Case Study of the Week: Inflammatory Breast Cancer

In keeping with this month's theme, breast cancer awareness, I have chosen inflammatory breast cancer as this week's case study.  A rare but serious form of breast cancer, it is crucial that nurse practitioners not misdiagnose this life-threatening disease. 

Inflammatory breast cancer (IBC) is a rare and aggressive form of breast cancer.  About 1 to 5% of all breast cancers in the United States are inflammatory in nature.  Due to it's rapid progression and tendency for metastasis, this form of cancer often remains undiagnosed until it has spread to the lymph nodes.  Outcomes in individuals with inflammatory breast cancer are much worse compared to other forms of breast cancer.  The five-year survival rate for IBC is just 25 to 50%.  This deadly cancer can easily be misdiagnosed as cellulitis or mastitis so it is important that nurse practitioners understand IBC and diagnose it properly.

Case Presentation

A 62 year-old African American woman presents to your clinic stating that her left breast has become swollen and the skin thickened over the course of the past two weeks.  For the past five days, she has noticed the breast is warm, tender and red.  She notes patches of skin that are dimpled and "look like an orange peel".  She is afebrile and vital signs are normal.  She states she does not feel ill.  She has a medical history including obesity and hypertension.  She denies personal and family history of breast cancer.

On exam, you note that the lower half of the woman's left breast is warm, erythematous, tender and indurated.  Dimpling of the skin resembling an orange peel (peau d'orange) is present.  You discover associated lymphadenopathy in her left axillary lymph node.  Although cellulitis is a more likely diagnosis, based on this patient's risk factors, history and exam findings you must urgently rule-out a diagnosis of inflammatory breast cancer.  You schedule the patient for a mammogram as well as making her an appointment with a breast specialist as you suspect she will require a biopsy to confirm her diagnosis. 

Management and Outcome

Breast inflammation may be related to infection and often differentiating between mastitis and IBC is difficult.  According to Dr. Maurice Rawlings Jr., an oncology surgeon and medical director of the MaryEllen Locher Breast Center, "Initially, a week of antibiotics is appropriate if a primary care provider believes the symptoms are from infection. However, if the breast inflammation does not improve within seven days of antibiotic use then the patient's next immediate step should be consultation with a surgical oncologist for a biopsy".

Once IBC is diagnosed, PET scan, ultrasound and CT scan are used to determine extent of metastasis (if any) and stage the disease.  IBC is typically diagnosed in stage III (cancer has metastasized to tissues near the breast as well as local lymph nodes) or stage IV (cancer has metastasized to other organs as well as lymph nodes).  

Inflammatory breast cancer is treated using a multimodal approach.  First, the patient undergoes systemic chemotherapy to help shrink the tumor.  Then, the tumor is surgically removed.  Surgical tumor removal is followed by radiation therapy.  Patients treated using the multimodal approach have a 34% 5 year survival rate.  This is compared to an 87% survival rate with non-inflammatory breast cancers. 

Discussion

Inflammatory breast cancer results when cancer cells invade the skin's lymphatic system.  The cancer forms in sheets across the breast rather than a mass most commonly associated with breast cancer.  Obstruction of the lymph channels results in the characteristic swelling, inflammation and skin changes observed with IBC.  Given IBC's aggressive nature, it is important that health care providers consider IBC as a differential diagnosis in women presenting with breast inflammation.  Patients not improving after a short course of antibiotics must be referred urgently for breast biopsy. 

References

Inflammatory Breast Cancer. National Cancer Institute. http://www.cancer.gov/cancertopics/factsheet/Sites-Types/IBC Accessed October 18, 2012. 

Inflammatory Breast Cancer. Mayo Clinic. http://www.mayoclinic.com/health/inflammatory-breast-cancer/DS00632 Accessed October 18, 2012.

Symptoms of Inflammatory Breast Cancer. BreastCancer.org. Accessed October 18, 2012.