Inflammatory breast cancer

Homeoprotein DLX4 expression is increased in inflammatory breast cancer cases from an urban African-American population

Protein expression of Distal-less homeobox 4 (DLX4) was analyzed in inflammatory breast cancer (IBC) cases from an African-American (AA) population to determine if a) DLX4 gene over expression exists in this cohort and b) if the overexpression is associated with breast cancer clinicopathological characteristics (ER, PR, HER2, triple-negative). Twenty-nine blocks of formalin-fixed paraffin-embedded (FFPE) tissue from well-characterized human IBC cases were used for immunohistochemical staining (IHC). IHC results were assigned an intensity and percentage score. Percentage scores were assigned as 0, 1, 2, 3, or 4 and intensity scores were assigned 0, 1+, 2+ or 3+. For the analysis of the IHC, a percentage score of 3 or 4 and an intensity score of 2+ or 3+ were categorized as high. Chi-square or Fisher's exact tests were used to compare the high and low groups. In this cohort, 89.7% (26 out of 29) of IBC cases showed high percentages of positive cells staining for the DLX4 protein, while 40.0% (12 out of 30) of normal breast tissue from reduction mammoplasty cases demonstrated DLX4 expression (p < 0.01). In IBC patients, 65.5% of cases showed a high level of staining intensity, compared to 20.0% of normal breast tissues (test, p = 0.001). Intensity to DLX4 was higher in the HER2 negative status (78.3%) than the HER2 positive status (16.7%) (test, p = 0.011). DLX4 expression is higher in the IBC cases in this study of an urban AA population than in normal breast tissue cases. HER2 negative status is positively associated with high intensity of DLX4.

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.

Abrogation of TGF-beta signaling enhances chemokine production and correlates with prognosis in human breast cancer

In human breast cancer, loss of carcinoma cell-specific response to TGF-beta signaling has been linked to poor patient prognosis. However, the mechanisms through which TGF-beta regulates these processes remain largely unknown. In an effort to address this issue, we have now identified gene expression signatures associated with the TGF-beta signaling pathway in human mammary carcinoma cells. The results strongly suggest that TGF-beta signaling mediates intrinsic, stromal-epithelial, and host-tumor interactions during breast cancer progression, at least in part, by regulating basal and oncostatin M-induced CXCL1, CXCL5, and CCL20 chemokine expression. To determine the clinical relevance of our results, we queried our TGF-beta-associated gene expression signatures in 4 human breast cancer data sets containing a total of 1,319 gene expression profiles and associated clinical outcome data. The signature representing complete abrogation of TGF-beta signaling correlated with reduced relapse-free survival in all patients; however, the strongest association was observed in patients with estrogen receptor-positive (ER-positive) tumors, specifically within the luminal A subtype. Together, the results suggest that assessment of TGF-beta signaling pathway status may further stratify the prognosis of ER-positive patients and provide novel therapeutic approaches in the management of breast cancer.

Metastatic esophageal carcinoma masquerading as inflammatory breast carcinoma

A 50-year-old Caucasian woman with a history of esophageal adenocarcinoma presented with a 3-week history of right breast swelling and progressive erythema. Twenty-two months prior to presentation, she had been diagnosed with adenocarcinoma of the esophagus (T3,N1,M1a) and underwent neoadjuvant chemoradiotherapy followed by surgical resection. On physical examination, the right breast was red, swollen (40% larger than the contralateral breast), tender to palpation, and warm to the touch (Fig. 1). No mass was palpable. On the basis of the clinical findings, inflammatory breast carcinoma was suspected. A punch biopsy revealed a poorly differentiated adenocarcinoma with extensive involvement of dermal lymphatics (Fig. 2). The clinical and histologic differential diagnosis included inflammatory breast carcinoma vs. metastatic esophageal adenocarcinoma to the skin of the breast. To resolve this question, immunohistochemical stains for estrogen and progesterone receptors and CDX-2 (BioGenex, San Ramon, CA, USA) were performed. CDX-2 is an intestinal homeobox gene expressed in gastrointestinal epithelium and gastrointestinal tumors. The tumor nuclei were positive for CDX-2 but negative for both steroid receptors (Fig. 3), confirming the diagnosis of metastatic esophageal adenocarcinoma.

“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.

