Inflammatory carcinoma of the breast

Inflammatory breast cancer defined: proposed common diagnostic criteria to guide treatment and research

PURPOSE

Inflammatory breast cancer is a deadly and aggressive type of breast cancer. A key challenge relates to the need for a more detailed, formal, objective definition of IBC, the lack of which compromises clinical care, hampers the conduct of clinical trials, and hinders the search for IBC-specific biomarkers and treatments because of the heterogeneity of patients considered to have IBC.

METHODS

Susan G. Komen, the Inflammatory Breast Cancer Research Foundation, and the Milburn Foundation convened patient advocates, clinicians, and researchers to review the state of IBC and to propose initiatives to advance the field. After literature review of the defining clinical, pathologic, and imaging characteristics of IBC, the experts developed a novel quantitative scoring system for diagnosis.

RESULTS

The experts identified through consensus several "defining characteristics" of IBC, including factors related to timing of onset and specific symptoms. These reflect common pathophysiologic changes, sometimes detectable on biopsy in the form of dermal lymphovascular tumor emboli and often reflected in imaging findings. Based on the importance and extent of these characteristics, the experts developed a scoring scale that yields a continuous score from 0 to 48 and proposed cut-points for categorization that can be tested in subsequent validation studies.

CONCLUSION

To move beyond subjective 'clinical diagnosis' of IBC, we propose a quantitative scoring system to define IBC, based on clinical, pathologic, and imaging features. This system is intended to predict outcome and biology, guide treatment decisions and inclusion in clinical trials, and increase diagnostic accuracy to aid basic research; future validation studies are necessary to evaluate its performance.

Dermal Lymphatic Invasion, Survival, and Time to Recurrence or Progression in Inflammatory Breast Cancer

OBJECTIVES

Dermal lymphatic invasion (DLI) with tumor emboli is a common pathologic characteristic of inflammatory breast cancer (IBC), although its presence is not required for diagnosis. We examined whether documented DLI on skin biopsy was associated with survival and time to recurrence or progression in IBC.

MATERIALS AND METHODS

A total of 340 women enrolled in the IBC Registry at Dana-Farber Cancer Institute between 1997 and 2019 were included in this study. Kaplan-Meier curves and multivariable Cox proportional hazards models were used to estimate hazard ratios and 95% confidence intervals for associations of DLI and overall survival, time to locoregional recurrence/progression, and distant metastasis by stage at presentation.

RESULTS

DLI was detected in 215 (63.2%) of IBC cases overall. At disease presentation, IBC with DLI had a higher prevalence of de novo metastases (37.7% vs. 26.4%), breast skin ulceration (6.1% vs. 2.4%), and lymphovascular invasion within the breast parenchyma (52.9% vs. 25.5%) and a lower prevalence of palpable breast mass (48.2% vs. 70.6%) than IBC without DLI. Over a median follow-up of 2.0 years, 147 deaths occurred. DLI was not associated with survival or recurrence in multivariable models (all P ≥0.10). For example, among women with stage III disease, hazard ratios (95% confidence intervals) for DLI presence was 1.29 (0.77-2.15) for overall survival, 1.29 (0.56-3.00) for locoregional recurrence, and 1.71 (0.97-3.02) for distant metastasis.

CONCLUSION

Although the extent of tumor emboli in dermal lymphatics may be associated with biological features of IBC, DLI was not an independent prognostic marker of clinical outcomes in this study.

Inflammatory breast cancer: A review from our experience

INTRODUCTION

Inflammatory Breast Cancer (IBC) is a distinct and rare type of breast cancer accounting for up to 6% of all breast cancer cases in Europe. The aim of this study was to investigate diagnostic methods, treatments, and outcome after IBC in patients treated at a single institution in Denmark.

METHOD

All patients treated for IBC at Aarhus University Hospital between 2000 and 2014 were identified and included in the cohort. Survival was assessed using Kaplan-Meier curves and log-rank statistics.

RESULTS

A total of 89 patients were identified with a median follow up of 3.6 years. The overall survival at 5 and 10 years were 41% and 18%, respectively. The disease free survival at 5 and 10 years were 47% and 27%, respectively. Thirty-four percent had distant metastasis at time of diagnosis. Patients with ER positive tumors had a significantly better overall survival than patients with ER negative tumors (p = 0.01).

CONCLUSION

Despite a more aggressive systemic and loco-regional treatment today, IBC is still a very serious disease with a high mortality.

Inflammatory Breast Cancer: a Separate Entity

PURPOSE OF REVIEW

Inflammatory breast cancer (IBC) is an uncommon but highly aggressive subtype of breast cancer that contributes significantly to breast cancer-related mortality. In this review, we provide an overview of the clinical and molecular characteristics of IBC, and highlight some areas of need for ongoing research.

RECENT FINDINGS

The disease is characterized by florid tumor emboli that obstruct dermal lymphatics, leading to swelling and inflammation of the affected breast. Recent studies have focused on tumor cell intrinsic features, such as signaling through pathways involved in growth and stem-like behavior, as well as extrinsic features, such as the immune system, that can be leveraged to develop new potential therapies. Key efforts have led to an increase in awareness of the disease as well as new insights into IBC pathogenesis. However, there is a strong need for new therapies designed specifically for IBC, and many unanswered questions remain.

