1909: Archibald Leitch describes the cause of “peau d’orange.”

Note: peau d’orange translation: skin of an orange; meaning “having the appearance of an orange’s skin;” likely clinical meaning: dimpled, pitted, not smooth.

Regarding breast cancer in general, Leitch wrote :

I do not know any criteria that will enable the pathologist to predict a slow or a rapid course in the disease. Starting from the atrophic scirrhus carcinoma lasting for years…we have all sorts of gradations to those tumours of such rapid growth and dissemination that they merit the term “acute cancers.” These last, fulminating in their progress, may produce a fatal issue within a few weeks of their commencement.

It is always of importance to recognise any cancer promptly…but in these cases of acute mammary carcinoma prompt recognition and immediate and extensive operation are absolutely essential if any hopes of its cure are to be entertained. Most of the current surgical text-books fail to make any reference to this particular class of cancers though they are a fairly well-defined class. That may be on account of the rarity of the condition. During five years’ clinical and laboratory investigation of cancer in London, in which time I must have examined some hundreds of cancers and other affections of the breast, I encountered the condition on two occasions only, and in both cases the disease was considered to be of an inflammatory nature by the surgeons who operated on them. Speedy recrudescence and dissemination showed the true nature of the disease….

Clinical characters. Acute carcinoma presents itself as a diffuse swelling of the breast in which the normal shape of the organ is retained….There is no flattening to be observed, no puckering even on digital movement, no asymmetrical bulging, no appearance as if of a healed scar. The nipple may not be appreciably indrawn nor give any sero-sanguineous discharge. There may or may not be a slight blush on the skin, especially in the lower part of the breast, but at any rate there is neither heightened temperature nor tenderness. Palpation of the breast shows that the swelling is diffuse and that there is no localised hardness, perhaps no hardness at all. The disease may exist during pregnancy or lactation, and in these cases is liable to escape detection, or it may be found at any age, though generally it occurs in women who have not reached the period at which the occurrence of cancer is most common. Thus it follows the broad law, to which there are exceptions, that the younger the age of the patient the more rapid the growth. There are two points in the diagnosis of the condition that are of great value — the diffuse swelling like a hypertrophy and the occurrence of peau d’orange….The name peau d’orange is descriptive enough to one who has seen it….In acute carcinoma, on the other hand, the skin has minute pits very regularly about a quarter of an inch apart, giving the appearance as if the skin had been dabbed with a blunt pin….

Appearance of the skin. When the skin is cut through it appears to be enormously thickened from the normal 0.5-1 millimetre over the breast to 8 millimetres or more….But the microscope shows that the epithelium itself is thinner than usual. The normal papillae are to a great extent obliterated or are only irregularly maintained….Where they are absent the change seems to be associated with the presence of collections of lymphocytes and some plasma cells directly under the epithelium….

The whole apparent thickening of the skin is due to the condition of the corium….The lymph channels are especially marked. Towards the deeper parts of the corium it would seem as if practically every lymphatic channel were filled with cancer cells; some are filled right up to their origin immediately under the epithelium, others as they approach the surface are seen to be empty and often dilated. Perilymphatic collections of lymphcytes, with a few plasma cells amongst them, are marked features, and these perilymphatic infiltrations seem to follow a definite plan.

The depressions of the surface that give the appearance of orange skin are the exaggerated pits of the hair follicles. The erector pilae has its fibres separated like the rest of the corium. To sum up, the thickening of the skin is due to changes in the corium. These changes are the results of lymphatic permeation and consequent lymph stasis. The corium is expanded and the overlying epithelium is raised above its normal level by the pressure except at those places where it is bound down by the insertion of a hair follicle deep in the corium, where it is moored, as it were…[I]t seems reasonable to argue that where we get the condition it must be due to lymph stasis cause by blockage of the lymphatics. There is no disease of the breast at all likely to produce this appearance other than cancer. Thus even in the absence of other signs a diagnosis of acute mammary cancer from this alone would be practically certain.

1924: Burton J. Lee and Norman E. Tannenbaum introduced the term “inflammatory breast cancer (IBC)” and considered it a distinct entity.

Inflammatory carcinoma of the female breast presents such unusual clinical manifestations that they are often misinterpreted by the physician who is first consulted. The object of this paper is to give a clear description of “inflammatory carcinoma of the breast,” in order that this unusual phase of carcinoma of the mammary gland may be better recognized by physicians generally and by surgeons and radiologists particularly.

Several times we have presented cases of inflammatory carcinoma before surgical societies, but apparently have failed to convince our audiences that these inflammatory symptoms were truly cancerous in nature.

Prior to this paper in 1924, the authors wrote:

Examples of this unusual type of mammary cancer have been described by numerous observers, but with variations in terminology suggesting the uncertainty which exists concerning the true nature of this process….All observers have focused their attention upon the pathology of the breast tumor itself, but have failed to recognize the significance of the erysipelatous involvement of the skin.

A considerable number of the patients are young women, in our series, 10, or 35.79 per cent, being 39 years or under. The youngest patient was 24, the oldest 62, and the average for the entire group was 44.6 years.

Note: In 1929 (statistic for 1924 not available), the average life expectancy for women (all races) was 58.7 years (60.3 years for white, and 47.8 years for black); in 1997 the life expectancies were 79.4, 79.9, and 74.7 years, respectively.

In only 2 of the cases was there any definite history of trauma to the breast. Hence, the inflammatory phase cannot be interpreted as in any sense traumatic in origin.

Except in a few instances neither mastectomy nor biopsy has been done….[I]n the recurrent cases few pathological reports or slides have been furnished by the hospitals….The findings vary from comedocarcinoma, carcinoma simplex, mammary carcinoma invading dermallymphatics, and large alveolar carcinoma to scirrhous carcinoma.

The marked variation in the pathological findings raises the questions: Is one justified in including these inflammatory carcinomata in a single group? Is it not possible that some additional factor has been added to account for the inflammatory manifestations?

In a few cases, a study of the material obtained through areas of skin invasion shows dermal lymphatics everywhere invaded by carcinoma cells. This diffuse lymphatic metastasis is the most distinctive microscopic pathological feature of this phase of mammary carcinoma.

The authors’ conclusions, in 1924, are:

  • Inflammatory carcinoma appears to be a distinct clinical phase of carcinoma of the breast.
  • Generally, this type has been unrecognized, being frequently mistaken for other diseases of the breast.
  • The inflammatory appearances are characteristic.
  • This variety of mammary cancer shows no constant pathological type.
  • The most striking pathological change is a wide invasion of dermal lymphatics by carcinoma.
  • Bacteriological and biochemical studies have failed to explain the inflammatory manifestations.
  • The cases do badly if treated surgically.
  • At present radiation offers the only hope of palliation, diminishing the patient’s suffering, and giving a
  • definite prolongation of life.

Citations:
Lee, B. J., & Tannenbaum, N. E. (1924). Inflammatory carcinoma of the breast: a report of twenty-eight cases from the breast clinic of the Memorial Hospital. Surgery, Gynecology & Obstetrics, 39, 580-95.

Leitch, A. (1909). Peau d’ orange in acute mammary carcinoma. its causes and diagnostic value. Lancet, 174 (4490), 861-63.