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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 7  |  Issue : 2  |  Page : 95-97

Puzzling Papules on the neck: Cutaneous metastasis from the breast


1 Department of Dermatology, Venereology and Leprosy, Mahatma Gandhi Institute of Medical Sciences, Wardha, Maharashtra, India
2 Department of Pathology, Mahatma Gandhi Institute of Medical Sciences, Wardha, Maharashtra, India

Date of Submission21-Dec-2019
Date of Decision16-Feb-2020
Date of Acceptance17-Feb-2020
Date of Web Publication2-Jun-2020

Correspondence Address:
Dr. Sumit Kar
Department of Dermatology, Venereology and Leprosy, Mahatma Gandhi Institute of Medical Sciences, Sewagram, Wardha - 442 102, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JCRP.JCRP_4_20

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  Abstract 


Cutaneous metastasis from a primary internal malignancy is rare. Breast cancer is the most common primary internal malignancy presenting with cutaneous metastases, and it presents in various morphological and histological forms. Medical practitioners should be aware of the possibility of the unusual presentation of an internal malignancy mimicking a dermatological condition. Herein, we report a case of 50-year-old women with ductal carcinoma of the breast with a cutaneous manifestation of secondary metastatic deposits in the skin.

Keywords: Breast cancer, carcinoma erysipeloides, intraductal adenocarcinoma, metastasis, secondaries


How to cite this article:
Sawant A, Kar S, Patrick S, Gangane N. Puzzling Papules on the neck: Cutaneous metastasis from the breast. J Cancer Res Pract 2020;7:95-7

How to cite this URL:
Sawant A, Kar S, Patrick S, Gangane N. Puzzling Papules on the neck: Cutaneous metastasis from the breast. J Cancer Res Pract [serial online] 2020 [cited 2020 Jul 7];7:95-7. Available from: http://www.ejcrp.org/text.asp?2020/7/2/95/285680




  Introduction Top


Cutaneous metastasis is seen in only 0.7%–0.9% of cancer patients.[1] Skin tumors due to the cutaneous metastasis of solid tumors account for only 2% of these cases.[2] The pattern of cutaneous metastasis varies between men and women. In females, cutaneous metastasis is the most common from breast carcinoma, melanoma, and colorectal carcinoma.[3] While in males, melanoma, lung cancer, and colorectal cancer account for most cases of cutaneous metastasis in males.[3] Breast carcinoma cutaneous metastasis (BCCM) has a wide range of cutaneous clinical manifestations, of which multiple or solitary infiltrating papule and/or nodules are most common. In addition, there are also rare variants such as alopecia neoplastica, telangiectatic carcinoma, carcinoma erysipeloides, zosteriform pattern, chest armor pattern mimicking radiation dermatitis.[4] BCCM has been reported in 23.9% of cases of cutaneous metastasis, making it the most common metastasis in women seen by dermatologists globally.[5],[6]


  Case Report Top


We report the case of a 50-year-old woman who presented with a skin eruption of 10 cm × 5 cm on the right side of her chest and neck for 1 month [Figure 1]. The skin eruption was enlarging rapidly and becoming painful. A cutaneous examination showed closely spaced multiple skin-colored hard papules and nodules which were indurated and slightly painful. Her right breast was found to be erythematous and indurated. Cervical and bilateral axillary lymph nodes were enlarged and fixed to underlying structures. A skin biopsy from one of the lesions over her neck showed the presence of nests of malignant cells characterized by atypical pleomorphic cells [Figure 2]. Fine-needle aspiration cytology and a core needle biopsy from the right breast lump were performed which showed duct carcinoma cells arranged in nests [Figure 3]. She then underwent right modified mastectomy. A hematoxylin and eosin stained section showed the presence of tumor cells arranged in sheets and individual tumor cells showed round to oval nuclei, prominent nucleoli and high nucleocytoplasmic ratio [Figure 4]a and a diagnosis of infiltrating duct carcinoma - Grade 2 was made. Immunohistochemistry showed that the tumor was “triple negative” (ER, PR, and Her2/neu negative) [Figure 4]b, [Figure 4]c,[Figure 4]d. She was referred for surgical and radiotherapy treatment as further management, where she received neoadjuvant chemotherapy and right modified radical mastectomy.
Figure 1: Erythematous papules and plaques over the neck

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Figure 2: Biopsy from the lesion over the neck showing nests of malignant cells with pleomorphic atypical cells (H and E, ×40)

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Figure 3: Right breast lump biopsy, duct carcinoma cells (arrows) arranged in nests (H and E, ×40)