Inflammatory breast cancer: A decade of experience

Inflammatory breast cancer (IBC) is an aggressive and rare form of breast cancer. At present, there are no established diagnostic, radiological, pathological or molecular diagnostic criteria for this entity. The aim of this study was to examine the patterns of presentation, treatment and outcomes of IBC in this institution over the course of a decade. This is a retrospective observational study using data from the Royal Perth Hospital from January 2001 to December 2010. Our results identified 57 women with IBC, representing 1.9% of all new breast cancer presentations. Human Epidermal Growth Factor Receptor 2 (HER2)-positive and triple negative tumors were overrepresented (41% and 18%, respectively). Forty-four (77%) patients had early disease at diagnosis, of whom 35 underwent surgery and 16 are relapse-free. All six patients achieving complete pathological response were relapse-free in contrast to 11 (38%) with lesser responses at a median follow-up of 59 months. Median survival in 13 patients with metastatic disease at diagnosis was 21.7 months, with two patients still in remission. Clearly, this small but important group continues to offer management challenges and warrants ongoing study, including better molecular and pathological profiling of tumors to allow improved diagnostic clarity and more effective targeted therapy.

A Brief Overview of the WHO Classification of Breast Tumors, 4th Edition, Focusing on Issues and Updates from the 3rd Edition

The WHO Classification of Tumors of the Breast, 4th edition, is an update to the 3rd edition that was published in 2003, and covers all neoplastic and preneoplastic lesions of the breast. Changes to the 4th edition include new aspects and changes to the terminology that reflect our present-day knowledge of these lesions. Definitions for histopathological diagnosis are complemented by a description of clinical features, epidemiology, macroscopy, genetics, and prognostic and predictive features. In this review of the WHO classification, we have focused on invasive carcinomas, precursor lesions, and some benign epithelial proliferations.

Assessment of diagnosis of inflammatory breast cancer cases at two cancer centers in Egypt and Tunisia

The diagnosis of inflammatory breast cancer (IBC) is largely clinical and therefore inherently somewhat subjective. The objective of this study was to evaluate the diagnosis of IBC at two centers in North Africa where a higher proportion of breast cancer is diagnosed as IBC than in the United States (U.S.). Physicians prospectively enrolled suspected IBC cases at the National Cancer Institute (NCI) - Cairo, Egypt, and the Institut Salah Azaiz (ISA), Tunisia, recorded extent and duration of signs/symptoms of IBC on standardized forms, and took digital photographs of the breast. After second-level review at study hospitals, photographs and clinical information for confirmed IBC cases were reviewed by two U.S. oncologists. We calculated percent agreement between study hospital and U.S. oncologist diagnoses. Among cases confirmed by at least one U.S. oncologist, we calculated median extent and duration of signs and Spearman correlations. At least one U.S. oncologist confirmed the IBC diagnosis for 69% (39/50) of cases with photographs at the NCI-Cairo and 88% (21/24) of cases at the ISA. All confirmed cases had at least one sign of IBC (erythema, edema, peau d'orange) that covered at least one-third of the breast. The median duration of signs ranged from 1 to 3 months; extent and duration of signs were not statistically significantly correlated. From the above-mentioned outcomes, it can be concluded that the diagnosis of a substantial proportion of IBC cases is unambiguous, but a subset is difficult to distinguish from other types of locally advanced breast cancer. Among confirmed cases, the extent of signs was not related to delay in diagnosis.

Correlation between the proportion of breast volume involved by locally advanced tumors and invasion of the skin and posterior structures

AIM: To evaluate any differences between the percentages of involved breast volume, pathologic attributes, and tumor marker expression of T3 and T4a-c tumors in locally advanced breast cancers (BC).

METHODS: All patients with T3N > 0 and T4a-c BC without evidence of distant metastasis (M0), presenting to the Breast Clinic from 1980 to 2010, were examined to determine whether their BC’s involved ≥ 50% of their breast volumes, defined by gross replacement of at least one hemisphere. Core needle biopsy or post-mastectomy specimens from tumors involving a known percent of breast volume were evaluated for: (1) pathological grades and lympho-vascular invasion (LVI); (2) hormone receptor (ER/PR) expression > 0; and (3) epidermoid growth factor 2 (her2) over-expression (3+) by immune-histochemical staining or fluorescent in situ hybridization.

RESULTS: The data base included 98 patients with T3N> 0 M0 and 120 with T4a-c, any N disease, M0 disease. T3 tumor masses involved 50% or more of the breast in 23/98 (24%), and T4a-c tumors 65/120 (54%) (P < 0.001). Only 1% of T3 tumors and 23% of T4a-c tumors presented with total breast replacement. There were no significant differences between the pathological attributes and marker expression of the T3 and T4a-c tumors.

CONCLUSION: These data suggest that erosion of the overlying skin or underlying chest wall by some BC may be due to neglect and delay, rather than inherent biological aggressiveness.

Inflammatory breast cancer: the disease, the biology, the treatment

Inflammatory breast cancer (IBC) is a rare and aggressive form of invasive breast cancer accounting for 2.5% of all breast cancer cases. It is characterized by rapid progression, local and distant metastases, younger age of onset, and lower overall survival compared with other breast cancers. Historically, IBC is a lethal disease with less than a 5% survival rate beyond 5 years when treated with surgery or radiation therapy. Because of its rarity, IBC is often misdiagnosed as mastitis or generalized dermatitis. This review examines IBC's unique clinical presentation, pathology, epidemiology, imaging, and biology and details current multidisciplinary management of the disease, which comprises systemic therapy, surgery, and radiation therapy.

