Ballestrero, Alberto

Boy, Davide

Murelli, Federica

Murialdo, Roberto

Musizzano, Yuri

Tixi, Lucia

English

PubMed

Murialdo R

BOY, DAVIDE

Musizzano Y

Tixi L

MURELLI, FEDERICA

BALLESTRERO, ALBERTO

Archivio istituzionale della ricerca - Università di Genova

Squamous cell carcinoma of the breast: a case report.

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Case report
Open Access
Squamous cell carcinoma of the breast: a case report
Roberto Murialdo1*†, Davide Boy1†, Yuri Musizzano2, Lucia Tixi1,
Federica Murelli3 and Alberto Ballestrero
Addresses: 1Department of Internal Medicine, S. Martino Hospital, University of Genoa, Viale Benedetto XV n.6 Genova, Italy
2Department of Surgical and Morphological Disciplines and Integrated Methodologies, Division of Pathology, University of Genoa,
Viale Benedetto XV n.6 Genova, Italy
3Department of Surgery, Breast Unit, S. Martino Hospital, University of Genoa, 16132, Italy
Email: RM* - rozzis75@hotmail.com; DB - davide.boy@gmail.com; YM - y_musizzano@yahoo.fr; LT - lucia.tixi@unige.it;
FM - federica.murelli@unige.it; AB - alberto.ballestrero@unige.it
*Corresponding author † Equal contribution
Received: 27 April 2009 Accepted: 23 May 2009 Published: 10 July 2009
Cases Journal 2009, 2:7336 doi: 10.4076/1757-1627-2-7336
This article is available from: http://casesjournal.com/casesjournal/article/view/7336
© 2009 Murialdo et al; licensee Cases Network Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
Introduction: Pure primary squamous cell carcinoma of the breast is uncommon and it’s debated
the correct management of this disease.
Case presentation: A54-years-oldwomanpresentedwith signs and symptomsofmastitis of left breast.
A palpable well circumscribed and firmmass, measuring about 40mm, was present in the left lower lateral
quadrant. She underwent antibiotic therapy without benefit. She performed an ultrasound and
mammographic scan of the left breast. Fine needle aspiration cytology revealed an infiltrative poorly
differentiated squamous cell carcinoma. Total body CT scan and bone scan excluded distant metastasis.
Subsequently wide local excision of the left breast with ipsilateral axillary lymph nodes dissection was
performed. The pathological examination revealed an infiltrative poorly differentiated squamous cell
carcinoma of the breast. Adjuvant chemotherapy cisplatin and 5-fluorouracil based was administered.
Patient refused locoregional radiotherapy. Twenty-eightmonths after surgery the patient was disease free.
Conclusions: Pure primary squamous cell carcinoma of the breast is a rare and aggressive disease
often treatment-refractory. An optimal systemic treatment is needed to improve patient’s outcome.
Introduction
Pure primary squamous cell carcinoma of the breast is a
relatively uncommon desease. It is diagnosed if more than
90 % of the malignant cells are squamous. It represents
less than 0.1 % of all breast carcinomas [1].
The prognosis of this type of breast cancer is still a subject
of controversy; some reports suggest that it is aggressive,
with an outcome comparable to poorly differentiated
ductal carcinoma of the breast [2-5].
Clinical and radiologic appearances are not specific to
discriminate malignant versus benign lesions or to
characterize the hystotype.
An extensive review of the literature reveals about fifty
reports and two important series of pure squamous cell
carcinoma of breast strictly following the Macia et al.
diagnostic criteria [6]: thirty-three patients by M.D.
Anderson Cancer Center and eleven patients reported by
a Spanish group [7,8].
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Macia and colleagues defined pure squamous cell carci-
noma as a tumor with following characteristics [6]:
1. No other neoplastic components, such as ductal or
mesenchymal elements, are present in the tumor.
2. The tumor origin must be independent from the
overlying skin and nipple.
3. Absence of an associated primary squamous cell
carcinoma in a second site.
In this report, we present a patient who initially appeared
with signs and symptoms of mastitis and underwent to