In vitro analysis of the invasive phenotype of SUM 149, an inflammatory breast cancer cell line

Background

Inflammatory breast cancer (IBC) is the most lethal form of locally invasive breast cancer known. However, very little information is available on the cellular mechanisms responsible for manifestation of the IBC phenotype. To understand the unique phenotype of IBC, we compared the motile and adhesive interactions of an IBC cell line, SUM 149, to the non-IBC cell line SUM 102.

Results

Our results demonstrate that both IBC and non-IBC cell lines exhibit similar adhesive properties to basal lamina, but SUM 149 showed a marked increase in adhesion to collagen I. In vitro haptotaxis assays demonstrate that SUM 149 was less invasive, while wound healing assays show a less in vitro migratory phenotype for SUM 149 cells relative to SUM 102 cells. We also demonstrate a role for Rho and E-cadherin in the unique invasive phenotype of IBC. Immunoblotting reveals higher E-cadherin and RhoA expression in the IBC cell line but similar RhoC expression. Rhodamine phalloidin staining demonstrates increased formation of actin stress fibers and larger focal adhesions in SUM 149 relative to the SUM 102 cell line.

Conclusion

The observed unique actin and cellular architecture as well as the invasive and adhesive responses to the extracellular matrix of SUM 149 IBC cells suggest that the preference of IBC cells for connective tissue, possibly a mediator important for the vasculogenic mimicry via tubulogenesis seen in IBC pathological specimens. Overexpression of E-cadherin and RhoA may contribute to passive dissemination of IBC by promoting cell-cell adhesion and actin cytoskeletal structures that maintain tissue integrity. Therefore, we believe that these findings indicate a passive metastatic mechanism by which IBC cells invade the circulatory system as tumor emboli rather than by active migratory mechanisms.

Ten-year outcome after combined modality therapy for inflammatory breast cancer

PURPOSE

To evaluate the long-term outcome of combined modality therapy for inflammatory breast cancer.

METHODS AND MATERIALS

The data from 54 women treated between 1983 and 1996 for inflammatory breast cancer were analyzed. Patients with metastatic disease or disease progression on induction chemotherapy were excluded. Induction chemotherapy was given to 52 patients. Mastectomy was performed in 52 patients. Radiotherapy was delivered to the breast or chest wall and regional lymph nodes in all patients. The median follow-up for all patients was 5.1 years.

RESULTS

The 5- and 10-year overall survival rate was 56% and 35%, respectively; the corresponding relapse-free survival rates were 49% and 34%. Patients with a pathologic complete response after chemotherapy with or without preoperative radiotherapy had better 5- and 10-year overall survival rates (65% and 46%, respectively) and 5- and 10-year relapse-free survival rates (59% and 50%, respectively) compared with patients without a pathologic complete response. Those patients had a 5- and 10-year relapse-free survival rate of 45% and 27%, respectively. Locoregional failure at 5 and 10 years was 8% and 19%, respectively.

CONCLUSION

The outcomes for patients completing multimodality therapy compare favorably with published data; however, the exclusion of patients with progression during induction chemotherapy may account in part for these results. The pathologic complete response rate was found to be an important prognostic factor. Selected patients with inflammatory breast cancer have the potential for long-term survival.

Inflammatory breast cancer: Where are we now?

Inflammatory breast cancer is perhaps the most aggressive form of breast neoplasm, with a poor prognosis. Clinically, inflammatory breast cancer is characterized by erythema and edema of the skin of the breast, called "peau d`orange", with or without an associated palpable mass. This form represents 1% to 6% (doubled during the past two decades) of all newly diagnosed breast malignancies and is often considered together with local advanced breast cancer, despite specific differential features. The reported 5-year survival rates range from 10% to 75%. On mammography, a diffuse increase in density and skin thickening may be present. Pathologic confirmation of invasion of dermal lymphatics by malignant cells can help distinguish this condition from benign mastitis. Most inflammatory breast cancers are on biopsy poorly differentiated ductal carcinomas, mainly estrogen and progesterone receptor negative. HER2/neu-overexpression and p53 gene mutations are frequently present. The probability of axillary node involvement is approximately 90%. Contralateral breast cancer develops in 25% to 50% of the patients, usually in the presence of metastases. Inflammatory breast cancer has a high rate of locoregional recurrence after surgery and/or radiotherapy and the rapid appearance of distant metastases. However, long-term survival is possible for these patients if treated with multimodality therapy including polychemotherapy, mastectomy, and loco-regional radiotherapy. The optimal sequencing of combined modality therapy has not been determined. Although not all patients are candidates for such a regimen (often due to progression during treatment), for those that complete all phases of therapy, more than one-third will be alive without disease at 10 years.

