Inflammatory breast cancer: Clinical sciences

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Introduction0:00–0:26

Inflammatory breast cancer is a highly aggressive form of locally advanced breast cancer. Due to similarities in physical appearance, inflammatory breast cancer can sometimes be mistaken for benign diseases such as acute mastitis.
Therefore, careful consideration must be given to rule out underlying malignancy if the benign disease doesn’t respond or quickly resolve with treatment.

History and physical0:26–2:27

When assessing a patient with a chief concern suggestive of inflammatory breast cancer, the first step is to obtain a focused history and physical exam, as well as labs such as CBC, CMP, LFTs, and Alkaline Phosphatase.
Now, history might reveal breast pain, and a firm or enlarged breast, with rapid onset of symptoms, usually within 6 months.
Some patients may report breast pruritus, swollen lymph nodes in the axilla or above the clavicle, fever, or even a recent history of suspected acute mastitis that hasn’t responded to antibiotics.
On the other hand, a physical exam typically shows a warm, tender breast, with extensive erythema that involves at least one-third of the breast, and thickened skin.
A very common skin finding is called peau d’Orange. This occurs when tumor microemboli block dermal lymphatics, leaving portions of the breast with an edematous and dimpled orange-peel appearance.
While peau d’Orange is highly associated with inflammatory breast cancer, it is important to remember that it might not always be present!
Other possible findings on physical exam include nipple changes, such as flattening or retraction, a palpable underlying breast mass, and regional lymphadenopathy, most commonly in the axilla.
Finally, labs can show leukocytosis, and possibly elevated transaminases or alkaline phosphatase, which is concerning for metastatic disease to the liver or bones, respectively.
Here’s a clinical pearl for you! Significant fever, leukocytosis, and acute onset within a few days are rare in inflammatory breast cancer but common in acute mastitis.
While these findings on their own can’t rule out an underlying malignancy, their prompt response to treatment with resolution can support a benign diagnosis.
Alright, now that we’ve finished our history and physical exam, let’s move on to imaging. To start, obtain a diagnostic mammogram of the affected breast as well as a screening mammogram of the other breast.

Imaging2:27–2:44

Also, get an ultrasound of the breasts and their regional lymph node basins. Okay, let’s go over the simple stuff first.
If the mammogram and ultrasound do not show any signs concerning for breast cancer, consider an alternative diagnosis, such as the previously mentioned acute mastitis.

Alternative diagnosis2:44–2:58

Let’s switch gears and talk about findings that are concerning for inflammatory breast cancer. Keep in mind that you’re looking for evidence of underlying invasive breast cancer and that inflammatory breast cancer does not have specific or unique radiographic characteristics.

Inflammatory breast cancer2:58–3:50

On a mammogram, you might encounter skin thickening, increased breast density, and evidence of edema or trabeculation, which refers to the thickening of fibrous septa within the breast.
You may or may not find an underlying breast mass or the presence of calcifications. Ultrasound will also show skin thickening and edema, and possibly an underlying mass or regional lymphadenopathy.
If you see any of these signs, suspect inflammatory breast cancer. Ok, now that initial imaging is done, the next step is to get a breast biopsy.
For inflammatory breast cancer, this means a core needle biopsy and typically two skin punch biopsies as well. While the vast majority of inflammatory breast cancers result from invasive ductal carcinoma, invasive lobular carcinoma is possible, too.

Biopsy3:50–4:37

The core needle biopsy will show malignant epithelial cells that have invaded through the basement membrane of the breast duct or lobule.
Here’s a clinical pearl to keep in mind! On skin punch biopsy, the presence of tumor cells infiltrating dermal lymphatics is a very common finding, but is not mandatory!
Now that our diagnosis is confirmed with the biopsy, the next move is to stage cancer using the TNM system. TNM stands for Tumor size and extent, spread to lymph Nodes, and Metastasis or spread to distant parts of the body.
To stage cancer, you’ll need to order a CT scan of the chest, abdomen and pelvis, as well as a bone scan, to look for any metastatic disease.

TNM staging4:37–5:41

If the patient has any suspicious lymph nodes, either on physical exam or imaging, obtain an ultrasound-guided fine needle aspiration of the node to further investigate.
Also, establish tumor receptor status for estrogen, progesterone, and HER2; and repeat a full set of labs, including LFTs and alkaline phosphatase.Here’s another clinical pearl!
All inflammatory breast cancers involve the skin and are considered locally advanced, which means that they are always at least stage three.Okay, let’s go back to TNM staging.
First, you might find that the patient has no metastatic lesions. In this case, start with neoadjuvant chemotherapy and consider immunotherapy and endocrine therapy.
Then, assess your patient’s response to treatment.Now, if you notice that the tumor shrunk, or symptoms improved, that means that there’s a positive response to chemotherapy.

No metastases5:41–7:05

In this case, go ahead and consult the surgery team. Unlike other forms of breast cancer, breast-conserving therapy is unfortunately not an option, and patients need to undergo non-skin-sparing mastectomy with axillary dissection.
Then, initiate post-surgical radiation therapy. To maximize the efficacy of radiation therapy, delay breast reconstruction until after radiation therapy is complete.
If the patient fully completes neoadjuvant chemotherapy, no additional chemotherapy will be needed. However, if indicated, they can continue medical therapy, such as hormone therapy for hormone-sensitive tumors, or immunotherapy for HER2-positive tumors.
On the other hand, if there’s no response to neoadjuvant chemotherapy, meaning that the tumor and symptoms remain roughly the same, start supportive care and consider palliative care.Alright, now that the treatment for patients without metastases is complete, Let’s go back to staging and talk about metastatic disease.
When patients have stage four disease, the treatment goal is to prolong survival, minimize symptoms, and maximize the patient's quality of life.
In this case, you will once again start with chemotherapy. Keep in mind that these patients aren’t surgical candidates.

Metastatic disease7:05–7:50

Palliative mastectomy can be considered for patients with necrotic wounds. Next, if appropriate, initiate immunotherapy and hormone therapy, and consider enrollment in clinical trials if the patient is a candidate.
Finally, additional palliative adjuvant chemotherapy might be necessary as well. Alright, as a quick recap… Inflammatory breast cancer is a highly aggressive form of locally advanced breast cancer.
When assessing patients, start with a mammogram and ultrasound, and if the patient has evidence of underlying breast cancer proceed with a core needle biopsy and skin punch biopsy.
Once a diagnosis is made, inflammatory breast cancer should be staged with a CT of the chest, abdomen and pelvis, as well as bone scan, and FNA of lymph nodes.

Review7:50–8:44

Lastly, treatment is based on the stage. In patients with no metastasis, start with neoadjuvant chemotherapy and consider immunotherapy and endocrine therapy.
If the tumor responds, consult the surgery team for non-skin-sparing mastectomy with axillary dissection and post-surgical radiation.
On the other hand, in patients with metastasis, start with chemotherapy, and consider palliative mastectomy or enrollment in clinical trials.
as bone scan and fna of lymph nodes Lastly treatment is based on the stage in patients with no metastasis start with neoadjuvant chemotherapy and consider immunotherapy and endocrine therapy if the tumor responds consult the surgery team for nons skis sparing mastectomy with axillary dissection and post-surgical radiation On the other hand in patients with metastasis start with chemotherapy
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