Cell kinetics and hormonal receptor status in inflammatory breast carcinoma. Comparison with locally advanced disease

Inflammatory breast cancer biomarkers and biology

Inflammatory breast cancer (IBC) is a unique breast cancer with a highly virulent course and low 5- and 10-year survival rates. Even though it only accounts for 1-5% of breast cancers it is estimated to account for 10% of breast cancer deaths annually in the United States. The accuracy of diagnosis and classification of this unique cancer is a major concern within the medical community. Early molecular and biological studies incidentally included IBC samples with other conventional breast cancers and were not informative as to the unique nature of the disease. Subsequent molecular studies that focused specifically on IBC demonstrated that IBC has a unique biology different from other forms of breast cancer. Additionally, a handful of unique signature genes that are hallmarks of IBC have also been suggested. Further understanding of IBC biology can help with diagnosis and treatment of the disease. The current article reviews the history and highlights of IBC studies.

The Impact of Subtype Distribution in Inflammatory Breast Cancer Outcome

Objective

Inflammatory breast cancer (IBC) has an unfavourable prognosis despite the advances made in the treatment of breast cancer. Our study aimed to define immunohistochemistry-based surrogate subtype distribution to determine whether the breast cancer subtype accompanied survival outcome differences in IBC.

Materials and Methods

Medical records of female breast cancer patients with non-metastatic inflammatory breast cancer admitted to our clinic between March 2000 and December 2015 were retrospectively reviewed. Patient demographics, clinical and pathological feature of the primary tumour, adjuvant treatment options and survival data were analysed. Intrinsic breast cancer subtypes were defined according to ER, PR, HER-2 and ki-67 status.

Results

We identified 129 non-metastatic inflammatory breast cancer patients. Median follow-up was 73 months. 10 (7.7%) were luminal A-like, 67 (51.9%) were luminal B-like, 37 (28.6%) were HER-2 positive, and 15 (11.6%) were triple negative (TNBC) by immunohistochemistry. There were no statistically significant differences between subtypes in terms of histological type, grade, tumour size and lymph node status. Median disease-free survival was 47 months (95% confidence interval [CI] 29.2-82.6) and median overall survival was 75 months (95% CI 64.7-90.8). Triple negative breast cancer showed poorer outcome than other subgroups. Presence of TNBC disease was associated with poorer outcome compared to luminal A (HR: 0.19, 95% CI 0.04-0.92, p: 0.039), luminal B (HR: 0.34, 95% CI 0.15-0.74, p: 0.007) and HER-2 positive subgroups (HR: 0.40, 95% CI 0.17-0.94, p:0.037). Luminal A patients had a trend to have a better overall survival which did not reach to a statistical significant difference.

Conclusion

Our study put forth that IBC have a poor prognosis irrespective of breast cancer surrogate subtype distribution. Luminal A, the most frequent subtype of breast cancer was the least common in our IBC patient group. TNBC had the worst outcome when compared to other breast cancer subtypes.

Mammography and Morphobiologic Characteristics of Human Breast Cancer

Aims

A comparative analysis was performed to verify a possible correlation between mammographic features and morphobiologic characteristics of the tumor in a series of 176 invasive primary breast cancer patients.

Methods

Breast cancers were grouped according to mammographic features as follows: tumor mass with spiculated borders; tumor mass with well-circumscribed borders; tumor with density alteration of parenchyma with no clear borders; a cluster of micro-calcifications as the only sign of tumor presence; tumor without mammographic abnormality. The tumor tissue biologic characteristics investigated were: hormone receptor content, tumor proliferative activity, DNA content and cytohlstologic tumor-grade differentiation.

Results

Spiculated tumors showed a significantly higher percentage of estrogen-receptorpositive cases with respect to circumscribed tumors, independently of the patient's menopausal status. Tumors with only microcalcifications were all from premenopausal patients and showed a significantly higher percentage of progesterone-receptor-positive cases (83 %). Tumor proliferative activity did not significantly differ in the 5 mammographic breast cancer groups; aneuploidy was less frequent in tumors with spiculated borders than in mammographic types (39 % vs 57 %; p = 0.05); percentages of G1-G2-G3 tumors did not differ significantly among the mammographic groups considered.

Conclusions

Certain relationships between mammographic features and biologic characteristics could be of potential clinical interest and stimulate more detailed studies on this issue.

Contribution of ER and NF-κB to endocrine resistance in inflammatory breast cancer

SUMMARY Inflammatory breast cancer (IBC) is a very aggressive form of breast cancer with a high mortality rate. Most patients have lymph node metastasis at the time of diagnosis and 30% of patients already have metastases in distant organs. IBC is normally treated with multimodality therapy. Endocrine therapy is administered in cases of ER-positive tumors. Nevertheless, IBC has a high HOXB13:Il17RB ratio, predicting a poor response to tamoxifen treatment. These data suggest a possible role for IBC as a model for endocrine resistance. Previous studies have shown that NF-κB, a transcription factor regulating different cellular processes, is more highly activated in IBC than in non-IBC, while ER is often downregulated in this tumor type. This article summarizes the activity of ER and NF-κB in IBC and their possible contribution to endocrine resistance in this breast cancer subtype.

