In this week’s Case Record of the Massachusetts General Hospital, a 49-year-old woman presented with a 12-cm mass in the right breast, fixed to the chest wall. The overlying skin was erythematous and edematous. A core-biopsy specimen showed infiltrating ductal carcinoma.
Of all breast cancers, only 1 to 6% are classified as inflammatory breast cancer. Approximately 20 to 40% of patients with inflammatory breast cancer have evidence of distant metastases at the time of presentation.
Clinical Pearls
• How can locally advanced breast cancer with secondary inflammatory changes be distinguished from inflammatory breast cancer?
Locally advanced breast cancer with secondary inflammatory changes typically results from a long history of neglected disease; a short clinical course is more consistent with inflammatory breast cancer. Relatively younger age also supports the diagnosis of inflammatory breast cancer; the age-specific rate of inflammatory breast cancer peaks and plateaus at 50 years, whereas the rate of locally advanced disease continues to increase after 50 years of age.
• How should inflammatory breast cancer be optimally treated?
The optimal therapeutic approach for this disease is preoperative chemotherapy to render the tumor operable, followed by mastectomy and radiation.
Morning Report Questions
Q: What do skin biopsies from patients with inflammatory breast cancer typically reveal?
A: In cases of inflammatory breast cancer, skin-biopsy specimens characteristically reveal numerous tumor emboli occluding dermal lymphatics. Dermal lymphatic occlusion is believed to lead to increased vascular pressure and stasis, resulting in erythema, edema, and thickening of the skin. Although the changes mimic the appearance of an acute inflammatory process, inflammation does not actually contribute in any consequential way to the skin manifestations.
Q: What are the typical staining characteristics of inflammatory breast cancer?
A: Inflammatory breast carcinomas are more frequently negative for ER and PR than are noninflammatory breast carcinomas and have higher proliferation indexes. As compared with noninflammatory carcinomas, inflammatory carcinomas are more often positive for HER2.