Question of the Week # 479

479. A 57 year old female presents for second opinion of a left breast lesion that had been diagnosed as ‘eczema’ by her regular nurse practitioner, which briefly improved after a short course of topical steroids. On physical exam there is an erythematous, scaly lesion involving the left breast. Image is shown below. Her last mammogram was a year ago and it was “fine”. She does not report any family history of breast cancer. What is the next step in the patient’s management?

image br rash

A – Bilateral breast ultrasound

B – Bilateral mammography and punch biopsy of nipple

C – Maintain regular annual mammography appointment

D – Oral corticosteroids

E – Left breast MRI

18 Responses

  1. B must be right, there should be bilateral mamo

  2. C.. don’t see any need for emergency expedition except her age suggestive of increased risk where other history negates the possibilities.

  3. As mammography was done 1year ago so mammography & biopsy should be done now.So aswer is ‘B’.

    • Could be Inflammatory BC, need to know more abt the lesion, since how long was it present and any history of autoimmune disorders? Mammography at this time should be fine as she is due for it anyway. My q still would be punch biopsy of nipple, is it a gold standard to detect early cancer? rather I feel is cumbersome. Correct me if I m wrong.

    • I stand corrected for my earlier opinions and realise that any unilateral breast lesion could be a cancer until proven otherwise. Therefore expedite work up in this case. Did my research on this and agree with B.

  4. B , This is inflammatory Breast Cancer

  5. B . This inflammatory Breast Caner

  6. This is Paget’s disease of the breast or nipple if you like .Many theories but its thought to be due to migration of cancer cells from the underlying ducts onto the skin.The cells themselves being confined in the duct without invasion hence DCIS.Its easy to confuse with eczema but the clue is that the areolar is more affected in Pagets disease than the areolar ..This is the exact opposite in eczema …
    Whenever you are suspecting cancer its always good to do cytology and thus a biopsy is a logical thing to do..Also we know that about 50 % of woman with pages disease of the nipple /breast have an underlying mass..Therefore palpate for it or look for it with some imaging and in this 57 definitely mammography …It commonly affects one breast but of all the options provided in this vignette , B is the closest to this description ..

  7. I think Mr. Tee’s explanation is the best. Thanks.

  8. Without biopsy is hard to say … at first look appears as inflammatory BC .. what is common remains common ..

  9. First of all B
    Then E

  10. to rule out option was to get a biopsy of the lesuon.since that option is missing so
    i will go for an MRI of left breast.

  11. B

  12. B right ans

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