🧛‍♀️Inflammatory Breast Carcinoma (IBC) Flashcards
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Definition of IBC
Subtype of LABC, Represent 1-6% of all IDC.
- Aggressive behavior
- Occurred more frequency in young women. Mean age is 58 years old
Criteria to diagnose IBC
Criteria for the diagnosis:
- A rapid onset of erythema, edema and a peau d’orange appearance or abnormal breast warmth, with or without a palpable lump.
- Symptoms present < 6 months.
- Erythema covers at least a 1/3rd of the breast.
Pathophysiological of IBC
- Skin changes are due to lymphedema caused by tumor emboli within dermal lymphatic. How ever can be missed in up to 25% of patients related to skip regions within the breast, and therefore is not required for diagnosis.
- 80% of IBC have lymph node involvement and around 33 % have metastasis.
Presentation of IBC
It is clinical diagnosis and clinicopathologic pictures
History:
- Rapid erythema, enlargement of breast
- It is different from LABC which is neglect slower growing tumour
- Failure of trials of antibiotic - suspected infectious cause
- Symptoms of metastatic disease
Presentation:
The hallmark of IBC:
- Skin changes which cover 1/3 of breast → erythema, edema, peau d’orange, tenderness, induration, warmth
- Patient might feel heaviness, burning pain
- Nipple changes: retraction, flattening, erythema, crusting, blistering, retraction.
- 30% of cases at the time of diagnosis, the underlying mass is not palpable
Types of IBC
- Primary IBC - de novo IBC.
- Secondary IBC - inflammatory recurrence of a noninflammatory primary breast carcinoma which usually occurs on the chest wall at the site of previous mastectomy, but occasionally may be found at a distant cutaneous recurrence.
Investigation for IBC
Goals of initial imaging - to define extent of disease in breast parenchyma and skin, to evaluate for chest wall invasion, and to identify areas of regional lymph node involvement at diagnosis, as well as to monitor response during and after PST.
1) MMG
Diagnostic on affected side and screening on contralateral.
- Generalized increased breast density 37%
- Skin thickening 84%
- Microcalcification 56%
- Parenchymal distortion
- Asymmetric focal density
2) MRI
Most accurate imaging modality for detecting a primary breast lesion and defining the extent of skin involvement.
3) Ultrasound
- Skin thickening 96%
- Parenchymal echogenicity 73%
- Dilated lymphatics 68%
- Solid mass 80%
- Pectoral muscle invasion 10%
- Focal areas of parenchymal acoustic shadowing 37%
- Axillary lymphadenopathy 73%
Biopsy for IBC
Skin punch biopsy
- Able to show presence of tumour emboli within dermal lymphatics, the findings is supportive for IBC but it is not required for diagnosis.
CNB with USG guidance
- Able to show the histology of IDC with tumour marker
Phenotypical features of IBC:
- 38–39% ER+/HER2-
- 32–35% HER2 enriched
- 25–28% triple-negative.
- High mitotic index
- More pronounced angiogenesis and angioinvasion – high metastatic potential
- Overexpression of p53
- Increased MUC1 staining and E-cadherin
Differential Diagnosis for IBC
Differential Diagnosis:
- Mastitis
- Breast Abscess
- Venous congestion of the breast
- Dermatitis
- LABC
- Primary Breast Lymphoma
- Diabetic mastopathy
Staging for IBC
- IBC without metastasis: T4d N0-3 M0 - Thus all patients at diagnosis are at Stage III.
- Tumor emboli in dermal lymphatics without the clinical skin changes described above should be classified according to tumor size (T1, T2, or T3) and do not qualify as inflammatory carcinoma.
- Locally advanced breast cancers directly invading the dermis or ulcerating the skin without the clinical skin changes also do not qualify as inflammatory carcinoma.
Role of Neoadjuvant Chemotherapy and Surgery in IBC
- Anthracycline or/and taxane based (same in treating of LABC) minimum 6 cycles over 4-6mths followed by locoregional therapy (RT).Tumor respond to Neoadjuvant
- MRM + ALND → Chest wall RT for 6 weeks, ± Hormonal therapy – 5yrs, ± Trastuzumab
- Surgery indicated and performed approximately 3 weeks after completion of chemotherapy to allow cytotoxic effect to normalize.
- Wide skin resection is performed at the time of mastectomy (including all skin involved prior to initiation of chemotherapy) to achieve negative margins.
- Some cases, resecting the extent of skin disease will require chest wall coverage with reconstructive techniques (i.e., skin grafting or myocutaneous flap closures), with latissimus dorsi flap reconstruction, autologous reconstruction with an abdominal donor site.
- Breast reconstruction is considered primarily as a delayed procedure, occurring at least 6 months after completion of PMRT
- Second line chemotherapy and pre-operative RT
- Clinical response achieved as high as 86% and pathologic complete response (PCR) rates about 12-33%.
Role of Targeted Therapy in IBC
Herceptin / Trastuzumab
- Combination Herceptin in neoadjuvant therapy showed good result and response
- Trastuzumab is not given with anthracycline because it can potentiate cardiotoxicity
Lapatinib
- It is reversible dual inhibitor ErbB1 and ErbB2-tyrosine kinases
- Used for metastatic IBC whose tumors overexpressed ErbB1 and ErbB2
- Also, for disease has progressed despite prior using Trastuzumab therapy
Hormonal Therapy:
- In IBC which positive hormone receptor and older patient or unfit for chemotherapy, trial with endocrine/hormonal therapy is warranted
AntiVEGF (Bevacizumab - Avastin)
- Prevent growth of new tumor blood vessels.
- Complication – bowel perforation.
Follow up for IBC
American Society of Clinical Oncology 2006 Guidelines
- CBE – 3-6mths,
- Yearly MMG of contralateral breast.
- Genetic screening for women with strong family hx of breast and ovarian cancer.
- Prophylactic mastectomy of contralateral breast not recommended.
Prognosis is uniformly poor with 5 year survival is 40%. Compared to LABC for invasive breast cancer is 87%
