Inflammatory breast cancer (IBC) is a rare and aggressive form of breast cancer. In this post, I will discuss our most recent understanding of this aggressive disease.
almost all women with IBC have lymph node involvement at the time of diagnosis.
- Occurring in 0.5 to 2% of all invasive cancer.
- Tends to occur in younger age.
- Higher incidence in African American women.
- But incidence is also rising among whites.
- approximately one-third of newly diagnosed IBC present with distant metastases.
Diagnosis: Patients usually present with painful, rapidly growing breast lump with characteristic skin changes known as peau d’orange.
Clinical exam: Clinician often initially treat breast skin inflammatory changes with antibiotics for presumed mastitis, failure to improve on antibiotics should raise clinical suspicion for IBC. On examination, IBC is often associated with a breast lump, skin exam reveals thickened skin, warm to touch with the characteristic peau d’orange appearance.
Biopsy: this is a must in inflammatory breast cancer, fine needle or preferably core biopsy can be performed to establish the diagnosis of invasive breast cancer with skin lymphatic invasion by tumor cells. Additional samples submitted for Her2 status as well as hormonal status.
Imaging studies: a mammogram will reveal the skin thickening as well as an underlying breast mass.
Once a diagnosis is confirmed, a staging workup will need to completed and this will include,
- CT of chest, abdomen, and pelvis. PET scan is more preferable.
- lab. testing such as CBC, and a hepatic profile including Alk. Phos.
Staging: diagnosis of IBC is considered T4d in the TNM staging system, the following must be met:
- Rapid onset of erythema, edema and/or peau d’orang, and/or warm breast, with or without underlying palpable mass.
- Duration of history no more than six months.
- Erythema occupying at least one-third of the breast.
- Pathologic confirmation of invasive breast cancer.
Treatment of Inflammatory Breast Cancer
My discussion at this point will focus on treatment of non-metastatic IBC. On planing treatment for newly diagnosed non-metastatic IBC the following rules must adhere to,
Neoadjuvant therapy must always be the first treatment modality. The choice dose-dense AC>T vs TCH-P (also the NeoSphere trial)is illustrated below.
Patient with inflammatory breast cancer who do not respond to neoadjuvant chemotherapy should not proceed with surgery, and further systemic therapy and radiation therapy should be offered for these patients.
For patients with good response to neoadjuvant therapy, mastectomy and lymph node dissection is recommended. There is no place for breast-conserving surgery even for patients with complete response.
Post-mastectomy radiation therapy (RT) is recommended to improve local control, RT commonly includes chest wall, axilla, supraclavicular and infraclavicular lymph nodes, and internal mammary nodes. Other newer techniques are discussed here and here.
Multimodality therapy as shown above improved outcome for IBC from 10% five-years survival with single modality therapy to 30% to 70% five-years survival when multimodality approach is utilized.
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