Download Volume 15 Number 7 July 2009 A remarkable case of cutaneous

Volume 15 Number 7
July 2009
DOJ
Contents
A remarkable case of cutaneous metastatic breast
carcinoma
Felicidade Santiago MD1, Sofia Saleiro MD2, Maria Manuel
Brites MD1, Cristina Frutuoso MD2, Américo Figueiredo MD
PhD1
Dermatology Online Journal 15 (7): 10
1. Dermatology Department, Coimbra University Hospital, Coimbra, Portugal.
[email protected]
2. Gynaecology Department, Coimbra University Hospital, Coimbra, Portugal
Abstract
We describe a 50-year-old woman with a 5-month history of
multiple asymptomatic papulonodular lesions on the left chest area.
Biopsy was consistent with cutaneous metastases from a ductal
breast carcinoma. No distant metastatic lesions were detected. The
patient was referred to the Gynecologic Oncology Department.
Treatment included chemotherapy, radiotherapy and surgery. At
present the patient is well with no signs of recurrence. This case
reports a clinically remarkable cutaneous metastatic breast
carcinoma.
Introduction
Cutaneous metastases (CM) occur in 0.7 percent to 9 percent
of all patients with visceral malignancies and are considered a rare
and late event in the progression of metastatic disease [1, 2].
Rarely, CM may be the first evidence of an internal malignancy
[3]. Excluding melanoma, in women, the most common tumor that
metastasizes to the skin is breast carcinoma. In a recent study, that
included 12146 patients with internal malignancies, the rate of CM
associated with breast carcinoma was 2.42 percent [4].
Case report
A 50-year-old woman presented with a 5-month history of
multiple cutaneous lesions on the left breast. Physical examination
revealed papulonodular lesions which were erythematous,
exophytic, and firm, ranging from 0.3 mm to 40 mm. They were
asymptomatic (Figs. 1 & 2). Otherwise the physical examination
was unremarkable, namely no adenopathies were palpable in the
axillary region.
Biopsy of the involved skin was consistent with cutaneous
metastases from a ductal breast carcinoma (Fig. 3).
Immunostaining was positive for CK7, CAM5.2, and estrogens; it
was negative for progesterone and Cerb-B2. The CA 15.3 level was
elevated (35 for a range of 3.5 to 27 U/ml).
Mammogram detected a mammary asymmetry due to loss of
left breast volume. This breast had an increased density related to
edema. The mammogram also showed a distortion image with a
central dense core and multiple microcalcifications in the upper
external quadrant (Fig. 4) and ultrasound of this site revealed a 10
mm hypoechogenic solid nodule, suggestive of malignancy. Skin
thickening and multiple well-defined cutaneous dense nodules
were also observed.
Figure 1
Figure 2
Figures 1 and 2. Multiple papulonodular lesions limited to the left breast
Figure 3
Figure 4
Figures 3. In the dermis tumor cells arranged in a gland-like pattern
(H&E, x160)
Figure 4. A distortion image with a dense central core with multiple
microcalcifications is showed in the upper external quadrant of the left
breast.
The patient was submitted to extensive imagiological
investigation which was negative for metastatic disease and then
referred to the Gynecologic Oncology Department. She was
initially treated with systemic chemotherapy (four cycles of
docetaxel plus four cycles of docetaxel and epirrubicine) with
incomplete response and then preoperative radiotherapy. She
underwent a modified radical mastectomy and mammary
reconstruction with a myocutaneous flap. Pathologic examination
revealed a residual invasive ductal carcinoma localized mainly at
the upper external quadrant in an area of 6 cm of extension, with a
massive and multifocal dissemination to the dermis. The tumor
necrosis was 50 percent to 75 percent, and no axillary lymph node
metastases were detected. The patient was sequentially treated with
systemic adjuvant chemotherapy (eight cycles of vinorelbine and
gemcitabine). At present, 24 months after presentation and 17
months after surgery, the patient has no signs of recurrence and is
under anastrozole treatment only.
Discussion
The authors emphasize some particularities observed in this
case report.
Firstly, the clinical appearance of the CM in our patient was
remarkable. Breast carcinoma metastases may have variable
clinical manifestations. The inflammatory metastatic carcinoma is
characterized by an erythematous and tender patch or plaque with
an active border resembling an erysipela (but without the general
toxic symptoms). It usually affects the breast and nearby skin. "En
cuirasse" metastatic carcinoma is characterized by a diffuse
morphea-like induration of the skin. Telangiectatic metastatic
carcinoma is characterized by violaceous papulovesicles similar to
lymphangioma circumscriptum. The nodular metastatic carcinoma
usually appears as firm papulonodules or nodules, firm, pink to
reddish, multiple but occasionally solitary, that rarely ulcerates.
This was the clinical appearance observed in our patient. Alopecia
neoplastica may appear as painless, nonpruritic, well-demarcated
plaques of alopecia closely resembling alopecia areata [3, 5, 6].
In a review of 164 patients [5] the most frequent manifestation
were papules and/or nodules in 80 percent, followed by
telangiectatic carcinoma in 11.2 percent, erysipeloid carcinoma in 3
percent, "en cuirasse" carcinoma in 3 percent, alopecia neoplastica
in 2 percent and a zosteriform pattern in 0.8 percent.
The localization of metastatic skin disease does not occur in a
completely random fashion, denoting a predilection for certain
regions [3, 6]. Breast and lung cancers frequently metastasize to the
chest wall, whereas cancers of the bowel, ovary, and bladder most
often metastasize to the abdomen [3]. In the study of Mordenti et
al. [5] the commonest sites involved in breast CM were the sites of
previous mastectomy and the anterior part of the chest in over 75
percent of the patients. Additional common areas were head, neck
and extremities. Less common sites of CM reported in the literature
were a reddish nodule on the tip of the nose described as "clown
nose" [7] and eyelids (carcinomatosis blepharitis) [8].
Secondly, the present case highlights the rare event of CM as
the presenting manifestation of internal malignancy. Brownstein et
al. [9] reported that lung, kidney and ovary cancers are the most
common type of cancers with skin involvement as the presenting
sign. They indicated that 3 percent of cases of carcinoma of breast
presented with CM. Lookingbill et al. [6] reported that 6.3 percent
of patients with breast cancer had skin involvement at time of
diagnosis, but only 3.5 percent had this as the presenting sign.
Also in other study with 1287 patients [10], CM preceded the
diagnosis of breast cancer in only one case and was diagnosed
simultaneously with it in another.
Finally, the good evolution of the disease observed 24 months
after the initial diagnosis of breast carcinoma contrasts with the
remarkable initial clinical appearance. Cutaneous metastases from
breast carcinoma are usually associated with advanced stages of the
disease and, therefore, in most cases, are a sign of poor prognosis.
Death usually occurs within a few months (6.5 months), although
few patients have survived for several years [11].
To conclude, every practitioner should be highly suspicious of
CM upon the discovery of acute-onset, firm, painless
papulonodules, especially when they develop on the chest. Early
detection of CM provides a window of opportunity for a timely
diagnosis and treatment of the primary tumor.
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