What is inflammatory breast cancer? Revisiting the case definition

The case definition for inflammatory breast cancer (IBC) is controversial. The American Joint Committee on Cancer defines IBC as redness, warmth and edema involving at least half the breast. The SEER program relies on a pathologic finding of dermal lymphatic invasion and recently added those with clinical involvement of more than 3/4 of the breast. We established a registry to collect information and specimens from IBC patients to clarify the epidemiology and biology of these tumors. The goals of this report are to suggest improvements regarding case definitions and provide data on the variety of presentations relevant to early diagnosis.

Inflammatory breast cancer: MR imaging findings

PURPOSE

This paper describes the magnetic resonance (MR) imaging features of primary inflammatory breast cancer (IBC).

MATERIALS AND METHODS

Two radiologists reviewed the MR examinations of 14 women with a pathological diagnosis of IBC. Images were assessed for skin thickening, oedema, nipple retraction, architectural distortion, type and extent of parenchymal and cutaneous enhancement and enhancement kinetics over time, axillary and internal mammary lymphadenopathy, pectoral muscle enhancement and additional findings.

RESULTS

Skin thickening was identified in eight patients (58%), oedema in nine (64%), nipple retraction in two (14%), architectural distortion in eight (58%), mass-like enhancement in five (36%), non-mass-like enhancement in nine (64%) with washout enhancement curve in 12 (86%) and plateau curve in two (14%), axillary lymphadenopathy in 12 (86%) and internal mammary artery lymphadenopathy in two (14%), and pectoral muscle enhancement in one (7%). Additional findings included increased breast volume in two patients (14%), prepectoral fluid in four (28%) and hypertrophic internal mammary artery in three (21%).

CONCLUSIONS

The most characteristic MR findings of IBC are skin thickening, oedema, architectural distortion, mass-like enhancement with washout curve and axillary lymphadenopathy; less frequent ones are nipple retraction, mass-like enhancement and internal mammary lymphadenopathy. Prepectoral fluid is frequent but is not a sign of infiltration.

Dermal lymphatic invasion and inflammatory breast cancer are independent predictors of outcome after postmastectomy radiation

OBJECTIVES

Inflammatory breast cancer (IBC) is a clinical staging based on history and physical findings. Dermal lymphatic invasion (DLI) can occur with or without IBC. We examine how these independently affect outcome in women treated with postmastectomy radiation.

METHODS

Four hundred thirty-two patients treated with postmastectomy radiation for invasive mammary cancer were assessed. Kaplan-Meier methodology was used to calculate rates of locoregional recurrence (LRR), distant metastases (DM) and overall survival (OS). Variables entered into univariate and multivariate analysis included T stage, IBC, DLI, estrogen receptor/progesterone receptor status, HER-2/neu status, N stage, extracapsular node extension (ECE), and use of chemotherapy (CT). Median follow-up is 58 months.

RESULTS

For all 432 patients, the rate of LRR was 3% and DM 28%. Seven percent are alive with disease (AWD) and 26% are dead of disease (DOD). Thirty-one patients had IBC without DLI, 21 had DLI without IBC, and 18 had both IBC and DLI. For DLI 10% developed LRR, 45% DM, 7.5% are AWD and 50% are DOD. Of patients with IBC, 8% developed LRR, 44% DM, 8% are AWD and 48% DOD. DLI was the only significant independent predictor for LRR (HR 4.8, P < 0.05). Predictors of DM and OS were IBC, > or =4 positive nodes, and CT.

CONCLUSIONS

DLI and IBC are independent predictors of poor outcome after postmastectomy radiation. DLI is associated with an increased risk for LRR, and IBC with worse rates of DM and OS. Patients with both features have worse outcome than those with either alone.

Defining the clinical diagnosis of inflammatory breast cancer

Inflammatory breast cancer (IBC) is an extremely aggressive disease that progresses rapidly and carries a very grim prognosis. It is characterized by erythema, rapid enlargement of the breast, skin ridging, and a characteristic peau d'orange appearance of the skin secondary to dermal lymphatic tumor involvement. Although a palpable tumor may not be present, about 55% to 85% of patients will present with metastases to the axillary or supraclavicular lymph nodes. Diagnosis of IBC is made on the basis of these clinical characteristics, as well as histopathologic verification of carcinoma. Accurate diagnosis is critically important, as multimodal therapy can significantly improve outcomes if instituted early enough.

Epidemiology of inflammatory breast cancer (IBC)

Inflammatory breast cancer (IBC) is a rare and aggressive form of breast cancer with unknown etiology and generally poor outcome. It is characterized by diffuse edema (peau d'orange) and redness (erythema), although either the disease itself or case definitions have varied over time and place, confounding temporal trends and geographic variations. In this review, we discuss case definitions for IBC and its clinical characteristics; describe its geographic variation, age and racial distribution, incidence and survival patterns, and summarize the very limited information on its epidemiologic risk factors. We also incorporate emerging data from the National Cancer Institute's (NCI) Surveillance, Epidemiology, and End Results (SEER) Program.

Dermal lymphatic emboli in inflammatory and noninflammatory breast cancer: a French-Tunisian joint study in 337 patients

BACKGROUND

We studied whether dermal lymphatic emboli (DLE) add independent prognostic information to the clinical definition of inflammatory breast cancer (IBC).

