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Inflammatory Breast Cancer
By Dr. Jeff Patton of Tennessee OncologyInflammatory breast cancer is a unique and uncommon type of breast cancer. It is unique in that inflammatory breast cancer does not produce a distinct mass or lump that can be felt within the breast. The lack of a lump or mass also makes inflammatory breast cancer difficult to detect by mammograms. Inflammatory breast cancer cells infiltrate the skin and lymph vessels of the breast. When the lymph vessels become blocked by the breast cancer cells the breast typically becomes red, swollen, and warm. The skin changes associated with inflammatory can cause the breast skin to look like the skin of an orange, a finding called peau d'orange. The appearance of the breast is similar to other inflammatory conditions such as cellulitis or mastitis. Other possible associate symptoms include enlarged lymph nodes under the arm or above the collar bone on the affected side.
Inflammatory breast cancer is diagnosed based upon the results of a biopsy and the clinical judgment of the treating physician. Typically, inflammatory breast cancer grows rapidly and requires aggressive treatment. There are two aspects to treating all breast cancer, local treatment and systemic or total body treatment. Because inflammatory breast cancer is aggressive, most oncologists recommend both systemic and local treatment. The typical sequence of treatment is to start with chemotherapy, systemic treatment, followed by surgery and radiation therapy, which are the local treatments, often followed by additional chemotherapy and possibly hormone treatments. With aggressive treatment using this multimodality approach, the 5 year survival for inflammatory breast cancer has improved significantly from an average survival of 18 months to an approximately 50% survival rate at 5 years.
INFLAMMATORY BREAST CANCER
How many cases of IBC are diagnosed each year?The numbers vary, but approximately 1% to 2% of newly diagnosed invasive breast cancers (that have spread beyond the breast) in the United States are described as inflammatory breast cancers.
What are the symptoms of IBC?
- One breast larger than the other
- Red or pink skin
- Rash (entire breast or small patches)
- Orange-like texture (peau d' orange)
- Skin hot to the touch
- Pain and/or itchiness
- Ridges or thickened areas of breast
- Nipple discharge
- Nipples that appear inverted or flattened
- Swollen lymph nodes under the armpit
- Swollen lymph nodes of the neck (sometimes)
What should you do if you have these symptoms?If symptoms continue for more than a week, schedule an appointment with a physician who has experience with this disease. You can also prepare a list of questions by reading through this section and watching our in-depth video Beyond the Shock®.
What is the typical age of IBC patients at diagnosis?The median age is between 45 and 55, but patients can be younger or older. In each individual case, the symptoms should guide the diagnosis rather than age.
How well do diagnostic tests work in identifying IBC?IBC typically CANNOT be identified through:
- Mammogram: Because IBC usually does not occur in the form of a lump (the cancer is spread throughout breast tissue), it is difficult to detect with a mammogram. The most characteristic mammography findings consist of swelling of the skin.
- Ultrasound:This test confirms the swelling (edema) of the skin and can better identify breast nodules (if present). It also is the most appropriate test for the evaluation of lymph nodes.
- Magnetic Resonance Imaging(MRI):This is probably the most sensitive test because it includes a functional description of the abnormal findings. It should be included among the diagnostic tests once the pathological diagnosis is confirmed. It is extremely useful in evaluating the clinical response to chemotherapy.
- Core biopsy:A core biopsy, or fine-needle aspiration (removal of tissue with a needle) is performed to obtain a pathological diagnosis of invasive disease, but these diagnostic procedures are not appropriate for IBC because of the peculiar growth pattern in the breast lymphatic system.
What diagnostic tests identify IBC?
IBC CAN be identified through:
Most of the time a surgical or skin biopsy is necessary. These procedures are able to collect larger samples that include the skin and underlying tissue to better identify cancer cells.
- Positron Emission Tomography (PET Scans): In the near future, this could be one of the most important diagnostic/staging tests for IBC, though it still is under study. Findings show that a PET scan enables clinicians to see more of the disease, for example:
— PET scans show lymph nodes far from the breast that can indicate a metastatic cancer at the time of diagnosis. If staging is limited to mammograms, CT (computed tomography or computerized X-rays) and bone scans, different components of this inflammatory spreading may be missed, resulting in significant consequences for treatment and the way in which a patient is processed.
What is the survival rate for IBC?The 5-year median survival rate for inflammatory breast cancer is approximately 40%. The main reasons for such a disappointing outcome include: a delay in diagnosis, the lack of expertise in treating IBC (because it is so rare) and the relative resistance the disease has to standard chemotherapeutic agents.
With regard to the first critical issue, it is important to keep in mind that IBC is a fast-growing cancer (it can spread within weeks), and it is often mistaken for something other than breast cancer, such as a rash or infection.
What are common mistakes in treating IBC?A surgeon might want to remove the breast too early, which would increase the chance of local recurrence (return of the disease).
A radiation oncologist with experience in treating IBC also is important. IBC might require a different schedule than most breast cancers. You might need two treatments a day, instead of one, because this is a highly aggressive tumor. Patients also need a specific chemotherapy dose. A particular challenge with treating IBC is that it is difficult to measure response since a nodule or mass is usually not present.
If patients have had incorrect treatment, it may be hard to go back and improve the prognosis (outcome).