Clinical outcome and prognosis of patients with inflammatory breast cancer

This report analyzes clinical factors affecting outcome in 26 patients with inflammatory breast cancer. Peau d'orange was the most common clinical finding at diagnosis (65%). A palpable breast mass (PBM) was noted in 65% with axillary lymph node involvement in 81% of patients. Eighteen patients were staged as stage IIIB and eight as stage IV. Initial metastases included supraclavicular nodes (five of eight), bones (one of eight), skin (one of eight), and liver (one of eight). All patients were treated with neoadjuvant chemotherapy (cyclophosphamide, doxorubicin, and fluorouracil, 18 patients; other, 8 patients). Partial response was the best clinical response attained in 38% of patients. Only one patient was treated with total mastectomy after neoadjuvant chemotherapy, and 19 patients received radiotherapy followed (2 patients) or not (17 patients) by mastectomy. The progression rate in stage IIIB patients was 78%, with distant sites of progression in 93% of patients and only 7% with local progression. Mean time-to-progression was 13 months (Kaplan-Meier estimates of 45% and 11% at 24 and 48 months, respectively). The median overall survival (OS) value of the entire population was 13.2 months (Kaplan-Meier estimates at 24 and 48 months of 21% and 12.5%). By Kaplan-Meier method and log-rank test, a better OS was correlated with stage IIIB (p = 0.002), a PBM at diagnosis (p = 0.01), and a favorable response to initial chemotherapy (p = 0.03). Our results confirm the better clinical outcome of patients with stage IIIB and PBM at diagnosis. They also support the role for combined treatment as the best modality approach for this disease. However, overall prognosis remained poor, with recurrence and death resulting from the disease.

Dermatologic diseases of the breast and nipple

Breast and nipple skin is commonly affected by various inflammatory and neoplastic processes. Despite this fact, many physicians are unaware of the spectrum of diseases that can involve this area. Because breast and nipple skin represents a cosmetically, sexually, and functionally important entity to most patients, awareness of these disease entities is invaluable. This article reviews the normal anatomy of the breast, cutaneous manifestations of neoplastic processes that can present in these areas, and common inflammatory diseases of the breast and nipple skin.

Locally advanced breast cancer

Over the past 20 years, the prognosis for women diagnosed with locally advanced breast cancer (LABC; clinical stages IIB through IIIB) has improved significantly with recognition of the efficacy of multimodal therapy for reducing both local and distant recurrences, even in patients with inflammatory breast cancer (IBC). Most patients will respond to induction, or neoadjuvant, chemotherapy (NAC) with an anthracycline-based regimen, enabling many patients with large but operable tumors to undergo breast-conserving surgery (BCS) and enabling resection in most patients with inoperable disease. However, only a small percentage of patients achieve a pathologic complete response (CR) with this approach. Long-term disease-free survival (DFS) and overall survival (OS) correlate with the extent of residual disease in the breast and axillary nodes following NAC. The addition of paclitaxel or docetaxel, either in combination with an anthracycline or as a separate regimen administered before or after anthracycline-based therapy, increases clinical and pathologic response rates and may improve DFS. With the possible exception of patients with IBC, BCS does not compromise outcome. Partial mastectomy should be accompanied by standard nodal dissection in patients with clinically or radiographically positive axillae; in patients with negative axillae, sentinel lymph node (SLN) sampling, with subsequent axillary dissection reserved for patients with involved nodes, may reduce postoperative morbidity. Patients who received only anthracycline-based NAC who are found to have significant residual disease in the breast or involved axillary nodes at surgery should receive adjuvant chemotherapy with paclitaxel. Postoperative radiation to the residual breast or chest wall and regional nodal areas reduces locoregional recurrences, but its impact on OS remains controversial. Adjuvant hormonal therapy with tamoxifen improves DFS and OS in patients with hormone receptor (HR)-positive tumors, and ovarian ablation should be considered in premenopausal patients with HR-positive tumors and multiple involved nodes or stage IIIB disease. Neoadjuvant hormonal therapy with either tamoxifen or an aromatase inhibitor may benefit frail or elderly patients with HR-positive tumors for whom chemotherapy is not an option. No advantage has been demonstrated for high-dose chemotherapy requiring hematopoietic stem-cell support as either NAC or adjuvant therapy in LABC. Newer treatment approaches, including trastuzumab (Herceptin, Genentech, Inc., South San Francisco, CA), in patients with Her-2-overexpressing tumors or other biologic agents, do not have a proven role in the management of LABC at this time.

