Inflammatory Breast Cancer Cases Research Articles

Abstract PO2-02-14: Development of a multi-institutional, photograph-rich clinical dataset to test and validate a novel inflammatory breast cancer (IBC) scoring system

Abstract Purpose: Susan G. Komen, The Inflammatory Breast Cancer (IBC) Research Foundation, and the Milburn Foundation convened a collaborative of patient advocates, clinicians, and researchers and proposed a novel quantitative scoring system for IBC diagnosis. The score includes timing of symptoms, extent of skin edema and erythema/other discoloration, breast and nipple asymmetry, lympho-vascular space invasion, nodal stage, and diffuse extent disease in the breast on breast imaging. Total scores were categorized (< 14 Not IBC, 14-24 Weak Possibility of IBC, 25-41 Strong Possibility of IBC, > 41 Definitely IBC). Herein, we developed a multi-institutional clinical dataset to retrospectively test and validate the proposed scoring system. Methods: IBC (N= 988) and non-IBC (N=322) cases were identified at two institutions with dedicated multi-disciplinary IBC programs, UT MD Anderson Cancer Center (MDA) and Dana-Farber Cancer Institute (DFCI). The DFCI cohort was diagnosed from 1986-2021 and the MDA cohort was diagnosed from 2010-2020. The non-IBC cohorts were identified as consecutive T4b and T4c cases in existing retrospective databases. Photographs were reviewed for available cases. All scoring variables were reviewed with data extractors and standard operating procedures (SOPs) developed for all ambiguous findings and language. A subset of scores were reviewed by IBC clinicians (FL, WW) and discrepancies discussed to inform the SOPs. Missing data imputation using three methods was examined. Area under the curve (AUC) - Receiver operator characteristic (ROC) curves and values, and sensitivity and specificity for the proposed score cut offs were examined. Results: Of 1320 patients currently in the analysis, 421 (31.9%) have missing data on > 1 characteristics and 47 (3.6%) are missing data on > 4. The rubric characteristic most commonly missing was “nipple abnormalities” accounting for 21.0% and 19.3% for IBC and non-IBC cohorts respectively. Unavailable bilateral breast photograph was the primary source of missing data. The highest scoring finding was present in the following percentage of IBC and non-IBC cases, respectively: timing of symptom onset < 3 months (74.1% vs 38.6%), any peau d’orange (61.2% vs 30.1%), clinically apparent enlargement or new asymmetry of breast size (87.8% vs 90.1%), complete or near complete involvement of the breast skin by erythema or discoloration (55.6% vs 25.6%), new nipple inversion (24.6% vs 9.0%), dermal lymphovascular emboli present (17.9% vs 1.8%), diffuse involvement of the breast parenchyma by imaging (72% vs 77.7%). True IBC cases were categorized as Definitely IBC, Strong Possibility, Weak Possibility, not IBC and unknown 19.7%, 49.1%, 0.4%, 0.1%, and 30.7%. True non-IBC were 0.6%, 51.8%, 9.9%, 2.1%, and 35.5%. Random imputation, lowest value imputation, and median value imputation were compared to impute missing data. AUC-ROC values for each method were similar, 0.80 - 0.84. Conclusion: We describe the development of the largest multi-institutional IBC clinical database to date. SOPs for the rubric characteristics were developed. The importance of bilateral photography to assess the score retrospectively is highlighted. The score is associated with a good AUC-ROC but still leaves much overlap among cases between 25 and 42. Further optimization of the current scoring system and association with outcomes are in progress. Citation Format: Filipa Lynce, Samuel Niman, Megumi Kai, Sean Ryan, Elizabeth Troll, Li Li, Kathy Miller, Reshma Jagsi, Ginny Mason, Beth Overmoyer, H. T. Carisa Le-Petross, Faina Nakhlis, Savitri Krishnamurthy, Beth Harrison, Susie X. Sun, Eren Yeh, Jennifer Bellon, Laura Warren, Michael Stauder, Meredith Regan, Wendy Woodward. Development of a multi-institutional, photograph-rich clinical dataset to test and validate a novel inflammatory breast cancer (IBC) scoring system [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO2-02-14.

Abstract PO1-14-10: Comprehensive clinicogenomic characterization of inflammatory breast cancer

