Inflammatory Breast Cancer

Definition

• Invasive breast cancer with dermal lymphatic invasion and a clinical diagnosis of an inflammatory component
  • Rapid onset of erythema and Peau d’orange
  • Duration of history of < 6 months
  • ⅓ of breast skin involved
  • Pathologic confirmation of invasive carcinoma.
• Clinical pathological diagnosis - do not need skin biopsy to diagnoses.

Incidence:

• Constitutes < 3% of all cases

Classification

• Stage IIIb (T4d)

Clinical

• Natural history short
• Overlying skin erythematous, oedematous (peau d’orange) & warm (± pain)
• Often no distinct mass; breast diffusely involved/enlarged ± rapid growth
• Most patients have ALN positive and distant mets at diagnosis

Pathology

• Dermal lymphatic invasion
• Malignant cells - tumour emboli → local and met disease
• Majority - hormone receptor NEGATIVE and HER2 POSITIVE
• Almost always present with positive nodes and ⅓ mets

Differential Diagnoses

• Acute mastitis
• Locally advanced non-inflammatory breast cancer
• Lymphoma or leukaemia with diffuse infiltration

Investigations

• Bloods - R/O infection, FBC, U+E, LFTs
• Imaging (bilateral breast and axilla)
  • Mammo - mass, distortion, thickened skin
  • USS breast and axilla
  • CT chest abdomen pelvis- staging
  • Bone scan
• Biopsy
  • Core of breast lump - receptors, IDC grade
  • Punch biopsy of skin x2 (dermal lymphatic invasion)
  • FNA any obvious nodes

Treatment

• Neoadjuvent treatment
  • Goal - reduce disease burden to facilitate surgery
  • Anthracycline/Taxane (Doxorubicin and cyclophosphamide + paclitaxel)
    • ACT - anthracycline/taxane
      • Doxorubicin (cardiotoxicity, care taken when given with herceptin)
      • Cyclophosphamide
      • Paclitaxel
    • Trastuzumab if HER2 positive - for 1 year
• Then surgery
  • Mastectomy and AND
  • Only operate if able to resect macroscopically
  • If inoperable after NACT then give RTX and reassess
  • Skin sparing is contraindicated!
    • Any recon is delayed as all need adjuvant RTX
• Adjuvant therapy
  • RTX
    • All inflamm breast cancers
  • Chemo
    • None if had neoadj chemo
  • Hormonal
    • Give endocrine (5-10 yrs) and Trastuzumab (1 yr) if receptors allow
    • Often ER/PR NEGATIVE
• Mx Broad Spiel
  • Goals of treatment for inflammatory breast cancer are to macroscopically resect the cancer and reduce the risk of locoregional recurrence and maximise disease free survival
  • All patients should have neoadjuvant treatment by way of chemo and Herceptin if HER2 positive
  • If they respond well then surgery (mastectomy and AND) followed by adjuvant RTX
  • If they dont respond well then they can have neoadjuvant RTX and reassessment
  • If favorable → surgery
  • If not → palliation

Prognosis

• Poor prognostic factors
  • Triple negative → because no other txs can be given
  • HER2 neg and ER/PR positive
  • 4 or more LNs positive up front
  • Lack of response to NACT - test tumour biology
  • With all treatment - 5 yr survival is poorer than non-inflammatory

Follow up

• Routine breast cancer F/U
• Yearly clinical review, yearly mammogram