Australas Radio1 1992; 36: 253-254
Primary Squamous Cell Carcinoma of the Breast S.J. GAUDEN,B.Sc., M.B.B.S. Queensland Radium Institute, Herston, Queensland 4029.
ABSTRACT A patient with pure primary squamous cell carcinoma (SCC) of the breast is reported. The patient was a 72 year old female who presented with a 4 month history of an enlarging left breast mass. Surgery involved a radical mastectomy and this was followed by post-operative radiotherapy and chemotherapy. The patient died of extensive metastatic disease some four months after surgery. The various characteristics of SCC of the breast are briefly discussed. A sub-group of SCC of the breast is identified among reported cases in which the clinical course is characterised by a very rapid growth, extremely aggressive behaviour and early metastasis. INTRODUCTION Squamous cell carcinoma (SCC) of the breast is a very rare condition which accounts for less than 0.01% of all breast carcinomas. Most of the information concerning this disease has come from individual case reports. The only two relatively large reviews in the literature have been those by Lafreniere et a1 (1986) describing 18 cases of SCC of the breast (1) and the review by Wargotz and Norris (1990) which described 22 examples of this disease ( 2 ) . Notwithstanding the small number of cases in the literature, there can be no doubt that SCC of the breast is a clinically and histologically well defined entity which must be regarded as totally separate from other breast tumours, particularly adenocarcinoma of the breast with squamous cell metaplasia. CASE REPORT The patient was a 72 year old female who presented with a four month history of swelling of the left breast. The patient recalled that her problems had
Key words: Breast Neoplasm Carcinoma, Squamous Address for correspondence: Dr S.J. Gauden Queensland Radium Institute Herston Qld 4029 Australiisian Radiology. Vol. 36. No. 3 , August, I992
FIGURE 1 - Invasion of oedematous breast tissue by squamous cell carcinoma. (Haematoxylin and eosin; original magnification x 750).
started when she had bumped her left breast on the comer of a window frame and had subsequently developed a large haematoma. This had been treated with antibiotics and aspiration. Initial surgery in this case involved drainage of approximately 300mls of blood stained fluid from the mass in the left breast. The patient then proceeded to a radical mastectomy which also involved the excision of a large mass of enlarged lymph nodes in the left axilla as well as the excision of a large portion of pectoral muscle. Both the axilla and pectoral muscle were found to be involved with tumour. The patient was referred for consideration of post operative radiotherapy two weeks following her surgery. At that time, her left shoulder movement was markedly limited by pain and further treatment was postponed while the patient underwent a course of intensive physiotherapy. There was already tumour infiltration into the left brachial plexus. Palliative radiotherapy to the patient’s left shoulder and axilla was finally commenced one month after surgery. She received a total dose of 46 Gy, minimum target dose, in 20 fractions over 4 weeks using a 6 M V photon beam. The choice of fields was lim-
ited by the lack of left shoulder mobility and this required a modified treatment plan using anterior shoulder and posterior axillary fields. During this time, the patient also received weekly doses of Methotrexate 25 mg IVI. The patient was next seen four weeks after the completion of her radiotherapy. There had been a considerable deterioration in her condition. Specifically, she was anaemic, hypercalcaemic and had recurrence of disease on the left chest wall measuring 10 x 6 x lcm. This was associated with a frozen left shoulder and left sided cervical and supraclavicular lymphadenopathy. There was marked tenderness over the thoracic spine (T3 to T5) and hepatomegaly. The patient declined any further treatment and died three weeks later, only four months after her original surgery. Histopathological findings: The tumour was large and cystic with extensive necrosis. Sections showed the breast to be infiltrated by moderately to poorly differentiated SCC (Figure 1).
Submitted for publication on: 9th December, 1991 Resubmitted for publication on: 3rd March, 1992 Accepted for publication on: 17th March, 1992
253
S. J. GAUDEN The tumour was found to invade skeletal muscle and was also present within lymphatics. DISCUSSION Pure primary squamous cell carcinoma of the breast is a very rare disease. Even though the condition was first reported over 70 years ago (3), no large series of patients has been reported. Further, some of the cases reported are not necessarily pure SCC. Toikkanen (198 1) reviewed more than 30 cases and could find only 5 well documented cases of SCC (4). Several estimates of the proportion of SCC among all breast cancers have been made. These range from 0.00075% (4) to 0.004% (5). The case reported in this paper is only the second confirmed case of breast SCC of 3,146 cases of breast cancer seen at the Queensland Radium Institute in the period January, 1982 to November, 1991. A number of criteria need to be fulfilled in order to define “pure” SCC (6, 7). Specifically, the tumour must be independent of adjacent cutaneous structures and the possibility of other distant SCC in the patient must be excluded. As well, there must be no other neoplastic element, such as ductal or mesenchymal elements, present within the tumour. The case reported in the paper fulfilled all of the above criteria. The origin of SCC of the breast remains a controversial subject. Suggested possibilities have included complete metaplasia of the glandular breast tissue (4, 7) and malignancy arising from benign skin lesions (4, 7, 8). Other possibilities have included the development of malignancy from chronic breast abscesses (9), and subcutaneous seeding following trauma to the breast (10, 11). Lafreniere et a1 put forward a theory based on the embryological development of the breast (1).