Abstract BACKGROUND: Inflammatory breast cancer (IBC) is a rare type of breast cancer associated with a unique clinical presentation and overall poor outcomes, recognized as a distinct category by the AJCC staging system. The biological mechanisms driving the IBC phenotype are relatively undefined—partially due to a lack of comprehensive, large-scale genomic studies and limited clinical cohorts. Here, we report one of the largest, subtype-informed clinicogenomic characterizations of IBC to date. METHODS: A retrospective analysis of 2457 patients with metastatic breast cancer who underwent targeted tumor-only DNA-sequencing (OncoPanel, up to 447 cancer-associated genes) was performed at Dana-Farber Cancer Institute. Clinicopathologic, single nucleotide variant (SNV), copy number variant (CNV) and tumor mutational burden (TMB) comparisons were made between IBC and non-IBC cases. Median follow-up was 28.1 months. RESULTS: Our profiled cohort included 140 patients with IBC specimens (n = 68 primary tumors, 72 metastatic tumors) and 2317 patients with non-IBC specimens (n = 702 primaries, 65 local recurrences, 1550 metastases). Of these, 87.4% of patients were White, 4.7% Black, 3.6% Asian or Pacific Islander, and 4.3% other/unknown. Clinicopathologic differences between IBC and non-IBC cases were consistent with previous reports—including younger age at diagnosis of metastatic disease (51 vs 54 years, p = 0.04), and a higher proportion of grade 3, estrogen receptor-negative and HER2-positive tumors (p < 0.001). Among the hormone-receptor (HR)-positive subtype, IBC tumors showed a significant enrichment in Luminal B (LumB)-inferred disease (62.5% vs 39.8%, p < 0.005), defined as tumors with grade 3 or progesterone receptor staining < 10%. The most recurrent somatic alterations spanning all subtypes in IBC were TP53 (72%), ERBB2 (32%), PIK3CA (24%), CCND1 (12%), MYC (9%), FGFR1 (8%) and GATA3 (8%). A multivariate logistic regression analysis accounting for HR and HER2 status revealed a significant enrichment in TP53 SNVs in IBC vs non-IBC (OR 2.08 [95% CI 1.34-3.24], adjusted p-value 0.04). Frequency of TP53 alterations in IBC vs non-IBC cases was 85.1% vs 64.3% in HER2-positive and 50.0% vs 27.7% in HR-positive disease—with an enrichment of TP53 mutations in IBC LumB-inferred tumors vs non-LumB (64% vs 26%, p < 0.05). When comparing HR+ IBC LumB vs HR+ non-IBC LumB cases, TP53 mutations were again enriched (p < 0.05)—suggesting LumB-like histopathology is not the only driving feature of TP53 enrichment in HR+ IBC. TMB did not differ substantially between IBC and non-IBC and no other statistically significant enrichments were observed, including when grouping mutations into six canonical cancer pathways (cell cycle, Notch signaling, PI3K pathway, RTK/RAS signaling, TP53 pathway and WNT signaling). CONCLUSIONS: Taken together, this study provides a comprehensive landscape of somatic alterations in a large cohort of patients with metastatic IBC and non-IBC. Our data support a lack of major genomic differences other than enrichments in TP53 mutations and an associated LumB-like histopathology. These results both reinforce the importance of TP53 mutations in IBC biology and suggest additional analyses beyond somatic DNA-level changes are warranted. Future efforts with the DFCI IBC cohort will assess germline-somatic interactions, non-genomic or transcriptomic characterizations, and potential environmental influences to better understand the mechanisms driving this unique disease. Citation Format: Nolan Priedigkeit, Beth Harrison, Melissa Hughes, Robert Shue, Yvonne Li, Gregory Kirkner, Claire Remolano, Sarah Strauss, Janet Files, Anne-Marie Feeney, Ayesha Mohammed-Abreu, Ana Garrido-Castro, Romualdo Barroso-Sousa, Brittany Bychkovsky, Faina Nakhlis, Jennifer Bellon, Tari King, Bruce Johnson, Lynette Sholl, Deborah Dillon, Beth Overmoyer, Sara Tolaney, Andrew Cherniack, Nancy Lin, Filipa Lynce. Comprehensive clinicogenomic characterization of inflammatory breast cancer [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO1-14-10.

Abstract PO1-25-04: PTN-positive luminal progenitors induce angiogenesis and metastasis in inflammatory breast cancer

Abstract Background Inflammatory breast cancer (IBC) is a lethal subtype of breast cancer characterized by rapidly arising diffuse erythema and edema of the overlying skin that was thought to contribute to rapid metastasis. Dissecting the intricate cellular ecosystems within tumors and affected skin and their complex interplay may be pivotal in unraveling the aggressive nature of IBC. Methods Integrative analysis containing single-cell RNA sequencing, bulk RNA sequencing, and whole exome sequencing, was performed on paired tumor and skin samples from 17 treatment-naive IBC patients and 5 non-IBC patients from multiple centers. Meanwhile, paraffin sections and serum specimens from two centers were conducted to validate the omics results. Additionally, public single-cell transcriptomic data of non-IBC tumors and normal mammary glands, RNA microarray data from IBC cases, and the Cancer Genome Atlas (TCGA) database were utilized to validate the characteristics of IBC microenvironment. The regulatory mechanism was verified by in vitro experiments. Results We delineated the landscapes of IBC tumor and affected skin microenvironment at the single-cell level and demonstrated that the luminal progenitors (LP) cells highly expressing pleiotrophin (PTN) were most significantly enriched in IBC tumors compared to non-IBC tumors and normal mammary glands, in two independent cohorts. Moreover, the serum concentrations of PTN were significantly higher in IBC patients compared with non-IBC patients. Notably, PTN secreted by PTN+ LP cells interacted with Neuropilin 1(NRP1) receptor on endothelial tip cells in both tumor and affected skin of IBC. Moreover, in vitro assay demonstrated knocking down the expression of NRP1 on human umbilical vein endothelial cells significantly blocked PTN-induced migration, tube formation and sprouting, which might be independent of VEGFA. In addition, two immature phenotypes of PVL_MMP9 and PVL_CCL19 cells recruited by endothelial tip cells via PDGFB/PDGFRB axis were accumulated in affected skin of IBC, which might be associated with promotion of malignant cell metastasis. Finally, we revealed that malignant cells in affected skin of IBC had a higher ability of epithelial-mesenchymal transition than IBC intratumoral malignant cells and identified enhanced crosstalk between immature PVL cells and malignant cells in the skin affected with IBC , through TNFSF12-TNFRSF12A, TGFB-TGFBR1/TGFBR2, MDK-SDC1/4/NCL/(ITGA6+ITGB1). Conclusion We identified a unique, non-malignant epithelial cell subpopulation PTN+ LP cells, which induce massive angiogenesis via the PTN-NRP1 axis, recruit the immature phenotype PVL cells accumulated in affected skin of IBC thus promoting tumor progression. Our findings offer comprehensive insights into the pathogenesis of IBC and uncover a previously unknown, promising therapeutic target. Patient of discovery cohort details Clinical and pathology details for inflammatory breast cancer(IBC) and non-IBC patients analysed by single-cell RNA sequencing(scRNA-seq), bulk RNA sequencing(bulk RNA-seq) and whole exome sequencing(WES) in this study. Clinicalpathological feature of validation cohort Citation Format: Mengmeng Zhang, Kaiwen Zhou, Ting Liu, Filipa Lynce, Filipa Lynce, Wendy Chen, Qianjun Chen, Xiaoping Li, Zhongyu Yuan, Juan Xu, Zhenhai Cai, Jianping Guo, Nan Shao, Ying Lin. PTN-positive luminal progenitors induce angiogenesis and metastasis in inflammatory breast cancer [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO1-25-04.

