Skip to main content
Experimental Hematology & Oncology logoLink to Experimental Hematology & Oncology
letter
. 2014 Jan 4;3:1. doi: 10.1186/2162-3619-3-1

Demographic, clinical, pathological, molecular, treatment characteristics and outcomes of nonmetastatic inflammatory breast cancer in Morocco: 2007 and 2008

Nabil Ismaili 1,2,, Hind Elyaakoubi 1, Youssef Bensouda 1, Hassan Errihani 1
PMCID: PMC3897968  PMID: 24387242

Abstract

We analyze the epidemiological characteristics and outcomes of 72 patients diagnosed with non-metastatic inflammatory breast cancer (IBC) at National Institute of Oncology of Rabat in Morocco, between January 2007 and December 2008. IBC patients represent 5% of all breast cancers (90/1800). The median age of patients was 47 years. Thirty eight patients (53%) had premenoposal status and 69% of the cases had clinical lymph nodes. The dominant pathological funding was infiltrating ductal carcinoma (96%). Most patients had high grade II/III (77.8%), 43.4% of the cases were ER negative and 47.4% of the tumors overexpress the HER2/neu receptor on IHC. Only 48.6% of the patients received completed treatment (chemotherapy [CT], surgery and radiotherapy [RT]) and all patients received anthracycline based neoadjuvant CT, 51.4% of whom received Taxane. Seventy one% of the patients underwent surgery and 54% received RT. The clinical response to CT was 68%. Only 1 (1.4%) patient has pathological complete response (pCR) in the breast and 5 (7%) had pathologically negative lymph-nodes. Patient who achieved pCR was disease free at 27 months. LRRFS, EFS and OS rates at 1–2 years were 90.8%-78.1%, 81.7%-57.5%, and 94.3%-74.6%, respectively. Patients with ER-negative status (EFS: P = 0.043) had poorer outcomes and RT was associated with highly significant increase in LRRFS, EFS and OS (P < 0.0001, P < 0.001 and P = 0.017).

To the editor

Inflammatory breast cancer (IBC) is a rare and aggressive clinical form of BC representing less than 2% of all BC in westerns countries. However, in North Africa, the incidence of IBC is higher accounting for more than 5% of all BC. It is diagnosed clinically by the rapid onset of diffuse erythema and edema (peau d’orange) of at least a third of the skin overlying the breast that rapidly extends to the entire breast. IBC appears to behave as an ER-negative subtype and HER2-positive subtype. In addition, studies of molecular biology identified several anomalies such as EGFR1 over-expression. Considering cell-of-origin subtypes, most cases of IBC belong to the basal, the luminal-B, or the HER2-overexpressing subtype. The treatment of this disease has evolved significantly during the past three decades, incorporating combined modality; chemotherapy, surgery and radiotherapy. The 5- and 10-year overall survival rate was 56% and 35%, respectively for patients who have received multimodal therapy [1-4].

From 1800 patients having the diagnosis of BC registered at the National Institute of Oncology of Rabat between January 2007 and December 2008, we identified 90 patients (5% of BC) diagnosed (according to the international criteria) with IBC. Table 1 analyzes patient characteristics and outcomes. In our study, we included 72 patients with nonmetastatic IBC. The median age of patients was 47 years and the dominant histology was infiltrating ductal carcinoma (96%). Most patients had high nuclear grade II/III (77.8%), 43.4% [23/53] were ER-negative and 47.4% [18/38] were HER2-postive on IHC. Only 48.6% of the patients received completed treatment (CT, surgery, and RT). All patients received anthracycline neoadjuvant CT, 37 (51.4%) received Taxane and one received Trastuzumab. Fifty one patients (71% of the cases) underwent surgery (mastectomy) and 54% received RT.

Table 1.

