General Surgery · Year 3 · from General Surgery

Case 3: Inflammatory Breast Cancer

Patient Demographics

  • Age: 48 years
  • Sex: Female
  • Occupation: Office manager

Chief Complaint

"My breast has become red and swollen over the past month."

History of Present Illness

The patient presents with a 4-week history of progressive redness, warmth, and swelling of her right breast. She initially thought she had a breast infection and was treated with antibiotics (cephalexin) by her primary care physician 2 weeks ago with no improvement. The affected area has expanded to involve most of the breast. She also notes her breast feels heavier and the skin has developed an "orange peel" texture. She denies fever, trauma, or recent breastfeeding. She has noticed some discomfort but no discrete lump.

Past Medical History

  • Hypertension
  • Obesity (BMI 34)
  • Menarche at age 11
  • G3P3, first pregnancy at age 22
  • Regular menstrual periods
  • No prior breast disease

Family History

  • No family history of breast cancer

Medications

  • Amlodipine 10 mg daily

Physical Examination

  • Vitals: BP 138/86 mmHg, HR 82 bpm, Temp 37.0°C
  • Breast examination:
  • Right breast: Diffusely enlarged, erythematous involving >2/3 of breast skin
  • Peau d'orange (skin edema with prominent pores)
  • Warmth to touch
  • No discrete mass palpable (diffuse firmness)
  • Nipple flattening
  • Left breast: Normal
  • Axillary examination:
  • Right: Multiple enlarged, firm lymph nodes
  • Left: No palpable nodes

Diagnostic Workup

Diagnostic Mammogram:

  • Right breast: Diffuse skin thickening, trabecular thickening
  • Increased breast density
  • No discrete mass
  • Right axillary adenopathy

Breast Ultrasound:

  • Diffuse skin thickening (8 mm, normal <2 mm)
  • Diffuse parenchymal edema
  • Multiple abnormal axillary lymph nodes

MRI Breast:

  • Diffuse skin and trabecular thickening
  • Non-mass enhancement throughout right breast
  • Pectoralis muscle involvement suspected
  • Multiple pathologic axillary and internal mammary nodes

Skin Punch Biopsy:

  • Dermal lymphatic invasion by carcinoma
  • ER: Negative
  • PR: Negative
  • HER2: Positive (3+ by IHC, confirmed by FISH)

Core Biopsy of Breast Parenchyma:

  • Invasive ductal carcinoma, high grade
  • ER/PR negative, HER2 positive

Staging Workup:

  • CT Chest/Abdomen/Pelvis: Right axillary and internal mammary adenopathy, no distant metastases
  • PET-CT: Intense uptake in right breast, right axillary, and right internal mammary nodes; no distant metastases
  • Clinical Stage: cT4dN2M0 (Stage IIIB - Inflammatory Breast Cancer)

Multidisciplinary Tumor Board

  • Diagnosis: Inflammatory breast cancer (IBC), HER2-positive
  • Treatment plan: Neoadjuvant systemic therapy followed by surgery and radiation

Treatment Plan

Neoadjuvant Chemotherapy:

  • TCHP regimen (docetaxel, carboplatin, trastuzumab, pertuzumab) x 6 cycles

Response Assessment (after 6 cycles):

  • Clinical: Marked improvement - erythema resolved, breast size decreased
  • MRI: Significant reduction in enhancement, skin thickening improved
  • Clinical partial response

Surgery:

  • Modified radical mastectomy (skin-sparing not appropriate for IBC)
  • Wide skin excision including all previously involved skin
  • Axillary lymph node dissection

Pathology:

  • 1.2 cm residual invasive carcinoma
  • 2/18 axillary nodes positive
  • Pathologic partial response

Adjuvant Therapy:

  • Radiation therapy to chest wall and regional nodes
  • Continue HER2-targeted therapy (trastuzumab + pertuzumab) to complete 1 year
  • T-DM1 given residual disease (KATHERINE trial protocol)

Teaching Points

  1. Inflammatory breast cancer is a clinical diagnosis (erythema, peau d'orange, rapid onset)
  2. Often no palpable mass - diagnosis requires high clinical suspicion
  3. Skin punch biopsy showing dermal lymphatic invasion is pathognomonic
  4. ALWAYS staged as at least T4d (Stage III) at presentation
  5. Tri-modality treatment required: systemic therapy, surgery, radiation
  6. Neoadjuvant therapy is standard of care
  7. Breast conservation is contraindicated in IBC

Clinical Image

Image Description: Clinical photograph demonstrating the characteristic appearance of inflammatory breast cancer with diffuse erythema, skin edema (peau d'orange), and breast enlargement. The affected skin shows the typical "orange peel" texture due to dermal lymphatic obstruction.

Attribution: Image from Wikimedia Commons, Category:Breast cancer. Source: https://commons.wikimedia.org/wiki/Category:Breast_cancer

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