Breast+(Inflammatory)

In the U.S., breast cancer is the most common non-skin cancer and 2nd leading cause of cancer related death in women. 1 A small number of men are also diagnosed with, and die from, breast cancer. Breast cancer incidence is highest in white women for most age groups, but African American women have higher incidence rates before age 40, and have higher breast cancer mortality rates than women of any other racial/ethnic groups in the U.S. Women in rural areas have lower breast cancer rates than women in urban areas. Breast cancer is more common in Western countries than in Asian countries. Breast cancer is diagnosed more in women 55 years of age and older. Inflammatory breast cancer is diagnosed at younger ages than other types of breast cancer. 2 || - Environmental factors 1 - diet - endocrine factors - family history - radiation exposure - reproductive and menstrual history - certain genetic changes - long term use of menopausal/hormone therapy - increased breast density - obesity - lack of exercise || Inflammatory carcinoma presents with rapid onset of erythema, warmth and edema. 3 Symptoms to look for can include: 4 •pain in the breast •skin changes in breast •reddened area with texture and thickness of an orange (peau d'orange) •bruise that does not go away •sudden swelling of the breast •itching of the breast •nipple retraction (flattened look) or discharge •swelling of lymph nodes under the arm or in the neck •unusual warmth of the affected breast •breast is harder or firmer || The diagnostic workup for carcinoma of the breast begins with a general history including menstrual status, parity, and family history of cancer; in addition, to a physical examination. Special tests that may be done include needle aspiration or a biopsy to determine the histopathologic diagnosis, and/or an evaluation for horomone receptors. A biopsy can be performed through one of several techniques including a fine-needle biopsy, core-needle biopsy, incisional or excisional biopsy. Before a biopsy is done, a chest x-ray, mammogram, ultrasound, or magnetic resonance imaging (MRI) should be performed. Laboratory studies including a complete blood cell count, blood chemistry and urinalysis should be done. Optional tests such as growth factor, DNA index and oncogene assays may be performed. Bone scans are highly recommended and if results are positive, a computed tomography (CT) scan of the liver and spleen should be done. A postitron emission tomography (PET) is being utilized more frequently for detection of regional lymph nodes or distant metastases. If neurologic symptoms suggest cerebral metastases, a CT or MRI of the brain should be obtained. 5 || Inflammatory breast cancer is a rare and very aggressive disease in which cancer cells block lymph vessels in the skin of the breast. It’s called inflammatory because the breast often looks swollen and red, or “inflamed.” Most inflammatory breast cancers are invasive ductal carcinomas. Inflammatory breast cancer can be composed of any histological cell type. 6 || Most common lymph nodes involved with breast cancer are the axillary nodes. Metastatic spread to the internal mammary or supraclavicular nodes can be involved with inflammatory breast cancer. 7 || Grading refers to how the cancer cells look under the microscope compared with normal breast cells. 9 Note: definitions for classifying the primary tumor (T) are the same for clinical and pathologic classification. If the measurement is made by physical examination, the examiner will use the major headings (T1, T2, or T3). If other measurements, such as mammographic or pathologic, are used, the telescoped subset of T1 can be used. 10 With any radiation therapy treatment there is a chance of radiation side effects. In breast cancer, these side effects increase with the combination of chemotherapy as well, especially with Doxorubicin. 11 The main radiation side effects of radiation therapy alone include: 11
 * **Epidemiolgy:** || Lindsey
 * **Etiology:** || Lindsey
 * **Signs & Symptoms:** || Kevin T
 * **Diagnostic Procedures:** || Kevin T
 * **Histology:** || Jenn
 * **Lymph node drainage:** || Jenn
 * **Metastatic spread:** || Rachel
 * Often, biopsy of the skin covering the breast confirms tumor infiltration in the dermal lymphatics, or lymphatic tumor emboli, the hallmark of inflammatory breast cancer. 8
 * Metastatic spread can occur through lymphatic or hematogenous spread. Metastatic spread involves the axillary, internal mammary or supraclavicular nodes. Hematogenous spread involves bone, lung, pleura, liver and brain. ||
 * **Grading:** || Rachel
 * Grade 1 (Low Grade): The cancer cells look similar to normal cells and grow very slowly.
 * Grade 2 (moderate or intermediate grade): The cancer cells look more abnormal and are slightly faster growing.
