Letters to the Editor

represent a potentially malignant lesion which should warrant an immediate biopsy. It is frequently necessary to perform repeated examination before the diagnosis is made. In our patient, the palatal ulcer was first treated for suspected allergy and then as a wound after tooth extraction before he was referred to a specialized unit and biopsy was performed. In our case, CD56 was negative, but perforin and granzyme B were positive thus leading to the diagnosis. Current data suggest that many B‑cell and some T‑cell malignancies are associated with the presence of EBV in the tissue but this was not detected in our patient. According to a recent study, positron emission tomography/ computerized tomography (PET/CT) is the preferred technique for imaging this type of lymphoma as it has significantly better sensitivity than conventional CT (97.7% vs. 80.7%, P < 0.001) and the findings can also affect the treatment plan and radiotherapy planning in more than 40% of patients.[4] Treatment consists of conventional CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) or similar regimens followed by radiation therapy. Newer approaches may include asparaginase, gemcitabine or autologous stem cell transplantation.[5] The prognosis of this lymphoma remains poor. The 5‑year disease free survival of nasal lymphoma is about 25% and the 2‑year disease free survival in patients with extranasal lymphoma is about 10%.

Vladimíra Radochová, Jakub Radocha1, Markéta Nová2, David Belada1, Radovan Slezák Department of Dentistry, 14th Department of Medicine‑Hematology and 2Fingerland Department of Pathology, Faculty of Medicine, University Hospital in Hradec Králové, Charles University in Prague, Czech Republic Address for correspondence: Dr. Vladimíra Radochová, Sokolská 581, 50005 Hradec Králové, Czech Republic. E‑mail: [email protected]

REFERENCES 1. Al‑Hakeem DA, Fedele S, Carlos R, Porter S. Extranodal NK/ T‑cell lymphoma, nasal type. Oral Oncol 2007;43:4‑14. 2. Morovic A, Aurer I, Dotlic S, Weisenburger DD, Nola M. NK cell lymphoma, nasal type, with massive lung involvement: A case report. J Hematop 2010;3:19‑22. 3. Laohaburanakit P, Hardin KA. NK/T cell lymphoma of the lung: A case report and review of literature. Thora×2006;61:267‑70. 4. Moon SH, Cho SK, Kim WS, Kim SJ, Chan Ahn Y, Choe YS, et al. The role of 18F‑FDG PET/CT for initial staging of nasal type natural killer/T‑cell lymphoma: A comparison with conventional staging methods. J Nucl Med 2013;54:1039‑44. 5. Yamaguchi M, Kwong YL, Kim WS, Maeda Y, Hashimoto C, Suh C, et al. Phase II study of SMILE chemotherapy for newly diagnosed stage IV, relapsed, or refractory extranodal natural killer (NK)/T‑cell lymphoma, nasal type: The NK‑Cell Tumor Study Group study. J Clin Oncol 2011;29:4410‑6. 566

Access this article online Quick Response Code:

Website: www.ijdvl.com DOI: 10.4103/0378-6323.144213 PMID: *****

Malignant melanoma with metastasis to the male breast Sir, Although primary breast cancer is the most common malignancy in women worldwide, metastasis to the breast from other sites is rare, accounting for 0.5‑2% of all breast malignancies.[1] The source of metastasis is mainly contralateral breast cancer and extramammary tumors, including lymphoma, lung cancer, and malignant melanoma.[2] Approximately 20% of malignant melanomas result in metastasis, with the most common metastatic sites being the liver, lung, and brain.[3] Breast metastasis from malignant melanoma is uncommon and most case reports involve female patients. We report a case of metastatic malignant melanoma in the breast of a male patient. A 62‑year‑old man was referred to the breast clinic from the dermatology department with a recently detected palpable left breast mass and soreness. He had a history of a posterior auricular cutaneous malignant melanoma that was excised 8 years previously. On physical examination, a 4 × 2 cm firm mass was palpable in the upper outer quadrant of the left breast. The overlying skin showed thickening without pigmentation [Figure 1a]. Mammography showed bilateral nodular gynecomastia and a well‑defined lobulated hyperdense mass in the upper outer quadrant of the left breast [Figure 1b]. Ultrasonography revealed a 4.5 × 2.5 × 1.1 cm lobulated, complex echoic mass with a thick echogenic halo in the surrounding parenchyma [Figure 1c]. Fine‑needle aspiration cytology showed a few atypical cells in a necrotic background. Considering the history of malignant melanoma, immunohistochemical staining was performed for markers such as HMB‑45, Melan‑A, and S‑100, which were focally positive. Surgical excision was planned because the results were highly suspicious for, although not diagnostic of, metastatic melanoma. There was no evidence

Indian Journal of Dermatology, Venereology, and Leprology | November-December 2014 | Vol 80 | Issue 6