PATIENTS AND METHODS

The study was performed in 2 centers, one each in France and Tunisia. For every patient with IBC, 1-3 patients with noninflammatory breast cancer (non-IBC) were included. All patients were to have a surgical tumor biopsy, including a sample of the skin surrounding the tumor. The endpoint was the risk of a relapse at 2 years, which was estimated using univariate and multivariate Cox models.

RESULTS

Three hundred thirty-seven patients were included (150 in France and 187 in Tunisia). The IBC status was divided into 2 clinical categories according to the extent of inflammation in the breast (localized IBC, which was defined as clinical inflammation in the tumor area, vs. diffuse IBC, which was defined as inflammation of at least two thirds of the breast). In total, 57 patients presented with localized IBC, 71 with diffuse IBC, and 209 with non-IBC. Dermal lymphatic emboli were found in 7% of non-IBC cases, in 25% of localized IBC cases, and in 45% of diffuse IBC cases. We found a significant interaction between the presence of DLE and diffuse IBC (P = 0.01). In patients with diffuse IBC, the presence of DLE increased the risk of relapse 3-fold. Conversely, DLE were not associated with the risk of relapse in patients with non-IBC, nor in patients with localized IBC. In patients with diffuse IBC and no DLE, the risk of relapse was similar to that of patients with localized IBC.

CONCLUSION

A DLE status might be a useful prognostic indicator exclusively in patients with diffuse IBC. However, because all patients with localized and diffuse IBC generally receive similar types of treatment, additional information on the presence or absence of DLE will not have an impact on treatment practice.

“Inflammatory” breast cancer

BACKGROUND

"Inflammatory" breast cancer is a rare and very aggressive form of the disease characterised by rapid onset and dismal outcome.

METHODS

This review describes the clinical and molecular aspects of inflammatory breast cancer. The relevant English language literature on of inflammatory breast cancer was searched via Medline and ISI Web of Knowledge Cross Search (1924-2005), cross-referencing with key articles on the subject.

RESULTS AND CONCLUSION

An increasing body of evidence demonstrates that inflammatory breast cancer is a unique form of breast cancer. A prompt diagnosis and multidisciplinary approach (based on neoadjuvant chemotherapy, loco-regional treatment with surgery and/or radiotherapy, followed in some cases by adjuvant systemic therapy) are the two factors most likely to have an impact on survival. As the molecular basis of the disease is becoming increasingly more defined, new potential therapeutic targets may arise in the future.

Are risk factors for breast cancer similar in women with inflammatory breast cancer and in those with non-inflammatory breast cancer?

PURPOSE

The aim of the study was to compare reproductive factors in patients with inflammatory breast cancer (IBC), and with non-inflammatory breast cancer (non-IBC). The study was performed in two centers: one French including 49 IBC patients and 140 non-IBC and another Tunisian including 97 IBC and 139 non-IBC. Unconditional logistic regression was used for the analyses.

PATIENTS AND METHODS

The French IBC patients had a lower educational level, a higher body mass index and a longer cumulative duration of breast-feeding, and they included a greater proportion of non-European women, than the non-IBC patients. In the multivariate analysis, only breast-feeding duration remained associated with the IBC status (P=10(-3)). These results could not be verified in the Tunisian series, because the duration of breast-feeding was unavailable in this center.

RESULTS

This study suggests that the etiology of IBC might be different of that of non-IBC.

Trends in inflammatory breast carcinoma incidence and survival: the surveillance, epidemiology, and end results program at the National Cancer Institute

BACKGROUND

Inflammatory breast carcinoma (IBC) appears to be a clinicopathologic entity distinct from noninflammatory locally advanced breast cancer (LABC). We examined incidence and survival trends for IBC in Surveillance, Epidemiology, and End Results (SEER) Program data with a case definition designed to capture many of its unique clinical and pathologic characteristics.

METHODS

We analyzed breast cancer cases diagnosed in the SEER 9 Registries (n = 180,224), between 1988 and 2000. Breast cancer cases were categorized using SEER's "Extent of Disease" codes in combination with International Classification of Diseases for Oncology morphology code 8530/3 and classified as IBC (n = 3648), LABC (n = 3636), and non-T4 breast cancer (n = 172,940). We compared changes in incidence rates over 3-year intervals by breast cancer subtype and race using SEER*Stat. Survival differences by breast cancer subtype and race were assessed using Kaplan-Meier curves and log-rank statistics. All statistical tests were two-sided.

RESULTS

Between 1988 and 1990 and 1997 and 1999, IBC incidence rates (per 100,000 woman-years) increased from 2.0 to 2.5 (P < .001), whereas those for LABC declined (2.5 to 2.0, P = .0025), as did those for non-T4 breast cancer (108 to 101, P = .0084). IBC incidence rates were statistically significantly higher in black women (3.1) than in white women (2.2) during the study period (P < .001). Women diagnosed with IBC had statistically significantly poorer survival than women with either LABC or non-T4 breast cancer (log-rank test, P < .001). Median survival of women with IBC (2.9 years) was statistically significantly shorter than that of women with LABC (6.4 years; P < .0001) or non-T4 breast cancer (> 10 years, P < .0001). Black women with IBC or LABC had poorer survival than white women with IBC or LABC, respectively (log-rank test, P < .001).

CONCLUSIONS

Throughout the 1990s, IBC incidence rose, and survival improved modestly. Substantial racial differences were noted in age at diagnosis, age-specific incidence rates, and survival outcomes.