Comparison of molecular subtype distribution in triple-negative inflammatory and non-inflammatory breast cancers

Introduction

Because of its high rate of metastasis, inflammatory breast cancer (IBC) has a poor prognosis compared with non-inflammatory types of breast cancer (non-IBC). In a recent study, Lehmann and colleagues identified seven subtypes of triple-negative breast cancer (TNBC). We hypothesized that the distribution of TNBC subtypes differs between TN-IBC and TN-non-IBC. We determined the subtypes and compared clinical outcomes by subtype in TN-IBC and TN-non-IBC patients.

Methods

We determined TNBC subtypes in a TNBC cohort from the World IBC Consortium for which IBC status was known (39 cases of TN-IBC; 49 cases of TN-non-IBC). We then determined the associations between TNBC subtypes and IBC status and compared clinical outcomes between TNBC subtypes.

Results

We found the seven subtypes exist in both TN-IBC and TN-non-IBC. We found no association between TNBC subtype and IBC status (P = 0.47). TNBC subtype did not predict recurrence-free survival. IBC status was not a significant predictor of recurrence-free or overall survival in the TNBC cohort.

Conclusions

Our data show that, like TN-non-IBC, TN-IBC is a heterogeneous disease. Although clinical characteristics differ significantly between IBC and non-IBC, no unique IBC-specific TNBC subtypes were identified by mRNA gene-expression profiles of the tumor. Studies are needed to identify the subtle molecular or microenvironmental differences that contribute to the differing clinical behaviors between TN-IBC and TN-non-IBC.

Alternate estrogen receptors promote invasion of inflammatory breast cancer cells via non-genomic signaling

Although Inflammatory Breast Cancer (IBC) is a rare and an aggressive type of locally advanced breast cancer with a generally worst prognosis, little work has been done in identifying the status of non-genomic signaling in the invasiveness of IBC. The present study was performed to explore the status of non-genomic signaling as affected by various estrogenic and anti-estrogenic agents in IBC cell lines SUM149 and SUM190. We have identified the presence of estrogen receptor α (ERα) variant, ERα36 in SUM149 and SUM190 cells. This variant as well as ERβ was present in a substantial concentration in IBC cells. The treatment with estradiol (E2), anti-estrogenic agents 4-hydroxytamoxifen and ICI 182780, ERβ specific ligand DPN and GPR30 agonist G1 led to a rapid activation of p-ERK1/2, suggesting the involvement of ERα36, ERβ and GPR30 in the non-genomic signaling pathway in these cells. We also found a substantial increase in the cell migration and invasiveness of SUM149 cells upon the treatment with these ligands. Both basal and ligand-induced migration and invasiveness of SUM149 cells were drastically reduced in the presence of MEK inhibitor U0126, implicating that the phosphorylation of ERK1/2 by MEK is involved in the observed motility and invasiveness of IBC cells. We also provide evidence for the upregulation of p-ERK1/2 through immunostaining in IBC patient samples. These findings suggest a role of non-genomic signaling through the activation of p-ERK1/2 in the hormonal dependence of IBC by a combination of estrogen receptors. These findings only explain the failure of traditional anti-estrogen therapies in ER-positive IBC which induces the non-genomic signaling, but also opens newer avenues for design of modified therapies targeting these estrogen receptors.

Inflammatory breast cancer: what are the treatment options?

An otherwise healthy, 68-year-old woman presents to her primary-care physician complaining of right breast enlargement, warmth, and progressive pink to dark red skin changes over the past month. She denies fever, pain, or breast discharge. Physical examination reveals erythema of the whole right breast, warmth, swelling, induration, and nipple retraction. Palpable axillary lymphadenopathy is appreciated on the right only. The left breast is uninvolved. The physician is concerned that she may have inflammatory breast cancer.

Inflammatory breast cancer

Inflammatory breast cancer (IBC) represents the most virulent form of breast cancer, characterized by involvement of the skin and rapid progression of the disease. Management involves careful coordination of all multidisciplinary modalities, including imaging, systemic chemotherapy, surgery, and radiation therapy. The use of neoadjuvant chemotherapy has contributed significantly to improvement in overall survival since the first descriptions of this entity and has made the role of locoregional therapy, including surgery and radiation critical to continued improvements in this disease. In this article, we examine the unique epidemiology and pathology of IBC and review the various treatment modalities noting the significance of a multimodality approach and delineating each of the specific components. Moreover, we briefly describe the current research in IBC that will hopefully contribute further to improve systemic therapies.

Defining the molecular biology of inflammatory breast cancer

Inflammatory breast cancer (IBC) is a rare, but aggressive form of breast cancer. Despite the progress related to the introduction of primary combination chemotherapy (CT) to the multimodality treatment regimen, the prognosis of IBC remains poor with long-term survival inferior to 50%. Until recently, IBC remained understudied at the molecular level. In the past 10 years, advances have been made in the molecular characterization of the disease. Recently, the use of experimental models and new high-throughput molecular profiling technologies have led to the identification of genes or pathways potentially involved in disease development, which might represent new clinically relevant targets. The aim of this review is to present and discuss what is known about the biology of this particularly aggressive form of breast cancer and to discuss how this knowledge could improve its management.

