Breast—Inflammatory Breast Cancer
Concept
Poor prognosis regardless of therapy offered. Do want to try to provide local control. Need to look for tumor cells in subdermal lymphatics and treat aggressively.
Differential diagnosis includes mastitis, abscess, Mondor’s disease, and inflammatory breast CA.
Way Question May be Asked?
“A 58 y/o female presents to your office complaining of a breast infection. Examination reveals an erythematous, ede- matous right breast. What do you want to do?” May also be given a failed course of antibiotics, a history of trauma, or recent breast-feeding/nursing to try to lead you astray.
How to Answer?
History
Risk factors:
Family history Prior breast surgery History of malignancy
Age menarche, menopause, 1st pregnancy Estrogen use (OCPs)
Important questions:
History of trauma Nursing
Time course
Breast self exams (palpable masses before inflammation?)
Physical Exam
Examine both breasts (peau d’orange)
Examine lymph node basins (cervical/axillary) Palpable cord (Mondor’s disease)
Diagnostic Tests (in all Breast Questions!)
Mammogram (bilateral) U/S (if mass)
MRI (usually for palpable lesion not seen on mammo or U/S)
DDx
Mastitis Breast abscess
Superficial thrombophlebitis (palpable cord) Inflammatory breast cancer
Surgical Treatment
(1) Okay to try short course antibiotics (1 week) (2) If fails to resolve or strong suspicion, get incisional
biopsy (including skin) through reddened area and include adjacent normal skin (some recommend FNA because clinical grounds confirm stage of dis- ease and you just want a dx of cancer to start chemotherapy, but you get more info from core nee- dle or incisional biopsy—ER/PR receptor status) (3) If pathology confirms inflammatory breast Ca
(tumor in subdermal lymphatics), proceed with metastatic work-up
(a) CXR
(b) CT scan head/abd/pelvis (look for metastases) (c) Bone scan
(d) +/− PET scan
(4) Three cycles of chemotherapy (usually multi-agent) (5) Algorithm
(a) if pt has complete response→ MRM to aug- ment local control, followed by eight cycles of chemo, chest wall radiation, and tamoxifen if ER/PR positive
(b) no response→ chest wall radiation, MRM 7 Part 1.qxd 10/19/05 2:51 AM Page 7
8 Breast—Inflammatory Breast Cancer
(6) If already eroding through skin, can give XRT up front to shrink tumor (also works if grossly eroding through skin and infected)
Common Curveballs
Will erode through skin during treatment Pt will not have response to chemo Pt will be pregnant
Pt will somewhat respond during antibiotic treatment Pt will have mass/abnL mammogram for opposite
breast
Pt will develop DVT during chemo (switch scenario) Pt will push towards saving her breast or immediate
reconstruction (NO!)
FNA positive but can’t get any receptor information (need to do core or incisional biopsy)
Pt will develop lymphedema post ALND
Strikeouts
Not performing FNA instead of incisional biopsy (need receptor status)
Not recognizing inflammatory breast cancer as a T4 lesion
Not performing biopsy at all but proceeding straight to chemotherapy
Not performing mastectomy at end of neoadjuvant therapy (even if complete clinical resolution) Not treating first with chemotherapy but proceeding
straight with mastectomy
Talking about MRI (PET scan only be appropriate here for complete staging purposes)
Trying breast conservation/breast reconstruction Trying to perform SLN Bx’s
Part 1.qxd 10/19/05 2:51 AM Page 8