Letters to the Editor

a

b

c

a

b

c

d

Figure 1: (a) Approximately 4 x 2 cm firm mass at the left upper outer breast with no apparent skin pigmentation. (b) Bilateral gynecomastia and well-defined, lobulated hyperdense mass on mammography. (c) Approximately 4.5 x 2.5 x 1.1 cm oval, complex echoic mass with thick echogenic halo in the surrounding parenchyma on breast ultrasonography

of any other metastatic lesion on abdomen‑pelvic, and chest computed tomography and a whole body positron emission tomography. Partial mastectomy and sentinel lymph node biopsy using indigo carmine were performed. A dye‑tinged single lymph node was dissected and submitted for frozen section analysis and was subsequently deemed to be free of tumor. The haematoxylin and eosin (H and E) staining of the excised tissue showed pleomorphic tumor cells with abundant cytoplasm, large vesicular nuclei, prominent nucleoli and frequent mitoses [Figure 2a]. The immuno‑histochemical staining results for S‑100, HMB‑45, and Melan A were positive, confirming the diagnosis of metastatic melanoma [Figures 2b‑d]. Breast metastases from extramammary malignancies are uncommon, and when they do arise, the main primary lesions are lymphoma, lung cancer, and malignant melanoma. Most such cases are reported in females; reports in males are very rare. The role of estrogen in the development and progression of melanoma is still controversial, but epidemiologic evidence is accumulating.[2,3,5] There is no identified predisposing factor for metastasis to the breast from extra‑mammary tumors.[1] However, in the case of men with a history of prostatic cancer, estrogen therapy could be a predisposing factor.[4] Most earlier reports of melanoma metastatic to the breast were in premenopausal women with an average age at metastasis of 38‑40 years. Metastatic melanoma to the breast frequently occurs in the upper outer quadrant of the breast as a single lesion.[3,4] This may be explained, in part, by the good vascularity and abundant glandular tissue of younger patients, particularly in the upper outer area of the breast. The rarity of metastatic melanoma to the breast in men might be a result of the comparatively scant glandular tissue in the male breast. In young patients, the tumor may be difficult to differentiate from fibroadenoma on mammography and ultrasonography as it is seen as a

Figure 2: (a) Pleomorphic tumor cells with abundant cytoplasm, large vesicular nuclei, prominent nucleoli and frequent mitosis. H and E (×400), (b) Strongly positive immunohistochemical staining of neoplastic cells with S-100 (×100), (c) Strongly positive immunohistochemical staining of neoplastic cells with HMB-45 (×100), (d) Strongly positive immunohistochemical staining of neoplastic cells with Melan-A (×100)

well‑marginated, round mass. Fine‑needle aspiration cytology or core biopsy should be performed to confirm the diagnosis but a pathological diagnosis can also be difficult because of histological variability. A definitive diagnosis is possible by immunohistochemical staining for melanocytic markers. S‑100 is the most sensitive diagnostic marker for melanoma, and immunohistochemical staining should be performed for this marker along with one or more other markers such as Melan‑A, tyrosinase, or HMB‑45. The standard treatment for metastatic malignant melanoma to the breast is wide local excision with clear resection margins. A sentinel lymph node biopsy of the axilla may be considered but has no proven therapeutic value and a minor risk of morbidity. After local excision, systemic chemotherapy should be administered as an adjuvant treatment. Breast metastasis from malignant melanoma does not usually occur as an isolated lesion and presents in conjunction with disseminated disease, including metastases to the lung, liver, or brain.[5] In our case, we could not find any other metastasis at the time of diagnosis. Prognosis of breast metastasis from malignant melanoma has been reported as being poor.[1] In conclusion, metastatic melanoma to the breast is rare, especially in men. For accurate diagnosis and treatment, clinical suspicion is essential. When a breast lump is detected in a patient with previously diagnosed malignant melanoma, metastatic melanoma must be included in the differential diagnosis.

Indian Journal of Dermatology, Venereology, and Leprology | November-December 2014 | Vol 80 | Issue 6

567

Letters to the Editor

Bong‑Su Kang, Seung‑Ki Kim Department of Surgery, CHA Bundang Medical Center, CHA University, 59 Yatap-ro Bundang-gu Seongnam-si Gyeonggi-do, Korea Address for correspondence: Dr. Seung-Ki Kim, Department of Surgery, CHA Bundang Medical Center,CHA University, 59 Yatap-ro Bundang-gu Seongnam-si Gyeonggi-do, Korea. E-mail: [email protected]

REFERENCES 1. Loffeld A, Marsden JR. Management of melanoma metastasis to the breast: Case series and review of the literature. Br J Dermatol 2005;152:1206‑10. 2. Satoru T, Nayuko S, Hiroya F, Yuko T, Lpsei K, Mitsuhiko I, et al. A case of solitary breast metastasis from malignant melanoma of the nasal cavity. Oncol Lett 2012;4:889‑92. 3. James M. Bilateral breast masses as initial presentation of widely metastatic melanoma. J Surg Oncol 1999;72:175‑7. 4. Toombs B, Kalisher L. Metastatic disease to the breast: Clinical, pathologic, and radiologic features. Am J Roentgenol 1977;129:673‑6. 5. Larisa R, Wiliam AR, Karl L, Rene G. Metastatic melanoma in the breast: A report of 27 cases. J Surg Oncol 2006;94:101‑4. Access this article online Quick Response Code:

