Uncommon Breast Cancers Part two: INFLAMMATORY BREAST CANCER

August already, hard to believe, but here we are coming into the dog days of summer. I hope you all are having a great summer. Except those loyal readers from southern continents who are not yet in summer, and to you, I wish a happy spring.

August continues with the rare and unusual breast cancer series. Inflammatory breast cancer is next;  a rare but nasty one. Keep an eye out for the signs and symptoms. You could save a life today!

OBJECTIVES

Inflammatory breast cancer is a rare type of breast cancer that develops rapidly, making the affected breast red, swollen and tender. Inflammatory breast cancer occurs when cancer cells block the lymphatic vessels in the breast, causing the characteristic red, swollen appearance of the breast. Inflammatory breast cancer is considered a locally advanced cancer — meaning it has spread from its point of origin to nearby tissue and possibly to nearby lymph nodes.

IBC is uncommon and can grow and spread quickly even at a relatively early stage of the disease. This type of cancer can develop when breast cancer cells block the lymph vessels that remove fluids, bacteria and other waste products from breast tissue. As a result, the breasts can become inflamed. Unlike the most common types of breast cancer that develop one or more single solid tumours, inflammatory breast cancer tends to grow in layers or nests.

Symptoms and Charting:

• Rapid change in the appearance of one breast, over the course of days or weeks
• Thickness, heaviness or visible enlargement of one breast
• Discoloration, giving the breast a red, purple, pink or bruised appearance
• Unusual warmth of the affected breast
• Dimpling or ridges on the skin of the affected breast, similar to an orange peel
• Itching
• Tenderness, pain or aching
• Enlarged lymph nodes under the arm, above the collarbone or below the collarbone
• Flattening or turning inward of the nipple
• Inflammatory breast cancer doesn't commonly form a lump, as occurs with other forms of breast cancer
• The symptoms of inflammatory breast cancer can be similar to an infection of the breast (mastitis) which can be effectively treated with antibiotics
• Symptoms that do not go away in spite of antibiotic treatment are significant and should be charted
• Further testing to rule out inflammatory breast cancer may be needed.
• Nipple discharge.
• Sudden appearance of a lump in the breast. However, because inflammatory breast cancer tends to grow in layers, or nests, instead of forming a solid tumour, a patient with IBC may not present with a lump in the breast.

Diagnosis:

It's not clear what causes inflammatory breast cancer. Doctors know that inflammatory breast cancer begins with one abnormal cell in one of the breast's ducts. Mutations within the abnormal cell's DNA command it to grow and divide rapidly. The accumulating abnormal cells infiltrate and clog the lymphatic vessels in the skin of the breast. The blockage in the lymphatic vessels causes red, swollen and dimpled skin — a classic sign of inflammatory breast cancer.

Inflammatory breast cancer is not often detected by a mammogram or ultrasound unless a solid tumour has developed. The diagnosis is made by careful examination and charting. CBE, patient history, medication records and meticulous observation of the patient are indispensable to a successful diagnosis of IBC.

Images of Common Symptoms occurring with Inflammatory Breast Cancer:

Figure 1: Swelling, redness, heat and nipple involvement with advanced IBC

Figure 2: Mild discoloration and flattening of the nipple with early IBC

Figure 3: Peau d'Orange with severe lymphedema due to IBC

Chain of Diagnostics for IBC:

Tests and procedures used to diagnose inflammatory breast cancer include:

• A physical exam: The patient undergoes a vigilant CBE by a professional. A comprehensive history is taken which includes a review of patient medications.
• Imaging tests: A mammogram and a breast ultrasound should be performed to look for signs of any related breast cancer and to assess the extent of any thickened skin and lymphedema.
• A clinical approach: If the patient has not been on a course of antibiotics to rule out mastitis and/or other deep tissue infection.
• Histology: A biopsy is a performed to remove a small sample of tissue from both the skin and the deep tissue under the inflammation.

Positive pathology is the definitive diagnosis of inflammatory breast cancer.

Staging inflammatory Breast Cancer:

Additional testing assists in the staging of IBC:

• Computerized tomography (CT) scans
• Chest X-ray
• Bone scan

Inflammatory Breast Cancer is already a metastasized cancer; therefore, there are only 2 possible stages:

• Stage IIIB. At this stage, cancer is considered to be locally advanced cancer — meaning it has spread to nearby lymph nodes and to the fibrous connective tissue inside the breast.
• Stage IV. At this stage, cancer has spread to distant parts of the body.

Suggested Treatment for Inflammatory Breast Cancer:

Treatment of IBC should begin right away because it is already metastasized and can spread quickly. Treatment usually includes a combination of chemotherapy, surgery, radiation and hormonal therapy. Because inflammatory breast cancer cells grow widely through the tissues of the breast, rather than as a single tumour, chemotherapy is often given before surgery or radiation treatment.

Chemotherapy:

Chemotherapy uses chemicals to kill cancer cells. Chemotherapy is often used prior to surgery for inflammatory breast cancer. This pre-surgical treatment, referred to as neo-adjuvant therapy, aims to shrink the cancer before the operation and increase the chance that surgery will be successful. Chemotherapy can also be used after surgery to help lower the risk of recurrence.

Targeted chemo therapies kill cancer by focusing on the cancer cells' particular vulnerabilities. For inflammatory breast cancer cells with a certain genetic mutation, the medication trastuzumab (Herceptin) may be a treatment option. Trastuzumab targets a protein called HER2 that helps some inflammatory breast cancer cells grow and survive. If the inflammatory breast cancer cells make too much HER2, trastuzumab may help block that protein and cause the cancer cells to die. Trastuzumab can be combined with other chemotherapy and used before and after surgery.

Surgery:

After chemotherapy, women with inflammatory breast cancer usually undergo a modified radical mastectomy. A modified radical mastectomy involves removing the entire breast, skin envelope, IMF and part of the pec minor. The lymph nodes are tested for signs of cancer by way of a sentinel node biopsy. If the surgery proves node positive, an axillary node dissection is performed.

Radiation therapy:

Radiation therapy is usually used in these cases after chemotherapy and surgery to kill any cancer cells that might remain locally around the breast and under the arm.

Hormone therapy:

If the inflammatory breast cancer is hormonally driven and relies on estrogens for fuel, hormone therapy may be a valuable tool in retarding the disease. Hormone therapy is a series of medications that block hormones from attaching to cancer cells.

Hormone therapy treatments can include:

Tamoxifen is a type of drug called a selective estrogen receptor modulator (SERM). SERMs acts by blocking any estrogen present in the body from attaching to the estrogen receptor on the cancer cells, slowing the growth of tumours and killing tumour cells. Tamoxifen can be used in both pre- and postmenopausal women.

Aromatase inhibitors, these drugs block the action of an enzyme that converts androgens in the body into estrogen. These drugs are effective only in postmenopausal women. Aromatase inhibitors include anastrozole (Arimidex), letrozole (Femara) and exemestane (Aromasin).

SUMMARY:

We are the ‘thin pink line’ that stands as a protection against ignorance, a source of pertinent breast health information and as a foundation for the start of treatment or diagnosis. We have the chance to be the voice of reason, to dispel myth and present fact. The more we know about signs and symptoms that affect our patients the better professionals we become.

Power is knowledge; the truth is much less scary than myth, story and insinuation.