PRIMARY SQUAMOUS CELL CARCINOMA OF BREAST; A CASE REPORT.
Primary squamous cell carcinoma (SCC) of breast is an extremely rare malignant neoplasm although squamous cell carcinoma mixed with ductal carcinoma is more common. Primary SCC represents less than 0.1% of all breast malignancies1. The origin and exact histogenesis of tumor is unclear. Clinical and radiographic characteristics are nonspecific and usually present atypically e.g. abscesses etc. The diagnosis is established when malignant cells are entirely of squamous cells, and overlying skin malignancies or other primary sites of squamous cell carcinoma have been excluded2. In general they are very aggressive, treatment refractory tumors and have poor prognosis.
We report a case of primary squamous cell carcinoma of breast due to its extreme rarity and unusual clinical presentation.
A 45-year-old female presented with a lump in right breast which was first noticed by the patient one year back. The lump gradually increased in size and presented as an ulcerated wound three months before patient reported to the hospital. It exuded pus mixed with blood. Her menstrual cycles were regular and she had four children. No relevant family history or history of radiation exposure was found.
Examination revealed a fungating mass of 12x10cm in center of right breast. The ruptured abscess cavity contained puslike slough. Nipple areola complex was identifiable. No enlargement of axillary lymph node was found. Contra-lateral breast showed no pathology.
Routine laboratory investigations were normal except hemoglobin for which packed cells were given. Trucut biopsy reported keratinizing squamous cell carcinoma. Search was made for remote primary focus through chest radiograph, esophago-bronchoscopy, laryngoscopy, colonoscopy and Pap smear etc, which didnot reveal any extra-mammary focus and metastasis.
Later modified radical mastectomy with axillary clearance was performed. Specimen sent for histopathology and report revealed squamous cell carcinoma of breast with two axillary lymph nodes showing metastasis. Resection margins were free of tumor. Patient remained well in postoperative period and was later referred to oncologist for radiotherapy.
Primary squamous cell carcinoma has been classified as metaplastic breast carcinoma by World Health Organization. The reported incidence of SCC is 0.1% in western countries and 0.17% in Japan. Primary squamous cell carcinoma is a very uncommon tumor. Among 1000 cases of invasive breast carcinoma, Fisher et al found no cases of primary SCC3.
The histogenesis of tumor is unclear; it can arise from epidermoid cyst of breast, chronic abscesses or from metaplastic breast parenchyma4. These tumors have varying degrees of homogeneity. According to Macia et al5, squamous cell carcinoma is considered "pure" when no ductal or mesenchymal component is present in tumor, tumor is independent of adjacent cutaneous structures and no other primary squamous cell tumor is present in patient (oral cavity, bronchus, esophagus and bladder etc).
The affected age group is between 32 and 65 years, our patient came in the similar age group range. There is left sided predominance of SCC of breast contrary to our patient who was having lump right breast. In contrast to most breast malignancies, these are fast growing tumors. Patient complains of breast masses that enlarge over a period of 12-18 months6, as our patient developed skin involvement in four months of short duration.
Primary tumors tend to be relatively large lumps that have a central cystic component due to rapid overgrowth. We didnot encounter the central necrosis of tumor in our case. Axillary lymph nodes were involved against the literature reports which depicts involvement only in the invasive carcinoma of breast with metaplastic SCC6,7.
Squamous cell carcinoma does not have characteristic radiological features. The most consistent feature is lack of micro-calcification on mammography8. Our case also did not show the micro-calcification on mammogram. The primary tumors are mostly estrogen and progesterone negative.
Breast conservation is not possible due to rapid local infiltration so recommendation is modified radical mastectomy with adjuvant radiotherapy and chemotherapy9. However Hennessy et al described no difference in recurrence with or without radiotherapy and chemotherapy with 5-flourouracil. We followed the norm and did the MRM and subjected the patient to radiotherapy.
The prognosis can be predicted on tumor size and tumor stage. In general they behave badly. The SEER database reflected five year survival rate of 64%1.
Primary squamous cell carcinoma is a rare breast neoplasm that can present atypically like ruptured breast abscess. Histological work up is mandatory for such uncommon entities. Management is alike the invasive breast carcinomas.
1. Hennessey T, Krishnamurthy S, Giordano S. Squamous cell carcinoma of the breast. J Clin Oncol 2005; 23:7827-35.
2. Behranwala KA, Nasiri N, Abdullah N. Clinico-pathologic implications and outcome. Eur J Surg Oncol 2003; 29: 386.
3. Cappellani A, Di Vita M, Zanghni A: A pure squamous cel breast carcinoma presenting as a breast abscess: a case report and review of the literature. Ann Ital. Chir., LXXV 2004; 2: 259-63.
4. Macia M, Ces JA, Becerra E. Pure squamous carcinoma of the breast; report of a case diagnosed by aspiration cytology. Acta Cytol 1989; 33: 201.
5. Siegelmann-Danieli N, Murphy JT, Meschter S: Primary squamous cell carcinoma of the breast. Clinical of breast cancer. 2005; 6(3): 270.
6. Rokutanda N, Iino Y, Yokoe T, Maemura M, Horiguchi J, Takei H, et al: Primary squamous cell carcinoma of the breast during lactation: a case report. Jpn J Clin Oncol 2000; 30:279-82.
7. Karamouzis MV, Fida A, Apostolikas N, @ et al. A case of Her-2 positive squamous cell breast carcinoma: an unusual presentation of an unusual clinical entity. Eur J Surg oncal 2006; 32:1250-51.
8. Grunwald S, Ohlinger R, Schwesinger G, Kohler G. Primary intracystic squamous cell cancer of female breast. Zentralbl Gynakol 2004; 126:36-40.
9. Rosen PR. Rosen's Breast Pathology. Philadelphia, New York: lippincott-Raven 1997; p. 397-404.
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|Author:||Niaz, Khurram; Awan, Mohammad Saeed; Khan, Shahnawaz|
|Publication:||Pakistan Armed Forces Medical Journal|
|Article Type:||Clinical report|
|Date:||Jun 30, 2012|
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