Pathologic aspects of inflammatory breast cancer: part 2. Biologic insights into its aggressive phenotype

Inflammatory breast cancer (IBC) is the most aggressive and distinct form of primary breast cancer with a peculiar clinical presentation and dismal clinical outcome. This review addresses the pathologic aspects of this entity and discusses the molecular alterations involved in the highly malignant phenotype of IBC.

NF-kappa B genes have a major role in inflammatory breast cancer

Background

IBC (Inflammatory Breast cancer) is a rare form of breast cancer with a particular phenotype. New molecular targets are needed to improve the treatment of this rapidly fatal disease. Given the role of NF-κB-related genes in cell proliferation, invasiveness, angiogenesis and inflammation, we postulated that they might be deregulated in IBC.

Methods

We measured the mRNA expression levels of 60 NF-κB-related genes by using real-time quantitative RT-PCR in a well-defined series of 35 IBCs, by comparison with 22 stage IIB and III non inflammatory breast cancers. Twenty-four distant metastases of breast cancer served as "poor prognosis" breast tumor controls.

Results

Thirty-five (58%) of the 60 NF-κB-related genes were significantly upregulated in IBC compared with non IBC. The upregulated genes were NF-κB genes (NFKB1, RELA, IKBKG, NFKBIB, NFKB2, REL, CHUK), apoptosis genes (MCL1L, TNFAIP3/A20, GADD45B, FASLG, MCL1S, IER3L, TNFRSF10B/TRAILR2), immune response genes (CD40, CD48, TNFSF11/RANKL, TNFRSF11A/RANK, CCL2/MCP-1, CD40LG, IL15, GBP1), proliferation genes (CCND2, CCND3, CSF1R, CSF1, SOD2), tumor-promoting genes (CXCL12, SELE, TNC, VCAM1, ICAM1, PLAU/UPA) or angiogenesis genes (PTGS2/COX2, CXCL1/GRO1). Only two of these 35 genes (PTGS2/COX2 and CXCL1/GRO1)were also upregulated in breast cancer metastases. We identified a five-gene molecular signature that matched patient outcomes, consisting of IL8 and VEGF plus three NF-κB-unrelated genes that we had previously identified as prognostic markers in the same series of IBC.

Conclusion

The NF-κB pathway appears to play a major role in IBC, possibly contributing to the unusual phenotype and aggressiveness of this form of breast cancer. Some upregulated NF-κB-related genes might serve as novel therapeutic targets in IBC.

Lack of uniform diagnostic criteria for inflammatory breast cancer limits interpretation of treatment outcomes: a systematic review

PURPOSE

Inflammatory breast cancer (IBC) is the most aggressive type of breast cancer. No randomized controlled trial or systematic review with an IBC-only cohort that evaluates interventions has been published. We conducted a systematic review of the literature to characterize the reporting of clinical criteria and response to neoadjuvant therapy for IBC.

PATIENTS AND METHODS

We searched MEDLINE and other sources for the following: previously untreated patients with IBC without metastasis in cohort studies; utilized chemotherapy; and reported clinical outcomes. The following 4 groups were analyzed: no anthracycline induction, low-dose anthracycline induction, moderate-dose anthracycline induction, and high-dose chemotherapy requiring stem cell support. Weighted averages for the overall response rates were calculated using a random effects model.

RESULTS

Twenty-seven studies met all criteria, totaling 1232 patients. Clinical description of IBC eligibility criteria and reported response assessments varied significantly among studies. The response rates and 3- and 5-year overall survival for all 27 studies ranged from 14% to 100%, 22% to 84%, and 32% to 75%, respectively. Pathologic complete response rates after no anthracycline induction, low-dose anthracycline induction, moderate-dose anthracycline induction, and neoadjuvant high-dose chemotherapy subgroups were 4% (95% confidence interval [CI], 1%-18%), 11% (95% CI, 7%-17%), 14% (95% CI, 8%-22%), and 32% (95% CI, 24%-41%), respectively.

CONCLUSION

The criteria and reporting of IBC and treatment response was notably variable, with significant potential for subject heterogeneity. Pathologic complete response rates appear to be related to intensity of neoadjuvant treatment; however, this analysis is not based on randomized data. Future clinical trials should define and report the criteria for IBC diagnosis and response assessment to enhance interstudy comparisons.

Molecular Heterogeneity of Inflammatory Breast Cancer: A Hyperproliferative Phenotype

PURPOSE

Inflammatory breast cancer (IBC) is associated with very poor prognosis. The aims of this study are (a) to prospectively identify differential gene expression patterns associated with IBC and (b) to confirm these pathways using tissue arrays.

EXPERIMENTAL DESIGN

For gene expression analysis, IBC (n=14) was clinically defined as rapid-onset cancer associated with erythema and skin changes, whereas non-IBC patients (n=20) had stage III breast cancers, and cDNA analysis was carried out using the Affymetrix (Santa Clara, CA) HG-U133A microarrays. Tissue arrays were constructed from paraffin-embedded material, and the molecular phenotype of 75 IBC was compared with results from>2,000 non-IBC.