Abstract PO5-06-02: Phase II Trial of Combination of Atezolizumab, Cobimetinib and Eribulin (ACE) or Atezolizumab and Eribulin (AE) in patients with metastatic inflammatory breast cancer (IBC): Clinical data of both cohorts

Abstract Background: Metastatic IBC is an unmet clinical need due to the aggressiveness of this breast cancer subtype. Gene expression analysis of IBC samples post-neoadjuvant chemotherapy has revealed that dysregulation of immune pathways is common in tumors that do not have a complete pathologic response (pCR) to chemotherapy. The immune checkpoint PD-L1 is expressed in a third of IBC cases, and the MEK inhibitor, cobimetinib, has been shown to enhance the expression of PD-L1, the target of atezolizumab. Taken together, dual targeted therapy with atezolizumab and cobimetinib is hypothesized to be synergistic. Eribulin is a standard of care chemotherapy used in patients who have progressed on anthracycline-taxane based regimens. Materials and Methods: Patients received triple or double combination therapy depending on the timing of their enrollment. Patients with metastatic IBC who had measurable disease after at least 1 standard regimen were eligible. Any receptor subtype was allowed, and PD-L1 positivity was not required. The study began with a single cohort (n=17 patients) receiving all 3 agents with a lead-in phase to determine the MTD of cobimetinib in this setting. The study was later amended to include only atezolizumab and eribulin (cohort 2). Ten patients were treated in cohort 2. The study closed early due to lack of efficacy in cohort 2 and the changing landscape of metastatic breast cancer therapies. In cohort 1, atezolizumab was given every 2 weeks (840 mg), cobimetinib was given at 60/40/20 mg once daily, and eribulin was given at 1.4mg/m2 on day 1 and day 8 of 21-day cycles. In cohort 2, atezolizumab was given every 3 weeks (1200 mg) during the PD window and cycles 1-4, and then every 4 weeks (1680 mg) during maintenance, and eribulin was given at 1.4mg/m2 on day 1 and day 8 of 21-day cycles. Results: The MTD of cobimetinib was 40mg. In cohort 1, 17 patients were treated, 14 had at least 1 restaging evaluation. Seven patients had a partial response (50%) and 3 stable disease. The cohort was predominantly triple receptor-negative (n=13/17), with a median age of 51 yrs. The median PFS for patients in cohort 1 was 6.2 months (0-54.1). There were 2 exceptional responders, both with triple negative subtype, one of whom remains on therapy for >4.5 years without evidence of disease. The median overall survival was 29.6 months (2.9-133). The AE profile was largely expected, with 3 irAEs (1 grade 5 colitis, and 2 grade 2 pneumonitis), and one other patient with cardiac dysfunction requiring discontinuation of cobimetinib and atezolizumab. The MTD of cobimetinib was 40 mg. Cobimetinib-related toxicities were mild and largely gastrointestinal tract related. In cohort 2, only 1 patient experienced PR, and the median PFS was 3 months (1.2-6.2) and overall survival 8.3 months (1.8-19.9). One patient experienced autoimmune related hepatitis requiring discontinuation of protocol therapy. Due to excesive myelosuppression, dose of erublin was reduced to 1.1 mg per meter squared on day 1 and 8 and pegfilgastrim was added on day 9< Conclusions: The response profile of the triple combination demonstrated promise, and suggests that MEK inhibition may warrant further investigation as a strategy in metastatic IBC in a larger sample size. However, there does not appear to be synergy between atezolizumab and eribulin without the addition of targeted therapy. Citation Format: Angela Alexander, Hope Murphy, James Reuben, H. T. Carisa Le-Petross, Deanna Lane, Monica Huang, Savitri Krishnamurthy, Yun Gong, Dan Gombos, Nimisha Patel, Richard Allen, Suyu Liu, Anisha Patel, Andrew Futreal, Ignacio Wistuba, Rachel Layman, Naoto Ueno, Debu Tripathy, Bora Lim, Vicente Valero. Phase II Trial of Combination of Atezolizumab, Cobimetinib and Eribulin (ACE) or Atezolizumab and Eribulin (AE) in patients with metastatic inflammatory breast cancer (IBC): Clinical data of both cohorts [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO5-06-02.

Post burn and bilateral inflammatory breast cancer: Three case reports from one patient

Inflammatory Breast Cancer (IBC) is the most aggressive form of primary breast cancer. IBC has an incidence of approximately 2.5 cases per 100,000 women. Malignant neoplasms arising from burn scars are well-known but rarely encountered. The subject was reviewed in a comprehensive publication that reviewed the literature between 1923 and 2007 and found 412 well-documented cases of squamous cell carcinoma (71%), basal cell carcinoma (12%), melanoma (6%), sarcoma (5%), other neoplasms (4%), squamo-basal cell carcinoma (1%), and squamous cell-melanoma (1%). In 2008, two cases were reported by Losanof, et al. both female, who were diagnosed with advanced breast cancer many years after severe thermal injury to their breasts. Bilateral synchronous or metachronous breast cancer is well-known and documented except for IBC. To our knowledge, our search using Medline and other searches did not reveal any post-burn IBC or bilateral IBC cases reported in the literature that occurred till 2006. There are only 2 cases reported in 2010 and 2016. We report our 3 case reports presented from one patient; who was diagnosed in 2006; a case of post-burn breast cancer, and to our knowledge the first case report of post-burn IBC type and a rare case report of bilateral metachronous IBC.

Inflammatory breast cancer: An overview about the histo-pathological aspect and diagnosis.

