From the Guidelines
The workup for suspected inflammatory breast carcinoma (IBC) should begin with a thorough clinical examination, followed by diagnostic imaging, including a diagnostic mammogram with accompanying ultrasound of the breast and regional lymph nodes, as recommended by the international expert panel on inflammatory breast cancer 1. The diagnosis of IBC requires a combination of clinical and pathological findings, including rapid onset of breast erythema, edema, and/or peau d’orange, with or without an underlying palpable mass, and pathological confirmation of invasive carcinoma.
- Key diagnostic criteria include:
- Rapid onset of symptoms
- Erythema occupying at least one-third of the breast
- Pathological confirmation of invasive carcinoma
- Initial imaging should include:
- Diagnostic mammogram
- Ultrasound of the affected breast and regional lymph nodes
- MRI breast may be considered in instances where breast parenchymal lesions are not detected by mammography or breast ultrasound, as recommended by the international expert panel on inflammatory breast cancer 1. A core biopsy to confirm invasive carcinoma, and a skin punch biopsy to demonstrate dermal lymphatic invasion, are essential for diagnosis, as recommended by the international expert panel on inflammatory breast cancer 1. Complete staging workup includes:
- CT chest/abdomen/pelvis
- Bone scan
- The use of PET or PET/CT is not recommended for routine staging, as stated by the international expert panel on inflammatory breast cancer 1. Laboratory tests should include:
- Complete blood count
- Liver function tests
- Renal function assessment Genetic testing should be considered, especially in younger patients. Multidisciplinary discussion is crucial before initiating treatment, as IBC typically requires neoadjuvant chemotherapy, followed by modified radical mastectomy and post-mastectomy radiation, as recommended by the international expert panel on inflammatory breast cancer 1 and the National Comprehensive Cancer Network 1. The treatment of IBC should involve a combined modality approach, including preoperative chemotherapy with an anthracycline-based regimen, with or without taxanes, and trastuzumab for HER2-positive disease, followed by mastectomy and post-mastectomy radiation, as recommended by the National Comprehensive Cancer Network 1.
From the Research
Diagnostic Criteria for Inflammatory Breast Cancer
The diagnosis of inflammatory breast cancer (IBC) is based on a combination of clinical, pathologic, and imaging characteristics. Key findings include:
- Erythema occupying at least one-third of the breast
- Edema
- Peau d' orange or nipple inversion
- Warmth of the affected breast
- Rapid onset of symptoms (<3 months)
- Pathologic confirmation of invasive carcinoma 2
Imaging Modalities for IBC
Various imaging modalities can be used to characterize and define the extent of disease in IBC, including:
- Mammography
- Ultrasonography
- Computerized tomography
- Positron emission tomography
- MRI, particularly T2-weighted images, which can increase the specificity of IBC diagnosis 3, 4
Proposed Diagnostic Criteria
A novel quantitative scoring system for diagnosis has been proposed, based on clinical, pathologic, and imaging features, including:
- Timing of onset
- Specific symptoms
- Dermal lymphovascular tumor emboli on biopsy
- Imaging findings This system yields a continuous score from 0 to 48 and proposes cut-points for categorization, which can be tested in subsequent validation studies 5
Treatment Approaches
Treatment of IBC typically involves trimodal therapy with: