From the Guidelines
The diagnosis of peau d'orange skin changes in the breast should start with a thorough clinical examination, followed by diagnostic imaging with bilateral mammography and ultrasound, and then tissue sampling, including punch biopsy of the affected skin and core needle biopsy of any suspicious breast lesions, as recommended by the NCCN Guidelines 1. The clinical examination should note the extent of skin thickening, dimpling, and edema that creates the characteristic orange peel appearance. Next, diagnostic imaging is essential to evaluate breast tissue and identify any underlying masses or architectural distortion. Breast MRI may be added for better tissue characterization and to assess the extent of disease, although its routine use is not recommended by the international expert panel on inflammatory breast cancer 1. Following imaging, tissue sampling is crucial, and a skin punch biopsy is strongly recommended to confirm invasive carcinoma, with testing for hormone receptors and HER2 1. Additional staging workup with CT chest/abdomen/pelvis and bone scan is indicated if cancer is confirmed, as inflammatory breast cancer often presents at an advanced stage 1. The diagnostic process should be expedited as peau d'orange is concerning for aggressive disease, and prompt referral to a multidisciplinary breast team is recommended for coordinated care and treatment planning. Some key points to consider in the diagnosis of peau d'orange skin changes in the breast include:
- Rapid onset of breast erythema, edema, and/or peau d’orange, and/or warm breast, with or without an underlying palpable mass 1
- Duration of history of no more than 6 months 1
- Erythema occupying at least one-third of the breast 1
- Pathological confirmation of invasive carcinoma 1 The international expert panel on inflammatory breast cancer recommends a multidisciplinary approach, with primary systemic chemotherapy, definitive surgery, and postmastectomy radiation as needed 1.
From the Research
Diagnosis of Peau d'Orange Skin Changes in Breast
The diagnosis of peau d'orange skin changes in breast cancer involves several steps, including:
- Clinical evaluation: Presenting symptoms of inflammatory breast cancer include erythema, skin changes such as peau d'orange or nipple inversion, edema, and warmth of the affected breast 2
- Imaging studies:
- Mammography: To detect breast parenchymal lesions (BPLs) or calcifications 3, 4
- Sonography: To evaluate BPLs, architectural distortion, or regional nodal disease 3, 4
- Magnetic Resonance Imaging (MRI): To detect enhancing BPLs, skin abnormalities, or regional nodal disease 3, 4
- Positron Emission Tomography/Computed Tomography (PET/CT): To evaluate distant metastatic disease or hypermetabolic BPLs 5, 4
- Histopathological examination: To confirm the presence of malignant cells in skin biopsies or excised tissue 6
Diagnostic Criteria
The diagnostic criteria for inflammatory breast cancer, which often presents with peau d'orange skin changes, include:
- Erythema occupying at least one-third of the breast
- Edema
- Peau d'orange
- Warmth of the affected breast
- Rapid onset of symptoms (<3 months)
- Pathologic confirmation of invasive carcinoma 2
Importance of Early Diagnosis
Early recognition and diagnosis of peau d'orange skin changes in breast cancer are critical for timely treatment and improved outcomes 2