Long-term results of combined-modality therapy for inflammatory breast carcinoma

Sixty-eight patients with inflammatory breast carcinoma (IBC) received treatment in 2 prospective randomized trials of multimodality therapy for locally advanced breast cancer. The treatment plan consisted of 3 courses of neoadjuvant chemotherapy with CAF (cyclophosphamide/doxorubicin/5-fluorouracil [5-FU]) or CEF (cyclophosphamide/epirubicin/5-FU) followed by surgery and 6 adjuvant courses of CAF or CEF alternated with CMF (cyclophosphamide/methotrexate/5-FU). Radiation therapy was administered at the end of adjuvant treatment. All patients with estrogen receptor-positive tumors received tamoxifen 20 mg daily for 5 years. The response rate to induction chemotherapy was 73.6% (95% CI, 61.4%-83.5%): 4 of 68 patients (6%) exhibited a pathologic remission of primary breast tumor (persistent disease in the axilla), and 2 patients (3%) exhibited a pathologic complete response. Median follow-up was 10 years (range, 5 months to 14.7 years). Disease-free survival (DFS) rates at 5 and 10 years were 29% and 20%, respectively, and median DFS was 2.2 years (range, 3.8 months to 11.5 years). Overall survival (OS) rates at 5 and 10 years were 44% and 32%, respectively, and median OS was 4 years (range, 5 months to 14.7 years). Significant prognostic factors for DFS and OS were the number of axillary nodes and residual disease in the breast at surgery. This analysis confirmed that patients with IBC obtained significant long-term survival benefit from combined-modality therapy.

Prognosis of dermal lymphatic invasion with or without clinical signs of inflammatory breast cancer

It is still an open debate whether tumor emboli in dermal lymphatics without inflammatory signs represent a similar bad prognosis like inflammatory breast cancer. We evaluated the prognostic role of dermal lymphatic invasion (DLI) in breast cancer with (DLI + ID) or without (DLI w/o ID) inflammatory disease (ID). From August 1988 to January 2000, 42 patients with DLI were irradiated. Twenty-five were classified as pT4, 13 out of them as pT4d (inflammatory disease); the 17 remaining patients had 1 T1c, 12 T2 and 4 T3 cancers with DLI. Axillary dissection revealed node-positive disease in 39/41 patients (median, 9 positive nodes). Thirty-eight out of 42 patients received adjuvant systemic treatment(s). After a mean follow-up of 33 months, 22/42 patients (52%) are disease-free. The actuarial 3-year disease-free survival is 50% (DLI w/o ID, 61%; DLI + ID, 31%; p < 0.03); the corresponding overall survival was 69% (DLI w/o ID, 87%; DLI + ID, 37%; p = 0.005). The presence or absence of ID was the only significant parameter for all endpoints in multivariate analyses. Dissemination occurred in 19 (45%), local relapse in 7 (n = 17%) and regional failure in 4 (10%). Nine patients (21%) had contralateral breast cancer/relapse. Despite the same histopathologic presentation, DLI w/o ID offered a significantly better disease-free survival and overall survival than ID. The finding of dermal lymphatic tumor invasion predicts a high probability for node-positive disease.

Inflammatory breast carcinoma: Outcomes with trimodality therapy for nonmetastatic disease

BACKGROUND

The objectives of this study were to summarize a single-institution experience in treating patients with inflammatory breast carcinoma (IBC) using trimodality therapy and to identify prognostic factors for outcome.

METHODS

Sixty-one women underwent radiation therapy with curative intent for IBC between 1982 and 2001. All but five women received trimodality therapy. Neoadjuvant chemotherapy was given to the majority of women (n = 43 patients), although some received "up-front" surgery as first therapy (n = 18 patients).

RESULTS

With a median potential observation time after diagnosis of 14 years, freedom from locoregional disease progression was 78%, freedom from distant metastasis was 45%, and the cause-specific survival rate was 47% at 5 years. Approximately 40% of the 56 patients who received trimodality therapy remained free of disease. Multivariate analysis demonstrated three factors that were found to be associated significantly with improved cause-specific survival: pathologic tumor size < 4 cm (P = 0.0001), up-front surgery (P = 0.0078), and local disease control (P = 0.0003). Factors that were found to be associated with better freedom from locoregional disease progression were pathologic tumor size (< 4 cm; P = 0.0157), age (> 55 years; P = 0.0596), and radiation dose (> or = 60 grays [Gy]; P = 0.0621).

CONCLUSIONS

IBC is an aggressive disease that is treated effectively in select patients by multimodality therapy. Patient outcomes may be improved with therapies that result in better local and systemic control. Further studies are warranted to address the optimal sequence of trimodality therapy and the optimal administration of each agent.

Inflammatory breast carcinoma and noninflammatory locally advanced breast carcinoma: distinct clinicopathologic entities?

PURPOSE

Inflammatory breast carcinoma (IBC) and noninflammatory locally advanced breast carcinoma (LABC) are both associated with poor prognosis; however, whether they are distinct clinicopathologic entities remains controversial.

MATERIALS AND METHODS

To determine whether IBC and LABC were different, we compared tumor characteristics, prognosis, and age-specific incidence rate patterns in the Surveillance, Epidemiology, and End-Results program. An age of 50 years served as a surrogate marker for menopause.

