18523 Corwin Rd.
Apple Valley, CA  92307		 Victor Valley Advanced Imaging - (760) 242-4444 PH: (760) 242-4444
FX: (760) 242-7288

 

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Inflammatory breast cancer is a rare and aggressive form of breast cancer that is often initially confused with infections of the breast. The typical initial symptoms of both benign breast infection and inflammatory breast cancer are redness of the skin, local heat, breast enlargement, and thickening of the skin, which may have an orange peel appearance. Patients with inflammatory breast cancer often experience breast pain, and swelling of the lymph nodes under the arm often they can feel a localized mass.

Most women who experience these symptoms are first seen by their primary doctor or in an emergency room setting. Most are initially treated with a course of antibiotics. Inflammatory changes secondary to bacterial infections typically go away in a few days.

When the inflammatory response does not respond to treatment, referral to a specialist is essential. A note of caution: we have seen a few cases in which the inflammatory reaction seemed to improve dramatically, only to reoccur in a few weeks. We now follow all patients who have had breast inflammation for at least 12 months.

The main purpose of this discussion of inflammatory breast cancer to outline our experience with making the diagnosis, and to identify pitfalls in establishing an accurate diagnosis. We have learned from experience that the diagnosis can be extremely difficult. We assume that any woman with redness of the breast has inflammatory breast cancer until proven otherwise. With our aggressive approach to diagnosis which will be outlined below, we usually make the diagnosis within 2-10 days.

A major challenge in discussing inflammatory breast cancer is that there is no generally accepted definition. In the classic sutuation, 2/3rd of the breast is involved with redness and/ or skin thickening (see link to photograph of classic case). We use the term inflammatory breast cancer to describe any case of breast cancer which includes redness of the skin. Thus, the reader of this web-page should take into consideration that our definition is much broader than that used by many respected authorities.

We have chosen our definition for two reasons. First, cancers that are associated with an inflammatory response, even if limited to a small section of the breast, tend to have a worse prognosis. We therefore treat all breast cancers with an inflammatory component more aggressively. Secondly, cancers with an inflammatory component are often confused with benign conditions. As a result the diagnosis is too often delayed. For both reasons we take an aggressive approach to implied.

How the diagnosis is made : Our Approach to Evaluating Patients with Inflammatory Changes in the Breast :

First visit :

* Take a careful history, and do a careful physical examination. * Do an ultrasound examination, and if tolerated also do a diagnostic mammogram. (note we also use the ultrasound to examine the under arm lymph nodes, which can show evidence of metastasis)

* Take tissue samples for both cultures and microscopic evaluation. If there is a mass associated with the inflammation, tissue sampling is concentrated on the mass. If there is no mass, tissue sampling is focused to breast tissue under the center of the inflammatory process. We do 5 types of tissue sampling. Our goal is to get sufficient material for cultures as well as sufficient tissue for a microscopic diagnosis.

The following are guidelines to our decision making :

If we are most suspicious of infection we usually start with a large gage needle (i.e.16 gage), to aspirate the area of concern. If we withdraw pus, we are fairly certain we are dealing with an infection. We send off cultures (aerobic, anaerobic, fungus and AFB) and treat with antibiotics. If we don't get pus, we culture the aspirated fluid, and proceed to fine needle aspiration.

Fine needle aspiration: We routinely obtain a FNA on the first visit for any suspicious inflammatory process. If the results are negative it is of limited value, but it the results are suspicious for cancer we go directly to core biopsy.

In cases in which we are clinically suspicious of an underlying cancer, we usually do a core biopsy on the first visit. A negative core is reassuring, but at times we have missed cancers using this technique, and therefore assume a negative core is non-diagnostic.

Skin punch biopsy. In the classic definition of inflammatory breast cancer, cancer cells are seen in the lymph channels under the skin (subdermal lymphatics). A skin biopsy can be done in the office under local anesthesia. It takes a few minutes to perform and is well tolerated by the patient. A negative biopsy is of no value, but a positive biopsy makes the diagnosis of inflammatory cancer with certainty. We reserve this biopsy procedure for selective cases, and usually make the initial diagnosis of inflammatory breast cancer with other techniques.

Open surgical biopsy: This was the standard diagnostic operation in the past, but is rarely required today as a diagnostic tool. In general we avoid an open biopsy to make a diagnosis of breast cancer, but on rare occasions it has been helpful. In situations in which all tests have been negative and symptoms persist, the option of open biopsy should be considered.

Once we have completed the diagnostic work-up, the patient is started on antibiotics and scheduled for a follow-up visit the next week. If biopsy results come back positive, patients are referred to our oncologists. If the biopsies were negative, but the inflammation has resolved the patient is scheduled for follow-up mammogram and in most cases an MRI (note: we have not done a sufficient number of MRI's under these circumstance to have a clear sense of its diagnostic value).