RESULTS

Gene expression analyses indicated that IBC has higher expression of genes associated with increased metabolic rate, lipid signaling, and cell turnover relative to non-IBC tumors. Consistent with the expression analysis, IBC had statistically higher Ki-67 (93% versus 11%; P<0.001). BAX expression, reflecting increased apoptosis and cell turnover, was significantly uniformly higher in almost all IBC (98% versus 66%; P<0.05), whereas the expression of Bcl-2 was not significantly different. IBC tumors were more likely to be steroid hormone receptor negative (estrogen receptor, 49% versus 30%; P=0.002; progesterone receptor, 68% versus 42%; P=0.001). The expression of tyrosine kinases was not significantly different. E-cadherin was found to be expressed in 87% of IBC, whereas the expression p53 was not significantly different.

CONCLUSION

This study is one of the largest molecular analyses of IBC. Both IBC and non-IBC are genetically heterogeneous with consistent differences in the molecular phenotype of IBC.

Epidemiology of inflammatory breast cancer (IBC)

Inflammatory breast cancer (IBC) is a rare and aggressive form of breast cancer with unknown etiology and generally poor outcome. It is characterized by diffuse edema (peau d'orange) and redness (erythema), although either the disease itself or case definitions have varied over time and place, confounding temporal trends and geographic variations. In this review, we discuss case definitions for IBC and its clinical characteristics; describe its geographic variation, age and racial distribution, incidence and survival patterns, and summarize the very limited information on its epidemiologic risk factors. We also incorporate emerging data from the National Cancer Institute's (NCI) Surveillance, Epidemiology, and End Results (SEER) Program.

The current understanding of the molecular determinants of inflammatory breast cancer metastasis

Inflammatory breast cancer is a highly aggressive and metastatic form of locally advanced breast cancer that carries a significantly worse prognosis than non-inflammatory breast cancers. Unfortunately, the molecular basis of this deadly form of breast cancer has been understudied. Over the past 10 years new studies have begun to reveal a unique molecular profile of IBC shedding light on its unique ability to rapidly invade and metastasize via the dermal lymphatic system of the skin overlying the breast. The goal of this review is to introduce IBC to the reader and provide a brief overview of what is known about the metastatic mechanisms of the disease.

“Inflammatory” breast cancer

BACKGROUND

"Inflammatory" breast cancer is a rare and very aggressive form of the disease characterised by rapid onset and dismal outcome.

METHODS

This review describes the clinical and molecular aspects of inflammatory breast cancer. The relevant English language literature on of inflammatory breast cancer was searched via Medline and ISI Web of Knowledge Cross Search (1924-2005), cross-referencing with key articles on the subject.

RESULTS AND CONCLUSION

An increasing body of evidence demonstrates that inflammatory breast cancer is a unique form of breast cancer. A prompt diagnosis and multidisciplinary approach (based on neoadjuvant chemotherapy, loco-regional treatment with surgery and/or radiotherapy, followed in some cases by adjuvant systemic therapy) are the two factors most likely to have an impact on survival. As the molecular basis of the disease is becoming increasingly more defined, new potential therapeutic targets may arise in the future.

Molecular profiling of inflammatory breast cancer: identification of a poor-prognosis gene expression signature

PURPOSE

Inflammatory breast cancer (IBC) is a rare but particularly aggressive form of primary breast cancer. The molecular mechanisms responsible for IBC are largely unknown.

EXPERIMENTAL DESIGN

To obtain further insight into the molecular pathogenesis of IBC, we used real-time quantitative reverse transcription (RT)-PCR to quantify the mRNA expression of 538 selected genes in IBC relative to non-IBC.

RESULTS

Twenty-seven (5.0%) of the 538 genes were significantly up-regulated in IBC compared with non-IBC. None were down-regulated. The 27 up-regulated genes mainly encoded transcription factors (JUN, EGR1, JUNB, FOS, FOSB, MYCN, and SNAIL1), growth factors (VEGF, DTR/HB-EGF, IGFBP7, IL6, ANGPT2, EREG, CCL3/MIP1A, and CCL5/RANTES) and growth factor receptors (TBXA2R, TNFRSF10A/TRAILR1, and ROBO2). We also identified a gene expression profile, based on MYCN, EREG, and SHH, which discriminated subgroups of IBC patients with good, intermediate, and poor outcome.

CONCLUSION

Our study has identified a limited number of signaling pathways that require inappropriate activation for IBC development. Some of the up-regulated genes identified here could offer useful diagnostic or prognostic markers and could form the basis of novel therapeutic strategies.

Update on inflammatory breast cancer

Inflammatory breast cancer (IBC) is both the least frequent and the most severe form of epithelial breast cancer. The diagnosis is based on clinical inflammatory signs and is reinforced by pathological findings. Significant progress has been made in the management of IBC in the past 20 years. Yet survival among IBC patients is still only one-half that among patients with non-IBC. Identification of the molecular determinants of IBC would probably lead to more specific treatments and to improved survival. In the present article we review recent advances in the molecular pathogenesis of IBC. A more comprehensive view will probably be obtained by pan-genomic analysis of human IBC samples, and by functional in vitro and in vivo assays. These approaches may offer better patient outcome in the near future.

