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INFLAMMATORY BREAST CANCER
Inflammatory breast cancer is a rare and aggressive form of breast cancer that
is often initially confused with infections of the breast. The typical initial
symptoms of both benign breast infection and inflammatory breast cancer are
redness of the skin,
local heat, breast enlargement, and thickening of the skin, which may have an
orange peel appearance. Patients with inflammatory
breast cancer often experience breast pain, and swelling of the lymph nodes under
the arm often they can feel a localized mass.
Most women who experience these symptoms are first seen by their primary doctor
or in an emergency room setting. Most are initially treated with a course of
antibiotics. Inflammatory changes secondary to bacterial infections typically
go away in a few days.
When the inflammatory response does not respond to treatment,
referral to a specialist is essential. A note of caution: we have seen a few
cases in which the inflammatory reaction seemed
to improve dramatically, only to reoccur in a few weeks. We now follow all patients
who have had breast inflammation for at least 12 months.
The main purpose of this discussion of inflammatory breast cancer
to outline our experience with making the diagnosis, and to identify pitfalls
in establishing an accurate diagnosis. We have learned from experience that
the diagnosis can be extremely difficult. We assume that any woman with redness
of the breast has inflammatory breast cancer until proven otherwise. With our
aggressive approach to diagnosis which will be outlined below, we usually make
the diagnosis within 2-10 days.
A major challenge in discussing inflammatory breast cancer is that there is
no generally accepted definition. In the classic sutuation,
2/3rd of the breast is involved with redness and/ or skin thickening (see link
to photograph of classic case). We use the term inflammatory breast cancer to
describe any case of breast cancer which includes redness of the
skin. Thus, the reader of this web-page should take into consideration that
our definition is much broader than that used by many respected authorities.
We have chosen our definition for two reasons. First, cancers that are associated
with an inflammatory response, even if limited to a small section of the breast,
tend to have a worse prognosis. We therefore treat all breast cancers with an
inflammatory component more aggressively. Secondly, cancers with an inflammatory
component are often confused with benign conditions. As a result the diagnosis
is too often delayed. For both reasons we take an aggressive approach to implied.
How the diagnosis is made:
Our Approach to Evaluating Patients with Inflammatory Changes in the
Breast:
First visit:
* Take a careful history, and do a careful physical examination.
* Do an ultrasound examination, and if tolerated also do a diagnostic mammogram.
(note we also use the ultrasound to examine the under arm lymph nodes, which
can show evidence of metastasis)
* Take tissue samples for both cultures and microscopic evaluation. If
there is a mass associated with the inflammation, tissue sampling is concentrated
on the mass. If there is no mass, tissue sampling is focused to breast tissue
under the center of the inflammatory process. We do 5 types of tissue sampling.
Our goal is to get sufficient material for cultures as well as sufficient tissue
for a microscopic diagnosis. The following are guidelines to our decision making:
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If we are most suspicious of infection we usually start with a large gage needle (i.e.16 gage), to aspirate the area of concern. If we withdraw pus, we are fairly certain we are dealing with an infection. We send off cultures (aerobic, anaerobic, fungus and AFB) and treat with antibiotics. If we don't get pus, we culture the aspirated fluid, and proceed to fine needle aspiration.
Fine needle aspiration: We routinely obtain a FNA on the first visit for any suspicious inflammatory process. If the results are negative it is of limited value, but it the results are suspicious for cancer we go directly to core biopsy.
In cases in which we are clinically suspicious of an underlying cancer, we usually do a core biopsy on the first visit. A negative core is reassuring, but at times we have missed cancers using this technique, and therefore assume a negative core is non-diagnostic.
Skin punch biopsy. In the classic definition of inflammatory breast cancer, cancer cells are seen in the lymph channels under the skin (subdermal lymphatics). A skin biopsy can be done in the office under local anesthesia. It takes a few minutes to perform and is well tolerated by the patient. A negative biopsy is of no value, but a positive biopsy makes the diagnosis of inflammatory cancer with certainty. We reserve this biopsy procedure for selective cases, and usually make the initial diagnosis of inflammatory breast cancer with other techniques.
Open surgical biopsy: This was the standard diagnostic operation in the past, but is rarely required today as a diagnostic tool. In general we avoid an open biopsy to make a diagnosis of breast cancer, but on rare occasions it has been helpful. In situations in which all tests have been negative and symptoms persist, the option of open biopsy should be considered.
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Once we have completed the diagnostic work-up, the patient is started on antibiotics
and scheduled for a follow-up visit the next week. If biopsy results come
back positive, patients are referred to our oncologists. If the biopsies were negative,
but the inflammation has resolved the patient is scheduled for follow-up mammogram
and in most cases an MRI (note: we have not done a sufficient number of MRI's
under these circumstance to have a clear sense of its diagnostic value).
If the inflammation has not responded dramatically to treatment, and if the
cultures are negative, we become more suspicious of an underlying cancer. Our
next step is usually an MRI. Although the MRI cannot distinguish between inflammation
and cancer, it can localize areas of concern that were not evident clinically.
Further tissue sampling can be directed to areas of concern on the MRI. We also
examine the axilla with ultrasound to look for suspicious lymph nodes.
In rare cases in which the inflammation persists and the work-up is non-diagnostic,
we may proceed to an open biopsy along with random breast sampling with core
biopsies. If the entire work-up remains negative we follow the patient at monthly
intervals and encourage her to return immediately if inflammatory changes are
noted.
We have had two patients in which the cancer was missed despite complete work-up
including open biopsy. However, the majority of our patients who have had a
negative work-up and have been followed for more than one year, have return
to normal with no explanation as to the cause of the inflammatory response.
Treatment of Inflammatory breast cancer
The treatment of inflammatory breast cancer has become standardized. Patients
are first given a course of chemotherapy to shrink the tumor, which in most cases
is very effective. This is usually followed by mastectomy and lymph node removal.
Immediate reconstruction is not done in these cases. A follow-up course of radiation
therapy is given. This combined approach to therapy has proven to be remarkably
effective.
Pictures of Patients with Inflammatory breast cancer and benign inflammation
1. Classic Peau de orange:
2. classic inflammatory breast cancer..right breast:
3. Inflammatory breast cancer left & Right breasts:
4. Benign inflammation right breast:
Helpful
links:
http://cis.nci.nih.gov/fact/6_2.htm
http://www.ibcresearch.org
http://www.healthopedia.com/breast-cancer.html
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