Inflammatory breast carcinoma

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.

Steroid pathway and oestrone sulphate production in canine inflammatory mammary carcinoma

Spontaneous canine mammary inflammatory carcinoma (IMC) shares epidemiologic, histopathologic and clinical characteristics with the inflammatory breast carcinoma (IBC) disease in humans. We have analysed the steroids levels in serum and in tissue homogenates of IMC, the expression of two of their receptors (androgen and beta-estrogen) and of three enzymes included in the steroidogenesis pathway (aromatase (CYP19A1), steroid sulphatase (STS) and estrogen sulfotransferase (EST)) trying to explain the specific accumulation of steroids in IMC tissues generating deposits in the form of lipid droplets whose presence can be attributed to steroids secreted by IMC cells. According to our working hypothesis, oestrone sulphate would be the main component of these lipid droplets. The presence of these steroid deposits would contribute to the intense proliferation and invasive behaviour of IMC and IBC, although their involvement in angiogenesis is yet to be demonstrated.

Metastatic esophageal carcinoma masquerading as inflammatory breast carcinoma

A 50-year-old Caucasian woman with a history of esophageal adenocarcinoma presented with a 3-week history of right breast swelling and progressive erythema. Twenty-two months prior to presentation, she had been diagnosed with adenocarcinoma of the esophagus (T3,N1,M1a) and underwent neoadjuvant chemoradiotherapy followed by surgical resection. On physical examination, the right breast was red, swollen (40% larger than the contralateral breast), tender to palpation, and warm to the touch (Fig. 1). No mass was palpable. On the basis of the clinical findings, inflammatory breast carcinoma was suspected. A punch biopsy revealed a poorly differentiated adenocarcinoma with extensive involvement of dermal lymphatics (Fig. 2). The clinical and histologic differential diagnosis included inflammatory breast carcinoma vs. metastatic esophageal adenocarcinoma to the skin of the breast. To resolve this question, immunohistochemical stains for estrogen and progesterone receptors and CDX-2 (BioGenex, San Ramon, CA, USA) were performed. CDX-2 is an intestinal homeobox gene expressed in gastrointestinal epithelium and gastrointestinal tumors. The tumor nuclei were positive for CDX-2 but negative for both steroid receptors (Fig. 3), confirming the diagnosis of metastatic esophageal adenocarcinoma.

Inflammatory breast cancer shows angiogenesis with high endothelial proliferation rate and strong E-cadherin expression

Inflammatory breast cancer (IBC) is the most aggressive form of breast cancer. Improved understanding of the mechanisms responsible for the differences between IBC and non-IBC might provide novel therapeutic targets. We studied 35 consecutive patients with IBC, biopsied prior to the initiation of chemotherapy. Angiogenesis was evaluated by Chalkley counting and by assessment of endothelial cell proliferation (ECP) and vessel maturity. The presence of fibrin, expression of the hypoxia marker carbonic anhydrase IX (CA IX) and epithelialcadherin (E-cadherin) expression were immunohistochemically detected. The same parameters were obtained in a group of 104 non-IBC patients. Vascular density, assessed by Chalkley counting (P<0.0001), and ECP (P=0.01) were significantly higher in IBC than in non-IBC. Abundant stromal fibrin deposition was observed in 26% of IBC and in only 8% of non-IBC (P=0.02). Expression of CA IX was significantly less frequent in IBC than in non-IBC with early metastasis (P=0.047). There was a significant positive correlation between the expression of CA IX and ECP in IBC (r=0.4, P=0.03), implying that the angiogenesis is partly hypoxia driven. However, the higher ECP in IBC and the less frequent expression of CA IX in IBC vs non-IBC points at a role for other factors than hypoxia in stimulating angiogenesis. Strong, homogeneous E-cadherin expression was found at cell-cell contacts in all but two IBC cases, both in lymphovascular tumour emboli and in infiltrating tumour cells, challenging our current understanding of the metastatic process. Both the intense angiogenesis and the strong E-cadherin expression may contribute to the highly metastatic phenotype of IBC.

Canine inflammatory mammary carcinoma: histopathology, immunohistochemistry and clinical implications of 21 cases

Human inflammatory breast carcinoma (IBC) is the most malignant type of breast cancer with an extremely poor prognosis. The dog is the unique animal species in which spontaneous inflammatory mammary carcinoma (IC) has been reported, although it is not well documented. The purpose of this study was to characterize histopathologically and immunohistochemically the canine IC, considering associated clinical features. Twenty-one dogs diagnosed with IC and with known clinical and necropsy data were included in the study. Tissue samples from necropsies underwent a histopathological review and an immunohistochemical study (Ki-67, estrogen receptor (ER), progesterone receptor (PR), and P53 tumor suppressor protein). The histological study revealed several types of carcinomas (solid, tubular, papillary, and adenosquamous) and three lipid-rich carcinomas. All tumors were ER negative. Two histological patterns of neoplastic dermal infiltration were observed: tubular/papillary and sarcomatous-like. Dermal sarcomatous-like infiltration was significantly related to previous treatments with progestagens (p = 0.006), primary type of IC (p = 0.03), extreme local pain (p = 0.02), reduced observation of emboli in dermal lymphatic vessels (p = 0.01), and increased expression of p53 (p = 0.001). PR expression was significantly higher in secondary post-surgical IC (p = 0.04). The absence of PR was related to the existence of pulmonary metastases at necropsy (p = 0.04). Canine primary IC is the most aggressive form of this disease with distinct histopathological and immunohistochemical characteristics. Progestins and endocrine-related mechanisms seem to be involved in canine IC development. Canine IC could serve as a spontaneous model for human IBC, particularly in studies concerned with new therapeutics approaches.

