A remarkable case of cutaneous metastatic breast carcinoma
Published Web Locationhttps://doi.org/10.5070/D35863c2vq
A remarkable case of cutaneous metastatic breast carcinoma1. Dermatology Department, Coimbra University Hospital, Coimbra, Portugal. email@example.com
Felicidade Santiago MD1, Sofia Saleiro MD2, Maria Manuel Brites MD1, Cristina Frutuoso MD2, Américo Figueiredo MD PhD1
Dermatology Online Journal 15 (7): 10
2. Gynaecology Department, Coimbra University Hospital, Coimbra, Portugal
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.
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 . 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 .
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.
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  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 . In the study of Mordenti et al.  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"  and eyelids (carcinomatosis blepharitis) .
Secondly, the present case highlights the rare event of CM as the presenting manifestation of internal malignancy. Brownstein et al.  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.  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 , 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 .
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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