Patient characteristics and outcomes

Characteristics All patients (n = 90) 5% of all breast cancers (n = 1800) Patients with nonmetastatic disease (n = 72)
Patient’s characteristics
 
 
Age
 
 
  Median
47
47
  Range
29 - 75
29 - 75
Menoposal status
 
 
  Premenoposal
51 (56.7%)
38 (53%)
  Postmenoposal
34 (37.8%)
30
  Unknown
5
4
Histilogy
 
 
  Infiltrating ductal carcinoma
84 (93.3%)
69 (96%)
  Infiltrating lobular carcinoma
3 (3.3%)
2
  Other
3 (3.3%)
3
SBR
 
 
  I
5 (5.6%)
4
  II
45 (50%)
36
  III
24 (26.7%)
20
  Unknown
16 (17.7%)
12
Hormone receptor status
 
 
  ER+/PR+
37
30
  ER+/PR-
0
0
  ER-/PR+
23
19 (26.4%)
  ER-/PR-
4
4 (5.6%)
  Unknown
26
19
HER2/neu status
 
 
  Positif
23 (25.5%)
18 (25%)
  Negatif
22
20
  Unknown
45
34
Clinical stage N
 
 
  N0
31 (34.4%)
23 (32%)
  N1
42 (46.7%)
33
  N2
12 (13.3%)
12
  N3
5 (5.6%)
4
Clinical stage M
 
 
  M0
72 (80%)
72
  M1
18 (20%)
0
Taxanes
 
 
  Yes
45
37 (51.4%)
  No
43
35 (48.6%)
  Unknown
2
0
Surgery
 
 
  Yes
53
51 (71%)
  No
37
21 (29%)
Radiotherapy
 
 
  Yes
40
39 (54%)
  No
50
33 (36%)
  cOR (CR + PR)
-
49 (68%)
  pCR
-
1 (1.4%)
  Pathologically negative lymph nodes
 
5 (7%)
  1 and 2 y LRRFS
-
90.8%; 78.1%
  1 and 2 y EFS
-
81.7%; 57.5%
  1 and 2 y OS - 94.3%; 74.6%

Outcomes of our patients are poor in concordance with a recent American study [5]; cOR was 68% and only 1 (1.4%) patient had pCR in the breast and 5 (7%) in lymph nodes. At 15 months median follow-up, LRRFS, EFS and OS rates at 1–2 years were 90.8%-78.1%, 81.7%-57.5%, and 94.3%-74.6%, respectively (Figures 1A, B, and C, respectively). Patients with ER-negative tumors had worse prognosis than patients with ER + tumors; the difference in EFS between the two groups was statistically significant (P = 0.043) (Figure 1D). RT was associated with significant increase of LRRFS, EFS and OS (P < 0.0001, P < 0.001 and P = 0.017, respectively) (Figures 1E, F and G). These data confirmed the higher impact of RT in the management of this aggressive disease. In addition, others factors have been demonstrated to influence survival in patients with IBC according to the most powered investigations, such as menopausal status, nuclear grade, lymphovascular invasion, surgical margins and Trastuzumab [6-11]. We analyzed the impact of these factors on the outcomes of IBC patients; however, due to the limited statistical power of the cohort, no other significant factors were identified. Only 35 patients had the determination of the HR status and the HER2 status. Kaplan Meier curves showed that ER+/HER2- and ER+/HER2+ patients had better outcome than ER-/HER2+ and ER-/HER2- patients, however the difference was not significant (P = 0.3) (Figure 1H).

Figure 1.

Figure 1

The figure below shows the outcomes of nonmetastatic IBC in Morocco (A, B and C), the prognostic factors (D, E, F and G) and the impact of molecular subtypes (H). A: LRRFS probability in nonmetastatic IBC patients; B: EFS probability in nonmetastatic IBC patients; C: OS probability in nonmetastatic IBC patients; D: Positive effect of ER-positive status in EFS; E: Positive impact of RT in LRRFS; F: Positive impact of RT in EFS; G: Positive impact of RT in OS; H: Survival according to molecular subtypes.

Abbreviations

BC: Breast cancers; IBC: Inflammatory breast cancer; CT: Chemotherapy; RT: Radiotherapy; LRRFS: Locoregional recurrence free survival; EFS: Event free survival; OS: Overall survival; HR: Hormone receptor; ER: Estrogen receptor; PR: Progesterone receptor; HER2: Human Epidermal Growth Factor Receptor 2; cOR: Clinical objective response; pCR: Pathological complete response.

