Surgical Management of Inflammatory Breast Cancer

Improved Rate of Negative Margins for Inflammatory Breast Cancer Using Intraoperative Frozen Section Analysis

BACKGROUND

Inflammatory breast cancer (IBC) is a rare and aggressive form of breast cancer with a poor survival rate. Modified radical mastectomy (MRM) with negative pathologic margins is critical for improved survival. We aim to study the potential benefit of intraoperative frozen section analysis (FSA) to improve disease-free margins.

METHODS

This prospective, monocentric study included 19 patients who underwent MRM for IBC. For each patient, a 2 mm continuous skin edge was sent for FSA to guide further resection. The rate of tumor-free margins and the concurrence between the FSA and permanent pathological results were analyzed.

RESULTS

Overall, 15 of the 19 patients achieved negative margins, including four patients who would have had positive margins without FSA. The odds ratio of achieving a negative final margin with FSA was infinity (p = 0.031), and there was a strong agreement between the FSA and permanent pathological results (Kappa-0.83; p < 0.0001).

CONCLUSIONS

The FSA technique decreased the number of positive margins in IBC patients undergoing MRM, thereby potentially reducing the need for re-operation, allowing immediate wound closure, and preventing delays in the administration of adjuvant radiation therapy. More extensive trials are warranted to establish the use of intraoperative FSA in IBC treatment.

MRI Changes in Breast Skin Following Preoperative Therapy for Patients with Inflammatory Breast Cancer

RATIONALE AND OBJECTIVES

Preoperative systemic therapy (PST) followed by mastectomy and radiation improves survival for patients with inflammatory breast cancer (IBC). Residual disease within the skin post-PST adversely impacts surgical outcome and risk of local-regional recurrence (LRR). We aimed to assess magnetic resonance imaging (MRI) breast skin changes post-PST with pathologic response and its impact on surgical resectability.

MATERIALS AND METHODS

We retrospectively reviewed 152 baseline and post-PST breast MRIs of 76 patients with IBC. Using the ACR-BIRADS MRI lexicon, we correlated skin thickness, qualitative enhancement, and kinetic analysis with pathologic response in the skin at mastectomy.

RESULTS

Baseline MRI showed skin thickening in all 76 patients, 75/76 (99%) showed skin enhancement, 54/75 (72%) had medium/fast initial kinetics, usually with persistent delayed kinetics in 49/54 (91%). Following PST, 66/76 (87%) had residual skin thickening with 64/76 (84%) showing a decrease; 33/76 (43%) had persistent enhancement. The median thickness post-PST was 4.7 mm with residual tumor in the skin, and 3.0 mm without residual tumor (p = 0.008). Regardless of pathologic response, the majority of patients had persistent skin thickening on MRI following PST (100% [14/14] with residual tumor and 84% [52/62] without residual tumor). There was no association between post-PST skin thickness on breast MRI and rate of LRR.

CONCLUSION

Patients with IBC have skin thickening and enhancement on baseline breast MRI, with a statistically significant reduction in skin thickness following successful PST. Despite persistent skin changes on MRI, patients achieving a partial or complete parenchymal response to PST may proceed to mastectomy with low LRR rates.

Trends, survival outcomes, and predictors of nonadherence to mastectomy guidelines for nonmetastatic inflammatory breast cancer

BACKGROUND

The Current National Comprehensive Cancer Network guidelines recommend modified radical mastectomy (MRM) as the surgical treatment of choice for nonmetastatic inflammatory breast cancer (IBC). Limited studies have looked into the outcomes of breast conserving surgery (BCS) vs. MRM for IBC.

METHODS

National Cancer Database (NCDB) data from 2004 to 2014 were retrospectively analyzed. Patients' demographics, tumor characteristics, and overall survival (OS) trends were compared for BCS and MRM cases of nonmetastatic IBC. Univariate and multivariate analyses were performed.

