Why Diagnosing Inflammatory Breast Cancer Is Hard and How to Overcome the Challenges

A Narrative Review

Huong T. Le-Petross; Wintana Balema; Wendy A. Woodward

Disclosures

Chin Clin Oncol. 2021;10(6):58 

In This Article

Conclusions

IBC is an oncologic emergency, and making the diagnosis promptly can be the difference between curable and incurable disease. Understanding how to make this difficult diagnosis can save lives. Although IBC is relatively uncommon, at one tertiary referral center for breast symptoms, it represented 50% of patients who presented with inflammatory breast symptoms,[17] so a high index of suspicion and immediate imaging work-up is not excessive. Dedicated IBC clinics operating in the United States are willing to discuss complicated diagnostic cases with colleagues. Our recommendation, based on the literature reviewed, is that any patient with presumed benign mastitis that does not rapidly resolve with recommended therapy for benign disease should undergo breast imaging with mammography and ultrasonography, followed by MRI if available, and biopsy. Several studies have highlighted the limitations of mammography and, to a lesser degree, ultrasonography for identifying IBC with high specificity; however, abnormal findings on these exams should prompt further work-up, and even if MRI is not available, ultrasonography adds important diagnostic information over mammography alone.[20–22] Notably, several groups have reported cases in which experienced breast oncology specialists diagnosed IBC that failed to meet AJCC or international consensus definitions because of the absence of erythema or the lack of concurrent breast edema and peau d'orange.[7,8,12] We assert that some IBC patients will not have frank erythema; however, compelling non-erythematous skin changes such as peau d'orange or other skin discolorations due to diffuse disease should be diagnosed as IBC, and patients should be treated with trimodality therapy including neoadjuvant systemic agents, and referral to a dedicated center for enrollment in an IBC-specific trial should be strongly encouraged.

The rarity of IBC and the lack of available information to fully quantify the number of women who present with inflammatory breast syndrome in terms of age and pregnancy status undoubtedly limit our understanding of the true incidence of IBC in women with symptoms. Further, the lack of objective pathobiological diagnostic criteria means that there is no "gold standard" against which to test assertions about clinical symptoms. Nevertheless, the information that is available affords a useful algorithm, and as many experts agree, revision of the staging criteria may be in order.

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