Photo Quiz

A Persistent Rash on the Back, Chest, and Abdomen

 

Am Fam Physician. 2017 Sep 15;96(6):390-392.

A 62-year-old woman presented with an erythematous, pruritic, expanding rash on her back, chest, and left lower abdomen (Figures 1 and 2). It appeared two months earlier and did not improve with conservative home treatment, including application of skin lotion, petroleum jelly, and an over-the-counter topical steroid cream. There was no pain or drainage from the affected area. The patient was diagnosed with breast cancer three years earlier, for which she underwent right simple mastectomy and left modified radical mastectomy.

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Figure 1


Figure 1

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Figure 2


Figure 2

She was afebrile on physical examination. The rash was a large, erythematous plaque with discrete borders. There was some slight edema noted in the lower portion of the back. There was no tenderness or warmth. A punch biopsy was performed.

Question

Based on the patient's history and physical examination findings, which one of the following is the most likely diagnosis?

A. Inflammatory breast cancer.

B. Mycosis fungoides.

C. Radiation dermatitis.

D. Tinea corporis.

Discussion

The answer is A: inflammatory breast cancer. Inflammatory breast cancer is a rare subtype of locally advanced primary breast cancer, accounting for roughly 2.5% of breast cancers in the United States.1 It is characterized by the disruption of dermal lymphatics with tumor emboli, leading to diffuse skin erythema, ulceration, and edema.2 It is commonly high grade, estrogen receptor negative, and progesterone receptor negative, and it often affects younger patients.3 Onset of symptoms can be rapid over days to weeks. Erythema and edema can appear overnight, and the breast may swell to two to three times its normal size within weeks. Recurrent inflammatory breast cancer appears with the same skin and microscopic characteristics as the original primary breast cancer biopsies.

Inflammatory

Address correspondence to Derek D. Kane, MD, MS, at dkane@primecare.org. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

REFERENCES

show all references

1. Robertson FM, Bondy M, Yang W, et al. Inflammatory breast cancer: the disease, the biology, the treatment [published correction appears in CA Cancer J Clin. 2011;61(2):134]. CA Cancer J Clin. 2010;60(6):351–375....

2. Mvere MZ, James JJ, Cornford EJ, et al. Frequency and patterns of metastatic disease in locally advanced inflammatory and non-inflammatory breast cancer. Clin Oncol (R Coll Radiol). 2011;23(9):608–612.

3. Hall CS, Karhade M, Laubacher BA, et al. Circulating tumor cells and recurrence after primary systemic therapy in stage III inflammatory breast cancer. J Natl Cancer Inst. 2015;107(11). https://academic.oup.com/jnci/article-lookup/doi/10.1093/jnci/djv250. Accessed June 16, 2017.

4. Giordano SH, Hortobagyi GN. Inflammatory breast cancer: clinical progress and the main problems that must be addressed. Breast Cancer Res. 2003;5(6):284–288.

5. Rea D, Francis A, Hanby AM, et al.; UK Inflammatory Breast Cancer Working Group. Inflammatory breast cancer: time to standardise diagnosis assessment and management, and for the joining forces to facilitate effective research. Br J Cancer. 2015;112(9):1613–1615.

This series is coordinated by John E. Delzell Jr., MD, MSPH, Assistant Medical Editor.

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