RESULTS

Younger age at diagnosis, poorer tumor grade, and negative estrogen receptors (ERs) were more predictive of IBC (n = 2,237) than of LABC (n = 7,985). Breast carcinoma survival was worse for patients with IBC than for those with LABC (log-rank test, P <.0001). Age-specific incidence rates for IBC increased until 50 years and then flattened, whereas rates for LABC increased for all ages. When rates for LABC were stratified by estrogen receptor-positive (ERP) and -negative (ERN) expression, rates for ERP and ERN diverged; that is, rates for ERP increased with advancing age, whereas rates for ERN flattened after 50 years. When rates for IBC were stratified by ER expression, rates for both ERP and ERN flattened after 50 years of age.

CONCLUSION

IBC and LABC seemed to be distinct biologic entities, as indicated by different prognostic factor profiles and age-specific incidence rate patterns. Rates that increased before 50 years and then stabilized, possibly indicated that premenopausal exposures had a greater effect on maintaining rates for IBC than for LABC.

Prognoses of T4 breast cancer subsets

BACKGROUND

The relative prognoses of subsets of patients with T4 breast tumors, since the advent of neoadjuvant therapy, are unknown, although inflammatory carcinoma (T4d) is considered to have the worst prognosis.

METHODS

Subsets of T4 patients were analyzed for the incidence of distant metastases at presentation (M1; n = 263). T4M0 patients treated with neoadjuvant therapy (n = 126) were analyzed for relapse-free survival (RFS). T4d tumors with (Cut/CW+) and without (Cut/CW-) skin nodules, posterior fixation, or both were analyzed separately.

RESULTS

Fewer patients with T4d (Cut/CW-) tumors had distant metastases at presentation than T4d (Cut/CW+) patients or T4b and T4c patients (P =.001,.001, and.009, respectively). RFS was longer for T4b patients than for T4c patients (P =.018) or T4d (Cut/CW+) patients (P =.003). RFS of the T4d (Cut/CW+) patients was shorter than for T4d (Cut/CW-) patients (P =.050).

CONCLUSIONS

The incidence of distant metastases at presentation was lowest, and RFS was longest, for patients with T4d tumors not grossly involving the skin or posterior structures. Patients whose tumors grossly invaded both skin and posterior structures (T4c) or those with T4d tumors grossly invading either most frequently presented with distant metastases and had the shortest RFS.

Inflammatory breast carcinoma: pathological or clinical entity?

Inflammatory breast carcinoma (IBC) diagnosis is usually based in the presence of typical clinical symptoms (redness and edema in more than 2/3 of the breast), which are not always associated with pathologic characteristics (subdermal lymphatics involvement). Whether exclusively pathologic findings without clinical symptoms are sufficient for IBC diagnosis remains controversial. A retrospective analysis of 163 clinically diagnosed IBC (CIC) either with dermal lymphatics invasion or not, was compared with another group of 99 patients with dermal lymphatics invasion without clinical symptoms (occult inflammatory carcinoma) (OIC). The following clinical and pathological characteristics have been analyzed and compared: age, menopausal status, clinical axillar node involvement, symptoms duration before diagnosis, grade, estrogen receptors, presence of metastases at diagnosis, local recurrence, metastasic dissemination, disease-free (DFS) and overall survival (OS). Median age was younger in CIC (52.3 vs. 63.8 years; p < 0.001). Symptom duration before diagnosis were significantly shorter in CIC (3.4 vs. 6.8 months: p < 0.0001). Visceral (36.2% vs. 17.2%; p = 0.001) and brain metastases (7.4% vs. 1%; p = 0.02) was significantly more frequent in CIC. Negative estrogen receptors were more frequent in CIC (34.9% vs. 65.1%: p < 0.004). Five-years DFS (25.6 vs. 51.6%; p < 0.0001) and OS (28.6 vs. 40%; p < 0.05) were shorter in CIC. CIC (regardless of subdermal lymphatics involvement) must be clearly differentiated from OIC. Prognosis of CIC patients is poorer, so this two entities should be clearly differentiated when therepeutic results are reported.

Continuous infusional combination chemotherapy in inflammatory breast cancer: a phase II study

Despite the introduction of systemic chemotherapy, inflammatory breast cancer (IBC) remains a disease with a poor prognosis. We performed this phase II study to evaluate the efficacy of infusional chemotherapy as initial treatment in patients with IBC. Fifty-four patients with newly diagnosed IBC were offered infusional chemotherapy and 34 accepted. The schedule consisted of continuous infusional ECF (bolus epirubicin and cisplatin, substituted by carboplatin or cyclophosphamide in some patients) plus continuous 5-FU, given three weekly for six cycles. Following chemotherapy patients went on to have surgery and/or radiotherapy. The chemotherapy was well tolerated and resulted in an overall response rate of 79% with 35% of patients achieving a complete clinical response. The median response duration, time to progression and overall survival were 12 months (4-89+ months), 12 months (4-89+ months) and 23 months (7-89+ months), respectively. Patients had a 5 year disease free and overall survival of 11% and 29%, respectively. Infusional ECF is well tolerated and achieves a high clinical response rate in patients with IBC, but survival results do not appear to be superior to those achieved with conventional bolus chemotherapy schedules.

Inflammatory metastatic melanoma

An 87-year-old woman developed erythema, induration and tenderness of the skin overlying each breast. One year before, she had undergone an axillary lymph node dissection because of metastases from melanoma. The primary site was unknown. A skin biopsy showed pigmented tumor nests within the dermal lymphatic vessels, and immunohistochemistry confirmed the melanocytic origin. The diagnosis of inflammatory metastatic melanoma was made.