Inflammatory Breast Cancer (IBC) is a rare and aggressive form of locally advanced breast cancer, classified as stage T4d according to the tumor-node-metastasisstaging criteria. This subtype of breast cancer is known for its rapid progression and significantly lower survival rates compared to other forms of breast cancer. Despite its distinctive clinical features outlined by the World Health Organization, the histopathological characteristics of IBC remain not fully elucidated, presenting challenges in its diagnosis and treatment. Histologically, IBC tumors often exhibit a ductal phenotype, characterized by emboli composed of pleomorphic cells with a high nuclear grade. These emboli are predominantly found in the papillary and reticular dermis of the skin overlaying the breast, suggesting a primary involvement of the lymphatic vessels. The tumor microenvironmentin IBC is a complex network involving various cells such as macrophages, monocytes, and predominantly T CD8+lymphocytes, and elements including blood vessels and extracellular matrix molecules, which play a pivotal role in the aggressive nature of IBC. A significant aspect of IBC is the frequent loss of expression of hormone receptors like estrogen and progesterone receptors, a phenomenon that is still under active investigation. Moreover, the overexpression of ERBB2/HER2 and TP53 in IBC cases is a topic of ongoing debate, with studies indicating a higher prevalence in IBC compared to non-inflammatory breast cancer. This overview seeks to provide a comprehensive understanding of the histopathological features and diagnostic approaches to IBC, emphasizing the critical areas that require further research.

Neoadjuvant Radiation Therapy in the Treatment of Breast Cancer

Radiation therapy improves locoregional control and increases breast cancer patient's survival. Its neoadjuvant setting is a rarely used alternative that favors tumor resectability and, in addition, allows immediate breast reconstruction. This study aims to characterize locally advanced breast cancer patients that were treated with neoadjuvant radiotherapy (naRT), its indications and results. Medical records were reviewed retrospectively. All patients diagnosed with breast cancer treated with curative-intent naRT in a Chilean oncologic hospital between January 2017 and 2019 were included. Inflammatory breast cancer cases and sarcomas were excluded. We described demographic, clinical and treatment characteristics, naRT indications and outcomes. Information was collected from 112 patients (98% women) referred from 7 public hospitals. The median age was 57 years [28-85 years]. At diagnosis, 78% corresponded to clinical stage cT4b, and 83% had cN+ axilla (axillary biopsy was performed in 44 cases, 35 were positive). 53% were classified as luminal B, 19% as triple negative, 17% as luminal A, and 11% as HER2 enriched. 98% of patients began treatment with neoadjuvant systemic therapy (91 patients received chemotherapy and 19 patients hormone therapy). naRT indications were: immediate breast reconstruction in 23% and contraindication or unsatisfactory response to systemic therapy in 77%. In 99% of naRT the dose was 45-50 Gy to the breast/chest wall and peripheral lymphatics. 86% of patients underwent surgery (14 patients did not undergo surgery due to disease progression or because they refused surgery and 2 patients were on the waiting list at the time of follow up). Immediate breast reconstruction was performed in 31 patients with a median age of 45 years, all of them were derived from 2 referral centers that suggest this altered sequence of treatments. Surgical biopsies of 96 patients were reviewed: 13% had pathological complete response in the breast/chest wall, 55% in the axilla, and 12% at both levels. 30% of post-surgical complications were reported in the subgroup of patients who continued follow-up in our institution (total of 47 patients). With a median follow-up of 29 months, 18% of the patients had died from breast cancer. naRT is not only an option when systemic therapy is not a good alternative, but also favors resectability of locally advanced tumors making pathological complete response and immediate breast reconstruction possible in selected cases, obtaining an oncological and reconstructive objective in the same surgery.

Imaging Modalities in Inflammatory Breast Cancer (IBC) Diagnosis: A Computer-Aided Diagnosis System Using Bilateral Mammography Images.

Inflammatory breast cancer (IBC) is an aggressive type of breast cancer. It leads to a significantly shorter survival than other types of breast cancer in the U.S. The American Joint Committee on Cancer (AJCC) defines the diagnosis based on specific criteria. However, the clinical presentation of IBC in North Africa (Egypt, Morocco, and Tunisia) does not agree, in many cases, with the AJCC criteria. Healthcare providers with expertise in IBC diagnosis are limited because of the rare nature of the disease. This paper reviewed current imaging modalities for IBC diagnosis and proposed a computer-aided diagnosis system using bilateral mammograms for early and improved diagnosis. The National Institute of Cancer in Egypt provided the image dataset consisting of IBC and non-IBC cancer cases. Type 1 and Type 2 fuzzy logic classifiers use the IBC markers that the expert team identified and extracted carefully. As this research is a pioneering work in its field, we focused on breast skin thickening, its percentage, the level of nipple retraction, bilateral breast density asymmetry, and the ratio of the breast density of both breasts in bilateral digital mammogram images. Granulomatous mastitis cases are not included in the dataset. The system's performance is evaluated according to the accuracy, recall, precision, F1 score, and area under the curve. The system achieved accuracy in the range of 92.3-100%.

Geometric tumor embolic budding characterizes inflammatory breast cancer.

Inflammatory breast cancer (IBC) is characterized by numerous tumor emboli especially within dermal lymphatics. The explanation remains a mystery. This study combines experimental studies with two different IBC xenografts with image algorithmic studies utilizing human tissue microarrays (TMAs) of IBC vs non-IBC cases to support a novel hypothesis to explain IBC's sina qua non signature of florid lymphovascular emboli. In the human TMAs, compared to tumor features like nuclear grade (size), mitosis and Ki-67 immunoreactivity which show that IBC is only modestly more proliferative with larger nuclei than non-IBC, what really sets IBC apart is the markedly greater number of tumor emboli and distinctly smaller emboli whose numbers indicate geometric or exponential differences between IBC and non-IBC. In the experimental xenograft studies, Mary-X gives rise to tight spheroids in vitro which exhibit dynamic budding into smaller daughter spheroids whereas Karen-X exhibits only loose non-budding aggregates. Furthermore Mary-X emboli also bud dramatically into smaller daughter emboli in vivo. The mechanism that regulates this involves the generation of E-cad/NTF1, a calpain-mediated cleavage 100kDa product of 120kDa full length membrane E-cadherin. Inhibiting this calpain-mediated cleavage of E-cadherin by blocking either the calpain site of cleavage (SC) or the site of binding (SB) with specific decapeptides that both penetrate the cell membrane and mimic either the cleavage site or the binding site on E-cadherin, inhibits the generation of E-cad/NTF1 in a dose-dependent manner, reduces spheroid compactness and decreases budding. Since E-cad/NFT1 retains the p120ctn binding site but loses the α-and β-catenin sites, promoting its 360° distribution around the cell's membrane, the vacilating levels of this molecule trigger budding of both the spheroids as well as the emboli. Recurrent and geometric budding of parental emboli into daughter emboli then would account for the plethora of emboli seen in IBC.