Competing interests

The authors declare that they have no competing interests.

Author’s contribution

NI wrote and approved the final manuscript. HE, YB, and HE approved the final manuscript.

Contributor Information

Nabil Ismaili, Email: ismailinabil@yahoo.fr.

Hind Elyaakoubi, Email: drhind@hotmail.fr.

Youssef Bensouda, Email: yoss.onco@hotmail.com.

Hassan Errihani, Email: h_errihani@yahoo.fr.

References

  1. Levine PH, Steinhorn SC, Ries LG. et al. Inflammatory breast cancer: the experience of the Surveillance, Epidemiology, and End Results (SEER) program. J Natl Cancer Inst. 1985;74:291–297. [PubMed] [Google Scholar]
  2. Ismaili N. In regard to Rehman et al. Re: Modern outcomes of inflammatory breast cancer. Int J Radiat Oncol Biol Phys. 2013;85(1):8–9. doi: 10.1016/j.ijrobp.2012.05.013. [DOI] [PubMed] [Google Scholar]
  3. Boussen H, Bouzaiene H, Ben Hassouna J, Dhiab T, Khomsi F, Benna F, Gamoudi A, Mourali N, Hechiche M, Rahal K, Levine PH. Inflammatory breast cancer in Tunisia: epidemiological and clinical trends. Cancer. 2010;116(11 Suppl):2730–5. doi: 10.1002/cncr.25175. doi:10.1002/cncr.25175. [DOI] [PubMed] [Google Scholar]
  4. Dawood S, Merajver SD, Viens P. et al. International expert panel on inflammatory breast cancer: consensus statement for standardized diagnosis and treatment. Ann Oncol. 2011;22:515–523. doi: 10.1093/annonc/mdq345. [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Rehman S, Reddy CA, Tendulkar RD. Modern outcomes of inflammatory breast cancer. Int J Radiat Oncol Biol Phys. 2012;84:619–624. doi: 10.1016/j.ijrobp.2012.01.030. [DOI] [PubMed] [Google Scholar]
  6. Li J, Gonzalez-Angulo AM, Allen PK. et al. Triple-negative subtype predicts poor overall survival and high locoregional relapse in inflammatory breast cancer. Oncologist. 2011;16:1675–1683. doi: 10.1634/theoncologist.2011-0196. [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Dawood S, Ueno NT, Valero V. et al. Differences in survival among women with stage III inflammatory and noninflammatory locally advanced breast cancer appear early: a large population-based study. Cancer. 2011;117:1819–1826. doi: 10.1002/cncr.25682. [DOI] [PubMed] [Google Scholar]
  8. Gianni L, Eiermann W, Semiglazov V. et al. Neoadjuvant chemotherapy with trastuzumab followed by adjuvant trastuzumab versus neoadjuvant chemotherapy alone, in patients with HER2-positive locally advanced breast cancer (the NOAH trial): a randomised controlled superiority trial with a parallel HER2-negative cohort. Lancet. 2010;375:377–384. doi: 10.1016/S0140-6736(09)61964-4. [DOI] [PubMed] [Google Scholar]
  9. Curcio LD, Rupp E, Williams WL. et al. Beyond palliative mastectomy in inflammatory breast cancerda reassessment of margin status. Ann Surg Oncol. 1999;6:249–254. doi: 10.1007/s10434-999-0249-3. [DOI] [PubMed] [Google Scholar]
  10. Incorvati JA, Shilpan S, Ying M, Janice L. Targeted therapy for HER2 positive breast cancer. Journal of Hematology & Oncology. 2013;6:38. doi: 10.1186/1756-8722-6-38. 3 June 2013. [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Harris EE, Schultz D, Bertsch H. et al. Ten-year outcome after combined modality therapy for inflammatory breast cancer. Int J Radiat Oncol Biol Phys. 2003;55:1200–1208. doi: 10.1016/S0360-3016(02)04201-3. [DOI] [PubMed] [Google Scholar]

Articles from Experimental Hematology & Oncology are provided here courtesy of BMC

RESOURCES