Early symptoms of IBC
As the name suggests, the early symptoms of IBC (inflammatory breast cancer) include first and foremost the swelling or inflammation of one breast. This is a result of the tumor – more often than not an invasive ductal carcinoma – blocking the lymph vessels in the breast’s skin. IBC is a rare type of cancer, accounting for 1%-5% of all breast cancers that are diagnosed in the U.S. It is also very aggressive and spreads much faster to other parts of the body because its cells are found in the lymphatic system of the breast. Therefore, the earliest stage of inflammatory breast cancer is at least stage IIIB. The symptoms of IBC are different from those of more common forms of breast cancer, and include:
· Rapid changes in the appearance of the affected breast, which turns red, swollen or warm in the course of a few weeks or months.
· Thickness, heaviness or enlargement of one breast.
· Red, purple, or pink discoloration that gives the breast a bruised appearance.
· Dimpling or ridges resembling an orange peel on the skin of the breast, known as peau d’orange.
· Tenderness or pain.
· Enlarged lymph nodes under the arm, or above or below the collarbone.
· The nipple flattens or turns inward.
· Nipple discharge.
· Unlike most types of breast cancer, IBC seldom forms a lump.
Inflammatory breast cancer is very difficult to diagnose, and can even escape detection by a screening mammogram. Moreover, IBC can be mistaken for mastitis, an infection that is far more common and has similar symptoms. As a result, the doctor may prescribe antibiotics, but if the condition does not improve in 7-10 days, then the physician should start looking for cancer, especially if the patient is not pregnant or breastfeeding which would make breast infection less likely, in particular after menopause. IBC is usually diagnosed at a younger age; 57 years on average, as opposed to 62 years for other forms of breast cancer. In addition, African-American women and women who are overweight are at an increased risk. The minimum criteria for an IBC diagnosis includes rapid onset of redness in a least a third of the breast, as well as swelling and peau d’orange that have been present for less than 6 months, and initial biopsy samples showing invasive carcinoma.
A biopsy involves removing a tissue sample, and there are four different types:
1. Fine needle aspiration (FNA). Employs a thin needle to collect a small sample.
2. Core needle biopsy. A wider needle is used to extract a larger sample.
3. Surgical biopsy. This procedure removes the largest amount of tissue, but it is generally recommended only if FNA and core needle biopsy are not conclusive.
4. Image-guided biopsy. This is performed to investigate an anomaly seen on a radiologic image, even if there is not distinct lump.
Although a biopsy is the surest method of diagnosing cancer, there are other tests that can be run in order to confirm or deny inflammatory breast cancer, such as:
· Diagnostic mammography. An ex-ray of the breast usually ordered when a patient experiences nipple discharge or a new lump. However, the swelling and tenderness of the breast can hinder the mammogram, though it may show thickened skin without a visible tumor, or that the affected breast is larger and denser than the other.
· Ultrasound. It can distinguish between a solid mass (cancer) and a fluid-filled cyst (not cancer). It can also show enlarged lymph nodes under the arm.
· Magnetic resonance imaging. An MRI can find breast tissue anomalies after a normal mammogram, and measure the size of the tumor.
· Computed tomography. Looks for spread of the cancer in the chest, abdomen, and pelvis.
· Positron emission tomography. Usually done in combination with a CT scan to find areas of cancer spread to lymph nodes and distant sites.
Once inflammatory breast cancer has been diagnosed, it is usually treated with a multimodal approach in which surgery is only the second option after systemic therapy and before radiation therapy. Chemotherapy is the use of drugs – administered in pill form or intravenously – to attempt to shrink the tumor. It is also known as preoperative or neoadjuvant chemotherapy, and is considered to be a systemic treatment because the drugs enter the blood stream and circulate all through the body to seek and destroy both the main tumor and any cancer cells that may have broken off and spread to other organs. Chemotherapy drugs for IBC include:
· Pegylated liposomal doxorubicin
· Protein bound paclitaxel
· Doxorubicin/cyclophosphamide (AC) followed by paclitaxel or docetaxel
· Docetaxel/cyclophosphamide (TC)
· Docetaxel/doxorubicin/cyclophosphamide (TAC)
Following chemotherapy, IBC patients undergo a single mastectomy to remove the entire affected breast as well as several nearby lymph nodes, which are tested for signs of cancer. Chemo is given before surgery to increase the chances that no cancer is left at the edges of the tissue removed during surgery. Later on, after radiation therapy, the patient may opt for breast reconstruction surgery. Radiation therapy is given after surgery or before surgery if chemo doesn’t relieve the swelling and redness. Multimodal breast cancer treatment may also include hormone therapy if the tumor depends on hormones such as estrogen for growth. Drugs like tamoxifen block estrogen from binding to cancer cells, while aromatase inhibitors keep the body from converting androgens into estrogen after menopause. Similarly, drugs like trastuzumab or pertuzumab may be given if the tumor is HER2-positive; that is, if it has an excess of a protein known as HER2.
Treatment for inflammatory breast cancer has many side effects and even when successful there is a chance of recurrence, meaning a patient may again experience the early symptoms of IBF, as well as others such as a new lump in the breast, under the arm, or along the chest wall; bone pain or fractures; headaches or seizures; chronic coughing or trouble breathing; extreme fatigue; and/or feeling ill. IBF patients are encouraged to seek emotional support to help them cope with their condition.