A 57 year-old postmenopausal Caucasian woman with no significant past medical history presented with a four week history of rapid swelling, pain and erythema in her right breast. There was no history of trauma, and symptoms had not settled with oral antibiotics. She had never taken hormone replacement therapy. She had a low grade pyrexia, but was otherwise systemically well.
On examination, her entire right breast was erythematous, warm and swollen, with fluctuance and pointing in the outer lower quadrant. Otherwise, the breast was firm and non-fluctuant. The right nipple had been inverted since her symptoms began. Initial investigations revealed raised inflammatory markers and a neutrophillia. She also had a raised alkaline phosphatase of 615.
An initial diagnosis of a breast abscess was made, possibly secondary to an inflammatory carcinoma, and needle aspiration was attempted, although this did not yield pus. She was commenced on intravenous antibiotics and an ultrasound was arranged, which showed multiple loculations containing thick pus.
As the patient was in considerable distress, she underwent incision and drainage of this collection. The abscess was drained, although the cavity wall was noted to be suspicious and open biopsies were taken. Histology showed "metaplastic carcinoma with features of osteogenic sarcoma." She then underwent staging CT and bone scans. CT demonstrated multiple small calcified nodules in both lungs consistent with metastatic deposits. Bone scan did not show any skeletal lesions.
The patient underwent three cycles of neoadjuvant chemotherapy with ifosphamide and adriamycin, but this was poorly tolerated, and had only a modest effect on the primary tumour and metastatic lesions. Upon cessation of chemotherapy, there was rapid re-growth in the primary lesion, and the patient was admitted for surgery, in an attempt to achieve local disease control. She underwent radical mastectomy, axillary clearance and primary reconstruction with a latissimus dorsi flap. Recovery was uneventful.
Histology described a large tumour (16 × 11 × 8 cm), invading the breast and muscle, with extensive vascular and lymphatic invasion and confirmed the diagnosis of metaplastic breast carcinoma with osteogenic sarcoma predominating. All sixteen lymph nodes removed were involved. Surgical margins were at least 1 cm in all directions, and Paget's disease of the nipple was noted. The tumour was negative for oestrogen and progesterone receptors.
Two months later, she developed a new mass in the infra-axillary region on the right, which rapidly enlarged. She was given palliative chemotherapy with etopiside and carboplatin, during which she was admitted with neutropenic sepsis, from which she recovered. She was, however, re-admitted three weeks later with deterioration in her condition, and died in hospital a week later. The time from first presentation to her death was almost exactly eight months.