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TitlePrimary squamous cell carcinoma of the breast: a case report
Tsuchiya, Atsuo; Endo, Yoshiyuki; Yazawa, Takashi; Konno,
Yutaka; Saito, Atsuko
CitationFukushima Journal of Medical Science. 51(2): 105-111
Rights© 2005 The Fukushima Society of Medical Science
Text Version publisher
Fukushima]. Med. Sci.,
Vol. 51, No.2, 2005
PRIMARY SQUAMOUS CELL CARCINOMA OF THE BREAST:
A CASE REPORT
ATSUO TSUCHIY AI), YOSHIYUKI ENDOl), T AKASHI YAZA W AI),
YUT AKA KONNO') and ATSUKO SAIT03)
l)Division of Surgery, Jusendo General Hospital, Koriyama, 963-8585, Japan
2)Division of Neurosurgery, Jusendo General Hospital, Koriyama, 963-8585, Japan
3)Division of Pathology, Jusendo General Hospital, Koriyama, 963-8585, Japan
(Received August 25, 2005, accepted November 14, 2005)
Abstract: Primary squamous cell carcinoma of the breast is a rare entity. We
treated a 55-year old woman who came to us with bleeding from the left breast
tumor. The tumor was 7 X 8 X 10 cm in size with ulceration and surgical biopsy
results showed it to be squamous cell carcinoma of the breast, while metastatic
work-up findings ruled out other sources of primary tumor. She also complained of
nausea and vomiting, and brain CT disclosed cerebellar metastasis. The metastatic
brain tumor was surgically removed, however, the symptoms became gradually
exacerbated. The patient died 67 days after admission.
Key words: breast neoplasms, breast carcinoma, squamous cell carcinoma
Primary squamous cell carcinoma of the breast is rare, as it accounts for only
0.04% to 0.075% of all breast malignanciesl). Nearly all cases are regarded as
squamous metaplasia that occurs in other types of breast carcinoma and the pure
type of squamous cell carcinoma is not commonly encountered, though it seems to
merely represent an extreme form of squamous metaplasia within adenocar-
cinoma,,3). Due to the rarity of this disease, no data concerning to definition,
diagnosis and treatment has been reported. Herein, we describe a case of primary
squamous cell carcinoma of the breast that presented metastasis and a fatal course.
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Correspondence to: Atsuo Tsuchiya, Division of Surgery, Jusendo General Hospital, 1-8-16
Ekimae, Koriyama City 963-8585, Japan.
A. TSUCI-IIY A el ai.
A 55-year old woman was admitted to J usendo General Hospital at the begin-
ning of June 2004 complaining of bleeding from a breast mass, which she had noticed
at the beginning of the year and had been growing rapidly for the past 4 months. A
physical examination revealed a 7 x 8 x 10 cm tumor in size in the upper half of the
left breast with ulceration (Fig. 1) and the overlying skin showed peau d'orange
appearance (Fig. 2). The left axillary lymph nodes and supraclavicular lymph nodes
were positively palpable. The patient noticed bleeding from the left tumor when
she coughed and decided to visit our hospital. An incisional biopsy of the tumor
revealed squamous cell carcinoma (large cell keratinizing variant type) of the breast,
with no other histological tumor types found in this specimen (Fig. 3). The tumor
was negative for estrogen receptor (ER), progesterone receptor (PgR), and human
epidermal growth factor receptor type 2 (HER2) by immunohistochemical staining.
The serum level of tumor marker CEA was 2.1 ng/ml (normal: < 5.0), CA15-3 was
264.2 U/ml «30.0), NCC-ST-439 was 4.0 U/ml «7.0) and serum LDH was 661 IUI
I (213-463). No metastases were seen in bone, lungs and Ii ver. She had anemia and
complained of nausea and vomiting after admission, after which brain computed
Fig. l. Chest CT scan revealed a protruding tumor with ulceration on the left chest
PRIMARY SQUAMOUS CELL CARCINOMA OF THE BREAST
Fig. 2. A breast tumor located in the left AC-portion with edema of the skin of the
breast due to carcinoma.
Fig. 3. Magnetic resonance imaging scanning revealed a tUlllor in the cerebellulll.
A. TSUCHIY A et al.
Fig. 4. Squamous cell carcinoma with keratinization. (I-I.E. x 200).
Fig. 5. Metastatic lesion of the cerebellum (H.E. x 200).
tomography (CT) and magnetic resonance imaging (MRI) scanning disclosed cerebel-
lar tumor (Fig. 4). Brain edema was shown surrounding cerebellar tumor and
various symptoms of brain tumor increased. To undergo the brain surgery, the
patient was transferred to the Division of Neurosurgery and total removal of a
tumor was performed. Histologically, the brain tumor was also squamous cell
carcinoma which was compatible with metastasis of the breast tumor (Fig. 5). She
recovered from neurological symptoms, though complained of impaired hearing 11
days after the operation. Cytologic analysis of the cerebrospinal fluid which was
aspirated from the subcutaneous space of the operated lesion showed class V, which
PRIMARY SQUAMOUS CELL CARCINOMA OF THE BREAST 109
is suggestive of meningeal carcinomatosis. The impaired hearing gradually exacer-
bated and sight loss was also demonstrated. The patient received a single course of
anticancer chemotherapy (epirubicin, cyclophosphamide, 5-fluorouracil), after which
her general status declined and died 47 days from admission. A postmortem autopy
was not done.