Multivariate analysis of survival in inflammatory breast cancer: impact of intensity of chemotherapy in multimodality treatment

The prognosis of inflammatory breast cancer (IBC) is poor. We evaluated clinical and biopathological characteristics that could affect survival in 74 women with nonmetastatic IBC consecutively treated in our institution between 1976 and 2000. Patients received primary anthracycline-based chemotherapy at conventional doses (n=20) or high-dose chemotherapy (HDC) with haematopoietic stem cell support (HSCS) (n=54). After chemotherapy, 84% of patients underwent mastectomy, 95% were given radiotherapy and 55% tamoxifen. Immunohistochemistry data (ER, PR, ERBB2, P53) on pre-chemotherapy specimens suggested strong differences between IBC and non-IBC. The rate of pathological complete response to chemotherapy was 26% (27% with HDC and 17% with conventional doses, not significant). No single factor was found predictive of response. With a median follow-up of 48 months after diagnosis, the 5-year projected disease-free survival (DFS) was 24% and overall survival (OS) 41%. In multivariate analysis, the strongest independent prognostic factor was the delivery of HDC. The 5-year DFS and OS of patients were respectively 28 and 50% with HDC and 15 and 18% with conventional chemotherapy. These results and comparisons with other series of patients suggest a role for HDC with HSCS as part of the therapeutic approach in IBC. Further prospective studies are required to confirm it.

Validation of a tissue microarray to study differential protein expression in inflammatory and non-inflammatory breast cancer

AIMS

Inflammatory breast cancer (IBC) is an aggressive subtype of breast cancer with poor prognosis. The mechanisms responsible for the aggressive clinical evolution are incompletely understood. We constructed a tissue microarray (TMA) and validated its use in translational IBC research. Differential expression of proteins that might play a role in causing the IBC phenotype was studied.

METHODS AND RESULTS

A TMA containing 34 IBC and 41 non-stage matched non-IBC tumours was constructed. Five core biopsies were taken for each IBC and three cores for each non-IBC tumour. The TMA was validated using three approaches: (1) the excellent concordance between immunohistochemical results of the initial pathological examination and the results obtained with the TMA for ER, PR and HER2/neu (kappa > 0.74); (2) the known differential expression between IBC and non-IBC for four bio-markers in IBC (ER, PR, p53 and HER2/neu) was confirmed ( p < 0.01); (3) the HER2/neu status using three different antibodies (CB11, TAB250 and HercepTest) was highly concordant (kappa > 0.75). Furthermore, the overexpression of E-Cadherin and RhoC GTPase in IBC ( p < 0.05) was confirmed. We did not find a differential expression pattern for carbonic anhydrase IX (CA IX) and EGFR.

CONCLUSIONS

Using different approaches, we have validated the use of our TMA for studying differential protein expression in IBC and non-IBC. We confirm the overexpression of E-Cadherin and RhoC GTPase in IBC. The lack of differential expression for CA IX and EGFR might suggest the pathways are equally utilised in both types of breast cancer.

Prognosis of dermal lymphatic invasion with or without clinical signs of inflammatory breast cancer

It is still an open debate whether tumor emboli in dermal lymphatics without inflammatory signs represent a similar bad prognosis like inflammatory breast cancer. We evaluated the prognostic role of dermal lymphatic invasion (DLI) in breast cancer with (DLI + ID) or without (DLI w/o ID) inflammatory disease (ID). From August 1988 to January 2000, 42 patients with DLI were irradiated. Twenty-five were classified as pT4, 13 out of them as pT4d (inflammatory disease); the 17 remaining patients had 1 T1c, 12 T2 and 4 T3 cancers with DLI. Axillary dissection revealed node-positive disease in 39/41 patients (median, 9 positive nodes). Thirty-eight out of 42 patients received adjuvant systemic treatment(s). After a mean follow-up of 33 months, 22/42 patients (52%) are disease-free. The actuarial 3-year disease-free survival is 50% (DLI w/o ID, 61%; DLI + ID, 31%; p < 0.03); the corresponding overall survival was 69% (DLI w/o ID, 87%; DLI + ID, 37%; p = 0.005). The presence or absence of ID was the only significant parameter for all endpoints in multivariate analyses. Dissemination occurred in 19 (45%), local relapse in 7 (n = 17%) and regional failure in 4 (10%). Nine patients (21%) had contralateral breast cancer/relapse. Despite the same histopathologic presentation, DLI w/o ID offered a significantly better disease-free survival and overall survival than ID. The finding of dermal lymphatic tumor invasion predicts a high probability for node-positive disease.

Update on locally advanced breast cancer

Locally advanced breast cancer remains a clinical challenge as the majority of patients with this diagnosis develop distant metastases despite appropriate therapy. Patients with locally advanced disease encompass a wide range of clinical scenarios including advanced primary tumors (stage T4), advanced nodal disease (fixed axillary nodes or involvement of ipsilateral supraclavicular, infraclavicular, or internal mammary nodes), and inflammatory carcinomas. The prognoses of women with locally advanced breast tumors are also heterogeneous and depend on tumor size, extent of lymph node involvement, and the presence or absence of inflammatory carcinoma. Women with locally advanced disease require multimodal therapy, and coordinated treatment planning among the medical oncologist, surgical oncologist, and radiation oncologist is necessary to optimize patient care. In this article, the epidemiology, evaluation, prognostic factors, and treatment for locally advanced breast cancer are discussed. Inflammatory cancer is also reviewed, but is considered separately due to its distinct biology and clinical behavior.