254
On presentation, the tumour reported in this paper was very large and was characterised by a cystic appearance with extensive areas of necrosis. These findings coincide with previously reported cases of SCC of the breast (4, 8, 9, 11). Of more recent larger series published, the series of Lafreniere et a1 reported that 12 of 18 tumours were large and cystic ( l ) , while Wargotz and Norris reported that 16 of the 22 SCCs in their series were predominantly cystic ( 2 ) . Information describing the clinical course of this condition is generally variable and often incomplete. Lafreniere et al have stated that stagefor-stage the prognosis was equal to the more common infiltrating ductal carcinomas (1). Ermilova (1989) reported a more favourable prognosis for SCC of the breast compared to invasive ductal breast carcinoma (12), while Wargotz and Noms reported a 5 year cumulative survival rate of 63% based on the 22 cases of SCC they reviewed (2). However, there are other reported cases in which the behaviour of the tumour is totally different to that noted above. Toikkanen (198 1) described a group of tumours which showed extremely aggressive behaviour with a mean survival of only 8.3 months, regardless of treatment with either surgery or radiotherapy (4). Such behaviour of SCC of the breast has been confirmed by more recent reports in which survival times of the order of 5 months were the norm (13, 14). In short, pure SCC of the breast is a rare and unpredictable tumour. There exists evidence to suggest the presence of a sub-set of SCC of the breast characterised by very rapid growth, aggressive clinical course and early metastasis. In this sub-group, surgery, radiotherapy, chemotherapy or combinations of treatment have failed to control the disease.
ACKNOWLEDGEMENTS I am indebted to the Director, Queensland Radium Institute, for allowing me to publish this report, and to his staff for their assistance in the preparation of the manuscript. I am grateful to Dr S Chalk and Dr C Ades for their review of the histopathology. REFERENCES 1. Lafreniere R, Moskowitz L, Ketcham A. Pure squamous cell carcinoma of the breast. J Surg Oncol 1986; 31: 113-119. 2. Wargotz ES, Noms HJ. Metaplastic carcinomas of the breast in squamous cell carcinoma of ductal origin. Cancer 1990; 65: 272-276. 3. Johnson R, Lawrence TWP. Two cases of squamous epithelial tumour of the breast. Br J Surg 1917; 5 : 417-421. 4. Toikkanen S. Primary squamous cell carcinoma of the breast. Cancer 1981; 48: 16291632. 5. James TGI, Treip C. Squamous cell carcinoma of the breast. Br J Surg 1955; 42: 650-654. 6. Macia M, Ces J, Becerra E, Nova A. Pure squamous carcinoma of the breast. Report of a case diagnosed by aspiration cytology. Acta Cytologica 1989; 33(2): 201-204. 7. Pricolo R, Crose P, Voltolini F, Paties C, Schema C. Pure and primary squamous cell carcinoma of the breast. Minerva Chir 1991; 46(5): 215-219. 8. Haselton PS, Misch KA, Vasuder KS, George D. Squamous carcinoma of the breast. J Clin Pathol 1978; 31: 116-124. 9. Jones EL. Primary squamous cell carcinoma of the breast with pseudosarcomatous stroma. J Pathol 1969; 97: 383-385. 10. Foot NC, Moore SW. A fatal case of deep seated epidennoid carcinoma of the breast with wide spread metastatses. AM J Cancer 1938; 34: 226-233. 11. Willis RA. Squamous cell mammary carcinoma of predominatly fibrosarcoma like structure. J Pathol Bacteriol 1958; 76: 5 11-515. 12. Ermolova VD, Krylova MO. Squamous cell breast cancer. Vopr Onkol 1989; 35(9): 1040-1044. 13. Mosonou J, Aizawa M, Nakamura S, et al. A rare autopsy involving primary squamous cell carcinoma of the breast showing a very rapid and aggressive clinical course. Gan No Rinsho 1987; 33(14): 1833-1838. 14. Nishimura Y, Tanaka Y, Koga T, et 01. A case of squamous cell carcinoma of the breast. Gan No Rinsho 1988; 34(6): 803-806.
