Description 

A 56-year-old woman presented to the emergency department with a left breast mass. Initially, she noticed two small lumps on the left breast that evolved in 18 months into an ulcerated mass with foul-odour drainage. Four months prior to admission, she developed fevers, fatigue and progressive dyspnoea. She normally could walk a block without limitations but progressed to dyspnoea with minimal exertion. Her family noted that she was spending most of the day in bed secondary to fatigue. Her fevers measured as high as 101.5°F and was alleviated by acetaminophen. One week prior to admission, she had a syncopal episode while standing up from her couch. Her mother came to visit after the syncope and noticed a foul odour. After she revealed the mass to her mother, she was taken to a primary care doctor who recommended the emergency department. The patient had no known medical history. She denied ever having a screening colonoscopy or mammography. She had no history of tobacco, hormone contraceptive or replacement use. Her paternal aunt and grandmother had breast cancer.

On physical examination, she initially presented with a heart rate of 112 beats per minute, respiratory rate of 18 breaths per minute and an oxygen saturation of 95% on 3 L nasal cannula. There was an ulcerative-necrotic left breast mass with violaceous skin changes (figure 1) along with palpable bilateral axillary and cervical lymphadenopathy. She had decreased breath sounds bilaterally with crackles noted on the right posterior base. CT imaging visualised bilateral peribronchovascular hypodense masses measuring up to 5.0×4.7×6.1 cm (figure 2A). It also noted a significant pleural effusion on the right and a distant L3 soft tissue mass (figure 2B). Core needle biopsy described oestrogen- receptor negative, progesterone-receptor positive, human epidermal growth factor receptor 2 (HER2)-positive infiltrating ductal carcinoma. The necrotic breast mass had a superimposed infection with Escherichia coli that was treated with piperacillin–tazobactam for 7 days. Her dyspnoea was alleviated after 1250 mL thoracentesis of the malignant effusion. After discussion with the surgical and medical oncologist, the patient was discharged for outpatient chemotherapy.

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Figure 1

Lateral (A) and anterior (B) views of left fungating breast mass.

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Figure 2

Axial CT of peribronchovascular hypodense masses with pleural effusion (A) and L3 soft tissue mass (B white arrow).

Infiltrating ductal carcinoma is the most common type of invasive breast cancer accounting for 73.5% of invasive disease cases in the USA.1 It has a 98.9% 5-year survival if diagnosed at a localised stage.1 The patient never sought out medical care for the breast mass out of financial concerns for the cost of diagnosis and treatment. Breast cancer screening is recommended starting at age 40 in select women and biennially in all women aged 50–74 years. Meta-analysis exhibits a 62% relative reduction of advanced breast cancer in patients over the age of 50 who participate in screening mammography.2 The overall benefit of screening mammography is most evident in patients aged 50–74 years. There is a 24.1%–31.8% relative reduction in lifetime breast cancer mortality.2 This patient’s advanced disease emphasises the importance of early diagnosis by screening and symptomatic presentation.