RESULTS

A total of 413 (3.89%) BCS and 10,197 (96.11%) MRM cases were identified. Median follow-up was 58.45 months. Compared to MRM, BCS patients were more likely to be older, be African American, have Medicare/Medicaid or be uninsured, live in lower education ZIP codes, and live in a metropolitan area (all p < 0.05). BCS rates significantly decreased from 5.84% in 2004 to 3.19% in 2014 (p < 0.001). BCS patients also were more likely to have less than 50% of the breast involved (51.57% vs. 43.88%; p = 0.0081) and were less likely to receive trimodal therapy (50.85% vs. 74.62%; p = <0.0001). The OS was significantly higher in the mastectomy group over 9 years at 62.02% vs. 54.47% in the BCS group. Additionally, in the adjusted multivariate model, BCS cases were associated with 23% higher hazards of overall mortality (p = 0.0091).

CONCLUSION

BCS was performed in a limited number of cases, which decreased over the study period. The analysis identified both demographic predictors of receiving BCS and significantly lower OS for IBC patients undergoing a BCS.

Immediate Breast Reconstruction for Inflammatory Breast Cancer: Trends in Use and Clinical Outcomes 2004-2016

INTRODUCTION

National guidelines specify against immediate breast reconstruction (IBR) among inflammatory breast cancer (IBC) patients. However, limited data exist regarding this practice. We report practice patterns and oncologic outcomes among nonmetastatic IBC patients receiving trimodality therapy, with or without IBR.

METHODS

Using the National Cancer Database, we identified nonmetastatic IBC patients treated with trimodality therapy from 2004 to 2016. Primary outcome was overall survival (OS), assessed on unadjusted analysis using Kaplan-Meier estimates and on adjusted analysis using multivariable Cox proportional hazards and inverse probability weighting (IPW) models. OS analysis was also conducted with propensity score matched (PSM) cohorts. Secondary outcomes included IBR utilization rates, time to postmastectomy radiotherapy (PMRT), and surgical outcomes.

RESULTS

6589 women were included, including 5954 (90.4%) non-reconstructed and 635 (9.6%) IBR. Among IBR recipients, 250 (39.4%) underwent autologous reconstruction, 171 (26.9%) underwent implant-based reconstruction, and 214 (33.7%) unspecified. IBR utilization increased from 6.3% to 10.1% from 2004 to 2016 at a 4% average annual growth rate (P < 0.001). Median follow-up was 43 and 45 months for IBR and non-reconstructed patients, respectively (P = 0.29). On Cox multivariable analysis, IBR was associated with improved OS (HR 0.63, 95% CI 0.44-0.90, P = 0.01), but this association was not significant on IPW analysis (P = 0.06). In PSM cohorts, this association remained significant (HR 0.60, 95% CI 0.40-0.92, P = 0.02). Margin status, time to PMRT, 30-day readmission, and 30-/90-day mortality did not differ between groups (all P > 0.05).

CONCLUSION

Although not endorsed by national guidelines, IBR is increasing among IBC patients; however, more granular data are needed to determine oncologic safety.

Inflammatory Breast Cancer: What surgeons need to know

Strict criteria to identify Inflammatory Breast Cancer (IBC) have been made available - these are based on pathological as well as clinical observations. It is mandatory to confirm the criteria used in any further report. Scientific evidence accumulated so far is confusing, and unclear therefore no hard conclusion can be drawn from the available literature on the management of IBC. The advent of new medications results into an up-to-date management and different outcomes. It is mandatory to follow these criteria if reliable guidelines are to be made available in the next future.

A standard mastectomy should not be the only recommended breast surgical treatment for non-metastatic inflammatory breast cancer: A large population-based study in the Surveillance, Epidemiology, and End Results database 18

BACKGROUND

Standard mastectomy has long been the recommended breast surgical treatment for non-metastatic inflammatory breast cancer (IBC). The objective of this population-based study was to evaluate the significance of various breast surgical treatments for this highly aggressive subtype.

METHODS

The Surveillance, Epidemiology, and End Results program registry was searched to identify women with non-metastatic IBC receiving standard treatment including breast surgery, radiation therapy and chemotherapy diagnosed between 1998 and 2013. Comparisons of the proportions of various breast surgery procedures over the years were performed using Pearson's chi-square test. Breast cancer-specific survival (BCSS) and overall survival (OS) were estimated using the Kaplan-Meier product limit method and compared across groups using the log-rank statistic. Cox models were then fitted to compare the association between various breast surgical procedures and BCSS or OS after adjusting for patient and tumor characteristics.