Synchronous inflammatory breast cancer and advanced ovarian carcinoma: a case with prolonged disease-free survival

Despite the known association of these malignancies, the incidence of a synchronous presentation of breast and ovarian cancer is low, and the current literature does not address an approach to this clinical problem directly. We report a greater than 2.5 year disease-free survival in a patient treated for synchronous stage IIIB inflammatory breast cancer and stage IIIC epithelial ovarian cancer. The prolonged disease-free survival in our case may provide some guidance in this unusual clinical situation.

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.

Effect of glutamine on methotrexate efficacy and toxicity

OBJECTIVE

To examine the effect of oral glutamine (GLN) on the efficacy and toxicity of methotrexate (MTX).

SUMMARY BACKGROUND DATA

The use of high-dose chemotherapy regimens is limited by the severity of their toxicities. Oral GLN has been shown to decrease the gut toxicity seen with MTX treatment while enhancing its tumoricidal effect.

METHODS AND RESULTS

Studies were done in laboratory rats and in breast cancer outpatients. Fischer 344 rats were randomized to 48 hours of prefeeding with GLN (1 g/kg/day) or an isonitrogenous amount of glycine. Rats were killed 24 hours after receiving a 20-mg/kg intraperitoneal dose of MTX. In the GLN group, there was a threefold increase in total MTX in the tumor as compared with the control group, and this increase was in both the diglutamated and pentaglutamated MTX. Inversely, there was a significant decrease in the total polyglutamated MTX in the gut in the GLN group. Given the results of this preclinical study, the authors performed a phase I trial. Nine patients diagnosed with inflammatory breast cancer received GLN (0.5 g/kg/day) during MTX neoadjuvant therapy, escalating from doses of 40 mg/m2 to 100 mg/m2 weekly for 3 weeks, followed by a doxorubicin-based regimen. No toxicity of oral GLN was detected. No patient showed any sign of chemotherapy-related toxicity. One patient had a grade I mucositis. Except for one, all patients responded to the chemotherapy regimen. Median survival was 35 months.

CONCLUSIONS

These studies suggest that GLN supplementation is safe in its administration to the tumor-bearing host receiving MTX. By preferentially increasing tumor retention of MTX over that of normal host tissue, GLN may serve to increase the therapeutic window of this chemotherapeutic age.

Inflammatory Carcinoma of the Breast: Characteristic Findings of MR Imaging

Inflammatory breast carcinoma (IBC) Shows a unique clinical appearance and has an extremely poor prognosis. Although immediate intensive therapy has been proposed, diagnosis of this disease tends to be delayed as its clinical features can be confused with acute mastitis. The conventional imaging modalities including mammography and ultrasonography are of limited value in the diagnosis of IBC, as it is difficult to delineate specific findings of the swollen dense breast. Recently, magnetic resonance (MR) imaging has been widely applied to breast diseases. One of the excellent features of this modality is its diagnostic ability in dense breasts. However, few trials to evaluate the capability of this new modality for IBC have been documented. In recent years, we found that a characteristic feature in 5 cases of IBC was a strong signal on T2-weighted images (T2WI) of MR imaging at the retromammary and subcutaneous area. Pathological features of the retromammary area showed marked interstitial edema and focal lymphatic involvement by tumor cells. These characteristic images obtained by MR imaging may be suggestive of inflammatroy breast carcinoma. Furthermore, subtracted dynamic MR imaging indicated the site of the tumor. Therefore, the application of MR imaging for swollen breasts would assist in the immediate diagnosis of IBC and would contribute to appropriate and timely therapy.