antibiotic therapy without benefit.
Histologic examination of the tissue obtained from
surgery revealed a pure primary squamous cell carcinoma
of the breast.
Case presentation
The patient was a 54-year-old Italian Caucasian female.
She was a non-smoker. She was evaluated in our hospital
for recent onset of pain and tenderness in the left breast.
She referred swelling of the breast, but denied nipple
discharge. Her past medical history was not significant.
Her family history was not significant for breast cancer; she
denied oral contraceptives use in the past and she give
birth to one child. Her most recent Pap smear had been
negative for any squamous lesion. Physical examination
revealed erythema, hyperaemia and tenderness to touch of
the left breast. A palpable well circumscribed and firm
mass measuring about 40 mm was present in the left
inferior lateral quadrant. The right breast examination was
normal. There was no evidence of lymphadenopathy on
physical examination, including the axillary and supracla-
vicular regions.
She underwent an ultrasound examination of the left
breast, which revealed a defined 29 mm mass with a thick
rind and reduced central echogenicity, consistent with a
cystic space. Mammography showed a round, high-density
mass with almost regular but partially irregular margins,
measuring approximately 30 mm.
Fine needle aspiration cytology revealed an infiltrative
poorly differentiated squamous cell carcinoma.
Total body CT scan, bone scan, laboratory data (blood
count, serum electrolytes, liver function tests, creatinine,
prothrombin and partial thromboplastin time), tumors
markers, including the levels of serum carcinoembryonic
antigen, carbohydrate 15-3 and squamous cell carcinoma
antigen were within normal range.
The patient underwent a wide local excision of the left
breast with ipsilateral axillary lymph nodes dissection.
Gross examination revealed a 4.7 cm tumor with central
cystic space located in the center to lower outer quadrant
of the left breast. There were no component of obvious
invasive ductal carcinoma or other features of metaplastic
carcinoma for example spindle cells, or osseous or
cartilaginous metaplasia. It revealed large squamous cells
with keratinizing eosinophilic glassy (Figure 1). The lesion
tends to be differentiated sufficiently to form keratohya-
line granules. The central cystic space contain keratin and
necrotic debris (Figure 2). Vascular or neural invasion was
not identified. There was no involvement of the skin or
skin adenexae of the breast or the nipple. The uninvolved
mammary parenchyma contained fibrocystic changes.
Figure 1. Large Squamous cells with keratinising
eosinophilic glassy. It’s present a modest inflammatory
intralesional reaction (Hematoxylin-Eosin, 20x).
Figure 2. Solid structure with central cystic space
containing keratin and necrotic debris
(Hematoxylin-Eosin, 10x).
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Cases Journal 2009, 2:7336 http://casesjournal.com/casesjournal/article/view/7336
Seventeen axillary lymph nodes were dissected and they
were negative for metastatic disease. Immunohistochem-
ical evaluation was negative for estrogen receptor (ER),
progesterone receptor (PgR) and Her2/neu overexpression
and positive for EGFR. Ki-67 proliferation index was
unfavourably high at 60%.
The patient received an adjuvant therapy based on
5-Fluouracil 600 mg/mq day 1 and Cisplatin (CDDP)
25mg/mqdays1, 2, 3 every 3weeks for six cycles. Afterwards
patient refuse radiation therapy to the residual left breast.
Twenty-eight months after surgery the patient was
asymptomatic and disease free.
Discussion
Pure primary squamous cell carcinoma of the breast is
a rare condition and is considered to arise through
metaplastic change of ductal carcinoma cells [9].
The concept of a disease continuum with varying degrees
of squamous metaplasia was supported by Stevenson et al.
who conclude that SqCC mostly represents an extreme
form of squamous metaplasia within adenocarcinoma [9].
An alternate theory is that arise directly from the
