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Inflammatory Breast Carcinoma in Magnetic Resonance Imaging

Posted Jan 31, 2008 Updated Apr 7, 2023
By Diane M. Renz MD , Pascal A.T. Baltzer MD , Joachim Böttcher MD , Fady Thaher MD , Mieczyslaw Gajda MD , Oumar Camara MD , Ingo B. Runnebaum MD , Werner A. Kaiser MD MS
15 min read

Rationale and Objectives

Although inflammatory breast carcinoma (IBC) accounts for 1%–4% of all breast cancer cases, the appearance of this highly malignant tumor in magnetic resonance imaging (MRI) is still not well characterized. The aim of this study was to identify typical imaging features of IBC in comparison with noninflammatory locally advanced breast carcinoma (LABC).

Materials and Methods

MRIs of 48 patients with IBC were compared with an equivalent cohort of 52 subjects with LABC. Age and histopathologic subtype were equivalent between the two groups. To delineate characteristic features, a multitude of dynamic and morphologic parameters were evaluated using T1- and T2-weighted sequences.

Results

No significant differences of prevalences could be found for the following criteria: dynamic tumor signal characteristics, prominent vessels, perifocal edema, axillary lymph node involvement, morphology of focal masses, and morphologic pattern of non–mass like enhancement. Otherwise, the quantity of focal masses and the spatial distribution of the tumoral infiltration significantly differed between the two cancer groups. The following parameters occurred more frequently in the IBC cases: edema (cutaneous/subcutaneous 81.3%, perimamillar 70.8%, diffuse 89.6%, prepectoral 72.9%, intramuscular pectoral 41.7%), thickening (75.0%) and pathologic enhancement (60.4%) of Cooper’s ligaments, skin thickening (83.3%), punched-out sign (initially strong, focal increase of some dermal or subcutaneous parts followed by slow-continuous enhancement of the surrounding skin; 56.3%).

Conclusions

Inflammatory breast carcinoma seems to represent a specific biological entity resulting in typical MRI characteristics. Some of the parameters are supposed to visualize the characteristic extensive lymphovascular infiltration and therefore may improve the diagnosis of IBC.

Inflammatory breast carcinoma (IBC) is a very malignant form of invasive breast cancer with a tendency to metastasize at an early stage, resulting in a poor outcome ( ). This aggressive variant accounts for about 1%–4% of all breast cancer cases with an increasing incidence rate, probably because of changing patterns of risk factor exposure ( ). The term inflammatory carcinoma derives from the inflammatory-like symptoms that are associated with this cancer type; typical clinical manifestations are increased volume and induration of the breast, pain, peau d’orange appearance, increased cutaneous temperature, dermal redness of at least one-third of the breast, and the presence of a palpable mass ( ).

The clinical manifestations of IBC are histologically related to dermal or subcutaneous lymphatic infiltration by tumor emboli that obstruct the lymphatic capillaries ( ). However, lymphatic infiltration of the skin cannot be detected by histology in all patients suffering from IBC. Thus, inflammatory breast carcinoma comprises the following subtypes ( ): the presence of both clinical symptoms of inflammation and dermal or subcutaneous lymphatic tumoral invasion verified by histology, accounts for about 50% and is known as common IBC . A further 40% is only characterized by the appearance of clinical signs in the absence of histopathologically verified lymphatic infiltration and is consecutively named clinical IBC . A small proportion of cases, about 10%, do not present any clinical inflammatory signs, and the diagnosis is only made by lymphatic invasion of the skin, the so-called occult IBC . This occult inflammatory carcinoma is proved to show a better prognosis than the other two types and may therefore be an early IBC form ( ).

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Figure 1

A 43-year-old woman with inflammatory carcinoma (invasive lobular, G3) in the left breast. The craniocaudal (a) and mediolateral-oblique (b) mammogram demonstrates a diffuse increase of breast density and skin thickening. The magnetic resonance examination ( c: subtraction 1 minute after bolus injection; d: T2-weighted image) shows the tumor characteristics in much more detail: the diffuse enhancement infiltrating the skin and the pectoralis muscle (continuous arrows), and edema in a cutaneous/subcutaneous, diffuse, and prepectoral localization (discontinuous arrows).

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Materials and methods

Subjects

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MR Mammography

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Evaluation Criteria

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Statistical Analysis

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Results

Patient Characteristics

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Histopathologic Results

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Dynamic Criteria

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Table 1

Signal Kinetic Characteristics of Inflammatory Carcinomas and Locally Advanced Cancers

Inflammatory Breast Carcinomas ( n = 48) Locally Advanced Cancers ( n = 52)P Values of Pearson’s Chi-Square Test (Two-Sided) Initial signal increase <50% 1 (2.1) 1 (1.9) 50%–100% 6 (12.5) 10 (19.2) >.05 >100% 41 (85.4) 41 (78.9) Postinitial enhancement Continuous increase 4 (8.3) 3 (5.8) Plateau phenomenon 11 (22.9) 15 (28.8) >.05 Washout sign 33 (68.8) 34 (65.4)

Numbers in parentheses are percentages.

