Infiltrating ductal carcinoma is the most common form of invasive breast cancer. It accounts for 80% of all types of breast cancer. We report an unusual presentation of histologically proven case of infiltrating ductal carcinoma of breast presented clinically as a small palpable areolar dermal lesion. Well defined hypoechoic cystic lesion in areolar dermis was present on ultrasound with a negative mammogram

Afzal, Shaista

Khan, Shaista

Minhas, Khurram

Shafqat, Gulnaz

eCommons@AKU

eCommons@AKUDepartment of Radiology Medical College, PakistanMay 2012Infiltrating ductal carcinoma of breast presenting asareolar dermal lesionGulnaz ShafqatAga Khan UniversityShaista KhanAga Khan UniversityKhurram MinhasAga Khan UniversityShaista AfzalAga Khan UniversityFollow this and additional works at: http://ecommons.aku.edu/pakistan_fhs_mc_radiolPart of the Radiology CommonsRecommended CitationShafqat, G., Khan, S., Minhas, K., Afzal, S. (2012). Infiltrating ductal carcinoma of breast presenting as areolar dermal lesion. Journal ofthe College of Physicians and Surgeons Pakistan, 22(5), 323-4.Available at: http://ecommons.aku.edu/pakistan_fhs_mc_radiol/4Journal of the College of Physicians and Surgeons Pakistan 2012, Vol. 22 (5): 323-324 323INTRODUCTIONBreast parenchyma comprises of glandular element andstroma (connective tissue) separated anteriorly byanterior layer of superficial pectoral fascia from sub-cutaneous tissue and skin. This extraparenchymalsubcutaneous area contains fat, blood vessels andanterior suspensory ligaments. Posteriorly, pectoralfascia separates the breast parenchyma from chest wall.The area posterior to the posterior pectoral fascia andchest wall contains fat and suspensory ligaments.Dermal lesions are not uncommon in breast. Dermallesions are extraparenchymal in location lying anterior tothe anterior layer of superficial pectoral fascia insubcutaneous fat and in the echogenic layer of deepdermis on ultrasound. Most common dermal pathologiesare benign and not specific to the breast. These includeepidermal inclusion cyst, sebaceous cyst, vasculartumours, lipoma, infections, postsurgical scar and fatnecrosis.1 Histologically, the nipple areola complex isdifferent than the rest of the breast parenchyma. Theareolar dermis contains lactiferous ducts extending frommore deeply placed mammary glands. These lactiferousducts which are associated with modified sebaceousglands are present throughout the areola upto theperiphery.2-4 So the lesions in this area are notextraparenchymal in location and can be subjected tothe development of all types of breast abnormalities ofductal origin including carcinoma.2,4CASE REPORTA 70 years old lady presented with complaint of a smallpalpable nodule on left areolar region for the last 6months. No appreciable change in size was noticedsince then. This was her first mammogram in studycenter. Mammogram was reported by senior radiologist.Right breast was categorized as BIRAD-11 because offew specks of calcification and left breast as BIRAD-0requiring additional investigation. Palpable nodule on leftareola was not visualized on mammogram and she wasadvised for targeted ultrasound of left areolar region forfurther evaluation. Her targeted ultrasound (GE LOGIC-500) revealed well circumscribed anechoic lesion withimperceptible walls and internal echoes. The lesion waslocated between the echogenic lines of deep dermisbeneath the site of palpable nodule. It was measuring9.1 x 3.0 x 2.8 mm (Figure 1). No underlying mass orcommunication with the deeper breast tissue was noted.No abnormal vascularity was identified on Dopplerimaging. Findings were concluded as areolar sebaceouscyst.Based on the clinical findings, local excision of leftareolar lesion was done. Microscopic examinationrevealed infiltrating ductal carcinoma Grade-1, withtumour cells arranged in tubules of various sizes andshapes (Figure 2). Fused tubules were also seen. CellsCASE REPORTInfiltrating Ductal Carcinoma of Breast Presenting as Areolar Dermal LesionGulnaz Shafqat1, Shaista Khan2, Khurram Minhas3 and Shaista Afzal1ABSTRACTInfiltrating ductal carcinoma is the most common form of invasive breast cancer. It accounts for 80% of all types of breastcancer. We report an unusual presentation of histologically proven case of infiltrating ductal carcinoma of breast presentedclinically as a small palpable areolar dermal lesion. Well defined hypoechoic cystic lesion in areolar dermis was presenton ultrasound with a negative mammogram.Key words: Breast.   Infiltrating ductal carcinoma.   