Inflammatory Breast Cancer

A 40-year-old woman was concerned about an area of redness and tenderness on her left breast. Despite antibiotic therapy prescribed by another physician, the rash had progressed during the past month to erythema and nodules that involved the anterior chest and right breast.

A biopsy of a nodule revealed invasive ductal carcinoma with invasion of the dermal lymphatics. Inflammatory breast cancer was diagnosed.

Drs Kamal Boulous, Abdullah Altaych, Amier Harandi, Gamil Kostandy, and Hesham Taha of New York Methodist Hospital and Wycoff Heights Medical Center in Brooklyn, NY, report that inflammatory breast cancer is a relatively rare disease that affects 1% to 6% of all persons with breast cancer.¹ It is biologically aggressive and has a high rate of local recurrence and early systemic dissemination. Usually, the disease has metastasized at diagnosis; thus, the prognosis is poor.

Clinical features of inflammatory breast cancer include cutaneous edema (peau d'orange skin) and erythema involving more than one third of the breast. Tenderness, calor, breast enlargement, and nipple retraction also may be present.

Lesions of primary disease present acutely with erythema, edema, and ridging; there is often no palpable mass.² Secondary inflammatory breast cancer characteristically is a neglected, locally advanced condition featuring inflammatory-like changes that are caused by underlying necrosis and ulceration. Often, it is difficult to differentiate primary and secondary lesions. Dermal lymphatic invasion is present in both primary and secondary disease; this suggests that the mechanism for inflammatory skin changes is similar in both types of the disease.

The diagnosis of inflammatory breast cancer is made chiefly on clinical and pathologic evidence; however, mammography can identify inflammatory signs, such as edema and an increased vascular network. Thermography may be helpful by revealing a zone of hyperemia.

One study shows that the combined use of chemotherapy, surgery, and radiation provides the best locoregional tumor and distant metastatic control. Patients who received the multimodality therapy had a 5-year relapse-free survival rate of 40% compared with a 6% rate in those who received dual or single modality treatment.³ The 10-year disease-free survival rates were 35% and 0%, respectively.

Chemotherapy tends to destroy the micrometastatic foci present at the time of diagnosis. Since the initial response rate to chemotherapy is higher than 80%, consider combination chemotherapy at the outset of treatment. Long-term survival has been achieved with the use of cyclophosphamide, doxorubicin, and 5-fluorouracil.³

This patient was given induction chemotherapy with cyclophosphamide, doxorubicin, and 5-fluorouracil; the tumor regressed markedly and the inflammatory reaction disappeared. A modified radical mastectomy of the left breast was performed, followed by radiation therapy to the anterior chest wall.

REFERENCES:1. Levine PH, Steinhorn SC, Ries LG, Aron JL. Inflammatory breast cancer: the experience of the surveillance, epidemiology, and end results (SEER) program. J Natl Cancer Inst. 1985;74:291-297.
2. Taylor GW, Metzler A. Inflammatory carcinoma of the breast. Am J Cancer. 1938;38:33-49.
3. Perez CA, Fields JN, Fracasso PM, et al. Management of locally advanced carcinoma of the breast, II: inflammatory carcinoma. Cancer. 1994;74(suppl 1):466-476.