RESULTS

A total of 3374 cases were identified. Over the years, the proportion of contralateral prophylactic mastectomy (CPM), breast reconstruction and both were increasing. The proportion of implant-based reconstruction was also increasing with no difference in survival compared with other types of reconstruction. There was no statistically significant difference in BCSS or OS among various breast surgery treatments, such as breast conserving surgery, CPM, breast reconstruction and standard unilateral mastectomy.

CONCLUSIONS

Breast surgery is of great significance to the clinical outcome of IBC. Standard mastectomy should not be the only recommended breast surgical treatment.

Immediate Reconstruction in Inflammatory Breast Cancer: Challenging Current Care

BACKGROUND

Inflammatory breast cancer (IBC) is an aggressive disease that is treated with trimodality therapy consisting of neoadjuvant chemotherapy, surgery, and post-mastectomy radiation therapy (PMRT). Traditionally, modified radical mastectomy without reconstruction has been the operation of choice for patients with IBC due to fears of high rates of margin positivity, risk of local recurrence, and the need for PMRT.

METHODS

A retrospective review was performed to evaluate women with IBC at our institution from 2006 to 2014 who completed trimodality therapy. Patients were identified as undergoing reconstruction or no reconstruction (NR), with reconstruction being further classified as immediate (IR) if reconstruction occurred at the initial surgery, or delayed (DR) if initial reconstruction occurred after PMRT.

RESULTS

Sixty women with IBC were identified using inclusion criteria. The median follow-up was 2.3 years (range 1.4-4.6). Patients with IR had a statistically significant increased risk (p = 0.006) in postoperative complication rates compared with DR (0 %) and NR (2.6 %). Two patients had positive skin margins on final pathology (one IR, one NR), with both eventually having recurrence. Time to PMRT was delayed 10 days in patients with IR compared with those without IR. No statistically significant difference in recurrence rates was observed (p = 0.86) when comparing patients with IR and those with NR, and no difference in survival was observed between patients who had reconstruction and those without (p = 0.91).

CONCLUSION

Performing IR with mastectomy for IBC is associated with increased complications, but is not associated with decreased survival or increased recurrence in selected patients. IR in selected IBC patients can facilitate successful breast reconstruction.

Contemporary operative management of T4 breast cancer

BACKGROUND

Guidelines advise modified radical mastectomy following neoadjuvant systemic therapy for T4 breast cancer. We studied the influence of current systemic therapy and tumor subtype on pathologic stage and practice patterns to identify patients for whom less aggressive operative treatment might be considered.

METHODS

We identified 98 clinical T4 M0 cases operated on at our institution from October 2008-July 2015. Patient, tumor, and treatment variables were analyzed.

RESULTS

Clinical T4 substage was 7% T4a, 32% T4b, 3% T4c, and 58% T4d. Tumor biologic subtype was 41% ER+/HER2-, 36% HER2+, and 23% ER-/HER2-. A total of 86 patients (88%) had neoadjuvant systemic therapy; 87% of patients underwent total mastectomy, 9% skin-sparing mastectomy, and 4% breast conservation. Axillary dissection was performed in 74% of patients and sentinel node surgery with (14%) or without (11%) axillary dissection in the remainder; 41/98 (42%) were lymph node negative at operation. The pathologic complete response rate in the breast (31%) and axilla (39%, cN+ cases) correlated with biologic subtype (P < .0001). Overall 5-year, disease-free, and breast cancer-specific survival were 68% and 86%.

CONCLUSION

Alignment with guidelines was substantial for both breast and axillary operation. Favorable breast cancer-specific survival suggests current multidisciplinary treatment has improved outcomes. Careful assessment of pathology and treatment response may identify clinical T4 patients appropriate for breast or axillary conservation.