Inflammatory breast cancer: clinical progress and the main problems that must be addressed

Inflammatory breast cancer is a rare but highly aggressive form of locally advanced breast cancer. Historically, this disease was uniformly fatal; however, with the advent of induction chemotherapy and carefully coordinated multimodality treatment, the prognosis of these patients has improved. This article reviews the clinical characteristics of inflammatory breast cancer and the recent advances in therapy.

Inflammatory breast cancer: results of antracycline-based neoadjuvant chemotherapy

Twenty-three patients with inflammatory breast cancer treated with a combined modality approach including anthracycline-based induction chemotherapy-surgery-chemotherapy-radiotherapy were reviewed. Twelve patients (52.2%) received FAC (5-fluorouracil, adriamycin, cyclophosphamide) and 11 patients (47.8%) were treated with FEC (5-fluorouracil, epirubicin, cyclophosphamide) induction chemotherapy for three cycles every 3 weeks. Surgery was followed by the initial chemotherapy or second-line chemotherapy for an additional six cycles to complete nine cycles and radiotherapy, respectively. The median overall survival (OS) time was 27 months and the median disease-free survival (DFS) was 13 months. Furthermore, patients treated with FAC induction chemotherapy have been found to have longer median OS and DFS periods compared to patients with FEC induction chemotherapy in both univariate and multivariate analysis. In conclusion, the superiority of doxorubicin-containing chemotherapy over epirubicin-containing chemotherapy should be established in larger randomized studies and more effective chemotherapeutic agents such as taxans are required for better survival rates in inflammatory breast cancer patients.

Evidence of chromosome regions and gene involvement in inflammatory breast cancer

Inflammatory breast cancer (IBC) is a rare but particularly aggressive form of primary breast cancer. In contrast to noninflammatory breast cancer (non IBC), the molecular alterations underlying IBC are poorly known. We postulated that the kind and frequency of these alterations might differ between IBC and non IBC and account for its particular aggressiveness. We investigated allelic losses associated with primary breast cancer (on chromosome arms 1p, 3p, 6p, 6q, 7q, 8p, 9p, 11p, 11q, 16q, 17p and 17q) by analyzing 71 microsatellite markers in 66 cases of IBC. Loss of heterozygosity (LOH) was frequent, with a mean fractional allelic loss (FAL) index of 52%. Relative to published data on non IBC, allelic loss was particularly frequent at 3p21-p14, 6p, 8p22, 11q, 13q14 and 17q21, suggesting the presence of genes that are markedly altered in IBC. In contrast, the DNA amplification levels of ERBB2, MYC and CCND1, as measured by real-time quantitative PCR, did not differ between IBC and non IBC.

Prognoses of T4 breast cancer subsets

BACKGROUND

The relative prognoses of subsets of patients with T4 breast tumors, since the advent of neoadjuvant therapy, are unknown, although inflammatory carcinoma (T4d) is considered to have the worst prognosis.

METHODS

Subsets of T4 patients were analyzed for the incidence of distant metastases at presentation (M1; n = 263). T4M0 patients treated with neoadjuvant therapy (n = 126) were analyzed for relapse-free survival (RFS). T4d tumors with (Cut/CW+) and without (Cut/CW-) skin nodules, posterior fixation, or both were analyzed separately.

RESULTS

Fewer patients with T4d (Cut/CW-) tumors had distant metastases at presentation than T4d (Cut/CW+) patients or T4b and T4c patients (P =.001,.001, and.009, respectively). RFS was longer for T4b patients than for T4c patients (P =.018) or T4d (Cut/CW+) patients (P =.003). RFS of the T4d (Cut/CW+) patients was shorter than for T4d (Cut/CW-) patients (P =.050).

CONCLUSIONS

The incidence of distant metastases at presentation was lowest, and RFS was longest, for patients with T4d tumors not grossly involving the skin or posterior structures. Patients whose tumors grossly invaded both skin and posterior structures (T4c) or those with T4d tumors grossly invading either most frequently presented with distant metastases and had the shortest RFS.

Biological considerations in locally advanced breast cancer treated with anthracycline-based neoadjuvant chemotherapy: thymidine labelling index is an independent indicator of clinical outcome

The present retrospective study aims to determine the clinical value of thymidine labelling index (TLI) together with other established clinical and biological factors in 116 locally advanced breast cancer (LABC) patients treated with anthracycline-based neoadjuvant chemotherapy, surgery, adjuvant chemotherapy and radiotherapy. TLI was determined in 71 LABC patients with a median of 2.62% (0-23.64%) and a mean of 4.71% +/- 5.54. As a result of neoadjuvant chemotherapy, 85 patients (73%) responded to chemotherapy (CT), whereas 31 patients were unresponsive (27%). No relationship has been found between the pretreatment biological variables including TLI, estrogen receptor (ER), progesteron receptor (PgR) status and clinical parameters such as the chemotherapy response rates and axillary lymph node involvement following chemotherapy. Median follow-up was 35 months (18-97 months) and the 3-year overall survival (OS) and disease free survival (DFS) rates were 71.6% and 52.2%, respectively. In univariate analysis, patients with inflammatory breast cancer, high TLI-index (> or = 2.62%), lymph node (LN) positivity or > 3 positive lymph nodes following neoadjuvant chemotherapy and without any response to neoadjuvant chemotherapy were found to have worse DFS and OS-rates and high local and systemic recurrence rates. In multivariate analysis, TLI was estimated as the most powerful independent factor affecting the OS in LABC patients among the other established clinical and biological parameters (p = 0.02). These results suggest that TLI is an important independent indicator of clinical outcome in patients with LABC and these patients with high TLI levels require more effective treatment modalities.