Australasian Radiology, Vol. 36, No. 3, August, I992
Primary Squamous Cell Carcinoma of the Breast S.J. GAUDEN,B.Sc., M.B.B.S. Queensland Radium Institute, Herston, Queensland 4029.
ABSTRACT A patient with pure primary squamous cell carcinoma (SCC) of the breast is reported. The patient was a 72 year old female who presented with a 4 month history of an enlarging left breast mass. Surgery involved a radical mastectomy and this was followed by post-operative radiotherapy and chemotherapy. The patient died of extensive metastatic disease some four months after surgery. The various characteristics of SCC of the breast are briefly discussed. A sub-group of SCC of the breast is identified among reported cases in which the clinical course is characterised by a very rapid growth, extremely aggressive behaviour and early metastasis. INTRODUCTION Squamous cell carcinoma (SCC) of the breast is a very rare condition which accounts for less than 0.01% of all breast carcinomas. Most of the information concerning this disease has come from individual case reports. The only two relatively large reviews in the literature have been those by Lafreniere et a1 (1986) describing 18 cases of SCC of the breast (1) and the review by Wargotz and Norris (1990) which described 22 examples of this disease ( 2 ) . Notwithstanding the small number of cases in the literature, there can be no doubt that SCC of the breast is a clinically and histologically well defined entity which must be regarded as totally separate from other breast tumours, particularly adenocarcinoma of the breast with squamous cell metaplasia. CASE REPORT The patient was a 72 year old female who presented with a four month history of swelling of the left breast. The patient recalled that her problems had
Key words: Breast Neoplasm Carcinoma, Squamous Address for correspondence: Dr S.J. Gauden Queensland Radium Institute Herston Qld 4029 Australiisian Radiology. Vol. 36. No. 3 , August, I992
FIGURE 1 - Invasion of oedematous breast tissue by squamous cell carcinoma. (Haematoxylin and eosin; original magnification x 750).
started when she had bumped her left breast on the comer of a window frame and had subsequently developed a large haematoma. This had been treated with antibiotics and aspiration. Initial surgery in this case involved drainage of approximately 300mls of blood stained fluid from the mass in the left breast. The patient then proceeded to a radical mastectomy which also involved the excision of a large mass of enlarged lymph nodes in the left axilla as well as the excision of a large portion of pectoral muscle. Both the axilla and pectoral muscle were found to be involved with tumour. The patient was referred for consideration of post operative radiotherapy two weeks following her surgery. At that time, her left shoulder movement was markedly limited by pain and further treatment was postponed while the patient underwent a course of intensive physiotherapy. There was already tumour infiltration into the left brachial plexus. Palliative radiotherapy to the patient’s left shoulder and axilla was finally commenced one month after surgery. She received a total dose of 46 Gy, minimum target dose, in 20 fractions over 4 weeks using a 6 M V photon beam. The choice of fields was lim-
ited by the lack of left shoulder mobility and this required a modified treatment plan using anterior shoulder and posterior axillary fields. During this time, the patient also received weekly doses of Methotrexate 25 mg IVI. The patient was next seen four weeks after the completion of her radiotherapy. There had been a considerable deterioration in her condition. Specifically, she was anaemic, hypercalcaemic and had recurrence of disease on the left chest wall measuring 10 x 6 x lcm. This was associated with a frozen left shoulder and left sided cervical and supraclavicular lymphadenopathy. There was marked tenderness over the thoracic spine (T3 to T5) and hepatomegaly. The patient declined any further treatment and died three weeks later, only four months after her original surgery. Histopathological findings: The tumour was large and cystic with extensive necrosis. Sections showed the breast to be infiltrated by moderately to poorly differentiated SCC (Figure 1).
Submitted for publication on: 9th December, 1991 Resubmitted for publication on: 3rd March, 1992 Accepted for publication on: 17th March, 1992
253
S. J. GAUDEN The tumour was found to invade skeletal muscle and was also present within lymphatics. DISCUSSION Pure primary squamous cell carcinoma of the breast is a very rare disease. Even though the condition was first reported over 70 years ago (3), no large series of patients has been reported. Further, some of the cases reported are not necessarily pure SCC. Toikkanen (198 1) reviewed more than 30 cases and could find only 5 well documented cases of SCC (4). Several estimates of the proportion of SCC among all breast cancers have been made. These range from 0.00075% (4) to 0.004% (5). The case reported in this paper is only the second confirmed case of breast SCC of 3,146 cases of breast cancer seen at the Queensland Radium Institute in the period January, 1982 to November, 1991. A number of criteria need to be fulfilled in order to define “pure” SCC (6, 7). Specifically, the tumour must be independent of adjacent cutaneous structures and the possibility of other distant SCC in the patient must be excluded. As well, there must be no other neoplastic element, such as ductal or mesenchymal elements, present within the tumour. The case reported in the paper fulfilled all of the above criteria. The origin of SCC of the breast remains a controversial subject. Suggested possibilities have included complete metaplasia of the glandular breast tissue (4, 7) and malignancy arising from benign skin lesions (4, 7, 8). Other possibilities have included the development of malignancy from chronic breast abscesses (9), and subcutaneous seeding following trauma to the breast (10, 11). Lafreniere et a1 put forward a theory based on the embryological development of the breast (1).
