Original Source
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Cancerwise

August 2006

The University of Texas
M. D. Anderson Cancer Center
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Massimo Cristofanilli, MD
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Q&A: Inflammatory Breast Cancer

Inflammatory breast cancer (IBC) is an extremely rare, very aggressive (fast-growing) and lethal form of breast cancer. Because of its aggressive behavior and unusual appearance it can be easily misdiagnosed or treated incorrectly, M. D. Anderson experts say.
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For that reason, it is critical that anyone experiencing any of the symptoms of IBC seek immediate consultation with breast cancer oncologists who have expertise and experience in treating IBC.
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Offering further information on the topic is Massimo Cristofanilli, M.D., an IBC specialist and associate professor in M. D. Anderson's Department of Breast Medical Oncology.
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How many cases of IBC are diagnosed each year?
What are the symptoms of IBC?
What should people do if they have IBC symptoms?
How old are typical IBC patients at diagnosis?
How well do diagnostic tests work in identifying IBC?
What diagnostic tests identify IBC?
What is the survival rate for IBC?
What are common mistakes in treating IBC?
How is IBC currently treated?
What clinical trials are testing new IBC treatments?
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How many cases of IBC are diagnosed each year?

The numbers vary, but approximately 1% to 2% of newly diagnosed invasive breast cancers (that have spread beyond the breast) in the United States are described as inflammatory breast cancers.
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What are the symptoms of IBC?
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Symptoms may include:

• One breast larger than the other
• Red or pink skin
• Swelling
• Rash (entire breast or small patches)
• Orange-like texture (peau d' orange)
• Skin hot to the touch
• Pain and/or itchiness
• Ridges or thickened areas of breast
• Nipple discharge
• Nipples that appear inverted or flattened
• Swollen lymph nodes under the armpit
• Swollen lymph nodes of the neck (sometimes)

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What should people do if they have IBC symptoms?

If one or more symptoms continue for more than a week, look for information and talk to a physician with experience with this particular type of breast cancer.

The resources below may help guide you to physicians and centers with this expertise.
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How old are typical IBC patients at diagnosis?

The median age range is between 45 and 55 years old, but there may be patients either younger or older. The symptoms must guide the diagnosis, and age should not be used to exclude it.
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How well do diagnostic tests work in identifying IBC?

IBC typically cannot be identified through:

• Mammogram - Because IBC usually does not occur in the form of a lump (the cancer is spread throughout breast tissue), it is difficult to detect with a mammogram. The most characteristic mammography findings consist of swelling of the skin.
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• Ultrasound - This test confirms the swelling (edema) of the skin and can better identify breast nodules (if present). It also is the most appropriate test for the evaluation of lymph nodes.
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• Magnetic Resonance Imaging (MRI) - This is probably the most sensitive test because it includes a functional description of the abnormal findings. It should be included among the diagnostic tests once the pathological diagnosis is confirmed. It is extremely useful in evaluating the clinical response to chemotherapy.
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• Core biopsy - Typically, fine-needle aspiration or a core biopsy (removal of tissue with a needle) is performed to obtain a pathological diagnosis of invasive disease, but these diagnostic procedures are not appropriate for IBC because of the peculiar growth pattern in the breast lymphatic system.

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What diagnostic tests identify IBC?

Surgical biopsy - Most of the time a skin biopsy or a surgical biopsy is necessary. These procedures are able to collect larger samples that include the skin and underlying tissue with higher chances to identify the cancer cells.
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PET Scan - In the near future, this could be one of the most important diagnostic/staging tests for IBC, though it still is under study. We have found that with the PET scan we can see more disease.

We can see lymph nodes far from the breast, which tells us we have a metastatic cancer already at the time of diagnosis. If we limit staging to mammogram, CT (computed tomography - computerized X-rays) and bone scans we may miss different components of this inflammatory spreading, which may have significant consequences in the way we treat the cancer and the way we process patients.
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What is the survival rate for IBC?

The five-year median survival rate for inflammatory breast cancer is approximately 40%. The main reasons for such a disappointing outcome are multiple and include: a delay in diagnosis, the lack of expertise in treating IBC because it is so rare and the relative resistance the disease has to standard chemotherapeutic agents.
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With regard to the first critical issue, it is important to keep in mind that IBC is a fast-growing cancer (it can spread within weeks), and it is often mistaken for something other than breast cancer, such as a rash or infection.
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What are common mistakes in treating IBC?

A surgeon might want to remove the breast too early, which would increase the chance of local recurrence (return of the disease).

A radiation oncologist with experience in treating IBC also is important. IBC might require a different schedule than most breast cancers. You might need two treatments a day, instead of one, because this is a highly aggressive tumor. Patients also need a specific chemotherapy dose.
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A particular challenge with treating IBC is that it is difficult to measure response since a nodule or mass is usually not present.

If patients have had incorrect treatment, it may be hard to go back and improve the prognosis (outcome).
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How is IBC currently treated?

We typically treat IBC with chemotherapy before surgery, and we also are using drugs like Herceptinr (trastuzumab) or TykerbT (lapatinib) in a subset of IBC patients who have the HER-2 gene.

One of our challenges is to improve our current treatments. We are focused on finding ways to eliminate microscopic disease to prolong survival.
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What clinical trials are testing new IBC treatments?

We are currently treating patients with the drug lapatinib in a clinical trial that closed to further patient enrollment two months ago. The preliminary analysis is promising but we have not completed the follow-up to make definitive conclusions. There is hope that this drug may represent the first agent to treat patients with IBC, more specifically.
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For every treatment we study we need to determine if the drug works by itself, with chemotherapy or several chemotherapies. We still need to figure out the best way to use lapatinib, but it looks promising.

As far as IBC clinical trials overall, we need to make improvements in diagnostic tests and treatment extremely quickly. The new diagnostics may offer the possibility of an accurate and more objective diagnosis and help in clarifying the biology of the disease. Additional therapies will provide options that will improve the response and prolong survival of patients with IBC.
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The only way to make such progress and achieve these objectives is to have dedicated resources for funding more research for IBC.
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Related story:

Rare Breast Cancer Has Unusual Symptoms


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Resources:

Inflammatory Breast Cancer Research Foundation

Inflammatory Breast Cancer (National Cancer Institute Fact Sheet)
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Types of Breast Cancer - Inflammatory Breast Cancer (Y-ME National Breast Cancer OrganizationT)

Facts for Life - Inflammatory Breast Cancer (PDF) (The Susan G. Komen Breast Cancer Foundation)

FAQ - Inflammatory Breast Cancer (Young Survival Coalitionr)