1909: Archibald Leitch describes the cause of “peau d’orange”
“Peau d’ orange in acute mammary carcinoma. Its causes and diagnostic value” Lancet 1909;1:861-3, Leitch A.
Note: peau d’orange translation: skin of an orange; meaning an orange skin; 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 patholgist to predict a slow or a rapid course in the disease. Starting from the atrophic scirrhus carcinoma lasting for years and regarded by some, to my mind erroneously, as a malignant tumour partially cured by a natural reparative process of fibrous, 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 and to operate promptly and as extensively as possible, no matter how small or how slow in growing it may be, 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. In Glasgow I have seen four cases and in Dundee one in the same number of years. Its rarity in hospital practice may not, however, be a correct indication of the frequency of its occurrence in general practice.
“Clinical characters. — Acute carcinoma presents itself as a diffuse swelling of the breast in which the normal shape of the organ is retained; in fact, in comparing the two breasts one would be inclined to say that from an artistic point of view the affected breast is the better modelled (sic). 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 (sic) 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 — and the conjunction of these two signs is pathognomonic. To the latter attention may be more fully directed. The name peau d’orange is descriptive enough to one who has seen it, but to those who have not noticed the condition it may not convey much impression, for orange skin is very variable and the irregular pitting and puckering of the latter might very well describe the fairly common appearance of the skin in cancer of the breast when it is affected by contraction of a growth underneath. 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. The term “pig skin” is also applied to it and is fairly descriptive; it resembles pig’s skin if the hairs were removed and the pits represented by the place of insertion of the hairs. But perhaps the best picture of the condition is obtained by examining the back of the arm, especially when warm, under a fairly strong lens.“
Leitch dismisses the “contraction of the fibrous tissue in the tumour acting through the suspensory ligaments of Astley Cooper” as the cause of peau d’orange, arguing that “the condition is found only in very rapidly growing, rapidly expanding tumours, in which the fibrous tissue is at a minimum.“
“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. It is dense and white and appears like ordinary squamous epithelium much thickened, and it retains this appearance in alcohol. 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. At some parts the papillary layers of elastic tissue are quite absent, at others they are dense, whilst intermediate conditions are found. 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 condition then resembles what has been described by Ribbert, Victor Bonney, and others as tissue prepared for cancerous invasion by the epithelium. It may, however, here be noted that the surface epithelium is not proliferating, almost certainly never would do so, and it is probable that the so-called “precancerous” conditions are brought about by the same mechanism.
“The whole apparent thickening of the skin is due to the condition of the corium. The connective tissue appears to be in a sodden condition, the fibrous strands are widely separated from each other, the arterioles are dilated, and their walls are thickened. 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. Taking into consideration the already known cause of the pitting in brawny arm and this same explanation advanced for the similar condition, peau d’orange, in the breast, it 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.“
Note: Aziz (2001) mistakenly attributed the following to Leitch when the citation should be to Lee and Tannenbaum (1924): “This disease has been known by different names over the years, including mastitis carcinomatosa, acute mammary carcinoma, acute brawny cancer, acute scirrhous carcinoma, lymphocytoma of the breast, acute encephaloid cancer, acute cancer of the breast, acute mammary carcinomatosis, and lactation cancer.“
