JEADV

LETTER TO THE EDITOR

Pigmented skin metastasis of breast cancer showing dermoscopic features of malignant melanoma Editor Breast cancer is the most prevalent cancer among women around the world.1 Skin metastases of breast carcinoma is relatively common, and they are usually found on the chest and the abdomen wall close to the mastectomy scar. These skin metastatic lesions are usually present as reddish papules and indurative erythema. Herein, we report a case of pigmented skin metastasis of breast cancer clinically mimicking malignant melanoma, with an emphasis on the dermoscopic features. A 70-year-old woman was referred to our hospital complaining of a pigmented lesion that had been present for about 18 months on the surface of her left chest wall, close to her mastectomy scar. Seven years ago, she was diagnosed with infiltrating ductal carcinoma of the left breast, for which she underwent mastectomy and left axillary node dissection followed with adjuvant hormone and chemotherapy. She had three local recurrences, and she underwent surgical excision on each occasion. After the surgery for the third time, she had post-operative radiation therapy (45 Gy).

(a)

Figure 1 (a) Clinical presentation; a black macule 12 mm in diameter on the left chest. (b) Dermoscopic examination of the macule reveals irregular diffuse pigmentation and multiple brown dots and globules with a whitish veil, and that of the marginal region reveals a typical regular pigment network. (c) Clusters of atypical cells are arranged in cords and nests, mainly in the upper dermis. In addition, large cells without nuclear atypia but containing melanin granules in the cytoplasm are abundantly scattered. (Hematoxylin and eosin; original magnification 9 100).

JEADV 2014

Physical examination revealed a blackish, irregularly bordered, asymmetrical macule of approximately 12 mm in diameter on her left chest (arrowhead) (Fig. 1a). Dermoscopic examination that was done under non-polarized light source with a gel interface and direct contact (Derma9500; Derma medical Inc, Tokyo, Japan) revealed irregular diffuse pigmentation and multiple brown dots and globules with a whitish veil, the so-called ‘multi-component pattern’ that is often seen in malignant melanoma (Fig. 1b). Dermoscopic examination of the marginal region revealed a typical regular pigment network. Surgical treatment was carried out, and the whole tumour was submitted for histopathological study. Histopathological of the central portion (arrowhead) showed clusters of atypical cells arranged in cords and nests, mainly in the upper dermis. In addition, large cells without nuclear atypia but containing melanin granules in their cytoplasm were scattered in the dermis (Fig. 1c). Pathological findings of the marginal region showed only basal melanosis. We were not able to detect any epidermotropism of tumour cells, nor evident increase in number of melanocytes at the epidermis; however, we could observe liquefaction degeneration at the basement membrane (Fig. 2a). Immunohistochemical study showed the atypical cells in the dermis to stain positive for ER (Fig. 2b) and PgR (Fig. 2c), but negative for melan-A and S-100. The large

(b)

(c)

© 2014 European Academy of Dermatology and Venereology

Letter to the Editor

2

(a)

(c)

(b)

(d)

cells, which contained melanin granules, stained positive only for CD68 (Fig. 2d). On the basis of the histological and immunohistochemical findings, we concluded that the atypical cells were metastatic breast cancer cells and that the large cells without nuclear atypia were melanophages as a result of pigmentary incontinence. We made the final diagnosis of skin metastasis of breast cancer. It has been known that a large number of breast cancer cases develop into skin metastasis.1 Some metastatic cases have pigmentation as a clinical feature. A search of the literature found only eight cases of skin metastasis of breast cancer ‘mimicking malignant melanoma;2–10 however, the mechanism of melanin deposition has not been clarified. Eight of these nine cases (including our case as the 9th) did not undergo radiation therapy as adjuvant therapy. In only our case, the patient had undergone radiation therapy. However, given that only one of nine similarly pigmented cases underwent radiation, we think that inflammation from radiation dermatitis does not contribute to the pigmentation. We speculate that an unknown cytokine pathway activated by metastatic tumour cells leads to the upregulation of melanin production and deposition. In our case, we found that dermoscopic examination did not diagnostically discriminate malignant melanoma from pigmented metastatic breast cancer. In conclusion, dermoscopy is ineffective in distinguishing pigmented metastatic breast cancer from malignant melanoma in our case. When we deal with pigmented lesions in patients with a history of breast cancer, we should perform a skin biopsy with immunostaining.

JEADV 2014

Figure 2 (a) We were not able to detect any epidermotropism of tumour cells, nor evident increase in number of melanocytes at the epidermis; however, we observed liquefaction degeneration at the basement membrane. (Hematoxylin and eosin; original magnification 9 200). Immunohistochemical findings; the atypical cells tested strongly positive for ER (b) and PgR (c) (original magnification 9 400). (d) Large cells with melanin granules within their cytoplasm tested positive for CD68 (original magnification 9 400).

S. Kitamura, H. Hata,* E. Homma, S. Aoyagi, H. Shimizu Department of Dermatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan *Correspondence: H. Hata. E-mail: [email protected]

References 1 Redig AJ, McAllister SS. Breast cancer as a systemic disease: a view of metastasis. J Intern Med 2013; 274: 113–126. 2 Azzopardi JG, Eusebi V. Melanocyte colonization and pigmentation of breast carcinoma. Histopathology 1977; 1: 21–30. 3 Garcıa-F-Villalta MJ, Adrados M, Dauden E et al. Pigmented metastasis of breast carcinoma mimicking malignant melanoma. J Eur Acad Dermatol Venereol 2004; 18: 223–224. 4 Micallef RA, Boffa MJ, DeGaetano J et al. Melanoma-like pigmented cutaneous metastases from breast carcinoma. Clin Exp Dermatol 2004; 29: 144–146. 5 Martı N, Molina I, Monteagudo C et al. Cutaneous metastasis of breast carcinoma mimicking malignant melanoma in scalp. Dermatol Online J 2008; 14: 12. 6 Min Wu I, Chiu HS, Lian HC. Cutaneous metastatic breast carcinoma mimicking malignant melanoma. Dermatol Sinica 2001; 19: 217–220. 7 Chisti MA, Alfadley AA, Banka N et al. Cutaneous metastasis from breast carcinoma: a brief report of a rare variant and proposed morphological classification. Gulf J Oncolog 2013; 1: 90–94. 8 Mele M, Laurberg T, Engberg Damsgaard T et al. Melanocyte colonization and pigmentation of breast carcinoma: pathological and clinical aspects. Case Rep Pathol 2012; 2012: Article ID: 427628. 9 Hamada M, Toyoshima S, Duan H et al. Pigmented cutaneous metastasis of mucinous carcinoma of the breast to the scalp mimicking malignant melanoma. Eur J Dermatol 2006; 16: 592–593. 10 Poiares-Baptista A, De Vasconcelos AA. Cutaneous pigmented metastasis from breast carcinoma simulating malignant melanoma. Int J Dermatol 1988; 27: 124–125. DOI: 10.1111/jdv.12459

© 2014 European Academy of Dermatology and Venereology

Pigmented skin metastasis of breast cancer showing dermoscopic features of malignant melanoma.

Pigmented skin metastasis of breast cancer showing dermoscopic features of malignant melanoma. - PDF Download Free
267KB Sizes 0 Downloads 3 Views