Targeting Estrogen Non‐Genomic Signaling in a Three‐Dimensional (3D) in VitroModel of Inflammatory Breast Cancer

Inflammatory Breast Cancer (IBC) is the most aggressive form of breast cancer with a low overall 5‐year survival rate of ~30‐60%. To this date the molecular signature associated with IBC has not been fully characterized, which lead to a lack of effective targeted therapeutics, especially for those patients that account for the 20‐40% of triple‐negative (TNBC) IBC cases. Several studies established that molecular signature of IBC shows important differences from the other breast cancer subtypes, such as overexpression of ErbB receptors, RhoC GTPase and Cox‐2, E‐cadherin aberrant expression, and loss of WISP3, among others. However, these molecular alterations do not explain completely the aggressive and rapid IBC progression. Recently, several studies have shown that estrogen can exert non‐genomic effect in triple‐negative IBC and other TNBCs, mediated by the expression of alternate estrogen receptors, including ERα36 and GPR30. Estrogen non‐genomic signaling refers to the rapid action of these alternate estrogen receptors that upon estrogen binding activates protein‐kinase cascades in the cytoplasm. We hypothesize that estrogen can elicit a specific non‐genomic signaling cascade that promotes the acquisition of aggressive oncogenic phenotypes in IBC and that targeting this pathway can be an effective anticancer therapy for IBC. To test this hypothesis, we used pharmacological inhibitors of the Epidermal Growth Factor Receptor (EGFR) alone and GPR30 alone or in combination. The first approach was to determine if inhibiting estrogen non‐genomic signaling by targeting one of the alternate receptors, GPR30, affects cell proliferation in a 3D colony formation assay using Matrigel. Preliminary observations showed that after G15 treatment (GPR30 inhibitor), there was a slight reduction in cell proliferation compared to E2, but when combined with IRESSA (EGFR inhibitor) there was a further decreased on proliferation when compared to IRESSA alone. Ongoing experiments include the effects of Icaritin (modulator of ERα36) and knockdown of ERα36 using siRNA experiments to test the effects in cell proliferation, migration and invasion. Also, we are in the process of determining the half‐maximal inhibitory concentration (IC50) of G15, IRESSA and IRESSA + G15 by performing a dose response curve (Alamar Blue cell viability assay) of SUM149 cell line, to observe if there is an additive effect when combined the pharmacological inhibitors of EGFR and GPR30. This study will provide the foundation for further characterization of the role estrogen non‐genomic signaling in the progression of IBC and to test its potential as a therapeutic target.

GPR30: A potential therapeutic target in Triple‐negative Inflammatory Breast Cancer

Inflammatory Breast Cancer (IBC) is rare and the most aggressive subtype of all breast cancers, with reported rapid progression, poor prognosis, and a unique clinical diagnosis (blockage of lymph vessels by tumor emboli). Approximately, 40% of IBC cases are classified as triple‐negative breast cancer (TNBC), meaning they test negative for hormone receptors (estrogen and progesterone) and the amplification of the epidermal growth factor receptor 2 (HER2), which result in no effective targeted therapies to date. However, 17β‐estrogen (E2) has been found to induce a non‐genomic cellular response to enhance oncogenic phenotypes in TN‐IBC and this has been associated with the presence of alternative estrogen receptors, including a novel G‐protein coupled estrogen receptor (GPR30). Recent studies have also reported a crosstalk between GPR30 and the epidermal growth factor receptor (EGFR) signaling pathway in the presence of E2, which enhances the phosphorylation of the extracellular signal‐regulated kinase (ERK1/2) and protein kinase B (AKT), and promotes migration and invasion phenotypes in TN‐BC cells. However, the exact role of GPR30 in the non‐genomic signaling pathway in TN‐IBC remains elusive. We hypothesize that GPR30 is necessary to undergo the estrogen non‐genomic signaling pathway to induce ERK1/2 and AKT phosphorilation levels and enhance migration and proliferation activities in TN‐IBC cells after treatment with E2.MethodsWe measured phosphorylation levels of ERK1/2 and AKT kinases (by western‐blot), migratory activity (by wound‐healing assay), and tumor emboli formation (by 3D‐cell proliferation assay) after treatments in time‐points with E2 alone and in combination with G15, GPR30 antagonist drug, in TN‐IBC cells SUM149PT.ResultsThe combined G15 + E2 treatment significantly reduced E2‐induced ERK1/2 and AKT phosphorylation levels, as well as decreased migratory activity in SUM149PT cells, suggesting that GPR30 is necessary to undergo the estrogen non‐genomic signaling pathway and can regulate the ERK1/2 and AKT signaling cascade in TN‐IBC. Data acquired from these experiments will contribute to a better understanding of TN‐IBC’s molecular structure and create new opportunities to develop novel targeted therapies.