A Case of a Bilateral Inflammatory Breast Cancer: A Case Report

Cases of bilateral inflammatory breast cancer (IBC) are extremely rare. Our search criteria only found one other record of metachronous bilateral IBC (1). We present the case of a patient who was treated for IBC with neoadjuvant chemotherapy, modified radical mastectomy (MRM), and whole breast radiation. Less than 1 year later, the patient had a recurrence of IBC on the left chest wall with in the radiated field, as well as a new IBC on the contralateral side. Bilateral IBC is extremely rare. This entity can present challenges for the standard treatment of IBC with neoadjuvant chemotherapy, MRM, and whole breast radiation (2). Our case study shows the importance of scheduled routine imaging, screening with physical examination after IBC management, and good patient compliance in this aggressive disease (3).

The influence of the extended indications for sentinel node biopsy on the identification of metastasis-free and metastatic sentinel nodes

BACKGROUND AND OBJECTIVE

Rates of sentinel node (SN) identification and metastasis-positive SNs were compared between the group with highly selective indications for sentinel node biopsy (SNB) and the group with merely no contraindications for SNB (Groups A and B, respectively).

MATERIALS AND METHODS

We performed a single-center retrospective data analysis of 471 breast cancer patients treated during 2004-2010. Data on clinical and pathologic staging, frozen section results, radiological measurements and pathologic examination results were obtained from patient records. Patients were analyzed in two groups. Group A (n=143) had SNB performed only when the patients fulfilled to the following criteria: breast tumor no greater than 3cm in diameter, unifocal disease, no pure ductal carcinoma in situ, no history of previous breast or lymph node surgery, and no neoadjuvant chemotherapy. Indications for SNB were extended in Group B (n=328) so that inflammatory breast cancer and positive lymph nodes became the only exclusion criteria.

RESULTS

The rate of SN identification was 97.9% in Group A vs. 99.09% in Group B (P=0.29). SNs were metastasis positive and frozen sections false negative at comparable proportions in both groups.

CONCLUSIONS

The extension of indications for SNB did not reduce the rates of SN identification or did not create any impact on the rate of metastatic SNs.

Challenging a traditional paradigm: 12-year experience with autologous free flap breast reconstruction for inflammatory breast cancer

BACKGROUND

Inflammatory breast cancer is a rare but aggressive breast cancer with an overall poor prognosis. Traditionally, reconstruction has not been offered, because of poor long-term survival, the need for multimodality treatment, and complex treatment sequencing. The authors examined the safety and feasibility of free flap breast reconstruction for inflammatory breast cancer.

METHODS

A retrospective analysis of all patients who underwent reconstruction for inflammatory breast cancer from January of 2000 to December of 2012 was conducted.

RESULTS

Of 830 inflammatory breast cancer patients, 59 (7.1 percent; median age, 48 years; range, 27 to 65 years) underwent free flap reconstruction. All patients received chemotherapy and radiation therapy. Most patients (n = 52) underwent delayed reconstruction. Five patients with a history of prior partial mastectomy and irradiation developed inflammatory breast cancer and underwent immediate reconstruction following completion mastectomy. Two others underwent immediate chest wall and breast reconstruction following resection. Thirteen patients underwent bilateral reconstruction, and seven required a bipedicled abdominal flap for the unilateral mastectomy defect. Thirty-seven patients (62.7 percent) required revision of the reconstructed breast, and 29 (49.2 percent) had a contralateral balancing procedure to optimize symmetry. Complications occurred in 21 patients (35.6 percent), with one total flap loss (1.7 percent). The median length of follow-up was 43.9 months; 49 patients (83.1 percent) were alive without evidence of recurrent disease.

CONCLUSIONS

Autologous free flap breast reconstruction can be performed safely in inflammatory breast cancer patients, with acceptable complication rates and without an increased risk for flap loss. Inflammatory breast cancer should not preclude free flap breast reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Long-term Follow-up of Breast-conserving Therapy in Patients with Inflammatory Breast Cancer Treated with Neoadjuvant Chemotherapy

