Peau D'orange

[Delacroix22]

Let's settle this once and for all

Is it

Lymphatic Obstruction

OR

Infiltration of the Suspensory Ligament

Moore's Clinical Anatomy:
"Interference with the lymphatic drainage by cancer may cause lymphedema, which in turn may result in deviation of the nipple and a thickened, leather like appearance of the skin. Prominent or "puffy" skin between dimpled pores gives it an orange-peel appearance (peau d'orange sign). Larger dimples (fingertip size or bigger) result from cancerous invasion of the glandular tissue and fibrosis, which causes shortening or places traction on the suspensory ligaments."

Pathoma:
"Advanced tumors may result in dimpling of the skin or retraction of the nipple."

First Aid:
"Peau d'orange; neoplastic cells block lymphatic drainage."

UWorld:
"Nipple inversion is observed when the tumor invades the central region of the breast, and skin retraction is identified when the cancer infiltrates the suspensory Cooper ligaments. Should the lymphatic drainage become impeded by the tumor, lymphadema and pitting and thickening of the skin - such that it adopts the appearance of an orange peel (peau d'orange) - may occur."

What irks me is that 3 answer choices in that question are "Suspensory ligament infiltration" and "Regional lymph note metastasis" and "Dermal lymphatic hyperplasia". While UWorld seems to drive home the concept it is a combination, with more significance given to the ligament infiltration - most other sources just mention lymphedema.

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[Enzymes]

First of all, all French names in medicine are awesome. Let us first acknowledge that.

Answer is always INVASION OF DERMAL LYMPHATICS. The Cooper ligament business had to do with general induration of the breast. The ligament is tugging on the breast, pulling it inward. Crazy, I know.

 

[thehundredthone]

Peau d'orange and dimpling are different things.

Involvement of dermal lymphatics causes blockage of lymph flow, causing lymphoedema of sorts. The breast tissue swells up (however marginally) uniformly, except for where the suspensory ligaments are attached. This is why you get peau d'orange, it's not really inward pulling at the attachment site, rather it is outward swelling of the surrounding area. Since it is generalised, it looks like an orange peel.

With direct suspensory ligament involvement, there is actual inward pulling of discrete attachment site(s) causing dimpling. Nipple retraction in case of malignancy works similarly.