Primary Peritoneal Serous Carcinoma Presenting as
Inflammatory Breast Cancer
Ibrahim Khalifeh, MD,* Michael T. Deavers, MD,* Massimo Cristofanilli, MD,?
Robert L. Coleman, MD,?Anais Malpica, MD,*
and Michael Z. Gilcrease, MD, PhD*
*Departments of Pathology;?Breast Medical Oncology; and?Gynecologic Oncology, MD Anderson
Cancer Center, Houston, Texas
because the prognosis and treatment differ from that of primary breast cancer. We report a unique case of primary perito-
neal serous carcinoma that initially presented as inflammatory breast cancer. The patient received neoadjuvant chemother-
apy for breast cancer and subsequently underwent bilateral total mastectomy and bilateral sentinel lymph node biopsy. She
was found to have extensive intralymphatic carcinoma in both breasts, with only focal minimal breast parenchymal involve-
ment, and residual metastatic carcinoma in bilateral sentinel lymph nodes. Further work-up revealed pelvic ascites and
omental nodularities. The patient underwent laparoscopic bilateral salpingo-oophorectomy, which revealed high-grade ser-
ous carcinoma involving both ovaries and fallopian tubes. Molecular testing of tumor from the ovary and axillary lymph node
showed an identical pattern of allelic loss, confirming a common origin for both tumors. To our knowledge, this is the first
reported case of an extramammary primary malignancy that not only presented as inflammatory breast cancer but also was
diagnosed and initially treated as such. n
Key Words: breast cancer, inflammatory carcinoma, primary peritoneal, serous carcinoma
Abstract:Metastasis to the breast from extramammary malignancies is rare. Nevertheless, its recognition is important
uncommon. Fewer than 50 cases have been reported
previously, of which fewer than five were primary
peritoneal carcinomas (1–12). Most of these have
occurred in patients with a known history of primary
ovarian or peritoneal carcinoma. It is rare for primary
ovarian or peritoneal carcinoma to present clinically
as a primary breast tumor, and it is rare for metastatic
carcinoma from any extramammary site to present
with signs of inflammatory breast cancer (6,7,9,
11,13–16). Although several cases of metastatic carci-
noma from various sites have produced clinical signs
mimicking inflammatory breast cancer, to our knowl-
edge there is no previous report of metastatic carci-
noma that not only presented as inflammatory breast
carcinoma but also was diagnosed and initially treated
varian or peritoneal serous carcinoma metastasiz-
ing to the breast and⁄or axillary lymph nodes is
We report a unique case of primary peritoneal ser-
ous carcinoma that presented clinically as inflamma-
tory breast cancer. The patient was treated with
neoadjuvant chemotherapy for breast cancer, and the
primary peritoneal tumor was not detected until
16 months after the initial breast manifestation.
A 56-year-old Caucasian woman with no family
history of breast cancer and negative annual mammo-
grams for seven consecutive years presented with
slight redness around the periareolar area of the right
breast. She was prescribed antibiotics, but the redness
did not improve. A few weeks later, redness involved
the left breast as well. Bilateral mammograms and
MRIs were obtained, and these were negative. She
had punch biopsies performed on both breasts, and
each of these showed carcinoma in the dermal lym-
phatics. In a survey for metastatic disease, an MRI of
the brain was negative. PET and CT scans from the
base of the brain to the proximal thighs showed the
Address correspondence and reprint requests to: Michael Z. Gilcrease,
MD, PhD, Unit 85, Department of Pathology, 1515 Holcombe Blvd, Houston,
TX 77030, USA, or e-mail: email@example.com.
? 2009 Wiley Periodicals, Inc., 1075-122X/09
The Breast Journal, Volume 15 Number 2, 2009 176–181
presence of a right pleural effusion, with abnormal
hypermetabolic activity within the fluid highly suspi-
cious for malignancy. Possible metastatic involvement
of the right pleura and sternum was also noted. No
other clear-cut evidence for metastatic disease was
noted in the neck, chest, abdomen, or pelvis. Thora-
centesis confirmed the presence of malignant cells
within the pleural fluid.
The patient underwent induction chemotherapy
consisting of four cycles of doxorubicin and cyclo-
phosphamide for presumed inflammatory breast can-
cer, followed by four cycles of paclitaxel. A repeat
PET scan no longer showed evidence of a right pleural
or sternal lesion. A small amount of pelvic fluid was
noted, which was thought likely to be physiologic.
The patient then underwent bilateral simple mastec-
tomy with bilateral sentinel node biopsies. Intralym-
involvement in the right breast. One sentinel node on
the right and two on the left were positive for meta-
static carcinoma. The tumor was strongly and dif-
fusely positive for Wilms’ tumor-1 antigen (WT-1).
