What is the standard treatment for inflammatory breast cancer?

Standard Treatment for Inflammatory Breast Cancer

The standard treatment for inflammatory breast cancer (IBC) requires a multidisciplinary approach consisting of primary systemic chemotherapy with an anthracycline and taxane regimen, followed by modified radical mastectomy and postmastectomy radiation therapy. 1, 2

Diagnosis and Initial Evaluation

• IBC is characterized by rapid onset of breast erythema, edema and/or peau d'orange occupying at least one-third of the breast, with a history of no more than 6 months 1, 2
• Core biopsy is required to confirm invasive carcinoma, with recommendation for at least two skin punch biopsies to potentially document dermal lymphovascular tumor emboli 1
• All IBC tumors must be tested for hormone receptors (ER, PR) and HER2 status to guide treatment decisions 1, 2
• Initial imaging should include diagnostic mammogram with accompanying ultrasound of the breast and regional lymph nodes 1, 2
• Systemic staging studies with CT and bone scan are recommended for all patients 1, 2
• MRI breast is not routinely recommended but may be used when parenchymal lesions are not detected by mammography or ultrasound 1, 2

Treatment Algorithm

1. Primary Systemic Chemotherapy

• Primary systemic chemotherapy is the first-line treatment for all patients with IBC 1, 2
• The recommended regimen consists of an anthracycline and taxane-based chemotherapy 1
• Anti-HER2 therapy (trastuzumab) should be added for HER2-positive disease 1, 2
• A minimum of six cycles over 4-6 months is recommended before proceeding to surgery 1, 2
• Response monitoring should include physical examination (every 6-9 weeks) and radiological assessment 1, 2

2. Surgery

• Modified radical mastectomy is the only recommended definitive surgery following preoperative systemic treatment 1, 2
• Breast-conserving approaches are contraindicated in IBC 1
• Sentinel lymph node biopsy is not reliable in IBC patients and should not be performed 1
• Breast reconstruction is an option but should be delayed rather than immediate, as immediate reconstruction is associated with higher complication rates 1, 3

3. Radiation Therapy

• Postmastectomy radiation to the chest wall and regional lymphatics is essential for locoregional control 1, 2
• Radiation dose escalation to 66 Gy is recommended for patients who are:
  • Over 45 years of age
  • Have close or positive surgical margins
  • Have four or more positive lymph nodes after preoperative treatment
  • Demonstrated poor response to preoperative systemic treatment 1

4. Additional Therapy

• Hormone therapy should be added for patients with hormone receptor-positive disease 1
• Continued HER2-targeted therapy should be completed for a full year in HER2-positive disease 1

Important Considerations and Pitfalls

• Avoid treatment delays: Primary systemic chemotherapy should be initiated promptly after diagnosis 2
• Avoid upfront surgery: Surgery without prior systemic therapy has poor outcomes due to high probability of residual disease 2, 4
• Never omit radiation therapy: Postmastectomy radiation is essential for locoregional control, with historical data showing less than 5% survival beyond 5 years when treated with surgery or radiation therapy alone 4, 5
• Avoid immediate breast reconstruction: Reconstruction should be delayed until after completion of therapy to prevent complications and treatment delays 1, 3
• Ensure adequate initial biopsy: Comprehensive tissue sampling before treatment is crucial for diagnosis and biomarker testing 2
• Don't mistake for mastitis: IBC is often misdiagnosed as mastitis or dermatitis; lack of response to antibiotics after one week should raise suspicion for IBC 2, 4

The multimodality approach to IBC has significantly improved outcomes over the past decades, with modern treatment protocols achieving 5-year survival rates of 40% compared to historical rates of less than 5% 1, 4.