Melanoma-in-transit presenting as panniculitis

Malignant melanoma presenting as an inflammatory skin metastasis has been described but is an exceedingly rare phenomenon. We report an unusual case of a patient who developed right leg lesions that were initially thought to be infectious in origin. There was no resolution of these lesions with antibiotic therapy, and the patient subsequently underwent an incisional biopsy that showed atypical S-100 positive cells within dermal vessels. On further questioning, the patient revealed that 20 years earlier she had a pigmented lesion removed from her right posterior calf. Review of that material revealed malignant melanoma, approximately 3.2 mm in depth. Although the patient was subsequently treated with a right groin lymph node dissection and isolated limb perfusion chemotherapy, she has continued to develop locally recurrent disease. This case is unusual both in terms of clinical presentation and interval of disease progression.

Male breast cancer: a review of the literature

Although breast cancer is uncommon in men, it can cause significant morbidity and mortality. The current review was undertaken to determine whether strategies applied for the evaluation and treatment of breast cancer in females are appropriate in male breast cancer. Male breast cancer has biological differences compared with female breast cancer, including a high prevalence in certain parts of Africa, a higher incidence of oestrogen receptor positivity and more aggressive clinical behaviour. It responds to hormonal manipulation and chemotherapy, but optimal treatment regimens in males are unknown. Male breast cancer remains an uncommon disease. Most of our current knowledge regarding its biology, natural history and treatment strategies has been extrapolated from its female counterpart. Much research is needed to further characterise the molecular biological properties of male breast tumours and their prognostic significance, and to devise treatment strategies, including optimal chemotherapy regimens.

Inflammatory breast carcinoma: a community hospital experience

BACKGROUND

Inflammatory breast cancer (IBC) is a rare form of rapidly progressive breast cancer. We reviewed the diagnosis, treatment, and outcome of IBC in our inner city community-based hospital and compared results with previous published reports.

STUDY DESIGN

Twenty-five patients were diagnosed and treated for IBC at the Catholic Medical Center of Brooklyn and Queens during the 6-year period of January 1989 through December 1995. Criteria for inclusion in this study were clinical or histopathologic evidence, or both, of inflammatory carcinoma.

RESULTS

IBC comprised 2.0% (25 of 1,257) of all breast cancer patients initially diagnosed during this study. All presented with clinical signs of IBC. Invasion of dermal lymphatics by neoplastic cells was demonstrated in 68% (17 of 25) of biopsy specimens. Sixty-eight percent (17 of 25) of patients presented with metastatic (ie, stage IV) disease and 28% (7 of 25) with stage IIIb; one patient (4%) died before staging. Estrogen and progesterone receptor studies were done on 72% (18 of 25) of all specimens. Of those patients who died, 85% were estrogen and progesterone receptor negative; of those surviving, 60% were estrogen receptor positive. Twenty (80%) of the 25 patients died, after a mean survival of 11.8 months and 5 (20%) remain alive, with a mean survival of 44.8 months. Of those who died, 85% were stage IV at presentation. All five survivors were stage IIIb at presentation. Patients underwent a variety of multimodal therapies. Survival was significantly associated with earlier stage at diagnosis and estrogen receptor positivity.

CONCLUSIONS

IBC is characterized by rapid progression and dismal outcome. Earlier stage at diagnosis and positive estrogen receptor status suggest a more favorable prognosis. Neoadjuvant chemotherapy, as part of a multimodal approach, has significantly improved the outcome for IBC, but this is limited to patients with stage IIIb disease. Most of our patients presented with stage IV disease. If improvement is to be realized at the community level, limited health care resources must be directed toward aggressive physician and public education.

Fine-needle aspiration of inflammatory carcinoma of the breast

Inflammatory carcinoma of the breast is an uncommon clinicopathologic entity which is characterized by a distinctive clinical appearance and poor prognosis. Histopathologically, it is characterized by plugging of dermal lymphatics with tumor emboli. Because this lesion usually does not form a discrete palpable mass, it is not as amenable to diagnosis by fine-needle aspiration (FNA) as other breast lesions. In the following, we report our experience with establishing the diagnosis of inflammatory carcinoma by FNA. Three patients underwent FNA for confirmation of clinically suspected inflammatory carcinoma. All aspirations were performed by a cytopathologist and required multiple passes to obtain diagnostic material. Aspirates were paucicellular and contained fragments of fibrous or adipose tissue. Malignant cells were predominantly distributed in tight, three-dimensional clusters and were identifiable as tumor cells based on large size, nuclear irregularity, and increased nuclear to cytoplasmic ratio. Unlike aspirates from conventional breast carcinoma, individual dispersed cells and cellular discohesiveness were not prominent features. Subsequent histologic material from these patients revealed the characteristic tumor emboli plugging dermal lymphatics. We conclude that in the appropriate setting, the diagnosis of inflammatory carcinoma can be established by FNA.

Inflammatory breast cancer: the evolution of multimodality treatment strategies

Inflammatory breast cancer is an aggressive subtype of invasive breast cancer. Early attempts to control the disease with local treatment modalities alone had a minimal impact on survival. More recently, multimodality treatment approaches that integrate systemic chemotherapy, surgery, and radiotherapy have resulted in improved local disease control and prolonged survival. Better systemic therapies need to be developed since metastatic disease develops in the majority of patients.