 * Grade 3 (high grade): The cancer cells look very different from normal cells and tend to grow quickly. ||
 * **Staging:** || Brandon
 * Primary Tumor (T) **
 * TX: Primary Tumor cannot be assessed
 * T0: No Evidence of Primary Tumor
 * Tis Carcinoma in situ: Intraductal carcinoma, lobular carcinoma in situ, or Paget’s disease of the nipple with no tumor
 * T1: Tumor ≤ 2 centimeters (cm) in greatest dimension
 * T1mic: Microinvasion ≤ 0.1cm in greatest dimension
 * T1a: Tumor > 0.1 cm but not > 0.5 cm in the greatest dimension
 * T1b: Tumor > 0.5 cm but not >1.0 cm in the greatest dimension
 * T1c: Tumor > 1.0 cm but not > 2.0 cm in the greatest dimension
 * T2: Tumor > 2 cm but not > 5 cm in greatest dimension
 * T3: Tumor > 5 cm in greatest dimension
 * T4: Tumor of any size with direst extension to (a) chest wall or (b) skin
 * T4a: Extension to chest wall
 * T4b: Edema or ulceration of the skin of the breast
 * T4c: Both (T4a and T4b)
 * T4d: Inflammatory Carcinoma
 * Regional Lymph Node (N) **
 * NX: Regional lymph nodes cannot be assessed
 * N0: No regional lymph node metastasis
 * N1: Metastasis to moveable lymph ipsilateral axillary lymph node(s)
 * N2: Metastasis to ipsilateral axillary lymph node(s) fixed to one another or other structures
 * N3: Metastasis to ipsilateral internal mammary lymph node(s)
 * Distant Metastasis (M) **
 * MX: Distant metastasis cannot be assessed
 * M0: No distant metastasis
 * M1: Distant metastasis (includes metastasis to ipsilateral supraclavicular lymph node(s) ||
 * **Radiation side effects:** || Brandon
 * Erythema (dryness and redness) - about 3000 centiGray (cGy)
 * Dry Desquamation (involves dry flaking of the skin) - about 4000 cGy
 * Moist Desquamation (loss of superficial and deep epithelial cells) - about 5000 cGy
 * Telangiectasia (permanent dilation of blood vessels, producing small, red lesions)

Other side effects include: fatigue, cardiac effects, pulmonary effects, lymphedema, brachia plexopathy (with supraclavicular nodal involvement), myelopathy, and osteoradionecrosis. 11 || There are several factors influencing the prognosis of patient’s diagnosed with inflammatory breast cancer including stage, tumor grade, ethnicity, estrogen receptor status and type of treatment. Inflammatory breast cancer is traditionally treated using a multimodal approach. This approach begins with systemic chemotherapy to decrease tumor size. Surgery follows chemotherapy to remove the tumor and treatment concludes with radiation therapy to further kill microscopic cells remaining. 12 Traditionally, patients who are treated with this approach have an increased survival rate and prognosis. Each of the possible treatment options for patients is discussed below.
 * **Prognosis:** || Ashley
 * **Stage:** Cancer staging plays a significant role in prognosis. Stage 3 inflammatory breast cancer patients have a 40% survival rate after diagnosis. 12 Patients diagnosed with stage 4 disease have a bout a 11% survival rate after prognosis. 12
 * **Tumor grade:** In general, patients who have a higher grade cancer are more susceptible to aggressive malignancies. The same is true for patients with inflammatory breast cancer. 77% of women who were diagnosed with Grade I or Grade II inflammatory breast cancer survived at least 2 years after diagnosis. 12 Approximately 65% of women with Grade III inflammatory disease survived 2 years after diagnosis. 12
 * **Ethicity:** Research has shown that in general, African American women have worse prognosis then women of other ethnicities. Approximately 53% of African American women survive 2 years after diagnosis whereas women of other ethnicities have a survival rate of 69%. 12
 * **Estrogen Receptor Status:** The estrogen receptor status plays a significant role in the prognosis of inflammatory breast cancer. If a patient is positive for estrogen receptor, they have a more positive prognosis then those patients who are estrogen receptor negative. 12
 * **Type of Treatment:** As with many other cancers, a multimodal approach to cancer treatment improves the patient’s likelihood of a positive prognosis. 12 When approaching the diagnosis from many treatment perspectives, there is a better chance the cancer will be safely managed and cured. This is heavily dependent on the patient’s health status and preference. ||
