Is erythema present? Erythema is associated with infection and with inflammatory carcinoma of the breast. Figure 16-11 shows marked erythema of the breast secondary to inflammatory breast carcinoma. The scar above the areola is from a previous biopsy of a benign breast mass.
Is dimpling present? The examiner must inspect the breasts for the presence of retraction phenomena. Dimpling is a sign of retraction phenomena that are caused by an underlying neoplasm and its fibrotic response. Skin retraction is commonly associated with malignancy that causes an abnormal traction on Cooper's ligaments. The shortening of the larger mammary ducts by cancer produces flattening or inversion of the nipple. A change in the position of the nipple is important because many women have a congenitally inverted nipple on one or both sides. The dimpling of the breast in Figure 16-12 is associated with a bloody nipple discharge; both are secondary to carcinoma.
Is there a red, scaling, crusting plaque around one nipple, areola, or surrounding skin? Paget's disease of the breast is a surface manifestation invariably associated with an underlying invasive or intraductal carcinoma. The lesion appears eczematous, but unlike eczema, it is unilateral. The skin may also weep and be eroded. A much less common form is extramammary Paget's disease, which is seen around the anus or genitalia and is usually associated with malignant disease of the adnexa, bowel, or genitourinary tract. Figure 16-13 shows Paget's disease of the breast; an underlying ductal adenocarcinoma was present.
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