Inflammatory breast cancer

Multimodal therapy with induction chemotherapy has improved significantly local disease control and overall survival in patients with IBC. This is now considered standard therapy for patients with this disease. Although survival has been improved, well over 50% of these patients will succumb to this disease. Ongoing and future investigations may better define the optimal approach for local control, the optimal duration of maintenance chemotherapy, and the possible role of biologic response modifiers and growth factors in further improving the outcome for patients with this disease.

Male breast carcinoma: an evaluation of prognostic factors contributing to a poorer outcome

BACKGROUND

Although breast cancer in men is far less common than breast cancer in women, it is associated with a less favorable prognosis. Conventional histopathologic features and new prognostic markers were evaluated to explain the less favorable survival outcome.

METHODS

Forty-six consecutive male breast carcinomas were studied for size, histologic and nuclear grade, histologic subtype, presence of carcinoma in situ, nipple involvement, lymphovascular invasion, hormone receptor status, c-erbB-2 protein overexpression, and p53 protein accumulation. These findings were correlated with survival.

RESULTS

Of the 46 carcinomas, 4 were noninvasive and 42 were invasive. In the invasive carcinomas, the median patient age was 64 years, and the median tumor size was 2 cm. The predominant histologic patterns were invasive ductal (45%) and mixed invasive ductal and cribriform (28%). Most tumors were of low histologic and nuclear grades (histologic grades: I, 17%; II, 50%; III, 33%; nuclear grade: I, 12%; II, 44%; III, 44%). Of those surgically staged, 22 patients (60%) were lymph node positive and 15 patients (40%) were node negative. Stage at presentation was higher than in women (0, 10%; 1, 17%; 2, 50%; 3, 13%; 4, 10%). The estrogen and progesterone receptor status was positive in 76% and 83% of tumors, respectively. Lymphatic vessel invasion (63%) and nipple involvement (48%) were also more common than in women. True Paget's disease of the nipple was not seen; all cases with nipple ulceration were the result of direct tumor extension to the epidermis. Of the 17 tumors tested, 41% were c-erbB-2 positive and 29% were p53 positive. Survival analysis was limited by the relatively small cohort size. Five- and 10-year adjusted overall survival rates for invasive tumors were 76 +/- 7% and 42 +/- 9%, respectively. Skin and nipple involvement (P = 0.03) and c-erbB-2-positivity (P = 0.03) were significant predictors of adverse survival.

CONCLUSIONS

Male breast carcinoma presents in an advanced stage with less favorable survival, despite low histologic grade, high estrogen receptor content, and small size. Anatomic factors may have been responsible for the poor survival outcome (i.e., paucity of breast tissue and close tumor proximity to skin and nipple, facilitating dermal lymphatic spread and early regional and distant metastasis).

Inflammatory breast carcinoma

Inflammatory breast cancer (IBC) is a rare subtype of breast cancer traditionally associated with an extremely poor prognosis. The appearance of the effected breast can be misleading, with the incorrect diagnosis of an infective process, rather than a malignant disease, further delaying treatment. Compared with the results achieved by monotherapy with either surgery, radiotherapy or chemotherapy; multimodality treatments have achieved significant improvements in both disease-free and overall survival. The purpose of this article is to provide a comprehensive review of the current literature and highlight those areas where potential advances in the overall management of IBC have been made.

Histopathologic aspects of cutaneous metastatic disease

In cutaneous metastatic disease the histologic pattern may be specific or nonspecific. Carcinoma cutis most often shows only the nonspecific pattern of an adenocarcinoma, a squamous cell carcinoma, or an undifferentiated metastatic tumor. However, certain clinical and histologic characteristics may suggest a primary tumor site and type. In addition, special histologic stains and the use of immunohistochemical and electronmicroscopic techniques may also prove valuable in the diagnosis of carcinoma cutis and other cutaneous metastatic diseases.

Inflammatory carcinomas of the breast: a clinical, pathological, or a clinical and pathological definition?

Some controversy remains about the clinical or pathological definition of the different types of inflammatory breast cancer (IBC) and especially the diagnostic and prognostic value of dermal lymphatic involvement. Our purpose was to classify the different types of IBC for which diagnosis was confirmed intraoperatively and ascertain features allowing reliable diagnosis. We studied clinical findings, biological data, and treatment outcome in a series of 144 successive patients. Our results suggest that there are 2 biologically different entities i.e., true IBC and pseudo-IBC. True IBC, whose course is currently fatal in all cases, can be divided into 2 sub-categories i.e., common true IBC (75.7% of cases), in which inflammatory signs occur primarily or secondarily, and occult true IBC (13.2% of cases). Dermal emboli have been observed in 61% of common true IBC, but their absence did not alter the rapidly unfavourable outcome. Extensive lymph-node involvement, other biological features and survival were the same in the 2 sub-categories. Pseudo-IBC (11.1% of cases) can easily be confused with common true IBC. The biological characteristics of pseudo-IBC differ from those of true IBC: no dermal lymphatic involvement and little or no lymph-node involvement. Despite large tumour size, outcome was particularly favourable. It is of great importance to differentiate true and pseudo-IBC, for which the treatments are different. Confirmation of true IBC requires pathological demonstration of dermal lymphatic emboli or extensive lymph-node involvement. Occult IBC must be identified for patients presenting rapidly growing tumours.