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Figure 4: (a) Section of infiltrating duct carcinoma (H and E, ×40) (b) Immunohistochemistry was negative for estrogen receptor. (c) Progesterone receptors. (d) Her 2/neu receptors (immunohistochemistry, ×100)

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  Discussion Top


Breast carcinoma constitutes is a more common cause of cutaneous metastasis in females than any visceral malignancy. BCCM has a broad range of clinical presentations varying from metastatic nodules to alopecia neoplastica, telangiectatic carcinoma, and carcinoma erysipeloides.[4] The most common site of metastasis is the chest, and other less common sites include the scalp, neck, upper extremities, and back.[7]

The tumor cells reach the skin through direct invasion and lymphatics, and less commonly through hematogenous routes. Secondary lesions usually occur close to the area of the primary tumor; however, few cases of cutaneous manifestations have been reported scattered all over the body.[8] Clinically, the skin metastasis can present in varying forms ranging from new skin nodules, which are the most common presentation to ulcers. Erythematous patches or plaques are other rarer presentations of skin metastasis. Clinically, skin metastasis may be confused with other dermatologic lesions such as erythema annulare, contact dermatitis, tinea infections, erysipelas, cellulitis, and cutaneous mucinosis.

The clinical diagnosis of cutaneous metastasis secondary to breast carcinoma is confirmed by histopathological examinations. Biopsy specimens show the invasion of the skin by malignant cells similar to that of the primary tumor. The prognosis of a patient with cutaneous metastasis depends primarily on the pathology and biological behavior of the primary neoplasm and its response to treatment. As a rule, cutaneous metastasis from breast cancer usually occurs in advanced stages and is poorly amenable to treatment. For patients with locally advanced breast cancer, the current treatment approaches emphasize the aggressive use of combined modalities of treatment, including neoadjuvant chemotherapy, mastectomy, and radiation therapy, with hormonal therapy for ER ER-positive tumors and trastuzumab for HER2-positive tumors. With multimodality treatment, relapse-free survival rates are higher as compared to patients receiving less aggressive treatment. Palliative treatment in the form of chemotherapy is advised to keep the skin lesions dry and clean. Other therapies may be helpful for skin involvement such as intralesional chemotherapy, carbon dioxide laser therapy, photodynamic therapy, pulsed dye laser, and cytokines.[8] New treatments include electrochemotherapy, which uses electrical impulses to enhance the effectiveness of cisplatin and bleomycin injected into the tumor. Simple excision of the skin lesions may enhance a patient's quality of life by removing disfigurement and discomfort, but it has little effect on the final outcome.


  Conclusion Top


BCCM is the most common metastasis in women. Multiple or solitary papules to nodules not responding to primary treatment can be due to cutaneous metastasis from the breast. Medical practitioners should be aware of the possibility of metastatic disease in breast cancer patients presenting with cutaneous lesions. This puzzle of a tumor with cutaneous metastasis and benign dermatological conditions can be solved easily with clinical awareness and histological confirmation.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Spencer PS, Helm TN. Skin metastases in cancer patients. Cutis 1987;39:119-21.  Back to cited text no. 1
    
2.
Cho J, Park Y, Lee JC, Jung WJ, Lee S. Case series of different onset of skin metastasis according to the breast cancer subtypes. Cancer Res Treat 2014;46:194-9.  Back to cited text no. 2
    
3.
Cidon EU. Cutaneous metastases in 42 patients with cancer. Indian J Dermatol Venereol Leprol 2010;76:409-12.  Back to cited text no. 3
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4.
De Giorgi V, Grazzini M, Alfaioli B, Savarese I, Corciova SA, Guerriero G, et al. Cutaneous manifestations of breast carcinoma. Dermatol Ther 2010;23:581-9.  Back to cited text no. 4
    
5.
Lookingbill DP, Spangler N, Helm KF. Cutaneous metastases in patients with metastatic carcinoma: A retrospective study of 4020 patients. J Am Acad Dermatol 1993;29:228-36.  Back to cited text no. 5
    
6.
Alcaraz I, Cerroni L, Rütten A, Kutzner H, Requena L. Cutaneous metastases from internal malignancies: A clinicopathologic and immunohistochemical review. Am J Dermatopathol 2012;34:347-93.  Back to cited text no. 6
    
7.
Hussein MR. Skin metastasis: A pathologist's perspective. J Cutan Pathol 2010;37:e1-20.  Back to cited text no. 7
    
8.
Daleep S, Akhil K, Kumar SM, Prakash S, Vanita K, Singh KH. Cutaneous metastasis involving face in breast cancer: A series of three patients. Clinical cancer Inv J 2014;6:545-7.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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