an elusive diagnosis. history p/c:39 yr female, presented with symptoms right breast pain swelling...
Post on 29-Dec-2015
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History
• P/C:39 yr female, presented with symptoms right breast
Pain Swelling Redness Edematous, thickened skin
• HOPC & Past history
No masses, no nipple discharge, no previous h/o similar complaint Non-smoker, non-diabetic, no family history of breast or any cancer 6 children, no breast feeding No previous h/o benign breast disease
Examination & Management
• Examination finding
Erythema Swelling Edematous skin right breast No masses, no nipple discharge, no lymphadenopathy
• WBC 7.7, normal haemoatology/biochemistry• Treated with intravenous antibiotics (staphylococcus and
anaerobic cover) with good clinical response• Follow-up in breast clinic
Follow-up and TBC
• Mastitis not fully settled• Persistent edematous and thickened skin in the retro-
areolar area• Referral to triple assessment clinic
Mammogram Ultrasound Image guided retro-areolar area biopsy
Repeat TBC Further follow-up Persistent pain right breast, symptoms not settling
• Clinical examination
Thickened skin in the areolar area with nipple inversion No masses, no area to be biopsied
• Haematological investigation
ESR, CRP, Immunoglobulin profile (plasma cell mastitis)
• Radiological assessment
Mammogram ultrasound
Repeat TBC
• Biopsy
Clinical punch biopsy of the edematous area with thickened skin in the areolar area (two 4mm biopies)
Inflammatory breast cancer
• Composite clinico-pathological entity characterized by diffuse edema (peau d’orange) and erythema of the breast, over the majority of the breast and often without an underlying mass
History
• First described by Sir Charles Bell (1814)• Known as Wokman’s syndrome in pregnant women• Taylor/Meltzer differentiated IBC from LABC (secondary
IBC) in 1938• Thomas Bryant in 1887 describe the pathology
Tumour invasion of the dermal lymphatic vessels
Classification
• Clinical findings onlyNo evidence of pathological plugging of the lymphatics
• Pathology onlyClinical findings not present
• Clinico-pathologicalBoth findings are present
• AJCC (TNM) T4d
Stage IIIB or IV
Epidemiology • Geographical USA : 1% new cases in females, 0.59% in males Europe: Spain 2.9% (series 1977-1993) France : France 5.4% (series 1955-1961) In our unit: 0.02% (2008, 3/149 cases)
• RaceHigher among black women
• Age 49.5 american indian 54 Black asian pacific 58 whites
• SexNo major difference
Risk factors
• No association with Menstrual history
Reproduction Family history Alcohol use
• Higher BMI poses a risk for IBC for pre and postmenopausal women
Diagnosis
• Haagensen criteria• Rapid enlargement of the breast• Generalized induration in the presence or absence of mass• Edema of the skin of the breast• Erythema involving more than 1/3 rd of the breast• Biopsy proven carcinoma (DLI is present in about 50-75% of cases although not a pre-
requisite for diagnosis)
• Clinical symptoms• Ache and heaviness before swelling and erythema• Skin changes can be very early• Erythema and edema intensify as disease progresses
• Imaging• Mammogram• Ultrasound• MRI
Tumour characteristics
• IBC is a distinct and aggressive disease entity• Tumour size: unknown in 82.5%• Nodal status positive• Grade II/III• Receptor status
ER/PR negative in 56-83% HER-2 positive higher portion than normal
E-cadherin positive p53 is a marker for survival (30-69%) inversely
Treatment
Remains a challenge
Neo-adjuvant chemotherapy Mastectomy +/- axilla Additional chemotherapy? Radiotherapy Hormonal therapy for ER positive tumours
Clinical outcome
• Median overall survival with multimodal therapy is less than four years
CPR at mastectomy indicates better DFS and OS
• Worse for black race• No difference between clinical sub-types
• Overall at 5 years ER + 48.5% (91% all breast cancer) ER - 25.3%(77% all breast cancer)
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