254
On presentation, the tumour reported in this paper was very large and was characterised by a cystic appearance with extensive areas of necrosis. These findings coincide with previously reported cases of SCC of the breast (4, 8, 9, 11). Of more recent larger series published, the series of Lafreniere et a1 reported that 12 of 18 tumours were large and cystic ( l ) , while Wargotz and Norris reported that 16 of the 22 SCCs in their series were predominantly cystic ( 2 ) . Information describing the clinical course of this condition is generally variable and often incomplete. Lafreniere et al have stated that stagefor-stage the prognosis was equal to the more common infiltrating ductal carcinomas (1). Ermilova (1989) reported a more favourable prognosis for SCC of the breast compared to invasive ductal breast carcinoma (12), while Wargotz and Noms reported a 5 year cumulative survival rate of 63% based on the 22 cases of SCC they reviewed (2). However, there are other reported cases in which the behaviour of the tumour is totally different to that noted above. Toikkanen (198 1) described a group of tumours which showed extremely aggressive behaviour with a mean survival of only 8.3 months, regardless of treatment with either surgery or radiotherapy (4). Such behaviour of SCC of the breast has been confirmed by more recent reports in which survival times of the order of 5 months were the norm (13, 14). In short, pure SCC of the breast is a rare and unpredictable tumour. There exists evidence to suggest the presence of a sub-set of SCC of the breast characterised by very rapid growth, aggressive clinical course and early metastasis. In this sub-group, surgery, radiotherapy, chemotherapy or combinations of treatment have failed to control the disease.
ACKNOWLEDGEMENTS I am indebted to the Director, Queensland Radium Institute, for allowing me to publish this report, and to his staff for their assistance in the preparation of the manuscript. I am grateful to Dr S Chalk and Dr C Ades for their review of the histopathology. REFERENCES 1. Lafreniere R, Moskowitz L, Ketcham A. Pure squamous cell carcinoma of the breast. J Surg Oncol 1986; 31: 113-119. 2. Wargotz ES, Noms HJ. Metaplastic carcinomas of the breast in squamous cell carcinoma of ductal origin. Cancer 1990; 65: 272-276. 3. Johnson R, Lawrence TWP. Two cases of squamous epithelial tumour of the breast. Br J Surg 1917; 5 : 417-421. 4. Toikkanen S. Primary squamous cell carcinoma of the breast. Cancer 1981; 48: 16291632. 5. James TGI, Treip C. Squamous cell carcinoma of the breast. Br J Surg 1955; 42: 650-654. 6. Macia M, Ces J, Becerra E, Nova A. Pure squamous carcinoma of the breast. Report of a case diagnosed by aspiration cytology. Acta Cytologica 1989; 33(2): 201-204. 7. Pricolo R, Crose P, Voltolini F, Paties C, Schema C. Pure and primary squamous cell carcinoma of the breast. Minerva Chir 1991; 46(5): 215-219. 8. Haselton PS, Misch KA, Vasuder KS, George D. Squamous carcinoma of the breast. J Clin Pathol 1978; 31: 116-124. 9. Jones EL. Primary squamous cell carcinoma of the breast with pseudosarcomatous stroma. J Pathol 1969; 97: 383-385. 10. Foot NC, Moore SW. A fatal case of deep seated epidennoid carcinoma of the breast with wide spread metastatses. AM J Cancer 1938; 34: 226-233. 11. Willis RA. Squamous cell mammary carcinoma of predominatly fibrosarcoma like structure. J Pathol Bacteriol 1958; 76: 5 11-515. 12. Ermolova VD, Krylova MO. Squamous cell breast cancer. Vopr Onkol 1989; 35(9): 1040-1044. 13. Mosonou J, Aizawa M, Nakamura S, et al. A rare autopsy involving primary squamous cell carcinoma of the breast showing a very rapid and aggressive clinical course. Gan No Rinsho 1987; 33(14): 1833-1838. 14. Nishimura Y, Tanaka Y, Koga T, et 01. A case of squamous cell carcinoma of the breast. Gan No Rinsho 1988; 34(6): 803-806.
Australasian Radiology, Vol. 36, No. 3, August, I992
