Congestive Heart Failure versus Inflammatory Carcinoma in Breast

Inflammatory breast cancer is a rare highly malignant form of breast cancer. Clinical signs and symptoms with histologic examination usually confirm the diagnosis. There are rare reports of breast edema of congestive heart failure which were difficult to differentiate from inflammatory carcinoma. The differential becomes more difficult when congestive heart failure is associated with unilateral breast edema. We present a case of a 70-year-old woman with congestive heart failure associated with unilateral breast edema and skin thickening simulating inflammatory breast carcinoma on mammography. 1. Introduction Congestive heart failure is a common disease especially in elderly population. Its common presentations are well known such as dyspnea, fatigue, weakness, swelling in legs, increased need to urinate at night, and lack of appetite, but familiarizing with the rare presentations of this common disease is also important to prevent unnecessary treatments, cost, and morbidity. We report a rare case of unilateral breast enlargement in an elderly woman with congestive heart failure who was clinically suspicious of inflammatory breast cancer. 2. Case Presentation A 70-year-old retired woman presented in breast clinic of cancer institute with complaint of gradual enlargement of right breast with peau d’orange appearance and pitting edema without accompanying arm edema and exertional dyspnea, which happened gradually during the last few months. She did not have fever or dermal erythema. She did not give any history of breast trauma or any previous surgery. She had a past medical history of congestive heart failure (EF 30%). On clinical exam, the patient was cooperative and tachypnoeic and had heart rate of 70/min, regular rhythm, and blood pressure of 130/70？mmHg. There were bilateral crepitations of the lungs, more in the right side. There were bilateral legs pitting edema. Abdominal exam was normal. Clinical breast examination showed an enlarged right breast mainly in dependent part with diffusely thickened peau d’orange skin. There was no nipple discharge, nipple retraction, palpable breast mass, or palpable axillary lymphadenopathy. Full digital mammography revealed skin thickening, cooper ligaments thickening, and edema without any apparent mass. Some punctate benign-type microcalcifications also spread in both breasts (Figures 1 and 2). Figure 1: Bilateral mammography (MLO view). Figure 2: Bilateral mammography (CC view). Ultrasound showed skin thickening, trabecular prominancy, and generalized mild tissue distortion due to edema without apparent mass