Efficacy
There is currently no published randomised controlled trials (RCTs) regarding the management of inflammatory breast cancer (IBC), and interpretation of published case series is limited by heterogeneous treatment regimens, including older staging, systemic therapy and radiation therapy techniques. The largest case series by Dawood et al. included 828 patients with inflammatory breast cancer (IBC) and 3,476 with non-IBC. It demonstrated a 7% absolute difference in 2-year breast cancer-specific survival between the two groups: IBC 84% (95% CI: 80-87%) vs non-IBC: 91% (95% CI: 90-92%).r Bristol et al. suggested improved locoregional control (LRC) with hyperfractionation to 66 Gy, when compared with lower radiation therapy doses, but this study included patients recruited between 1977 and 2004, and included a variety of chemotherapy and radiation therapy.r
Stecklein et al. published the most recent series, with 114 patients treated between 2007 and 2015 with neoadjuvant chemotherapy, surgery and radiation therapy.r Five-year overall survival (OS) was 69.14%. Improved disease-free control was seen in patients with HER2+ subtype, clinical stage IIIB, complete or partial radiologic response to neoadjuvant therapy, complete pathologic response and lower nodal burden on presentation. Radiation therapy volumes included the chest wall, undissected axilla, supraclavicular fossa and internal mammary chain (first 3 intercostal spaces). Patients were treated with daily fractionation (median dose 50 Gy in 25 fractions, median boost dose 10 Gy in 5 fractions) or bi-daily fractionation to median dose of 51 Gy in 34 fractions with a boost of 15 Gy in 10 fractions. Bi-daily fraction was used for all patients <45 years; close, positive, or unknown surgical margins; and those with limited response to neoadjuvant systemic therapy. Bolus (3 mm) was applied to the chest wall, up to and including the infraclavicular region, for all patients. For daily fractionation, bolus was used on alternate days for the first 10 days, then as needed to achieve brisk erythema. For bi-daily fractionation, bolus was used with each fraction for the first 5 days, then daily for the next 5 days, then as needed to achieve brisk erythema. Regional nodes were boosted in any patient with regional nodal involvement (at presentation) that was outside the area targeted by lymph node dissection – boost to 60 Gy for radiologic response and 66 Gy for radiologic residual disease.