Bilateral atrophic squirrhus of breast in neglected breast cancer: case report

The atrophic squirrhus carcinoma is an advanced form of breast cancer, which is most often neglected by patients. These days it has become very rare. The bilaterality of this form is even more exceptional. We present a case of atrophic squirrhus breast cancer of a 58 years old woman, rural origin, which is particular for its bilaterality and rapid evolution causing the death after 22 months from the first abnormal functional sign.


Introduction
The advanced malignant tumours of the breast are frequent in our country. Indeed, they represent 15 to 20% of the mammary carcinomas. The atrophic squirrhe of the breast is an entity which becomes currently exceptional, in that, its history is characterised by the disappearance of the glandular areas, which is responsible for an atrophy of the mammary gland with retraction of the tumour. It especially touches aged women. We study a case of atrophic squirrhe of the breast treated in the Obstetrics and Gynecology Department of university hospital Hèdi Chaker Sfax /Tunisia. The cancer is particular for its bilateralism and the circumstances of discovery.

Patient and observation
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. We present the case of mrs HK, 58 years old, rural origin, without any particular pathological history or breast cancer risk factors. She had 15 pregnancies and 15 parities. She has been in menopause for 8 years. Her disease history begun four months before her first consultation with a bilateral mammary out-flow and the retraction of the right nipple. These symptoms were ignored by the patient and the evolution was marked by a progressive atrophy of the two mammary glands, more accentuated at right, and thereafter with the development of ulcerations of the two breasts and a lymphoedema of the right arm added to a fever bringing the patient to medical consultation.
The examination had shown an altered general condition marked by a septic shock, 40-degree fever with thrill, tachycardia and low blood pressure. The examination of the breasts, which is painful on palpation, revealed an atrophy of the two mammary glands which is more accentuated on the right side, associated to multiple permeation nodules, a cutaneous thickening and ulcerations of the two breasts (Figure 1, Figure 2). The examination of the lymph nodes areas had not shown any palpable adenopathy. The examination of the right arm had shown a lymphoedema with a hot blotchy plate similar to erysipelas (Figure 3).
The Doppler scan of the right arm had shown a tumourous process infiltrating the clavicular region and surrounding the veins. The

Discussion
Breast cancer is the most common cancer among women [1]. Its incidence is increasing worldwide, but the prognosis is more Breast carcinoma is the most common malignancy to metastasize to skin among women [4]. Hutchinson was the first to describe the cutaneous metastases of breast cancers. In 1893, he had described a case of cutaneous erythematous squirrhe associated with a Page number not for citation purposes 3 mammary cancer. The erythematous infiltration was superficial and was followed by a blush and a light induration. The described lesion had recalled to the erysipelas, but there was a more important congestion attacking the sides of the erythema [5]. This form has also been observed in our patient called carcinoma "en cuirasse".

Conclusion
The atrophic squirrhe of the breast appearing especially in aged women is a macroscopic term designating some varieties of carcinomas characterized by their high extensive potential, their retractable character related to the existence of an abundant fibrous stroma. The bilateral forms are much rarer. This case illustrates the lack of education and incites to widespread screening programs for breast cancer in rural tunisian population.