Ten-year outcome results of cT4 breast cancer after neoadjuvant treatment.

cT4 breast cancer (BC) is classified as noninflammatory breast cancer (non-IBC) or inflammatory breast cancer (IBC). The outcome often is considered worse. The purpose of this study was to determine recurrence and outcomes in overall survival (OS), invasive disease-free survival (IDFS), distant disease-free survival (DDFS) according to pathological complete response (pCR), and inflammatory status. From 2000 to 2015 we selected 634 nonmetastatic cT4 BC patients treated with neoadjuvant therapy followed by surgery at the European Institute of Oncology. OS, IDFS, and DDFS were estimated with the Kaplan-Meier method. The median follow-up was 9.0 years. Twenty patients underwent only sentinel node biopsy (SNB), 13 SNB + AD, and 601 only AD. Considering the 614 patients with AD, only 2.5% of non-IBC patients reported pCR compared to 15% of IBC cases. Only two axillary recurrences were reported. Ten-year results were 52.3% (95% confidence interval [CI]: 47.8-56.5) for OS, 37.0% (95% CI: 32.6-41.3) for IDFS, and 49.8% (95% CI: 45.0-54.4) for DDFS. OS, IDFS, and DDFS were better in all BC with pCR (irrespective of inflammatory status). Our long-term results demonstrated that pCR significantly improves survival, reducing locoregional and distant recurrence risk in cT4 tumors with respect to patients with no pCR and according to inflammatory status of cT4 BC.

Trends, survival outcomes, and predictors of nonadherence to mastectomy guidelines for nonmetastatic inflammatory breast cancer.

The Current National Comprehensive Cancer Network guidelines recommend modified radical mastectomy (MRM) as the surgical treatment of choice for nonmetastatic inflammatory breast cancer (IBC). Limited studies have looked into the outcomes of breast conserving surgery (BCS) vs. MRM for IBC. National Cancer Database (NCDB) data from 2004 to 2014 were retrospectively analyzed. Patients' demographics, tumor characteristics, and overall survival (OS) trends were compared for BCS and MRM cases of nonmetastatic IBC. Univariate and multivariate analyses were performed. A total of 413 (3.89%) BCS and 10,197 (96.11%) MRM cases were identified. Median follow-up was 58.45months. Compared to MRM, BCS patients were more likely to be older, be African American, have Medicare/Medicaid or be uninsured, live in lower education ZIP codes, and live in a metropolitan area (all p<0.05). BCS rates significantly decreased from 5.84% in 2004 to 3.19% in 2014 (p<0.001). BCS patients also were more likely to have less than 50% of the breast involved (51.57% vs. 43.88%; p=0.0081) and were less likely to receive trimodal therapy (50.85% vs. 74.62%; p=<0.0001). The OS was significantly higher in the mastectomy group over 9years at 62.02% vs. 54.47% in the BCS group. Additionally, in the adjusted multivariate model, BCS cases were associated with 23% higher hazards of overall mortality (p=0.0091). BCS was performed in a limited number of cases, which decreased over the study period. The analysis identified both demographic predictors of receiving BCS and significantly lower OS for IBC patients undergoing a BCS.

Metastatic inflammatory breast cancer: survival outcomes and prognostic factors in the national, multicentric, and real-life French cohort (ESME)

BackgroundPrimary inflammatory breast cancer (IBC) is a rare and aggressive entity whose prognosis has been improved by multimodal therapy. However, 5-year overall survival (OS) remains poor. Given its low incidence, the prognosis of IBC at metastatic stage is poorly described.Materials and methodsThis study aimed to compare OS calculated from the diagnosis of metastatic disease between IBC patients and non-IBC patients in the Epidemiological Strategy and Medical Economics database (N = 16 702 patients). Secondary objectives included progression-free survival (PFS) after first-line metastatic treatment, identification of prognostic factors for OS and PFS, and evolution of survival during the study period.ResultsFrom 2008 to 2014, 7465 patients with metastatic breast cancer and known clinical status of their primary tumor (T) were identified (582 IBC and 6883 non-IBC). Compared with metastatic non-IBC, metastatic IBC was associated with less hormone receptor-positive (44% versus 65.6%), more human epidermal growth factor receptor 2-positive (30% versus 18.6%), and more triple-negative (25.9% versus 15.8%) cases, more frequent de novo M1 stage (53.3% versus 27.7%; P < 0.001), and shorter median disease-free interval (2.02 years versus 4.9 years; P < 0.001). With a median follow-up of 50.2 months, median OS was 28.4 months [95% confidence interval (CI) 24.1-33.8 months] versus 37.2 months (95% CI 36.1-38.5 months) in metastatic IBC and non-IBC cases, respectively (P < 0.0001, log-rank test). By multivariate analysis, OS was significantly shorter in the metastatic IBC group compared with the metastatic non-IBC group [hazard ratio = 1.27 (95% CI 1.1-1.4); P = 0.0001]. Survival of metastatic IBC patients improved over the study period: median OS was 24 months (95% CI 20-31.9 months), 29 months (95% CI 21.7-39.9 months), and 36 months (95% CI 27.9-not estimable months) if diagnosis of metastatic disease was carried out until 2010, between 2011 and 2012, and from 2013, respectively (P = 0.003).ConclusionIBC is independently associated with adverse outcome when compared with non-IBC in the metastatic setting.

Dermal Lymphatic Invasion, Survival, and Time to Recurrence or Progression in Inflammatory Breast Cancer.

Dermal lymphatic invasion (DLI) with tumor emboli is a common pathologic characteristic of inflammatory breast cancer (IBC), although its presence is not required for diagnosis. We examined whether documented DLI on skin biopsy was associated with survival and time to recurrence or progression in IBC. A total of 340 women enrolled in the IBC Registry at Dana-Farber Cancer Institute between 1997 and 2019 were included in this study. Kaplan-Meier curves and multivariable Cox proportional hazards models were used to estimate hazard ratios and 95% confidence intervals for associations of DLI and overall survival, time to locoregional recurrence/progression, and distant metastasis by stage at presentation. DLI was detected in 215 (63.2%) of IBC cases overall. At disease presentation, IBC with DLI had a higher prevalence of de novo metastases (37.7% vs. 26.4%), breast skin ulceration (6.1% vs. 2.4%), and lymphovascular invasion within the breast parenchyma (52.9% vs. 25.5%) and a lower prevalence of palpable breast mass (48.2% vs. 70.6%) than IBC without DLI. Over a median follow-up of 2.0 years, 147 deaths occurred. DLI was not associated with survival or recurrence in multivariable models (all P ≥0.10). For example, among women with stage III disease, hazard ratios (95% confidence intervals) for DLI presence was 1.29 (0.77-2.15) for overall survival, 1.29 (0.56-3.00) for locoregional recurrence, and 1.71 (0.97-3.02) for distant metastasis. Although the extent of tumor emboli in dermal lymphatics may be associated with biological features of IBC, DLI was not an independent prognostic marker of clinical outcomes in this study.

