainage. On inspection, it may be indistinguishable
from necrotizing skin and soft tissue infection. Oftentimes, necrotizing
fasciitis will have the appearance of skin blistering prior to ulceration
and sloughing. This patient had skin and soft tissue breakdown with
areas of firm nodularity of in-transit disease. It is critically important
to perform an incisional biopsy from an area that appears viable next
to the necrotic tissue for histological confirmation of invasive cancer.
The patient was admitted, and a biopsy of the chest wall was
performed. Thoracentesis was also performed with the removal of 1.5
L of fluid. Her shortness of breath significantly diminished. Her
histologic, cytologic, and cell block results were consistent with
breast carcinoma that was negative for estrogen receptors, progesterone
receptors, and HER-2/neu. Computed tomographic scans of the chest,
abdomen, and pelvis and positron emission tomography–computed
tomography confirmed primary breast cancer extending to the upper
extremity with distant metastasis. The results of venous Doppler ultrasonography
of the right upper extremity were negative for deep venous thrombosis.
She received 2 cycles of doxorubicin hydrochloride and docetaxel1 with some improvement of her ulceration
and the accompanying malodor. Local wound care included the use of
metronidazole gel to also aid in controlling the odor. She died 6
months later.
This patient had locoregionally advanced breast cancer with
metastasis at initial presentation. Approximately 4.6% of all cases
of breast cancer in female patients are cases of locally advanced
breast carcinoma.2 This type of breast
cancer represents a condition that has progressed owing to a delay
in diagnosis and neglect. The fact that she had metastasis at presentation
dictates an inability to cure the disease. Being African American
with a triple-negative tumor, she has an even poorer prognosis2 owing to a lack of targeted therapy. Metastatic
breast cancer to the pleura frequently presents with shortness of
breath3 as a result of malignant
pleural effusion. Breast cancer is the most frequent cause of malignant
pleural effusion in women, accounting for approximately 40% of these
effusions. For this patient, there was direct extension of the neoplastic
process from the breast to the chest wall, down to the pleural space,
and to the entire upper extremity. A multidisciplinary approach is
necessary in treating locally advanced breast carcinoma, and it usually
begins with a consideration for neoadjuvant systemic therapy followed
by some combination of surgery and/or radiation therapy.4 If the cancer had been hormonally sensitive,
it is unlikely that neoadjuvant therapy would have changed owing to
the extensive nature of the disease and the need for more rapid control.
However, hormonal therapy would have been used after neoadjuvant cytotoxic
and locoregional therapy. This patient had a tumor that was inoperable
and too extensive for effective radiation therapy. There was significant
soft tissue involvement, and local control may have been achieved
with systemic therapy to improve her quality of life.5,6
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Correspondence: Harvey L. Bumpers,
MD, Department of Surgery, College of Human Medicine, Michigan State
University, 1200 E Michigan Ave, Ste 655, Lansing, MI 48912 (harvey.bumpers@hc.msu.edu).
Accepted for Publication: January 11,
2012.
Author Contributions:Study concept and design: Bumpers, Okoli, and Rizzo. Acquisition of data: Bumpers. Analysis and interpretation of data: Gabram-Mendola, Okoli,
and Rizzo. Drafting of the manuscript: Bumpers,
Okoli, and Rizzo. Critical revision of the manuscript
for important intellectual content: Gabram-Mendola, Okoli,
and Rizzo. Administrative, technical, and material
support: Bumpers and Gabram-Mendola. Study
supervision: Rizzo.
Conflict of Interest Disclosures: None
reported.
1.Gajdos C, Tartter PI, Estabrook A, Gistrak MA, Jaffer S, Bleiweiss IJ. Relationship of clinical and pathologic response to neoadjuvant
chemotherapy and outcome of locally advanced breast cancer.
J Surg Oncol. 2002;80(1):4-1111967899
PubMedGoogle ScholarCrossref 2.Anderson WF, Chu KC, Chang S. Inflammatory breast carcinoma and noninflammatory locally advanced
breast carcinoma: distinct clinicopathologic entities?
J Clin Oncol. 2003;21(12):2254-225912805323
PubMedGoogle ScholarCrossref 3.Dawood S, Ueno NT, Valero V,
et al. Identifying factors that impact survival among women with inflammatory
breast cancer.
Ann Oncol. 2011;23(4):870-87521765048
PubMedGoogle ScholarCrossref 4.Chia S, Swain SM, Byrd DR, Mankoff DA. Locally advanced and inflammatory breast cancer.
J Clin Oncol. 2008;26(5):786-79018258987
PubMedGoogle ScholarCrossref 5.Sinclair S, Swain SM. Primary systemic chemotherapy for inflammatory breast cancer.
Cancer. 2010;116:(11 suppl)
2821-282820503414
PubMedGoogle ScholarCrossref 6.Kuerer HM, Newman LA, Smith TL,
et al. Clinical course of breast cancer patients with complete pathologic
primary tumor and axillary lymph node response to doxorubicin-based
neoadjuvant chemotherapy.
J Clin Oncol. 1999;17(2):460-46910080586
PubMedGoogle Scholar