What is the recommended treatment for a patient diagnosed with inflammatory breast cancer (IBC)?

Treatment for Inflammatory Breast Cancer (IBC)

Patients diagnosed with inflammatory breast cancer should receive a multimodality treatment approach consisting of primary systemic chemotherapy (anthracycline and taxane-based), followed by modified radical mastectomy and postmastectomy radiation therapy. 1

Diagnostic Criteria for IBC

• Rapid onset of breast erythema, edema and/or peau d'orange, and/or warm breast, with or without an underlying palpable mass 1
• Duration of history no more than 6 months 1
• Erythema occupying at least one-third of the breast 1
• Pathological confirmation of invasive carcinoma 1
• May present with history of mastitis not responding to at least 1 week of antibiotics 1, 2
• May have nipple abnormalities including flattening, crusting, or retraction 1

Initial Evaluation

• Core biopsy to confirm invasive carcinoma 1
• Skin punch biopsy (at least two) to potentially document dermal lymphovascular tumor emboli 1
• Testing for hormone receptors (ER, PR) and HER2 status 1
• Diagnostic mammogram with accompanying ultrasound of breast and regional lymph nodes 1
• Systemic staging studies with CT and bone scan 1
• MRI breast only when parenchymal lesions are not detected by mammography or ultrasound 1

Treatment Algorithm

Step 1: Primary Systemic Chemotherapy

• All patients should receive primary systemic chemotherapy as first-line treatment 1
• Recommended regimen: anthracycline and taxane-based chemotherapy 1
• For HER2-positive disease: add anti-HER2 therapy (trastuzumab) 1
• Minimum of six cycles over 4-6 months before proceeding to surgery 1
• Monitor response through physical examination (every 6-9 weeks) and radiological assessment 1

Step 2: Surgery

• Modified radical mastectomy is the only recommended definitive surgery following preoperative systemic treatment 1
• Breast-conserving surgery is not appropriate for IBC 1
• Breast reconstruction is an option but immediate reconstruction is not recommended 1

Step 3: Radiation Therapy

• Postmastectomy radiation to chest wall and regional lymphatics is essential 1
• Recommended dose escalation to 66 Gy for patients who are:

  • 45 years of age 1

  • Have close or positive surgical margins 1
  • Have four or more positive lymph nodes after preoperative treatment 1
  • Demonstrated poor response to preoperative systemic treatment 1

Treatment Outcomes and Prognosis

• 5-year disease-free survival varies based on response to initial therapy:
  • Complete response: approximately 70% 3
  • Partial response: approximately 35% 3
  • No response: poor prognosis with all patients failing by 34 months 3
• Overall 5-year disease-free survival for all IBC patients is approximately 27% 3

Important Considerations

• IBC is the most aggressive form of breast cancer with rapid growth and short doubling times 4
• Despite aggressive multimodal treatment, prognosis remains worse for IBC compared to non-inflammatory locally advanced breast cancers 5
• Response to neoadjuvant chemotherapy may be similar to other breast cancers when adjusted for baseline characteristics 6
• The presence of dermal lymphatic invasion (DLI) is considered a histological hallmark of IBC and contributes to its highly metastatic potential 1

Common Pitfalls to Avoid

• Delaying systemic therapy - primary systemic chemotherapy should be the first line of treatment 1
• Attempting upfront surgery - high probability of residual disease being left behind 1
• Omitting postmastectomy radiation - essential for locoregional control 1
• Performing immediate breast reconstruction - should be delayed until after completion of therapy 1
• Inadequate initial biopsy - comprehensive tissue sampling before treatment is crucial for diagnosis and biomarker testing 1