 * **Treatments:** || Ashley
 * **Neoadjuvant Chemotherapy**: The patient is given both anthracycline and taxane drugs to decrease tumor size prior to surgery. 12 Typically, the patient is administered 6 cycles of chemotherapy over 4-6 months to ensure the tumor can be resected with negative margins. 12
 * **Targeted Therapy**: This type of therapy is administered if the patient’s biopsy sample contains a particular indicator making the patient a good candidate for a specified drug. Often times the HER2 protein is an indicator for targeted therapy in inflammatory breast patients. 12
 * **Hormone Therapy**: The biopsy sample may also indicate the presence of hormone receptors in the cancer cells. There are particular chemotherapy drugs that best target this type of tumor differentiation and are used prior to surgery. 12
 * **Surgery**: The typical procedure for patients with inflammatory breast cancer is a modified radical mastectomy. During this procedure the breast tumor, lymph nodes and even the lining of chest muscles are removed to ensure total resection of the cancer. 12
 * **Radiation Therapy**: Patients who receive a modified radical mastectomy are treated with radiation to the remaining chest wall and nodal areas. 12 This multi-modal treatment procedure helps improve the chances that microscopic disease is killed
 * .**Adjuvant Therapy**: This treatment approach reduces the chances of a patient having a regional recurrence. This therapy may include antihormonal therapy, targeted therapy or other chemotherapy regimens. 12

The image below indicates survival rates of patients that underwent specific treatment modalities. 13 || Tissue dose associated with 5% injury rate within 5 years 14 . ||
 * **TD 5/5:** || Amanuel
 * Breast (adult): 6000cGy [Atrophy]
 * Lung [Pneumonitis]
 * 1/3 of the Lung: 4500cGy
 * 2/3 of the Lung: 3000cGy
 * The whole Lung: 1750cGy
 * Heart: 4000cGy [Pericarditis and Pancarditis]
 * Brachial plexus: 6000cGy [Clinically apparent nerve damage] ||
 * **References:** || Amanuel
 * 1) National Cancer Institute Web Site. [] . Accessed June 12, 2013.
 * 2) National Cancer Institute Web Site. [] . Accessed June 12, 2013.
 * 3) Chen A, Park C, Bevan A, et al. Breast Cancer. In: Hansen EK, Roach M. Handbook of Evidence-based Radiation Oncology, 1st ed: New York, NY: Springer, 2007: 182-207.
 * 4) Wikipedia. Inflammatory Breast Cancer. [] . Accessed June 11, 2013.
 * 5) Chao KS, Perez CA, Brady LW. Radiation Oncology Management Decisions. 3rd ed. Philadelphia, PA: Lippincott, Williams, and Wilkins; 2011: 376-386.
 * 6) Inflammatory breast cancer. Mayo Clinic. Available at: []. Accessed June 13, 2013.
 * 7) Chao KS, Perez CA, Brady LW. Radiation Oncology Management Decisions. 3rd . Philadelphia, PA: Lippincott, Williams and Wilkins; 2011:405-409.
 * 8) Chao KS, Perez CA, Brady LW. Radiation Oncology Management Decisions. 3rd ed. Philadelphia, PA: Lippincott, Williams, and Wilkins; 2011: 405.
 * 9) Staging and grading of Breast Cancer. Macmillan Cancer Support Web Site. []. Accessed June 13, 2013.
 * 10) Chao K, Perez C, Brady L. //Radiation Oncology Management Decisions//. 2nd ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2002: 348.
 * 11) Washington C, Leaver D. //Principles and Practice of Radiation Oncology.// 3rd ed. St. Louis, MO: Mosby Elsevier; 2010:891-892
 * 12) <span style="color: #008000; font-family: Arial,sans-serif; font-size: 10pt;">Inflammatory Breast Cancer. National Cancer Institute Website. <span style="font-family: Arial,sans-serif; font-size: 10pt;">[] <span style="color: #008000; font-family: Arial,sans-serif; font-size: 10pt;">. Updated April 18, 2012. Accessed June 11, 2013.
 * 13) <span style="color: #008000; font-family: Arial,sans-serif; font-size: 10pt;">Inflammatory Breast Carcinoma. About Cancer Web site. <span style="font-family: Arial,sans-serif; font-size: 10pt;">[] <span style="color: #008000; font-family: Arial,sans-serif; font-size: 10pt;">. Updated 2004. Accessed June 11, 2013.
 * 14) <span style="color: #ff7100; font-family: Arial,sans-serif; font-size: 10pt;">Washington CM, Leaver D. Principles and Practice of Radiation Therapy. 3rd ed. St. Louis, MO: Mosby-Elsevier; 2010

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