If the inflammation has not responded dramatically to treatment, and if the cultures are negative, we become more suspicious of an underlying cancer. Our next step is usually an MRI. Although the MRI cannot distinguish between inflammation and cancer, it can localize areas of concern that were not evident clinically. Further tissue sampling can be directed to areas of concern on the MRI. We also examine the axilla with ultrasound to look for suspicious lymph nodes.

In rare cases in which the inflammation persists and the work-up is non-diagnostic, we may proceed to an open biopsy along with random breast sampling with core biopsies. If the entire work-up remains negative we follow the patient at monthly intervals and encourage her to return immediately if inflammatory changes are noted.

We have had two patients in which the cancer was missed despite complete work-up including open biopsy. However, the majority of our patients who have had a negative work-up and have been followed for more than one year, have return to normal with no explanation as to the cause of the inflammatory response.

Treatment of Inflammatory breast cancer
The treatment of inflammatory breast cancer has become standardized. Patients are first given a course of chemotherapy to shrink the tumor, which in most cases is very effective. This is usually followed by mastectomy and lymph node removal. Immediate reconstruction is not done in these cases. A follow-up course of radiation therapy is given. This combined approach to therapy has proven to be remarkably effective.

 


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Here is a partial list of some of the services we offer:
MRI, MRA, CT, Ultrasound, Vascular Ultrasound, PET/CT, Nuclear Med, Nuclear Cardio, X-Ray, Open MRI, Fluoro, Arthrograms, Mammography, Breast Ultrasound, DEXA, Stereotactic Breast Biopsy, Breast Cancer Reconstructive Surgery, Helical CT, MR Angiography, High Field MRI, Orange County, Mission Viejo, Los Angeles, Anaheim, Santa Ana, Irvine, community, Southern California, California, orthopedic, sports medicine, bone fracture, Bone Density, Bone Densitometer, Osteoporosis, GE Lunar, broken bones, hip, knee, carpel tunnel, spine, back, Radiology, Diagnostics Imaging, Digital Breast MRI, Breast Biopsy, iCAD, DynaCAD, MRI CAD, Mammo CAD, Women's, Women's Imaging, Breast Cancer Screening
Here is partial list of some of the areas we service:
Los Angeles County:
Agoura Hills, Alhambra, Arcadia, Artesia, Azusa, Baldwin Park, Bellflower, Beverly Hills, Big Pines, Burbank, Carson, Century City, Cerritos, Chatsworth, China Town, City of Industry, Claremont, Commerce, Compton, Covina, Culver City, Downtown LA, Downey, Eagle Rock, El Monte, El Segundo, Encino, Gardena, Glendale, Glendora, Granada Hills, Hawaiian Gardens, Hawthorne, Hermosa Beach, Hidden Hills, Highland Park, Hollywood, Inglewood, Irwindale, Japan Town, Korea Town, La Canada/Flintridge, La Crescenta, La Habra, La Mirada, La Puente, La Verne, Lakewood, Lancaster, Lenox, Lomita, Long Beach, Los Angeles, Los Nietos, Lynwood, Manhattan Beach, Marina Del Rey, Monterey Park, Montrose, Northridge, Norwalk, Palmdale, Palos Verdes Estates, Paramount, Pasadena, Pico Rivera, Pomona, Rancho Palos Verdes, Redondo Beach, Reseda, Rolling Hills Estates, San Fernando Valley, San Gabriel, San Marino, Santa Clarita, Santa Fe Springs, Santa Monica, Signal Hill, South Pasadena, Temple City, Torrance, Valinda, Van Nuys, Ventura County, Verdugo City, Walnut, West Covina, West Hollywood, Westlake Village, Westwood, Whittier and all other cities and communities of Los Angeles County.

Orange County:
Aliso Viejo, Anaheim, Balboa Island, Brea, Buena Park, Capistrano Beach, Corona Del Mar, Costa Mesa, Coto de Caza, Cowan Heights, Cypress, Dana Point, El Modena, El Toro, Foothill Ranch, Fountain Valley, Fullerton, Garden Grove, Huntington Beach, Irvine, La Habra, Laguna Beach, Laguna Hills, Laguna Niguel, Lake Forest, Leisure World, Lemon Heights, Los Alamitos, Mission Viejo, Modjeska Canyon, Newport Beach, Orange, Orange Park Acres, Placentia, Rancho San Margarita, Rossmoor, San Clemente, Santa Ana, Seal Beach, Silverado Canyon, Stanton, Sunset Beach, Surfside, Tustin, Villa Park, Westminster, Yorba Linda and all other cities and communities of Orange County.

