From the Guidelines
I strongly recommend against ordering a chest X-ray (CXR) solely based on abnormal skin findings along the chest and side, as the initial evaluation should focus on assessing the breast skin changes according to the NCCN guidelines. The presence of unusual skin changes around the breast, such as dermal edema, breast erythema, nipple excoriation, scaling, and eczema, may represent serious disease and needs evaluation for conditions like inflammatory breast cancer (IBC) or Paget’s disease, as stated in the NCCN clinical practice guidelines in oncology 1.
The initial evaluation of a patient with breast skin changes begins with a bilateral diagnostic mammogram with or without ultrasound imaging, as recommended by the NCCN guidelines 1. If the imaging results are abnormal, the evaluation proceeds based on the imaging findings. If the breast imaging results are normal, further workup is still needed, which may include a punch biopsy of the skin or nipple biopsy.
In the context of abnormal skin findings, it is crucial to prioritize the evaluation of breast-related conditions over ordering a CXR, unless there are specific respiratory or thoracic symptoms that warrant chest imaging. The NCCN guidelines emphasize the importance of a thorough breast evaluation, including imaging and biopsy, to determine the underlying cause of the skin changes 1.
Therefore, the primary focus should be on evaluating the breast skin changes according to the NCCN guidelines, rather than ordering a CXR as an initial step. This approach ensures that potential breast-related conditions are promptly identified and addressed, which is critical for patient outcomes in terms of morbidity, mortality, and quality of life.
From the Research
Abnormal Skin Findings and Chest X-Ray (CXR) Order
- Abnormal skin findings along the chest and side may prompt a CXR order to investigate potential underlying conditions, such as pulmonary infections or other thoracic abnormalities 2, 3, 4, 5, 6.
Commonly Missed Findings on Chest Radiographs
- Chest radiography (CXR) is prone to frequent errors in interpretation, which can have adverse consequences for patients 2.
- Perceptual errors are the predominant source of missed findings on CXR 2.
Chest X-Ray Findings in Various Conditions
- Chest x-ray findings can be used in the diagnosis and follow-up of patients with COVID-19 pneumonia, with peripheral ground glass opacities (GGO) affecting the lower lobes being the most common finding 3.
- In Kawasaki disease, abnormal CXR findings, such as reticulogranular pattern, peribronchial cuffing, and pleural effusion, can occur in the acute phase 4.
- Pulmonary infections in immunocompromised hosts can present with various radiographic patterns, and chest imaging remains a crucial part of the initial workup 5.
Subtlety of Abnormal Findings in Chest Radiographs
- Abnormal findings in chest radiographs can be subtle, with pulmonary infiltrates, noncalcified pulmonary nodules, and pneumothoraces being among the most commonly detected abnormalities 6.