Molecular biology of breast cancer metastasis. Inflammatory breast cancer: clinical syndrome and molecular determinants

Inflammatory breast cancer (IBC) is an aggressive form of locally advanced breast cancer (LABC) that effects approximately 5% of women with breast cancer annually in the USA. It is a clinically and pathologically distinct form of LABC that is particularly fast growing, invasive, and angiogenic. Nearly all women have lymph node involvement at the time of diagnosis, and approximately 36% have gross distant metastases. Despite recent advances in multimodality treatments, the prognosis of patients with IBC is poor, with a median disease-free survival of less than 2.5 years. Recent work on the genetic determinants that underlie the IBC phenotype has led to the identification of genes that are involved in the development and progression of this disease. This work has been aided by the establishment of primary human cell lines and animal models. These advances suggest novel targets for future interventions in the diagnosis and treatment of IBC.

[Alternating chemotherapy and hyperfractionated accelerated radiotherapy in non-metastatic inflammatory breast cancer]

PURPOSE

Based on encouraging results reported in alternating radiotherapy and chemotherapy in inflammatory breast carcinoma, we have tried in this study to optimize locoregional treatment with a hyperfractionated accelerated radiotherapy schedule alternating with chemotherapy.

PATIENTS AND METHODS

From May 1991 to May 1995, 54 patients, previously untreated, with non-metastatic inflammatory breast cancer were entered in an alternating protocol consisting of eight courses of combined chemotherapy and two series of loco-regional hyperfractionated accelerated radiotherapy with a total dose of 66 Gy. Hyperfractionated accelerated radiotherapy was started after three courses of neoadjuvant chemotherapy (Adriamycin, Vincristine, Cyclophosphamide, Methotrexate, 5-fluoro-uracile) administered every 21 days +/- G.CSF. The first series delivered 45 Gy/three weeks to the breast, the axillary, subclavicular and internal mammary nodes, with two daily sessions of 1.5 Gy separated by an interval of eight hours; the second series consisted of a boost (21 Gy/14 fractions/10 d) alternating with another regimen of anthracycline-based-chemotherapy (a total of five cycles every three weeks). Hormonal treatment was given to all patients.

RESULTS

Of the 53 patients evaluated at the end of the treatment, 44 (83%) had a complete clinical response, seven (13%) had a partial response (> 50%) and two (4%) had tumoral progression. Of the 51 patients who were locally controlled, 18 (35%) presented a locoregional recurrence (LRR); eight (15%) had to undergo a mastectomy. All the patients but two with LRR developed metastases or died of local progressive disease and 26 (50%) developed metastases. With a median follow-up of 39 months (range: 4-74 months), survival rates at three and five years were respectively, 66 and 45% for overall survival and 45 and 36% for disease-free survival.

CONCLUSION

Alternating a combination of chemotherapy and hyperfractionated accelerated radiotherapy is a well-tolerated regimen which provides acceptable local control. The systemic dissemination remains the major problem of inflammatory breast carcinoma and further clinical trials using alternative drug regimens are warranted.

ERBB2 overexpression in breast carcinomas: no positive correlation with complete pathological response to preoperative high-dose anthracycline-based chemotherapy

The predictive value of ERBB2 amplification/expression to doxorubicin use is controversial. Preoperative chemotherapy, followed by the pathological assessment of tumour response to treatment provide optimal conditions for the evaluation of the predictive value of biological parameters. We report here data on the predictive value of ERBB2 in a series of 54 cases of breast cancer treated by preoperative high-dose anthracycline-based chemotherapy. Our series consisted of 26 women presenting an inflammatory breast cancer (IBC) and of 28 women with poor prognosis primary cancer (PPPC). Patients received a total of four cycles with doxorubicin (75 mg/m(2) for IBC or 70 mg/m(2) for PPPC) and cyclophosphamide (6 g/m(2) for IBC or 1400 mg/m(2) for PPPC), every 21 days. ERBB2 expression was determined by immunohistochemistry (clone CB11) performed on a tumour biopsy taken before chemotherapy. All patients underwent surgery as a second step of treatment, and the tumour response was assessed on pathological specimens. A complete pathological response was observed in 24 of the 54 cases (44%) (95% confidence interval (CI), 31-57). Pathological complete response was positively correlated with high histological grade (P=0. 02) and with the absence of oestrogen (P=0.003) or progesterone (P=0. 02) receptor expression. ERBB2 overexpression was found in 18 of the 54 cases (33%). A complete pathological response was observed in 33% of these cases (6/18). This figure was not significantly different from the 50% rate of complete response observed for tumours with no detectable ERBB2 expression (18/36). In this small series, ERBB2 overexpression was not a significant predictive marker of the pathological response to high-dose doxorubicin-based chemotherapy.