Areolar dermal lesion.1 Department of Radiology / Surgery2 / Pathology3, The Aga KhanUniversity Hospital, Karachi.Correspondence: Dr. Gulnaz Shafqat, Flat No. 608, Samae Residency,Block F, N. Nazimabad, Karachi.E-mail: gulnaz.shafqat@aku.eduReceived December 21, 2010;  accepted December 8, 2011.Figure 1: Ultrasound of the left breast areolar region showing anechoiclesion with internal echoes in areolar dermis.showed moderately pleomorphic hyperchromatic nuclei.Mitotic figures were also noted (7/10 HPF).As the lesion was central, her mastectomy was done. Noother focus was noted in rest of the left breast paren-chyma on histopathology.DISCUSSIONThe nipple areola complex anatomy is unique anddifferent than the rest of the breast parenchyma.Histologically, immediately beneath the areolar skin,apocrine sweat glands, modified sebaceous glands, andrudimentary mammary glands are present.5,6 On thesurface of areola there are certain protuberanceswhich are basically combined orifices for the modifiedsebaceous glands and mammary lactiferous ducts asdescribed by Montgomery (Montgomery tubercles).5Smith et al. confirmed the findings that modifiedsebaceous glands are associated with lactiferous ductsthat extend from more deeply placed lactiferous glands.5According to Schinitte et al. ducts in the dermis of areolaare similar to extra lobular ducts in breast parenchyma.6Common areolar dermal lesions mostly includesebaceous cyst originating from modified sebaceousglands, infective processes and epithelial cyst. Aslesions are superficial, mammogram is usuallynegative.7,8 Ultrasound provide mainstay for theevaluation of these lesion. In case of cystic lesions,ultrasound shows status of wall thickness, internalechoes, and neoangiogenesis.9,10 Infected sebaceouscyst and abscesses have the same sonographicfeatures while epithelial cyst mostly has a tractextending from the mass into the dermis. These lesionsare also cystic and give through transmission. Malignanttransformation of epithelial cyst is a rare complication.8Katrina et al. found that all areolar dermal lesions are notbenign. They mentioned two rare cases of areolardermal lesion that turned out to be carcinoma.2 Similarly,in this case the small palpable areolar lesion appearedas a benign cyst on ultrasound, while on histology thelesion was proven to be infiltrating ductal carcinoma.Since, malignant masses are indistinguishable fromabscesses at imaging, careful attention should be givento the clinical history. If there are no obvious signs ofinfection, biopsy should be performed to determine theorigin of the mass.10Review of literature does not reveal any definite statisticregarding the malignancy among areolar dermal lesion.However, as ducts are present in the areolar dermis,deeper malignant processes may follow the ducts andextend to the areola without involving the nipple. Soareolar lesion must be dealt cautiously and biopsiedirrespective of radiological findings.REFERENCES1. Siewert B, Jacobs T, Baum JK. Sonographic evaluation ofsubcutaneous hemangioma of the breast. AJR Am J Roentgenol 2002;178:1025-7.2. Glazebrook KN, Morton MJ, Reynolds C. Carcinoma of thebreast mimicking an areolar dermal lesion. J Ultrasound Med 2007;26:1083-7.3. Costa  DD, Taddese A, Luz CM, Gerson D, Poppiti R, EssemanLE. Common and unusual diseases of the nipple areolarcomplex. Radiographics 2007; 27:S65-S77.4. Hughes LE, Mansel RE, Webster DJ, editors. Benign disordersand diseases of the breast: concepts and clinical management.2nd ed. London: WB Saunders; 2000. 5. Smith DM, Peters TG, Donegan WL. Montgomery’s areolartubercle: a light microscopic study. Arch Pathol Lab Med 1982;106:60-3.6. Schinitt SJ, Goldwyn RM, Salvin SA. Mammary ducts in theareolar: implications for patients undergoing reconstructivesurgery of the breast. Plast Reconstr Surg 1993; 92:1290-3.7. Bergmann-Koester CU, Kolberg HC, Rudolf I, Krueger S,Gellison J, Stoeckihuber BM. Epidermal cyst of the breastmimicking malignancy, clinicl, radiological, and histologicalcorrelation. Arch Gynecol Obstet 2006; 273:312-4.8. Morris PC, Cawson JN, Balasubramaniam GS. Epidermal cystof the breast: detection in a screening programme. Australas Radiol1999; 43:12-5.9. Stavros AT. Sonographic evaluation of breast cyst. In: StavrosAT, Rapp CL, Parker SH, editors. Breast ultrasound.Philadelphia: Lippincott Williams & Wilkins; 2004. p. 276-349.10. Moon WK, Park JM, Kim Yi. Inflammatory and infectiousdiseases of the breast: imaging findings. Postgraduate Radiol 2000;20:131-242.Gulnaz Shafqat, Shaista Khan, Khurram Minhas and Shaista Afzal324 Journal of the College of Physicians and Surgeons Pakistan 2012, Vol. 22 (5): 323-324Figure 2: Photomicrograph of histopathology specimen A and B showinginfiltrating ductal carcinoma Grade 1. Tumour cells arranged in tubules ofvarious sizes and shapes. Cells show moderately pleomorphic hyperchromatic nuclei with mitotic figures.l l l l lOl l l l l

Infiltrating ductal carcinoma of breast presenting as areolar dermal lesion

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Infiltrating ductal carcinoma of breast presenting as areolar dermal lesion

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