epithelium of the mammary ducts.
The SqCC of the breast are generally large (> 4 cm) at
diagnosis and cystic in 50% of the cases [10].
The prognosis of this type of breast cancer is still regarded
as somewhat controversial, though many studies suggest
that it is an aggressive disease that may behave like poorly
differentiated breast carcinoma [1,5,11].
The breast SqCC is usually a high-grade and hormone
receptor-negative tumor [3]. This means that hormone-
based therapy may not be effective in these tumors.
HER2/neu is also usually not over-expressed or amplified
in this disease [12]. The high frequency of EGFR positivity
is interesting and may be exploited in the development of
future treatments.
No findings onmammography are specific for this diagnosis
and thismay explain the advanced disease stage at diagnosis
[13]. Breast ultrasound has been reported to be more
helpful with these tumors appearing as solid hypoechogenic
masses with complex cystic components [14].
The treatment of SqCC of the breast does not differ from
other common histological types of brest cancer and may
involve surgery, chemotherapy, hormonal therapy and
radiation therapy. Because of its rarity the most appropriate
therapeutic regimen for SqCC of the breast is still unclear.
A recent literature review reveals that an average of 70%
of patients with SqCC of the breast do not present axillary
lymph nodes involvement but due the unpredictable
lymph nodes dissemination, axillary lymph nodes dissec-
tion could always be performed for staging purposes [3].
As a result of lack of data, the issue of whether to prescribe
adjuvant treatment for SqCC of the breast, remain
unsolved [3]. A little contribution derived from a review
by M.D. Anderson group of clinical pathologic features,
management and outcome of SqCC of the breast in a series
of 33 patients. Nineteen of the 31 patients with localized
disease received adjuvant chemotherapy and 5 patients
received neoadjuvant chemotherapy. The neoadjuvant
regimens used were antracycline/taxane-based for four
patients and anthracycline-based for one patient. The
tumor did not respond to neoadjuvant chemotherapy in
any patients. No significant difference was seen in relapse
free survival or overall survival rates between the patients
treated with adjuvant (two patients received a regiment
cisplatin based) or neoadjuvant chemotherapy and those
not treated. They conclude that SqCC of the breast is an
extremely aggressive disease and better systemic treatment
is required to prevent recurrence [8].
These findings are in accord with Rostock et al. review
suggests that SqCC is not sensitive to chemotherapeutic
agents commonly used for ductal carcinoma such metho-
trexate, cyclophosphamide, 5-fluorouracil (5-FU) and
antracycline [12]. A good response on metastatic disease
has been reported in one patient who received cisplatin
and 5-fluorouracil but this has never been investigated in
other report [15].
Our patient received adjuvant chemotherapy with 5-
fluorouracil (5-FU) and cisplatin based on other experi-
ences derived from some reports [1,3,4,15].
The role of radiation has been reported as unclear in many
studies. Although squamous cell carcinomas are generally
radiosensitive, locoregional relapse occurred frequently
also in irradiated field. It seems that SqCC of the breast is
often relatively radioresistant [3,4,8,9]. However, consid-
ering the conservative surgery performed, we proposed
radiation therapy but the patient rejected.
Currently twenty-eight months passed from the surgery
without evidence of disease.
Conclusion
Pure Primary Squamous cell carcinoma of the breast is
a very rarely and aggressive disease. Poor response of the
SqCC of the breast to chemotherapeutic regimens com-
monly used in breast cancer, suggests that EGFR inhibitors
and platin based regimens could be a promising option for
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Cases Journal 2009, 2:7336 http://casesjournal.com/casesjournal/article/view/7336
treatment of these tumors. In our report the choice of
adjuvant therapy was perfectly in accord with the new
