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Case Report

An Atypical Presentation of Superficial Breast Cancer: A Case Report and Review of the Literature

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30 June 2023

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03 July 2023

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Abstract
(1) Background: Retroareolar breast tumors, although common, rarely develop into malignancies. This case report presents the case of a 54-year-old woman with a superficial breast tumor, high-lighting the significance of considering a wide range of possibilities when evaluating breast lumps. (2) Methods: The patient presented with a progressively enlarging, ulcerating superficial mass in her left breast. To determine the nature of the tumor and results confirmed the presence of a Grade II superficial infiltrating ductal carcinoma. To address the condition, the patient un-derwent a modified radical mastectomy under general anesthesia. Following the surgery, she was prescribed tamoxifen, an estrogen receptor modulator, in accordance with the current guidelines. (3) Results: The patient experienced a smooth recovery without any complications and displayed no signs of recurrence or metastasis during follow-up visits. This positive outcome highlights the importance of early detection and proactive management in improving patient prognosis. (4) Conclusions: This case report underscores the significance of conducting a comprehensive ex-amination and maintaining a high index of suspicion for breast lumps. This report contributes to the existing body of literature on the diverse presentations of breast cancer.
Keywords: 
Subject: Medicine and Pharmacology  -   Surgery

1. Introduction

Retroareolar breast tumors, also known as aberrant mammary glands, represent a condition where additional mammary tissue persists instead of degenerating during embryonic development[1]. Even though this condition is quite prevalent, malignancies arising from these glands are rare[2]. A case of a superficial breast tumor in a 54-year-old female presents a unique clinical scenario , and this case report aims to add to the body of knowledge concerning the diagnosis and treatment of such cases[3].

2. Case Presentation

A 54-year-old female patient, who was diabetic and hypertensive, presented with a concerning development in her left breast. She was also in menopause, a period known to present increased risks for various health complications, including cancer. The patient noticed a superficial mass in her left breast, which had been insidiously and progressively growing over the past nine months. Over the recent month, the mass had started to ulcerate, signaling a possible increase in the severity of the underlying condition.
At its inception, the mass was relatively small, approximately 1.0 cm × 1.5 cm in size. However, over time, it showed significant growth, expanding to a sizeable 3.0 cm × 3.0 cm mass. The mass was hard upon palpation, immovable, and exhibited an unclear boundary with the surrounding skin, which are characteristics often associated with malignancies. The patient reported escalating discomfort upon touch, further adding to her worry and discomfort.
Interestingly, no enlargement of the ipsilateral supraclavicular lymph nodes was observed. This observation was key as lymph node involvement often suggests an advanced stage in cancers [Figure 1].
The patient's condition was further complicated by her diabetes and hypertension, which are both known to impact overall health, the body's immune response, and potential recovery capabilities.[4] Additionally, being in the stage of menopause, her hormonal changes could potentially influence the progression and treatment response of certain conditions, including breast cancer. All these factors had to be carefully considered in evaluating her situation and planning her treatment course.
2.1. Diagnostic assessment: Positron emission computed tomography (PET) [5] revealed a dense nodule in the left breast's subcutaneous tissue, with the boundary unclear and some sections protruding to the skin surface. The Standardized Uptake Value max level was 9.0[6]., suggesting a malignant tumor. No enlarged lymph nodes were observed. The histopathological examination confirmed the diagnosis of a Grade II superficial infiltrating ductal carcinoma[7]. The immunohistochemical examination revealed estrogen receptor (+++) 95%, progesterone receptor (+++) 90%, human epidermal growth factor receptor-2 (1+), ki67 (30% positive), and other markers typical for breast carcinoma[8].
2.2 Therapeutic intervention: Following the confirmation of the diagnosis and after ruling out any contraindications, a decision was made to perform a modified radical mastectomy under general anesthesia [9]. This involved the resection of the tumor along with a margin of healthy tissue and dissection of the axillary lymph nodes[10]. The wound was thoroughly irrigated and dressed, and two drains were placed, one in the axilla and another near the surgical site.
2.3 Follow-up and outcomes: Postoperatively, the patient was initiated on tamoxifen, an estrogen receptor modulator, as per the current guidelines[11]. The patient made an uneventful recovery and was discharged three days postoperatively. She reported minimal discomfort, and no complications such as infection or hematoma were noted. Regular follow-ups were scheduled every three to six months [12]. No signs of recurrence or metastasis were observed during the follow-up period.

3. Results

This case highlights a rare presentation of a superficial breast tumor. The differential diagnoses for such a case would include benign breast conditions such as fibroadenomas or cysts, infections, and other malignancies[13]. Pathological and immunohistochemical examinations played a vital role in confirming the diagnosis in this case[14].
The treatment approach for such a case is primarily surgical, followed by appropriate adjuvant therapy based on the pathological and immunohistochemical findings[15]. Despite the rarity of such cases, they underscore the importance of a thorough examination and a high index of suspicion for any breast lumps, whether in the typical mammary region or in retroareolar breast tissue.
Early detection is crucial in managing such cases, as timely intervention can help prevent disease progression and metastasis. As with any breast cancer, the treatment regimen typically involves surgery, chemotherapy, radiation therapy, and targeted therapy, depending on the staging and the patient's overall health condition [16].
In our case, the patient underwent a mastectomy with axillary lymph node dissection, followed by adjuvant chemotherapy and radiation therapy. The importance of pathological examination in these cases cannot be overstated, as it not only confirms the diagnosis but also informs about the tumor's molecular characteristics[17].
These molecular characteristics can further guide the use of targeted therapy, such as hormone therapy in hormone receptor-positive breast cancers or monoclonal antibodies in HER2-positive breast cancers. In this patient, immunohistochemical analysis revealed a triple-negative breast cancer, which necessitated the use of an aggressive chemotherapy regimen due to the absence of targeted therapy options.
This case also emphasizes the importance of patient education and awareness. Women should be encouraged to perform regular self-breast examinations and seek medical advice if they notice any abnormal changes, regardless of their location.