Inflammatory breast cancer: the evolution of multimodality treatment strategies

Inflammatory breast cancer is an aggressive subtype of invasive breast cancer. Early attempts to control the disease with local treatment modalities alone had a minimal impact on survival. More recently, multimodality treatment approaches that integrate systemic chemotherapy, surgery, and radiotherapy have resulted in improved local disease control and prolonged survival. Better systemic therapies need to be developed since metastatic disease develops in the majority of patients.

Prognostic factors in inflammatory breast cancer and therapeutic implications

223 inflammatory breast cancer patients were diagnosed at the Institut Curie between 1977 and 1987. Patients received chemotherapy and radiation treatment according to three consecutive randomised trials. Five- and 10- year survival rates were 41 and 32%, respectively. Disease-free interval rates were 25.5% at 5 years and 19% at 10 years. Parameters significantly linked with a pejorative prognosis in a multivariate analysis were: diffuse erythema, lymph node involvement, chest wall adherence, and age above 50 years. When therapeutic response parameters were included in the multivariate analysis, the five most important prognostic factors in order of significance were complete tumour regression after completion of induction treatment (at 8 months), complete regression of inflammatory symptoms after 3 months of neoadjuvant chemotherapy, limited erythema at presentation and, less significantly, complete regression of inflammatory symptoms at 8 months and tumour regression at 3 months. In conclusion, patients who achieved a rapid and complete remission had a better prognosis than patients who had an incomplete response to chemotherapy. High-dose chemotherapy and reversal or prevention of drug resistance will be evaluated in future trials. Detailed information on the biology of this disease should allow the design of new strategies aiming to improve patient management.

Management of inflammatory breast cancer

Inflammatory breast cancer (IBC) is a rare but often fatal disease. This review discusses the following conclusions: (1) The diagnosis of IBC is based on the clinical triad of erythema, ridging with peau d'orange, and rapid onset. The importance of histologic evidence of dermal lymphatic involvement is controversial. (2) Combining doxorubicin-containing chemotherapy with mastectomy or radiation therapy improves survival over that achieved with mastectomy or irradiation alone. (3) Mastectomy after induction chemotherapy may not improve survival or decrease locoregional recurrence rates, but the surgery does provide important prognostic information on treatment response and enables use of a lower radiation dose afterward, which results in reduced long-term complications. (4) The optimal number of cycles and dose intensity of chemotherapy for IBC remain undefined.

Cytosol cathepsin-D content and proliferative activity of human breast cancer. The Comitato Italiano per il Controllo di Qualita del Laboratorio in Oncologia

Mitogenic properties have been demonstrated in vitro for the lysosomal acidic protease cathepsin-D (cath-D). We investigated possible relationships between cath-D cytosol cell content and tumor proliferative activity in a series of 129 operable breast cancer patients. For total cytosol cath-D evaluation, a solid phase two-site immunoradiometric assay was utilized on tumor cell cytosol obtained for hormone receptor assay (DCC method). The percentage of S-phase cells was analyzed by 3H-thymidine autoradiographic assay. Median 3H-thymidine Labeling Index (3H-Tdr-LI) of the series was 2.7%; median cath-D content resulted 57 pmol/mg of protein cytosol and was significantly higher in node-positive with respect to the node-negative subgroup (p < 0.03). When classified in low, intermediate or high tumor cath-D content and slow or fast proliferative activity (cut-off: median values of the series), no significant agreement was found between the two variables. Statistical analysis, however, showed that a significant inverse correlation existed in node positive tumors between cath-D and 3H-Tdr-LI values which was even more evident in N-positive high estrogen receptor-positive (ER+) cases (coefficient of correlation = 0.6828; p = 0.0001). Cytosol cath-D content cannot be generally proposed as a direct marker of proliferative activity for operable breast cancer.

Long-term results of a combined modality approach in treating inflammatory carcinoma of the breast

Twenty-eight patients with inflammatory carcinoma of the breast were managed initially by induction chemotherapy consisting of 3 courses of a combination of cyclophosphamide, doxorubicin hydrochloride, and 5-fluorouracil. Twenty-two showed a partial response, and 21 underwent mastectomies. Histopathologic examination of the surgical specimens revealed no residual tumor in 2 breasts, but all 21 patients had residual metastases in their axillary lymph nodes. Postoperatively, they received the same chemotherapy. The other six patients who failed to respond to induction chemotherapy received radical radiation therapy followed by a combination chemotherapy regimen that consisted of cyclophosphamide, methotrexate, 5-fluorouracil, vincristine, and prednisone. Any patient in whom chemotherapy failed during the follow-up period was treated by radiation therapy and/or a combination of mitomycin-C and vinblastine as necessary. At the time of diagnosis, 17 patients who had no evidence of distant metastasis, i.e., stage III B disease, had disease-free survival ranging from 5 to more than 84 months, with a median of 30 months, and an overall survival of 7 to more than 120 months with a median of 32 months. The 5-year survival rate was 18%. The other 11 patients who had distant metastases, i.e., stage IV disease, had an overall survival ranging from 4 to 14 months. The results of this approach of initial systemic chemotherapy followed by local-regional cytoreductive therapy, then systemic therapy, might suggest some survival benefits in patients with stage III disease.