San Bernardino County:
Adelanto, Apple Valley, Argus, Baker, Barstow, Big Bear, Bloomington, Chino, Chino Hills, Cima, Colton, Daggett, Devore, Earp, El Mirage, Etiwanda, Essex, Fawnskin, Fontana, Forest Falls, Grand Terrace, Harvard, Helendale, Hesperia, Highland, Hinkley, Hodge, Ivanpaw, Joshua Tree, Kelso, Landers, Lenwood, Loma Linda, Lucerne Valley, Ludlow, Montclair, Morongo Valley, Muscoy, Needles, Ontario, Oro Grande, Phelan, Pinon Hills, Rancho Cucamonga, Redlands, Rialto, Running Springs, San Bernardino, Twenty Nine Palms, Upland, Victorville, Wrightwood, Yucaipa, Yucca Valley and all other cities and communities of San Bernardino County.

Riverside County:
Anza, Arlington, Banning, Beaumont, Blythe, Cabazon, Calimesa, Canyon Lake, Cathedral City, Cherry Valley, Coachella, Corona, Desert Hot Springs, Edgemont, El Cerrito, Gilman, Glen Avon, Glenn Valley, Hemet, High Grove, Home Gardens, Homeland, Hot Springs, Idyllwild, Indian Wells, Indio, La Sierra, Lake Elsinore, Lakeview, La Quinta, Mecca, Mead Valley, Meadow Brook, Mira Loma, Moreno Valley, Murrieta, Murrieta Hot Springs, Norco, Nuevo, Palm Desert, Palm Springs, Perris, Quail Valley, Riverside, Rancho Mirage, Ripley, Rubidoux, Sage, San Jacinto, Sun City, Temecula, Temescal Canyon, Thousand Palms, Valle Vista, White Water, Winchester and all other cities and communities of Riverside County.

Imperial County:
Brawley, Calexico, Calipatria, El Centro, Holtville, Imperial, Westmorland and all other cities and communities of Imperial County.

Ventura County:
Camarillo, Fillmore, Moorpark, Ojai, Oxnard, Port Hueneme, San Buenaventura, Santa Paula, Simi Valley, Thousand Oaks and all other cities and communities of Ventura County. 

As well as the following zip-codes: 91302 Calabasas, Hidden Hills, 91304 west hills, 91307 west hills, 91303 Woodland Hills, 91311 Chatsworth, 91312 Chatsworth, 91313 Chatsworth, 91316 Encino, 91324 Northridge, 91325 Northridge, 91326 Northridge, 91327 Northridge, 91328 Northridge, 91329 Northridge, 91330 Northridge, 91356 Tarzana, 91357 Tarzana, 91364 Woodland Hills, 91365 Woodland Hills, 91367 Woodland Hills, 91371 Woodland Hills, 91372 Woodland hills, 91399 Calabasas, 91401 Sherman Oaks, 91411 Sherman Oaks, 91413 Sherman Oaks, 91423 Sherman Oaks, 91495 Sherman Oaks, Plumbing, Burbank (91501,91502,91503, 91504, 91505, 91506, 91507, 91508, 91510, 91521, 91522, 91523, 91526) North Hills 91393, Granada Hills 91394, Mission Hills 91395, Canoga Park 91396, Van Nuys (91404, 91405, 91406, 91407, 91408, 91409, 91410, 91426, 91436, 91470, 91482,91496, 91497,91499) Reseda 91335, 91337, 91343 North Hills, 91344 Granada Hills, 91346 mission hills, Studio City 91607, Universal City 91608, Studio City 91614, Universal City 91618, North Hollywood (91601, 91602, 91603, 91604, 91605, 91606, 91609, 91610, 91611, 91612, 91615, 91616, 91617, Santa Clarita, 91310, 91321, 91322, 91350, 91351, 91354, 91355, 91380, 91381, 91382, 91383, 91384, 91385, 91386, 91387, 91390, Valencia, 91354, 91355, 91380, 91385, Saugus, 91350, 91390, Newhall, 91321, 91322, 91381, 91382, Stevenson Ranch, 91381, Stevensons Ranch, Stevenson's Ranch, Thousand Oaks, 91319, 91320, 91358, 91359, 91360, 91361, 91362, 91363, Agoura Hills, 91301, 91376, 91377, Westlake Village, 91359, 91361, 91362, 91363, Oak Park, 91301, 91377, Simi Valley, CA:93062, 93063, 93064, 93065, 93093, 93094, 93099, Moorpark, CA:93020, 93021