Inhibitory Effects of Coumestrol in Triple‐Negative Inflammatory Breast Cancer

Breast cancer is the second leading cause of death in females in the United States, being Inflammatory Breast Cancer (IBC) the most aggressive subtype. Usually, this cancer is diagnosed in an advanced stage with metastasis. Experts in IBC pathogenesis think that IBC rapid metastasis is induces by tumor emboli formation, a hallmark of IBC. The poor prognosis for patients with IBC emphasizes the need to better understand the molecular signature of this disease to develop effective targeted therapeutics. To this date, there is no effective targeted therapeutics, especially for those patients that account for approximately 20-40% of IBC cases with triple-negative breast cancer (TNBC) classification. Importantly, several studies have shown that estrogen can exert non-genomic effects in IBC and non-IBC TNBC, mediated by the expression of an alternate isoform of estrogen receptor alpha-66, estrogen receptor alpha-36, and GPR30. In this context, estrogen can activate non-genomic signaling pathways involved in the acquisition of oncogenic phenotypes such as increased motility and invasion in IBC cells. Phytoestrogens, like coumestrol (Cou), are natural compounds found in plants, specifically soybeans or clover sprouts. Also, it is a polyphenolic compound that is structurally similar to estradiol (E2) and several studies have shown that coumestrol induces a cytotoxic effect in TNBC. We hypothesize (1) that estrogen non-genomic signaling has an active role in the aggressive metastatic phenotype of IBC, and (2) that Cou has anticancer activity by inhibiting estrogen non-genomic signaling in IBC. To test this hypothesis, IBC cells were treated with E2 or Cou, and activation of downstream kinases was analyzed by Western blot and using a Human Phospho-Kinase Array. A dose-response curve in 2D and 3D models were generated to determine the half-maximal inhibitory concentration (IC50) of Cou. Finally, treatment using the IC50 of Cou caused a decrease in cell viability in the TNBC cell line. Also, in comparison to E2, Cou decrease migration, proliferation, and tumor emboli formation in IBC cell line. In summary, IBC cells are responsive to E2 treatment making this signaling pathway attractive for the development of innovative therapeutic strategies. Importantly, these Cou preliminary studies show a potential anticancer activity in IBC cell lines.

Estrogen Induces Transcriptomic Changes Associated with Oncogenic Phenotypes in Inflammatory Breast Cancer

Inflammatory Breast Cancer (IBC) is rare and the most aggressive subtype of all breast cancers, reporting rapid progression, poor prognosis, and a unique clinical diagnosis. Approximately ~30% of IBC cases are classified as triple negative breast cancer (TNBC), meaning they do not test positive for hormone receptors (estrogen and progesterone) and amplification of the human epidermal growth factor receptor 2 (HER2); therefore limiting the effectiveness of hormonal therapeutics. However, recent studies have reported that estrogen (E2) can induce a rapid E2-response in IBC cells to enhance migration and invasion phenotypes by activation of novel cytoplasmic and membrane localized estrogen receptors (ERα36 isoform and G protein-coupled receptor 30 (GPR30)); both suggested as possible therapeutic targets. However, the role of these receptors in the estrogen genomic signaling pathway remains elusive and there is still no data published related to an E2-induced transcriptional stimulation of genes associated with IBC's aggressive phenotype. Here, we evaluated gene expression changes related to E2 in IBC cell lines SUM149PT to identify target genes and biological pathways associated with IBC's aggressive phenotype. We hypothesized that E2 exposure can induce transcriptional stimulation of genes related to migration and invasion phenotypes in IBC cells SUM149PT. Methods We performed RNA-seq (Illumina NextSeq PE 2x75bp) in 2 study groups (ETOH-treated and E2-treated) to identify specific changes in the expression of genes associated with migration and invasion in IBC SUM149PT. Functional and enrichment analysis of differentially expressed genes were performed using Metascape. qPCR was performed to validate a subset of genes related to the enriched terms associated with the migration and invasion phenotypes. Results After E2 exposue (3hrs), we have identified 370 significantly dysregulated genes (p<0.05), including the ZNF268 gene (adj. p-val significant), which can be potential therapeutic targets. Functional annotation of these genes showed association with mammary gland epithelial cell proliferation, actin cytoskeleton organization, and transmembrane receptor protein tyrosine kinase signaling pathway. Data acquired from these experiments will contribute to the better understanding of IBC's transcriptomic signature and create new opportunities to develop novel targeted therapies.

Survival Analysis of Patients with Inflammatory Breast Cancer in Relation to Clinical and Histopathological Characteristics.

PurposeTo evaluate the survival of patients with inflammatory breast cancer (IBC) and to correlate these survival rates with the histopathological parameters found in the resection specimen of the tumor.Patients and MethodsThis retrospective study was based on 27 patients that had been diagnosed and had undergone surgery in the 2nd General and Oncological Surgery Clinic of the County Emergency Hospital in Timisoara, Romania. Data about the patient group were collected from archived patient files over a period of eight years starting from January 2008. The collected data regarded age, tumor size and histopathological type and immunohistochemistry (IHC), presence or absence of tumor embolus in lymphatic or blood vessels and the presence or absence of distant metastases at the time of diagnosis. We evaluated the impact of tumor characteristics on the patients’ outcome.ResultsThe 12-month survival rates postsurgery were significantly increased if tumors were <5 cm compared to those >5 cm (p=0.046), if nodal status was N0 vs N1–2 (p=0.039), as well as in cases where distant metastases were absent, compared to patients with distant metastases (p=0.001, α=0.001) and positive-hormone receptors (p=0.043). Survival was influenced neither by histopathological type (p=0.357) nor by the presence of tumor embolus in the resection specimen (p=0.250) and HER2 status (p=0.763). Survival at 12 months after surgery was equal between those with stage IIIB noninflammatory breast cancer (NIBC) and IBC. At 24 months after surgery, IBC cases presented a significantly lower probability of survival.ConclusionThe prognosis of patients with IBC is reserved compared to NIBC, increased tumor size, positive lymph node, hormone receptors negative cases and distant metastases drastically decreasing survival rates.