Following surgery, the patient underwent chest wall
radiation and was treated with anastrozole. CT of the
chest subsequently revealed a recurrent pleural effu-
sion. Thoracentesis was performed, followed by pleu-
rodesis, and cytologic evaluation was again positive
for metastatic carcinoma. A CT scan and MRI of the
pelvis and abdomen revealed nodularities throughout
the omentum and a small amount of ascites. The
uterus and adnexa appeared to be of normal size. A
PET scan showed that the omental nodules and ascites
were not (18F)-fluorodeoxyglucose avid. The serum
CA125 level was significantly elevated at 274.1 U⁄mL
(reference range 0–35 U⁄mL), and the CA27.29 level
was increased to 175.7 U⁄mL (reference range 0–
Eleven months after her initial presentation, the
patient underwent a laparoscopic bilateral salpingo-
oophorectomy and endometrial curettage. The right
and left ovary were of normal size, but both ovaries
and fallopian tubes were found microscopically to be
involved by high-grade serous carcinoma. The endome-
trial curettage was negative. The histologic appearance
and the extent and pattern of involvement fulfilled
Gynecologic Oncology Group (GOG) criteria for pri-
mary peritoneal carcinoma (17). Subsequent DNA
polymorphism analysis showed an identical pattern of
allelic loss in 8 of 8 microsatellite foci, confirming that
tumor above and below the diaphragm was of com-
mon origin. CT scans following laparoscopic surgery
revealed progression of the intraabdominal disease.
Omental caking greater than 8 cm was observed, and a
second mesenteric nodule greater than 5 cm was noted.
There was additional involvement of the liver and gas-
trocolic ligament with associated ascites.
Because of active abdominal and extraabdominal
disease, the patient subsequently underwent additional
chemotherapy for a peritoneal primary with docetaxel
and carboplatin rather than debulking. At last follow-
up, 16 months after her initial presentation, the intra-
peritoneal tumor volume had decreased dramatically.
The omental involvement had decreased to approxi-
mately 3 cm and stabilized, and the CA125 and
CA25.29 levels had decreased to 29.3 and 57.7,
Punch biopsies of both breasts prior to neoadjuvant
chemotherapy showed dermal lymphatic carcinoma,
which consisted of small clusters of high-grade carci-
noma admixed with individual tumor cells within the
lymphatic channels (Fig. 1). The tumor cells had a
high nuclear to cytoplasmic ratio with either hyper-
chromatic or vesicular nuclei with prominent nucleoli.
The tumor cells were negative for both estrogen and
progesterone receptors, and FISH for evaluation of
HER2 gene copy level was negative for amplification
(the HER2:CEP17 ratio was 1.1). The Ki-67 labeling
index was 25%.
Following neoadjuvant chemotherapy, no mass was
identified in either of the mastectomy specimens, but
microscopically, there was extensive involvement of
lymphatic channels, including the dermal lymphatics,
by high-grade carcinoma. On the right, there was also
focal minimal breast parenchymal extension. One sen-
tinel node on the right and two on the left contained
clusters of high-grade metastatic carcinoma with a
papillary morphology and associated psammomatous
calcifications (Fig. 1). The metastatic tumor was posi-
tive for estrogen receptor, negative for progesterone
receptor, and negative for HER2 amplification (the
HER2:CEP17 ratio by FISH was 1.2). The Ki-67
labeling index was 47%. Immunohistochemical stain-
ing showed the tumor cells in the lymph node to be
strongly and diffusely positive for WT-1 and negative
for gross cystic disease fluid protein-15 (GCDFP-15),
favoring metastatic serous carcinoma (Fig. 2).
Serous Carcinoma Presenting as Inflammatory Breast Cancer • 177
In the subsequent bilateral salpingo-oophorectomy
involved both ovaries and fallopian tubes. The tumor in
the ovaries involved the ovarian surface and underlying
cortical stroma, with no parenchymal nodule larger
than 5 · 5 mm (Fig. 3). Molecular testing was per-
formed on tissue from the ovary and on metastatic
tumor in axillary sentinel lymph nodes to confirm a
common origin. Tissue was microdissected from three
histologically distinct sites in the ovary (normal ovary,
papillary serous carcinoma on the surface of the ovary,
and nonadjacent infiltrating carcinoma) and on meta-
static deposits of carcinoma in each of two involved
axillary sentinel lymph nodes, and the pattern of ran-
dom allelic loss of polymorphic microsatellite loci in
the tumor from each site was compared. The pattern of
allelic loss was found to be identical in 8 of 8 microsat-
ellite loci. LOH mutations at both tumor sites were
observed in 3p (5 foci), 17p, 17q, and 22q.