4. Discussion

This case report presents an intriguing case of a superficial breast tumor in a 54-year-old woman who is diabetic, hypertensive, and menopausal. It emphasizes the importance of maintaining a broad differential diagnosis when evaluating breast lumps[18]. The atypicality of the case is seen in the unusual superficial location of the tumor. Despite being uncommon, it brings to the fore the idea that breast cancer can have a myriad of presentations, making clinical vigilance and an extensive differential diagnosis a crucial part of the initial assessment.
In this scenario, the mass was not only growing over time but also began to ulcerate, a concerning sign that often indicates an aggressive or advanced disease. The lack of lymph node involvement, typically a marker of cancer spread, offered a slightly reassuring sign in this otherwise serious scenario.
This case underscores the critical role of diagnostic tools such as pathological and immunohistochemical examinations. They were instrumental in confirming the diagnosis of a Grade II superficial infiltrating ductal carcinoma and revealing its molecular characteristics. It showed a triple-negative profile, which, unfortunately, limits targeted therapy options, thus making the disease management more challenging[19].
Considering the patient's comorbid conditions - diabetes and hypertension - and her menopausal status, her clinical management required a comprehensive and individualized approach.[20] These factors are known to influence the progression of the disease and the patient's overall prognosis and response to treatment.
Early detection was crucial in this case, and it remains key in managing such conditions. This necessity underscores the importance of promoting public awareness and education about regular self-breast examinations. Breast cancer can manifest in various ways, and any new breast lump should be promptly evaluated.[21]
Furthermore, clinicians should maintain a high index of suspicion for breast cancer even in atypical presentations and in patients with complicating comorbid conditions. As demonstrated in this case, early diagnosis and appropriate management are vital in improving patient outcomes.
This report enhances the existing literature on the varied presentations of breast cancer, including the influences of underlying health conditions and menopausal status. It is hoped that this additional knowledge may aid in the identification and management of similar cases in the future, ultimately improving care and outcomes for patients.

5. Conclusion

This case report underlines the clinical importance of considering superficial breast tumors as potential malignancies.[22] While superficial breast tumors in aberrant mammary glands are rare[23], it is critical for clinicians to be aware of such possibilities and maintain a broad differential diagnosis when assessing patients presenting with breast masses, regardless of the unusual location or other atypical characteristics.[18]
The significance of diagnostic tools like histopathological and immunohistochemical examinations has been emphasized in this case, which not only established the diagnosis but also guided the appropriate treatment regimen. Furthermore, the absence of targeted therapy options in this case of triple-negative breast cancer reinforced the need for aggressive treatment plans.[24]
This case also draws attention to the necessity of public health initiatives aimed at raising awareness about breast cancer, including its atypical presentations.[25] Educating women about the importance of regular self-breast examinations and the need to seek medical advice when noticing any changes, irrespective of their location, is of paramount importance.[26]
With ongoing advancements in the field of oncology, the management of breast cancer continues to evolve. Despite the developments in diagnosis and treatment, the occurrence of rare cases such as this necessitates continued research. It is important to collect and analyze more data on such rare presentations to better understand their biology, prognosis, and most effective treatment strategies.
Additionally, the development of targeted therapies for triple-negative breast cancers is an area that requires further investigation.[27] While currently, these cancers are managed with aggressive chemotherapy regimens, there is a need for more personalized and efficient therapeutic approaches to improve patient outcomes.[28]
The unusual clinical scenario described in this report will contribute to the body of knowledge about breast cancer and its rare presentations, thereby aiding clinicians in the diagnosis and management of such unique cases in the future.
In conclusion, the importance of maintaining a high index of suspicion, ensuring early detection, and offering appropriate treatment cannot be overemphasized in the quest to improve the prognosis and quality of life of patients diagnosed with breast cancer, even in its rarest forms[29].

Author Contributions

P.I., S.I. and C.D.I. contributed to manuscript writing and editing and data collection; A.P., D.C., R.G. and S.S contributed to data analysis; L.I. and M.C.P. contributed to conceptualization and supervision; all authors have read and approved the final manuscript.

Funding

This research received no external funding.

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Conflicts of Interest

The authors declare no conflict of interest.

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Preprints 78175 g001
Figure 1. The mass on the left breast, which is 3.0 cm × 3.0 cm in size. The boundary is unclear, the shape is irregular and the mass is immovable.
Figure 1. The mass on the left breast, which is 3.0 cm × 3.0 cm in size. The boundary is unclear, the shape is irregular and the mass is immovable.
Preprints 78175 g001
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Copyright: This open access article is published under a Creative Commons CC BY 4.0 license, which permit the free download, distribution, and reuse, provided that the author and preprint are cited in any reuse.
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