Website: www.ijdvl.com DOI: 10.4103/0378-6323.144214 PMID: *****

Hidradenocarcinoma of the chest Sir, Sweat gland tumors, especially those of a malignant nature remain an elusive area of knowledge for dermatologists, oncologists and pathologists. Due to the paucity of published literature, there is not only a lack of consensus over histopathological classification but also on their optimal management. We report a middle‑aged patient with clear cell hidradenocarcinoma who was successfully treated with wide local excision and sentinel lymph node dissection. A 49‑year‑old male reported a 13‑month history of an asymptomatic, ulcerated, pink exophytic nodule measuring 3 cm in diameter and located on the right parasternal area [Figure 1]. His past medical history was non‑contributory though he stated that a similar 568

lesion was present 8 months ago which was excised at another center and whose histology results he was not aware of. He described a rapid relapse and growth of the lesion soon after this procedure. Surgical excision with 2 cm margins revealed a poorly circumscribed ulcerated tumor in continuity with the epidermis [Figure 2], with large cords and confluent areas of basaloid cells, occupying the entire dermis and part of the hypodermis [Figure 3]. Several areas of necrosis and mitoses were observed within the tumor limits. Cells were AE1/AE3 positive; epithelial membrane antigen (EMA) and carcinoembryonic antigen (CEA) negative. Sentinel lymph node biopsy was negative. Thoraco‑abdomino‑pelvic computed tomography did not show any pathological findings. In view of the lack of local or distant metastasis, local widening of the tumor bed was performed such that no residual tumor was detected. The patient remains disease free for the past 24 months. Clear cell hidradenocarcinoma is one of the most common forms of the rare eccrine sweat gland carcinomas. It arises from the eccrine apparatus and is known for aggressive behavior with high rates of local recurrences and metastases. Clinically, it appears most commonly on the face, hands, or feet, starting as an asymptomatic solitary skin lesion with a pink, blue, or purple surface, which may ulcerate. It usually expands slowly, but sudden spontaneous spurts of growth may occur.[1] Lack of any characteristic clinical findings usually leads to a delay in the diagnosis by which time the loco‑regional spread to lymph nodes or visceral metastasis to bone and lungs may have already occurred, making the course and prognosis of clear cell hidradenocarcinoma different from the commoner skin tumors. Only the “accelerated” growth mentioned by the patient raised our suspicion in this case, as the location was also not typical. On histology, sheets of pale, glycogen‑rich cells form the tumor. Rudimentary lumina formation within cells seen as intracellular vacuoles are an important feature, as is the cyto‑architectural atypia. The number of mitoses and degree of atypia varies and some tumors may have a deceptively innocent appearance.[2] Usually, tumors express CK5, CK7, and AE1/AE3 antigens. CEA and EMA expression is variable.[3] The treatment needs to be individualized and decisions are taken on a case‑to‑case basis relying on the experience of the attending physician. Surgical technique and adjuvant radiotherapy or chemotherapy

Indian Journal of Dermatology, Venereology, and Leprology | November-December 2014 | Vol 80 | Issue 6

Copyright of Indian Journal of Dermatology, Venereology & Leprology is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.

Malignant melanoma with metastasis to the male breast.

Malignant melanoma with metastasis to the male breast. - PDF Download Free
936KB Sizes 0 Downloads 5 Views

Recommend Documents


Isolated malignant melanoma metastasis to the pancreas.
Malignant melanomas rarely develop isolated pancreatic metastases. We describe a unique patient who is still alive 22 years following an isolated pancreatic melanoma metastasis, and we review the sparse literature in the field.

Primary oral malignant melanoma metastasis to the brain and breast: A case report and literature review.
Primary oral malignant melanoma is a rare tumor, which is estimated to comprise 0.2-8.0% of all melanoma cases. This type of cancer is fairly uncommon, its prognosis is dismal, and it frequently exhibits a biologically aggressive behavior. The common

Malignant Peripheral Nerve Sheath Tumour of the Male Breast with Nodal Metastasis.
Malignant peripheral nerve sheath tumour (MPNST) is a rare soft tissue sarcoma with high rate of local recurrences and metastases. Common sites include deeper soft tissues, usually in the proximity of a nerve trunk. MPNST of breast is a rare occurren

Metastatic breast disease from cutaneous malignant melanoma.
Malignant melanoma is one of the most rapidly increasing cancer in the world. Breast metastases from melanoma are uncommon but could reflect a widespread disease.

Single sternal metastasis due to malignant melanoma with unexpected long-term survival: a case report.
Metastases from melanoma have a very poor prognosis for the patient. Single metastatic lesions in the sternum due to melanoma are extremely rare. A rare case of a presternal mass in a 56-year-old patient who had undergone excision for malignant melan

Breast cancer or metastasis? An unusual case of metastatic malignant pleural mesothelioma to the breast.
Metastases to the breast from extramammary malignancies are very rare, and ruling out the diagnosis of primary breast tumor is important in order to decide on clinical management and predict prognosis.