Abscess as Initial Presentation of Pure Primary Squamous Cell Carcinoma of the Breast

Abstract

al.1 Pure primary squamous cell carcinoma of the breast is indeed an extremely rare tumor. In addition, review of the literature reveals only 4 reports of pure primary squamous cell carcinomas of the breast presenting as breast abscess.2-5 We were involved in the care of a 43-year-old woman who presented with acute onset pain and tenderness in the right breast. She had not had screening mammograms. Examination revealed erythema and hyperemia of the right breast. A mass lesion was not palpated. An ultrasound examination of the right breast revealed a slightly ill-defined 5-cm mass with a thick rind and diminished echogenicity centrally, consistent with an abscess. A clinical diagnosis of right breast abscess was rendered, and aspiration of the possible abscess was performed under local anesthesia. Brownish fluid was removed by aspiration, and this resulted in symptomatic improvement. The patient was discharged on antibiotics. The fluid was not submitted for cytologic evaluation. She returned a few days later without resolution of her symptoms; an incision and drainage of the abscess with biopsies of the abscess wall were performed under general anesthesia. Pathologic examination of the biopsy results revealed an infiltrative, poorly differentiated, squamous cell carcinoma in a background of necrotic debris, fibrosis, and granulation tissue. The patient underwent a modified radical mastectomy of the right breast, which confirmed the initial biopsy diagnosis. Areas of usual ductal adenocarcinoma were not identified with extensive sampling. There was no involvement of the skin or adenexal elements. Nineteen axillary lymph nodes were dissected and were negative for metastatic disease. Breast tumor profile was negative for estrogen receptor, progesterone receptor, and HER2/neu overexpression. An extensive workup that included computed tomography scans of the neck, chest, abdomen, and pelvis and a whole body [18F]fluorodeoxyglucose–positron emission tomography scan ruled out another primary squamous cell carcinoma. She received postoperative radiation therapy to the mastectomy site and supraclavicular region and has remained disease free for 3 years. Review of the 4 reports of pure primary squamous cell carcinoma presenting as breast abscess (total of 6 women) and the clinicopathologic features of our present patient support the observations made by Siegelmann-Danieli et al for all squamous cell carcinoma.1 We also found that the women tend to be older (postmenopausal), the lesions tend to be bigger (range, 2-5 cm), axillary lymph node metastasis is significantly lower, and breast tumor markers (estrogen receptor, progesterone receptor, and HER2/neu overexpression) are usually negative compared with usual ductal adenocarcinoma of the breast. Adjuvant chemotherapy with 5-fluorouracil and cisplatin, with or without doxorubicin, has been recommended.3-4 We should add that ultrasound has been reported as more helpful than mammography in the evaluation of these women.3,6 In conclusion, pure primary squamous cell carcinomas of the breast are rare tumors and can infrequently present as a breast abscess. Clinicians should keep this differential in mind, especially in postmenopausal women with large lesions not responding to antibiotics.