Inflammatory breast cancer (IBC) is a rare and aggressive form of breast cancer. Currently, multimodality treatment is recommended, but the optimal surgical management has not been fully elucidated. In this study, we investigated the long-term outcomes of using breast-conserving therapy in patients with IBC undergoing neoadjuvant chemotherapy (NAC). Twenty-four patients with IBC were treated from 2002 to 2006. NAC was initiated with doxorubicin and cyclophosphamide followed by paclitaxel. In addition, HER2/neu-positive patients received trastuzumab, whereas HER2/neu-negative patients received bevacizumab. Clinical response was assessed by dynamic contrast-enhanced magnetic resonance imaging before surgery and pathologic response after surgery. A partial mastectomy with sentinel lymph node biopsy and/or axillary lymph node dissection or a modified radical mastectomy was performed based on the surgeon's recommendations and patient's preference. All patients received adjuvant radiation. Of the 24 patients, seven (29%) underwent a partial mastectomy and 17 (71%) underwent a mastectomy. The overall survival rate for partial mastectomy and for mastectomy patients was 59 and 57 per cent ( P = 0.49), respectively, at a median follow-up of 60 months (range, 48 to 92 months). Breast-conserving therapy can be considered in a selected group of patients who demonstrate a good response to NAC.

How do I treat inflammatory breast cancer?

Inflammatory breast cancer (IBC) is an uncommon and aggressive presentation of locally advanced breast cancer that is potentially curable when localized but may be associated with distant metastasis in up to one-third of patients at presentation. The diagnosis of IBC is made based on clinical features, including the presence of skin edema and erythema involving at least one-third of the breast, with or without a mass, and usually associated with dermal lymphatic invasion (DLI) on skin biopsy. Management requires combined modality therapy, including neoadjuvant chemotherapy with an anthracycline and taxane-based regimen, followed by surgery and radiotherapy, plus concurrent anti-HER2 therapy for HER2-positive disease, and endocrine therapy for at least 5 years after surgery for estrogen-receptor-positive disease (Fig. 1). There have been few large clinical trials focused on IBC; therefore, most data regarding treatment are derived from retrospective analyses, small studies, and extrapolation of results from trials of noninflammatory locally advanced breast cancer. Patients with IBC should be encouraged to enroll in clinical trials whenever possible. In addition, further research into the biology of IBC may help to elucidate the mechanisms underlying its aggressive clinical behavior and to assist in the development of therapies targeted for this specific population.

Who should have or not have an axillary node dissection with breast cancer?

There have been dramatic changes in the approach to the axilla in women with breast cancer over the last 100 years, reflecting the evolution in our understanding of the underlying tumor biology, reduced disease burden because of early detection, and advances in all breast cancer treatment modalities. The approach to the axilla needs to be individualized, much like the extent of surgery for the primary tumor. Axillary dissection remains an important intervention for patients with more locally advanced disease. However, in patients with early-stage breast cancer, in whom regional recurrence is extremely low, the added benefit of an ALND has yet to be confirmed.

Histological, Immunohistological, and Ultrastructural Description of Vasculogenic Mimicry in Canine Mammary Cancer

Canine inflammatory mammary cancer (IMC) and human inflammatory breast cancer (IBC) are the most aggressive and lethal type of mammary cancer in female dogs and in women. The generation of microvascular channels by malignant tumor cells (endothelial-like cells [ELCs]) without endothelial cell participation (vasculogenic mimicry) has been reported in human breast cancer, including IBC, and is considered a new type of tumor angiogenesis. The aim of this study was to investigate the presence of ELCs in highly malignant canine mammary tumors (IMC and non-IMC) by histology, inmunohistochemistry (pancytokeratin, cytokeratin 14, vimentin, actin, desmin, vWF, CD31, and CD34), and electron microscopy. This retrospective study included 21 female dogs with diagnoses of IMC and 20 animals with metastatic grade III noninflammatory malignant mammary tumors (MMT). IMC tumors (33.33%) and MMT (5%) showed ELCs forming structures similar to small capillaries. The histological, immunohistochemical (positive to AE1/AE3 and cytokeratin 14, mostly negative to endothelial markers), and ultrastructural characteristics of these cells indicated vasculogenic mimicry. The higher frequency of this phenomenon in inflammatory versus noninflammatory canine mammary cancer is in agreement with previous studies in experimental and spontaneous human IBC, and it could be in relation with the extremely high lymphangiogenic capacity and metastatic lymphangiotropism characteristics of inflammatory breast cancer.