Figure 1. (a) Carcinoma cells within a der-
mal lymphatic channel of the breast. (b)
Focal breast parenchymal involvement by
invasive carcinoma. (c) Metastatic carcinoma
inan axillary sentinel
with the metastatic carcinoma.
Figure 2. The tumor cells are diffusely and strongly positive for
Figure 3. (a) Ovarian involvement by tumor was confined to the
ovarian surface and underlying cortical stroma. (b) The tumor
involving the ovary displays the typical morphology of papillary ser-
ous carcinoma and is morphologically similar to the tumor above
178 • khalifeh et al.
The case we describe is, to our knowledge, the first
report of an extramammary primary malignancy that
not only presented as inflammatory breast cancer but
also was diagnosed and treated as such. It is not sur-
prising that the site of origin in this case was not
detected until after the patient was treated for inflam-
matory breast cancer, as a punch biopsy with even
scant intralymphatic carcinoma
regarded as confirmatory for inflammatory breast can-
cer in a patient without a history of an extramammary
malignancy who presents with a swollen, erythema-
tous breast. The primary peritoneal tumor in this
patient was not detected until 11 months after the ini-
tial diagnosis of inflammatory breast cancer.
There have been rare reports of metastatic tumors
to the breast mimicking inflammatory breast carci-
noma. Six of these described metastases of ovarian
origin, all of which were recognized as metastases
following a previous diagnosis of primary ovarian
carcinoma (6,7,9,11,18,19). Three patients with meta-
static gastric carcinoma had clinical signs of inflamma-
tory breast cancer, and each of these were similarly
recognized as metastases following a previous diagno-
sis of signet ring cell carcinoma of the stomach (13–
15). One series of 16 patients with metastases to the
breast describes four patients who had ‘‘diffuse skin
thickening of one breast similar to inflammatory
breast cancer.’’ One of these was found to be meta-
static squamous cell carcinoma of the tonsil, and
another was metastatic squamous cell carcinoma of
the lung. Both of these were in patients with known
extramammary primaries. The breast lesion in a third
case was the first manifestation of pancreatic adeno-
carcinoma, but it is not stated whether the lesion was
initially diagnosed or treated as breast cancer. A
fourth case might also have been a metastasis from an
extramammary primary, although poorly differenti-
ated adenocarcinoma of the breast was included in the
differential diagnosis (16).
The breast is an uncommon site for metastasis. The
reported incidence from autopsy series ranges from
1.7% to 6.6% (20,21), whereas the range is from
0.5% to 1.3% in clinical series (22). Most metastases
to the breast appear as unilateral, well-circumscribed
masses that generally lack microcalcifications. Of
tumors that metastasize to the breast, the most com-
mon is carcinoma of the contralateral breast, followed
by tumors of hematologic origin, melanoma, and
bronchogenic carcinoma (5,23). Although metastases
to the breast of ovarian origin are not the most com-
mon, they appear most likely to produce a clinical pic-
ture of inflammatory breast cancer, as described
above. In all previous reports, however, this has
occurred in the setting of a known extramammary
Breast metastases of ovarian origin usually occur as
single or multiple unilateral breast masses in patients
with a history of advanced-stage ovarian carcinoma.
A few patients have presented with bilateral breast
masses. A majority of patients have also presented
with synchronous axillary lymph node involvement
(1,11). Metastases to the breast from ovarian prima-
ries generally occur 2–3 years after the initial diagno-
sis (24). Breast metastases
concurrent with the initial presentation of an ovarian
or peritoneal carcinoma are rare. Only 10 such cases
are reported in the English literature (2,3,5,10–
12,25,26), two of which presented initially as a breast
mass before a primary tumor of the ovary was recog-
nized (2,5). Metastases to the breast from primary
peritoneal serous carcinomas are also rare (11). Two
of the three cases of primary peritoneal carcinoma
reported by Recine et al. that metastasized to the
breast did so 11 and 16 months after the initial diag-
nosis of primary peritoneal carcinoma (11). The third
case had a metastasis to the breast concurrent with
the initial presentation of a primary peritoneal tumor.
The tumor in the breast and axillary lymph nodes
in this report was not suspected to be metastatic carci-
noma from an undiscovered ovarian or peritoneal pri-
mary until after the patient received neoadjuvant
chemotherapy and the breast and axillary nodes were
resected. Although the residual tumor in the breast
was scant and predominantly intralymphatic with
focal parenchymal extension, there was sufficient
residual tumor in the lymph nodes to recognize the
papillary architecture with associated psammomatous
calcifications. The differential diagnosis of tumors in
the breast with this morphology includes primary
invasive micropapillary carcinoma of the breast and
metastatic micropapillary carcinoma, most frequently
of ovarian or peritoneal origin. Both appear as micro-
papillary clusters of tumor cells invading the stroma
with prominent characteristic retraction artifact mim-
icking lymphovascular invasion (27).
