12.4 Inflammatory Carcinoma, Paget Disease, Sarcoma, Lymphoma, and Metastases

Special Malignancies Are Clinical Before They Are Histologic

IDC, ILC, and DCIS are the everyday malignant patterns. ARRT Mammography Procedures 1.E.4 also names inflammatory carcinoma, Paget disease of the breast, sarcoma, lymphoma, and metastatic lesions because a technologist who waits for a spiculated mass will miss them. Several of these patients should never have been on a screening schedule the day they arrive: they have a red, swollen breast or a destroyed nipple. Your first decisions are diagnostic technique, pain-limited compression, skin and nipple documentation, and how fast the images reach the radiologist.

You still do not diagnose. You describe skin orange-peel dimpling in the history, you photograph or diagram per facility policy, you obtain the views that can be tolerated, and you perform or set up ultrasound. The words "inflammatory carcinoma" and "Paget disease" on a report are physician conclusions after clinical exam plus imaging plus biopsy.

Inflammatory Carcinoma

Inflammatory breast cancer (IBC) is an aggressive invasive cancer in which tumor emboli block dermal lymphatics. The breast looks inflamed even though the process is not a primary infection. The American Cancer Society states that IBC is rare and accounts for about 1% to 5% of all breast cancers. ACS also teaches that symptoms often appear quickly (within 3 to 6 months), that IBC is at least locally advanced (stage III) at diagnosis because skin is involved, and that in about 1 of 3 cases it has already spread to distant sites at diagnosis.

What you see on the patient and on the image

• Erythema (redness) and warmth of a large portion of the breast
• Edema and enlargement; the breast may feel heavy
• Peau d'orange — skin dimpling like orange peel from blocked lymphatics and swollen pores
• Possible nipple retraction; a discrete lump is often absent (ACS emphasizes that IBC does not usually present with the lump people expect)

Mammography, when it can be performed, typically shows diffuse skin thickening, trabecular thickening, increased density, and sometimes distortion, calcifications, or adenopathy. A focal mass is less often obvious because edema whites-out the parenchyma. Ultrasound evaluates skin thickness, edema, underlying masses, and axillary and regional nodes. MRI, when used, maps extent; that is beyond what you acquire in the mammography room, but it explains why a "negative" 2D mammogram does not end the workup.

Diagnostic, not screening — and the mastitis overlap

A patient with a hot, red breast is not a screening patient. Use diagnostic protocols. Compression may need to be reduced and the reason documented; a rejected image from motion is worse than a slightly lighter diagnostic film that the radiologist can still use.

Mastitis and abscess (Section 12.1) overlap on purpose. Infection can look identical in the first week. ACS notes that antibiotics may be a reasonable first step, but if symptoms do not improve in about 7 to 10 days, cancer workup must proceed. The technologist's exam-stable actions: believe the skin findings, do not tell the patient "it is just an infection," and do not delay images because there is no lump. Punch biopsy of skin plus breast-parenchyma biopsy is how IBC is proven (dermal lymphatic invasion) — you may assist with localization, but you do not take the skin punch yourself unless that is in your licensed scope and facility policy.

Paget Disease of the Breast

Paget disease of the breast (Paget disease of the nipple) involves the epidermis of the nipple and areola with malignant cells that resemble DCIS. The American Cancer Society describes an eczema-like picture: crusted, scaly, red nipple-areolar skin; burning or itching; possible yellow or bloody nipple fluid; sometimes a flattened or inverted nipple. It is usually unilateral. Doctors may treat it as eczema first; failure to heal is the biopsy trigger.

ACS states that in most cases, Paget disease is found along with DCIS or infiltrating ductal carcinoma in the underlying breast. That is the operational fact for mammography: image the entire breast, not just a magnified nipple. Mammographic findings, when present, include nipple-areolar skin thickening, retraction, suspicious calcifications, a subareolar or distant mass, or distortion. Mammography can also be normal while Paget disease is real — another reason a visible nipple rash is a diagnostic presentation. Ultrasound looks at the nipple-areolar complex and any mass. MRI may be used when mammogram and ultrasound are negative but the nipple biopsy already showed Paget cells, to search for occult DCIS or invasion.

Mark the nipple finding the way you would mark a palpable lump so the radiologist can correlate. Do not wipe away crust as "poor hygiene" and send the patient to screening.

Sarcoma

Primary breast sarcoma is uncommon. It arises from mesenchymal (stromal, vascular, or other connective-tissue) elements rather than from ductal epithelium. Angiosarcoma is the subtype mammographers hear about most often in the post-treatment breast: it can occur in a breast that had radiation or in a chronically lymphedematous arm/chest wall (Stewart-Treves syndrome is the arm-skin version). Presentation is often a rapidly growing mass or violaceous skin nodules, not fine pleomorphic calcifications. Mammography may show a large, relatively circumscribed or irregular mass without the casting calcs of DCIS. Malignant phyllodes (Section 12.2) is a related stromal malignancy with leaf-like architecture; some questions will file it under phyllodes, others under sarcoma-like behavior (hematogenous metastases).

You will not "see sarcoma" as a unique pixel pattern. You will see a mass in a radiated breast or a very rapidly enlarging tumor, and you will flag the history of prior radiation and lymphedema.

Lymphoma

Breast lymphoma may be primary (rare) or secondary involvement of a systemic lymphoma. Imaging is nonspecific: a mass or masses, or diffuse increased density with adenopathy. Calcifications are uncommon compared with DCIS. Axillary or intramammary nodes may dominate the picture. The clue is often clinical (known lymphoma, B symptoms, rapidly enlarging nodes) rather than a spiculated IDC look. Ultrasound-guided biopsy of a node or mass provides tissue; mammography maps how much breast is involved. Do not assume every dense axillary node in a young patient is missed IDC — and do not assume it is "just a node" if the hilum is gone.

Metastatic Lesions in the Breast

Metastases to the breast are uncommon relative to primary breast cancer but are on the blueprint. Sources include:

• The contralateral breast (a second primary is more common than true metastasis, but metastatic contralateral disease occurs)
• Extra-mammary primaries — classically melanoma, ovarian carcinoma, lung cancer, and others, depending on the patient's known cancer history

The teaching mammographic pattern is multiple round, circumscribed masses, often bilateral, without spiculation and often without calcifications. A single round mass in a patient with a known extra-mammary primary is still in the differential with a cyst or fibroadenoma — ultrasound and the oncologic history sort it. Axillary nodes may be involved. Document the known primary on the requisition; a technologist who leaves "reason for exam: screening" on a patient with metastatic melanoma has failed the history step.

Multiple round masses also include cysts and fibroadenomas. Metastases are the malignant version of that round-mass pattern. The exam will usually hand you the extra-mammary primary or the word "multiple."

What the Mammographer Does — and Does Not Do

Exam trap: Screening language ("return in one year") does not apply to a red swollen breast or a destroyed nipple. Those are diagnostic presentations that overlap with benign inflammation and eczema. The correct professional stance is document, image, flag, do not diagnose. Peau d'orange plus failure of antibiotics is IBC until a physician proves otherwise. A scaly nipple plus underlying pleomorphic calcifications is Paget-plus-DCIS until histology speaks.