Association of Survival with Locoregional Therapy (Surgery and Radiation) Following Systemic Treatment for Metastatic Inflammatory Breast Cancer

Inflammatory breast cancer (IBC) is an aggressive and rare subtype that occurs in less than 5% of all breast cancers. Underusage of trimodality therapy (surgery, radiation and chemotherapy) for Stage III IBC has been described, despite improved overall survival (OS) benefit. De-novo metastatic IBC patients (Stage IV) have a dismal 5-year survival rate of 18% yet they account for 30% of all IBC cases. We evaluated the survival benefit of locoregional treatment (LRT) of surgery (Sg) and/or radiation (RT) following systemic treatment (ST) for metastatic IBC. 1,051 patients diagnosed with metastatic IBC from 2004-2015 and received ST with or without LRT were identified from the National Cancer Database (NCDB). Demographic, clinicopathologic and treatment variables were obtained. We excluded receipt of immunotherapy and patients likely upstaged during LRT and restricted a subset analysis to receipt of LRT following ST. Four treatment groups were defined: ST + adjuvant RT; ST + adjuvant Sg; ST + adjuvant Sg and RT; and ST only. Markov chain Monte Carlo (MCMC) estimation was used for imputation analysis of missing data. Differences in the distribution of time to the first treatment were assessed with non-parametric Kruskal-Wallis test. 3-year survival rates and median OS were assessed by Kaplan-Meier method. Other statistical computations were performed on SAS 9.3 system or GraphPad Prism software. Of 1,051 patients, 1,044 (99.3%) were female with average age of 57 years (interquartile range, IQR = 48-66). 83 (7.9%) had RT with ST; 181 (17.2%) had Sg with ST; 266 (25.3%) had Sg + adjuvant RT with ST; and 521 (49.6%) had only ST. The median OS was 23.4 months, with a 3-year survival rate of 33.9%. The 3-year survival rates for RT with ST, Sg with ST, Sg + adjuvant RT with ST and ST only were 36.6%, 39.0%, 52.6%, and 21.7%, respectively, P< 0.0001. On multivariate analysis (MVA), patients undergoing Sg with ST (adjusted HR 0.59, 95% CI 0.48-0.73, P< 0.0001) and Sg + adjuvant RT with ST (adjusted HR 0.43, 95% CI 0.36-0.52, P< 0.0001) had improved OS compared to only ST. This was consistent in the presence of hormone receptor status. In the multivariate cohort, 349 de novo patients had ST before LRT. 80% had definitive RT (40.5-66.4 Gy) and 92% had at least a simple total mastectomy. 3-year survival rates for ST + adjuvant RT, ST + adjuvant Sg, ST + adjuvant Sg and RT, and ST only groups were 34.9%, 45.0%, 49.3%, and 21.9%, respectively, P< 0.0001. On MVA, ST + adjuvant Sg (adjusted HR 0.54, 95% CI 0.43-0.69, P< 0.0001) and ST + adjuvant Sg and RT (adjusted HR 0.42, 95% CI 0.34-0.52, P < 0.0001) had improved OS compared to ST only. The significant association of overall survival benefit with trimodality therapy suggests a role for local therapy in the treatment of patients with de-novo Stage IV inflammatory breast cancer. Due to potential biases associated with a retrospective review, in order to make definitive conclusions about locoregional benefit, a randomized controlled trial is necessary.

Inflammatory Breast Cancer: Clinical Implications of Genomic Alterations and Mutational Profiling.

Simple SummaryInflammatory breast cancer (IBC) is an aggressive disease with high mortality rates. Nowadays, there is no targeted treatment for this tumor type. Based on this context, we investigated the molecular profile of this disease by using well-established methodologies (high-resolution microarray platform, targeted next-generation sequencing, and immunohistochemistry) that have proven potential to unveil cancer biomarkers. We found alterations related to IBC aggressiveness and metastasis (gains of MDM4, losses of CHL1, and high homologous recombination deficiency scores), and worse overall survival (variants in HR and mismatch repair genes). We also compared the mutational profiling of our cases with literature data, which includes both non-IBC and IBC cases, validating our findings. Overall, we describe genetic alterations with the potential to be used as prognostic or predictive biomarkers and ultimately improve IBC patients’ care.Inflammatory breast cancer (IBC) is a rare and aggressive type of breast cancer whose molecular basis is poorly understood. We performed a comprehensive molecular analysis of 24 IBC biopsies naïve of treatment, using a high-resolution microarray platform and targeted next-generation sequencing (105 cancer-related genes). The genes more frequently affected by gains were MYC (75%) and MDM4 (71%), while frequent losses encompassed TP53 (71%) and RB1 (58%). Increased MYC and MDM4 protein expression levels were detected in 18 cases. These genes have been related to IBC aggressiveness, and MDM4 is a potential therapeutic target in IBC. Functional enrichment analysis revealed genes associated with inflammatory regulation and immune response. High homologous recombination (HR) deficiency scores were detected in triple-negative and metastatic IBC cases. A high telomeric allelic imbalance score was found in patients having worse overall survival (OS). The mutational profiling was compared with non-IBC (TCGA, n = 250) and IBC (n = 118) from four datasets, validating our findings. Higher frequency of TP53 and BRCA2 variants were detected compared to non-IBC, while PIKC3A showed similar frequency. Variants in mismatch repair and HR genes were associated with worse OS. Our study provided a framework for improved diagnosis and therapeutic alternatives for this aggressive tumor type.