Primary invasive micropapillary carcinoma gener-
ally presents as a mass with indistinct borders,
whereas metastatic micropapillary
Serous Carcinoma Presenting as Inflammatory Breast Cancer • 179
usually observed radiographically as one or more
round, sharply circumscribed masses (28). The pres-
enceof associated intraductal
favors a primary breast tumor (27). Although immu-
nohistochemical staining for gross cystic disease fluid
protein-15 (GCDFP-15) can be positive in up to 50%
of breast cancers, it is an apocrine marker and is gen-
erally absent in the invasive micropapillary subtype of
breast cancer (29). WT-1 expression generally favors
an ovarian or peritoneal primary, as most papillary
serous carcinomas are strongly positive, whereas only
a minority of invasive micropapillary carcinomas of
the breast express WT-1, and those that do have only
focal expression (30–32). Levels of serum CA125 are
not useful in this differential diagnosis, as they may be
elevated with breast, ovarian, or peritoneal primaries
The tumor in this report lacked an associated intra-
ductal component and was diffusely positive for WT-1
by immunohistochemistry and negative for GCDFP-
15. The patient was subsequently found to have
ovarian involvement, with the bulk of tumor radio-
graphically in the omentum, and the tumor in the
axillary nodes was shown to have a pattern of allelic
loss identical to that of the pelvic tumor.
To determine whether tumor at two different sites
is derived from the same original neoplasm, DNA
polymorphism analysis can be performed to analyze
the pattern of random allelic loss of polymorphic
microsatellite loci at each site. In essence, the tumor’s
‘‘genetic fingerprint’’ at each site can be compared
(35,36). In this case, an identical pattern of allelic loss
was found in 8 of 8 microsatellite loci. Moreover, the
specific LOH mutations observed included mutations
at 17p and 17q. Although BRCA1 is located on chro-
mosome 17, it is known to undergo mutation in only
a small proportion of breast carcinomas, and this
patients with BRCA mutations (37). LOH mutations
in both 17p and 17q are commonly described in pri-
mary peritoneal serous carcinoma and are not com-
mon in breast cancer (38–40).
Because the pelvic tumor was recognized histologi-
cally to be high-grade papillary serous carcinoma and
ovarian involvement was confined to the ovarian sur-
face and underlying cortical stroma, with no tumor
nodule in the ovary greater than 5 · 5 mm, the pelvic
tumor fulfilled GOG criteria for primary peritoneal
carcinoma (17). The demonstration of common origin
by DNA polymorphism analysis confirmed that the
tumor above the diaphragm was a metastasis from the
peritoneal primary rather than a separate primary.
Although the prognosis of stage IV primary peritoneal
carcinoma is poor even with the most appropriate
treatment (median survival is 1.3 years compared with
2.9 years for inflammatory breast cancer), the recom-
mended chemotherapeutic regimens for primary peri-
toneal carcinoma and inflammatory breast cancer are
different, and misdiagnosis will result in inappropriate
In summary, the clinical presentation of an ery-
thematous, swollen breast has a broad differential
diagnosis that includes conditions ranging from non-
neoplastic disease (such as cellulitis, deep venous
thrombosis, radiation-induced change, and panniculi-
tis) to neoplasia, with inflammatory breast carcinoma
being the most common neoplastic etiology. Our
reported case highlights a rare but clinically crucial
pitfall that can occur in diagnosing inflammatory
breast cancer. A bilateral presentation should always
raise the possibility of metastatic disease, as bilateral
inflammatory breast cancer is exceedingly rare (43). In
the case we describe, the patient presented with unilat-
eral redness and was treated initially with antibiotics.
A few weeks later, redness involved the left breast as
With a classic unilateral presentation in the absence
of a known extramammary malignancy, routine stain-
ing of punch biopsy specimens for WT-1 is not war-
ranted. However, the presence of a micropapillary
architecture in tumor from a breast biopsy specimen
prior to neoadjuvant chemotherapy or from the subse-
quent surgical resection specimen should alert the
pathologist to the possibility of metastatic disease of
ovarian or peritoneal origin. In this situation, a thor-
ough clinical evaluation for a possible pelvic primary
tumor should be performed, and if ovarian or pelvic
involvement is detected, staining for WT-1 and DNA
polymorphism analysis can be useful in helping to
confirm a common mullerian origin for tumor above
and below the diaphragm.
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