LAUSR

In October 2016, Brzezinska et al. advocated for the use of breast conservation therapy (BCT) in select patients with inflammatory breast cancer (IBC) [1]. Thirty-five patients who were diagnosed with IBC from 1999 to 2013 and treated with BCT were reviewed from a prospectively collected database. All patients had a localized solid tumor component in the breast and were treated with trimodality therapy: neoadjuvant therapy, surgery, and adjuvant radiation. They were selected to undergo breast-conserving surgery at the discretion of the multidisciplinary treatment team if the erythema and characteristic peau d’orange resolved following neoadjuvant therapy. Surgical management consisted of segmental mastectomy with axillary staging in most of the cases. Management of the axilla included axillary lymph node dissection in 20 patients, sentinel lymph node dissection (SLND) in 14 patients (resulting in completion ALND in four patients), and axillary radiation alone in one patient. SLN identification rate was 100%. All the patients received adjuvant whole breast irradiation. Excellent results were demonstrated in loco-regional recurrence (LRR)-free survival (87.5%— 5 year LRR-free survival) and actuarial survival (70.3%— 5-year survival) over a considerably long follow-up (median 80 months). Despite these impressive recurrence and survival data, BCT and SLND remain controversial in the treatment of IBC. Given the rarity of this disease (annual incidence of 1.6–3.1%) [2], treatment recommendations are not informed by large randomized trials but rather by international multidisciplinary expert panels who draw upon our current knowledge of locally advanced, non-inflammatory breast cancer and smaller trials in which IBC patients were included. Two such groups [3, 4] advise against BCT. They instead recommend total mastectomy and axillary dissection, even in the setting of an excellent response to chemotherapy. The UK IBC working group [5], however, suggests that IBC patients who respond well to primary systemic chemotherapy may be candidates for BCT. The scope of these recommendations also includes the use of percutaneous lymph node biopsy or SLND to stage the axilla followed by axillary lymphadenectomy if axillary lymph nodes are positive.