suggestions coming from recent literature. Clinical trials
including large series of these rare tumors are needed to
increase our knowledge and to improve patient’s outcome.
List of abbreviations
SqCC, Squamous cell carcinoma; CT, Computed Tomo-
graphy; ER, Estrogen receptor.
Consent
Written informed consent was obtained from the patient
for publication of this case report and accompanying
images. A copy of written consent is available for review by
Editor-In-Chief of this journal.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
RM conceived the idea of the report and wrote the
manuscript. DB reviewed the literature and wrote the
manuscript. YM made the pathological diagnosis and
performed immunohistochemical EGFR evaluation. LT
reviewed the international literature and revised the
manuscript. AB interpreted the findings, revised critically
the manuscript and gave the final approval of the version
to be published. FM performed wide local excision of
the left breast with ipsilateral axillary lymphonodes
dissection. All authors read and approved final version
of manuscript.
Acknowledgements
The authors would like to thank GA on whom the case
report is based.
References
1. Rosen PR: Squamous Carcinoma. In Rosen’s Breast Pathology. 2nd
edition. Edited by Lippincott Williams & Wilkins. Philadelphia;
1997:455-461.
2. Tayeb K, Saadi I, Kharmash M, El Omari-Alaoui H, Mansouri A,
Errhani H, Benjaafar N, El Gueddari BK: Primary squamous cell
carcinoma of the breast: Report of three cases (French).
Cancer Radiother 2002, 6:366-368.
3. Behranwala KA, Nasiri N, Abdullah N, Trott PA, Gui GP: Squamous
cell carcinoma of the breast: Clinico-pathologic implications
and outcome. Eur J Sur Oncolo 2003, 29:386-389.
4. Menes T, Schachter J, Morgenstern S, Fenig E, Lurie H, Gutman H:
Primary squamous cell carcinoma (SqCC) of the breast. Am J
Clin Oncol 2003, 26:571-573.
5. Moisidis E, Ahmed S, Carmalt H, Gillett D: Primary squamous cell
carcinoma of the breast. ANZ J Sur 2002, 72:65-67.
6. Macia M, Ces JA, Becerra E, Nova A: Pure squamous carcinoma
of the breast. Report of a case diagnosed by aspiration
cytology. Acta Cytol 1989, 33:201-204.
7. Hennessy BT, Krishnamurthy S, Giordano S, Buchholtz TA, Kau SW,
Duan Z, Valero V, Hortobagy GN: Squamous cell carcinoma of
the breast. J Clinical Oncology 2005, 31:7827-7835.
8. Aparicio I, Martinez A, Hernandez G, Hardisson D, De Santiago J:
Squamous cell carcinoma of the breast. Eur J Obstet Gynecol
2008, 137:222-226.
9. Stevenson JT, Graham DJ, Khiyami A, Mansour EG: Squamous cell
carcinoma of the breast: A clinical approach. Ann Surg Oncol
1996, 3:367-374.
10. Gupta G, Malani AK, Weigand RT, Rangenini G: Pure primary
squamous cell carcinoma of the breast: A rare presentation
and clinicopathologic comparison with usual ductal carci-
noma of the breast. Pathol Res Pract 2006, 6:465-469.
11. Rostock RA, Bauer TW, Eggleston JC: Primary squamous
carcinoma of the breast: A review. Breast 1984, 10:27-31.
12. Cardoso F, Leal C, Meira A, Azevedo R, Mauricio MJ, Leal Da Silva JM,
Lopes C, Pinto Ferreira E: Squamous cell carcinoma of the
breast. Breast 2000, 9:315-319.
13. Siegelmann-Danieli N, Murphy TJ, Meschter SC, Stein ME, Prichard J:
Primary pure squamous cell carcinoma of the breast. Clin
Breast cancer 2005, 3:270-272.
14. Shigekawa T, Tsuda H, Sato K, Ueda S, Asakawa H, Shigenaga R,
Hiraide H, Mochizuki H: Squamous cell carcinoma of the breast
in the form of an intracystic tumor. Breast Cancer 2007,
14:109-112.
15. Hiramatsu K, Kato K, Hirata A, Matsuba H, Hara T, Ito T, Miyata T,
Akagawa T, Kutsuna Y, Machiki Y, Fujioka S: A resected case of
squamous cell carcinoma of the breast successfully treated by
5FU plus cisplatin (CDDP) adjuvant therapy against recur-
rent metastases. Gan To Kagaku Ryoho 2007, 34:443-446.
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Squamous cell carcinoma of the breast: a case report

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Squamous cell carcinoma of the breast: a case report

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