A 47-year-old woman comes to the office with a red rash on her breast that has been present for approximately 2 months. The rash is itchy, and the skin feels rough to the touch. The itching has worsened in the past few weeks, and moisturizers have provided no relief. The patient has a history of surgery for bilateral silicone breast implants 10 years ago. Temperature is 37 C (98.6 F). Physical examination shows redness and swelling of the right breast without any discrete masses. The overlying skin is indurated with a dimpled texture, and several enlarged, hard lymph nodes are palpated in the right axilla. The left breast is normal. Which of the following is the most likely cause of this patient's skin changes?

Question

A 47-year-old woman comes to the office with a red rash on her breast that has been present for approximately 2 months.  The rash is itchy, and the skin feels rough to the touch.  The itching has worsened in the past few weeks, and moisturizers have provided no relief.  The patient has a history of surgery for bilateral silicone breast implants 10 years ago.  Temperature is 37 C (98.6 F).  Physical examination shows redness and swelling of the right breast without any discrete masses.  The overlying skin is indurated with a dimpled texture, and several enlarged, hard lymph nodes are palpated in the right axilla.  The left breast is normal.  Which of the following is the most likely cause of this patient's skin changes?

Quizplus · Accepted Answer

11ec160b_3acd_7f14_9249_c15c5e074aca_MD0001_00 This patient has a classic peau d'orange rash, which is characterized by a generalized, erythematous rash that may be tender or itchy. The skin texture is firm and coarsely pitted like an orange peel (after which it is named). This rapidly progressive dermatological finding (with or without an underlying mass) and breast edema are consistent with the characteristic presentation of inflammatory breast cancer, a poorly differentiated breast malignancy with an unfavorable prognosis. The term "inflammatory" is a misnomer because the classic skin findings are not due to infection but are instead caused by cancerous cells obstructing lymphatic drainage after spreading to the dermal lymphatic spaces. Because of this cancer's propensity to metastasize to the lymphatic system, most patients have lymph node involvement (eg, axillary lymphadenopathy) at the time of presentation. (Choice A) Deep venous thrombosis occurs due to hypercoagulability related to malignancy, surgery, or intravenous catheter placement. Deep venous thrombosis most often affects the lower extremities but can also involve the upper extremities. It presents with edema and pain in the affected limb. (Choice B) Rupture of a silicone breast implant can lead to a foreign body reaction with local inflammation (eg, edema, induration), and granuloma formation can result in a palpable, tender mass. Although these findings can mimic inflammatory breast cancer, this patient's pitted skin texture (indicating lymphatic obstruction) and hard axillary lymph nodes make malignancy a more likely diagnosis. (Choice C) Mastitis (ie, breast infection) most commonly occurs in lactating women and presents with pain, breast swelling, and erythema. Most patients also have systemic findings such as fever, malaise, and leukocytosis. (Choice E) Breast implant surgery requires surgical incisions that can leave scars on the breast skin. A hypertrophic scar is a thick, raised, and pink fibrous tissue line that follows the original incision. Keloid scars occur due to disorganized collagen deposits; they have a thick, rubbery appearance and extend outside the incision borders. Educational objective: Peau d'orange is an erythematous, itchy breast rash with skin texture changes that resemble an orange peel. It is the key dermatologic presentation of inflammatory breast cancer and is caused by cancerous cells spreading to the dermal lymphatic spaces and obstructing lymphatic drainage. __________ References: Inflammatory breast cancer: an overview. (http://www.ncbi.nlm.nih.gov/pubmed/25459672)

A 47-Year-Old Woman Comes to the Office with a Red