Squamous cell carcinoma rarely occurs in the breast and the histogenesis is
controversial. This type of carcinoma is considered to mostly represent squamous
metaplasia within adenocarcinoma2,4,5) because the disease shows varying degrees of
squamous metaplasia and glandular features. A review of these cases revealed a
heterogenous group of infiltrating carcinomas of the breast with variable degrees of
squamous differentiation, though a number of studies reported no evidence of any
other histology type6). Therefore, squamous cell carcinoma of the breast is divided
into pure squamous cell carcinoma and that mixed with adenocarcinoma. Eggers7)
identified two cases of pure squamous cell carcinoma of the breast along with five
cases of adenosquamous cell carcinoma among a total of 4351 malignant breast
When encountered with an apparent squamous cell carcinoma in the breast, it is
necessary to exclude the presence of metastasis from an extra mammary primary or
a possible occult primary on detailed clinical assessmentS). A diagnosis of pure
squamous cell carcinoma must fulfill 3 conditions: no other neoplastic elements in
the tumor; the tumor is independent from adjacent cutaneous structures; and no
other primary epidermoid tumor exists in the patients. In our case, squamous cell
carcinoma elements were shown in the incised lesion and the level of CA15-3, which
is a specific tumor marker for breast cancer or ovarian cancer, was extraordinarily
high. Common sources of metastatic squamous cell carcinoma in the breast are the
lung, esophagus, uterine cervix, and urinary bladder2), but chest CT and abdomen CT
disclosed no findings of a primary lesion in these organs. The most common form
of primary cancer for the brain metastases are lung, breast and melanoma9). Thus
it is consistent with a squamous cell carcinoma of the breast as far as we examined
though the excised lesion does not always represent the whole figures of the disease.
Squamous metaplasia can also occur in inflammatory lesions and squamous cell
carcinomas occur in breast abscesses, thus chronic inflammation is a contributing
factor to the development of this type of tumorlO). Fine needle aspiration cytology
or incisional biopsy is recommended to confirm the diagnosis. Cytology often
provides a good information for a diagnosis if malignant cells possessing squamous
features are identifiedll,12). However, a surgical biopsy procedure is usually
required to firmly establish the diagnosis of squamous cell carcinoma.
Squamous cell carcinoma of the breast tends to be somewhat larger at presenta-
tion than other types of breast carcinoma, with more than half of the reported cases
A. TSUCHlYA et at.
in excess of 5cm in diameterI3). A large tumor size and positive lymph node status
are known to be prognostic indicators of poor outcome. In spite of the aggressive-
ness of the tumor, some investigators have noted only rare involvement of the lymph
nodesI4,IS,16). Recently, reported cases of squamous cell carcinoma of the breast
have been evaluated for ER activity and usually found to be either negative or
weakly positive with levels below those necessary for therapeutic response4,16),
though most have been reported to be ER negativel,8,13,17,18), which is histologic
evidence of poor tumor differentiation. There is no treatment recommendations,
because the number of patients with such a squamous cell carcinoma is few. Most
patients undergo a mastectomy if possible. Most researchers recommend treating
squamous cell carcinoma of the breast like infiltrating ductal carcinomal,4,7).
However, Menes et al.14) reported that squamous cell carcinoma of the breast is a
distinct entity and should not be automatically treated according to the protocol
used for invasive ductal carcinoma. Chemotherapy has not been used consistently
in the adjuvant setting for squamous cell carcinoma of the breast, though it has
recently been used in treating widespread disease8). Cisplatin and 5-Fu, used
together in a neoadjuvant setting, were reported to cause tumor shrinkage and a
complete pathologic responseI9). On the other hand, another review has suggested
that squamous cell carcinoma is not sensitive to chemotherapeutic agents commonly
used for ductal carcinomaI8). Radiation therapy has shown little benefit21), despite
the fact that squamous cell carcinoma are generally radiosensitive. The lack of
response in squamous cell carcinoma may reflect the presence of a mixed type.
There is no specific prognostic correlation with the morphologic characteristics
of squamous cell carcinoma of the breast. In our case, the disease progressed with
a rapid growth of the tumor in approximately half a year, and meningeal car-
cinomatosis, which is considered to be as a main cause of death, was noted immedi-
ately after the brain surgery. Most patients with breast cancer with squamous
differentiation are presented in an advanced stage and squamous cell carcinoma of
the breast is apparently associated with poor prognosis4,13). Identification of pure
types appears to be of no clinical importance. Since prognosis can not be accurately
ascertained, the stage at presentation is more important than histologic
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