Vasculogenic mimicry and pseudo-comedo formation in breast cancer

Tumors require a blood supply for growth and hematogenous metastases. Until recently, most research in this area has focused on the role of angiogenesis, the recruitment of new vessels into a tumor from preexisting vessels. Previously, in a study of breast cancer (IBC), in which we used established inflammatory breast cancer (IBC) xenografts (WIBC-9) originating from a patient with IBC (Shirakawa et al., Cancer Res 2001:61:445-451), we reported observing vasculogenic mimicry (VM), a condition in which bloodstreams within cancer tissue are not accompanied by a lining of endothelial cells (ECs) (Shirakawa et al., Cancer Res 2002:62:560-566). In the present study, we examined 331 surgically resected breast cancer specimens for evidence of VM, using immunohistochemistry and laser-captured microdissection (LCM) followed by nested reverse transcriptase polymerase chain reaction (RT-PCR). Surprisingly, 7.9% (26 specimens) of the 331 specimens exhibited evidence of VM. Of these 26 VM specimens, 84.6% (22 specimens) exhibited pseudo-comedo formation. RT-PCR analysis of 8 microdissected typical VM specimens revealed expression of Tie-2, Flt-1, thrombin receptor and CD31 in 63, 50, 0 and 0% of specimens, respectively. In contrast, results of RT-PCR analysis of 8 specimens from non-VM tumors were negative for expression of these genes. The 26 VM cases tended to have a higher percentage of hematogenous recurrence (p = 0.059) and a lower percentage of 5-year survival (p = 0.071) than the 305 non-VM cases. However, there were no significant differences in tumor size, lymph node metastasis, estrogen receptors or progesterone receptors between the 2 groups (p > 0.1). Our results suggest that the existence of VM increases the likelihood of hematogenous metastases and is in inverse proportion to prognosis.

Tumor-infiltrating endothelial cells and endothelial precursor cells in inflammatory breast cancer

Inflammatory breast cancer (IBC) is a specific type of breast tumor that generally has a poor prognosis, in spite of recent advances in treatment. In the present study, semiquantitative reverse transcriptase polymerase chain reaction examination of resected specimens showed that angiogenic factors, not lymphangiogenic factors, are overexpressed in IBC tumors, compared with non-IBC tumors. Immunohistochemical analysis of the specimens revealed a significantly higher population of tumor-infiltrating (TI) endothelial cells (ECs) or endothelial precursor cells (EPCs) in tumor-associated stroma of IBC specimens than in non-IBC specimens. In a previous study, we examined the phenotype of host cells in response to transplanted IBC cells, using an established human IBC xenograft model (WIBC-9) (Shirakawa et al., Cancer Res 2001;61:445-51). The data obtained in that study are consistent with the findings of the present study. To explore the therapeutic potential of blocking vascular endothelial growth factor (VEGF) and angiopoietin (Ang) pathways in IBC, established vectors encoding soluble Flt-1 (sFlt-1) and soluble Tie2 (sTie2) were injected directly into WIBC-9. Both vectors produced growth inhibition ratios of WIBC-9 that were significantly higher than those of a non-IBC xenograft (MC-5). Also, both vectors suppressed WIBC-9 lung metastases. The efficacy correlated with the number of TI ECs/EPCs, which was determined by fluorescence-activated cell sorting. These ECs/EPCs incorporated acetylated lipoprotein and were integrated within a HUVEC monolayer in vitro culture on day 5.

The Usefulness of MIBI Scanning to Detect Underlying Carcinoma in Women with Acute Mastitis

The efficacy of Tc-99m sestamibi scintimammography in the detection of breast carcinoma has been proven in previous studies. In this study we evaluated the influence of active mammary inflammation on Tc-99m sestamibi scintimammography and its ability to detect breast malignancy in the presence of this condition. Twenty-one women with acute nonpuerperal mastitis underwent breast scintimammography using Tc-99m sestamibi. Their mean age was 49.6 years. In 15 women the scan was positive, 2 suffered from inflammatory carcinoma of the breast, and all the other women had acute mastitis. Six patients had a negative scan, and in all of them, acute mastitis was diagnosed. Total accuracy, sensitivity and specificity in the detection of breast mastitis were 62%, 68%, and 88%, respectively. Scintimammography in patients with acute inflammation of the breast is frequently positive in the absence of malignant condition, therefore it should not be used during acute mastitis for the detection of breast cancer.

Inflammatory Carcinoma of the Breast: Characteristic Findings of MR Imaging

Inflammatory breast carcinoma (IBC) Shows a unique clinical appearance and has an extremely poor prognosis. Although immediate intensive therapy has been proposed, diagnosis of this disease tends to be delayed as its clinical features can be confused with acute mastitis. The conventional imaging modalities including mammography and ultrasonography are of limited value in the diagnosis of IBC, as it is difficult to delineate specific findings of the swollen dense breast. Recently, magnetic resonance (MR) imaging has been widely applied to breast diseases. One of the excellent features of this modality is its diagnostic ability in dense breasts. However, few trials to evaluate the capability of this new modality for IBC have been documented. In recent years, we found that a characteristic feature in 5 cases of IBC was a strong signal on T2-weighted images (T2WI) of MR imaging at the retromammary and subcutaneous area. Pathological features of the retromammary area showed marked interstitial edema and focal lymphatic involvement by tumor cells. These characteristic images obtained by MR imaging may be suggestive of inflammatroy breast carcinoma. Furthermore, subtracted dynamic MR imaging indicated the site of the tumor. Therefore, the application of MR imaging for swollen breasts would assist in the immediate diagnosis of IBC and would contribute to appropriate and timely therapy.