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Analysis of Focal Masses

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Table 2

Analysis of Focal Masses of Inflammatory Carcinomas and Locally Advanced Cancers

Inflammatory Breast Carcinomas ( n = 40) Locally Advanced Cancers ( n = 52)P Values of Pearson’s Chi-Square Test (Two-Sided) Quantity 1 focal mass 4 (10.0) 24 (46.2) <.001 2–4 masses 13 (32.5) 18 (34.6) 5–7 masses 7 (17.5) 5 (9.6) >7 masses 16 (40.0) 5 (9.6) Shape Round 15 (37.5) 21 (40.4) >.05 Oval 8 (20.0) 9 (17.3) Lobulated 5 (12.5) 4 (7.7) Irregular 12 (30.0) 18 (34.6) Margin Smooth 7 (17.5) 5 (9.6) >.05 Irregular 23 (57.5) 36 (69.2) Spiculated 10 (25.0) 11 (21.2)

Numbers in parentheses are percentages.

Figure 2, A 36-year-old woman with inflammatory carcinoma (invasive ductal, G3) in the left breast. The subtraction 1 minute after bolus injection (a) demonstrates multiple focal masses (continuous arrows) that partially present a central lack of enhancement. In the surroundings of the masses, a diffuse clumped enhancement is shown (discontinuous arrow). In the T2-weighted image (b) , the masses are hypointense; and distinct edema, which is mainly localized prepectoral and intramuscular pectoral (discontinuous arrows), as well as a pathological axillary lymph node (continuous arrow) are presented.

Figure 3, A 75-year-old woman with locally advanced cancer in the left breast (invasive ductal, G3). The subtraction 1 minute after bolus injection (a) demonstrates an extensive tumor mass infiltrating the exulcerated skin with central lack of enhancement (continuous arrow) as well as prominent vessels (discontinuous arrow). The T2-weighted image (b) reveals edema (discontinuous arrows), which is mainly localized perifocal and prepectoral.

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Evaluation of Tumoral Infiltration

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Table 3

Analysis of Non–Mass-Like Enhancement of Inflammatory Carcinomas and Locally Advanced Cancers

Inflammatory Breast Carcinomas ( n = 48) Locally Advanced Cancers ( n = 26)P Values of Pearson’s Chi-Square Test (Two-Sided) Spatial distribution Linear/ductal 0 (0.0) 2 (7.7) <.001 Segmental 7 (14.6) 13 (50.0) Regional 9 (18.7) 5 (19.2) Multiple regions 11 (22.9) 5 (19.2) Diffuse 21 (43.8) 1 (3.9) Internal enhancement Stippled/punctate 14 (29.2) 7 (26.9) >.05 Clumped 11 (22.9) 5 (19.2) Dendritic 17 (35.4) 10 (38.5) Nonspecific 6 (12.5) 4 (15.4)

Numbers in parentheses are percentages.

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Table 4

Evaluation of Morphologic Parameters of the Breast of Inflammatory Carcinomas and Locally Advanced Cancers

Inflammatory Breast Carcinomas ( n = 48) Locally Advanced Cancers ( n = 52)P Values of Fisher’s Exact Test (Two-Sided) Edema subtypes Cutaneous/subcutaneous 39 (81.3) 15 (28.8) <.001 Perimamillar 34 (70.8) 13 (25.0) <.001 Perifocal 32 (66.7) 37 (71.2) >.05 Diffuse 43 (89.6) 19 (36.5) <.001 Prepectoral 35 (72.9) 20 (38.5) <.01 Intramuscular pectoral 20 (41.7) 8 (15.4) <.01 Cooper’s ligaments Trabecular thickening 36 (75.0) 17 (32.7) <.001 Enhancing ligaments 29 (60.4) 13 (25.0) <.01 Skin involvement Diffuse skin thickening 40 (83.3) 15 (28.8) <.001 Punched-out sign 27 (56.3) 5 (9.6) <.001 Prominent vessels 41 (85.4) 40 (76.9) >.05 Lymph node involvement 32 (66.7) 28 (53.8) >.05

Numbers in parentheses are percentages.

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Figure 4, A 47-year-old woman with inflammatory carcinoma in the right breast (invasive ductal, G2). The magnetic resonance image ( a: subtraction 1 minute after bolus injection) shows thickening and pathologic enhancement of the Cooper’s ligaments (discontinuous arrows). The histopathologic image of the same case (b) demonstrates tumor emboli in two lymphatic capillaries (continuous arrows) of a Cooper’s ligament (hematoxylin-eosin; original magnification ×200).

Figure 5, A 78-year-old woman with inflammatory carcinoma in the left breast (invasive ductal, G3). The magnetic resonance images ( a: subtraction 1 minute after bolus injection; b: subtraction 7 minute after bolus injection) demonstrates a typical punched-out sign. Some parts of the skin present fast, accentuated, focal enhancement (continuous arrow), whereas the surrounding skin shows a slow-continuous signal increase (discontinuous arrows). The histopathologic image of the same case (c) reveals characteristic tumor emboli (circle) in a subcutaneous lymphatic capillary (hematoxylin-eosin; original magnification ×400).

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Discussion

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Academic Radiology, Volume 15, Issue 2
Journals General Radiology
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