Letters to the Editor
3 Storch CH, Hoeger PH. Propranolol for infantile haemangiomas: insights into the molecular mechanisms of action. Br J Dermatol 2010; 163: 269–274.
4 Chiu YE, Drolet BA, Blei F et al. Variable response to propranolol treatment of kaposiform hemangioendothelioma, tufted angioma, and Kasabach-Merritt phenomenon. Pediatr Blood Cancer 2012; 59: 934–938.
Primary breast carcinoma en cuirasse derived from invasive lobular carcinoma: The first case report Dear Editor, Carcinoma en cuirasse (CEC) preferentially arises in association with the cutaneous involvement of breast carcinomas. A large percentage of cases of breast CECs are secondary (recurrent) lesions following a breast operation, while 0.6– 10% of the cases are primary lesions, i.e., the first manifestation of the breast carcinoma.1 Herein we report an unusual case of primary breast CEC and discuss the importance of E-cadherin immunohistochemistry for their histopathological classification. A 60-year-old Japanese woman with no remarkable medical history visited our hospital complaining of an unusual eruption
(a)
on her right breast that slowly increased in size over 35 years. A physical examination revealed a keloid-like erythematous plaque around the right nipple (Fig. 1a). An MRI scan demonstrated an irregular mass on the right mammary gland directly extending to the overlying skin. No other neoplastic lesions were found by CT screening. The findings of the skin biopsy corresponded histologically to the “Indian file” pattern, which consists of dermal changes with a proliferation of thickened collagen bundles and infiltration of a small number of atypical neoplastic cells with linear arrangement between collagen bundles (Fig. 1b,c). Immunohistochemistry showed that the atypical cells were positive for the estrogen receptor (Fig. 1d) and
(b)
(d)
(c)
(e)
Figure 1. (a) Clinical picture of the eruption. Hard, thickened, irregular-shaped, keloid-like erythematous plaque, 10 9 8 cm in size, was observed around the right nipple. (b, c) Histopathology of the skin biopsy specimen taken from the keloid-like lesion revealed dermal changes marked by proliferation of thickened collagen bundles and infiltration of a small number of atypical neoplastic cells with large nuclei arranged in cords and strands between collagen bundles. (b) Low magnification (HE, 9200). (c) High magnification (HE, 9400). (d, e) Immunohistochemical examination demonstrated that the atypical cells were positive for estrogen receptor (d, 9400) but were negative for E-cadherin (e, 9400).
Correspondence: Yuta Kurashige, MD, PhD, Department of Dermatology, Tokai University School of Medicine, 143 Shimokasuya, Isehara-shi, Kanagawa 259-1193, Japan. Email: [email protected]
1122
© 2014 Japanese Dermatological Association
Letters to the Editor
progesterone receptor, but negative for HER2 (scored as 1) and E-cadherin (Fig. 1e). Given these facts, we diagnosed primary breast CEC derived from invasive lobular carcinoma (ILC). Invasive lobular carcinoma originates from the lobules within the mammary gland and is the second most prevalent type (5–15%) of invasive breast carcinoma, the most common (40–70%) being invasive ductal carcinoma (IDC).2 Regarding breast histopathology, “classical” ILC, a representative subtype of ILC, and some cases of IDC, can exhibit features consistent with the “Indian file” pattern, namely, stromal invasion of neoplastic cells within a linear arrangement. These two types of breast carcinomas are distinguished by immunohistochemistry; E-cadherin, a cell-to-cell adhesion molecule involved in carcinoma cell metastasis, is usually expressed in a large percentage of IDC cases, but is rarely expressed in ILCs.3 In previous English-language publications, only “secondary” cases of ILC-related CEC have been reported. To our knowledge, the present case is the first report of “primary” breast CEC derived from classical ILC. In the present case, the lack of E-cadherin expression successfully led to the diagnosis of ILC. Nevertheless, previous cases of primary breast CEC have rarely been examined for E-cadherin expression. Although ILC-related
primary breast CEC seems to be a rare entity, E-cadherin immunohistochemistry may be an important agent for detecting other similar cases.
CONFLICT OF INTEREST:
None declared.
Yuta KURASHIGE,1,2 Kumiko KURASHIGE,2 Tetsuo NAGATANI,2 Mitsuhiro HAYASHI3 1 Department of Dermatology, Tokai University School of Medicine, Kanagawa, Departments of 2Dermatology, and 3Breast Oncology, Hachioji Medical Center of Tokyo Medical University, Tokyo, Japan
doi: 10.1111/1346-8138.12671
REFERENCES 1 Mordenti C, Peris KM, Fargnoli C et al. Cutaneous metastatic breast carcinoma. Acta Dermatovenerol 2000; 9: 143–148 (e-edition). 2 Lakhani SR, Ellis IO, Schnitt SJ et al. WHO Classification of Tumours of the Breast, 4th edn. Skin Tumours. Lyon, France: IARC Press, 2012. 3 Rosen PP. Rosens Breast Pathology, 3rd edn. Invasive Lobular Carcinoma. Philadelphia: Lippincott Williams & Wilkins (Wolters Kluwer), 2009.
“Sprinkle brightness lesion” appearance in ultrasound B-mode findings of sinusoidal hemangioma Dear Editor, Sinusoidal hemangioma (SH) is an uncommon benign vascular tumor that is a distinctive subset of a group of lesions known as cavernous hemangiomas, first described in 1991 by Calonje and Fletcher.1 It commonly develops in middle-aged adults, predominantly in women, and presents as a solitary, painless, bluish subcutaneous or deep dermal mass on the trunk or the limb. Referring to the current classification of vascular tumors and malformations proposed by the International Society for the Study of Vascular Anomalies, SH does not fall into any of the categories; however, we could regard SH as some rare “dermatological” vascular anomaly.2 It is histopathologically characterized by the typical feature of gaping, markedly dilated and congested, thin-walled, “back-toback” vascular spaces in a sieve-like or sinusoidal arrangement.3 Thrombosis, hyalinization, dystrophic calcification and even areas of infarction can be seen in older lesions.4 Herein, we report a case of SH in which we were able to detect diffuse calcification from the “sprinkle brightness lesion” of the ultrasound B-mode findings. A 28-year-old man referred to us reported a bluish subcutaneous nodule that had been present for 10 years on his left
dorsal hand and that had gradually enlarged. Physical examination revealed a bluish, soft, mobile and regularly bordered nodule of 56 mm 9 40 mm 9 15 mm on the left dorsal hand (Fig. 1a). The patient underwent ultrasound scanning with the HI VISION 900 (Hitachi Medical, Tokyo, Japan). A conventional linear probe with a 5–13-MHz transducer was used in all scans, including B-mode, color Doppler test and elastography. Ultrasound B-mode examination revealed that the subcutaneous nodule contained numerous hyperechoic foci distributed diffusely, some of which cast an acoustic shadow, that resembled multiple stars in the sky (Fig. 1b). Color Doppler test showed poor blood flow within the tumor (data not shown). A surgical specimen showed multiple lobules in the subcutaneous area, with a lump of them coated by a thick fibrous membrane that was filled with red blood cells and blood clots. Each lobule was composed of thin-walled interconnecting vascular channels forming sinusoidal and pseudopapillary pattern (Fig. 1c). Focal calcification was seen intermittently throughout the tumor (Fig. 1d; red arrows). Each lobule was composed of thin-walled interconnecting vascular channels forming a sinusoidal pattern. Based on the histological findings, we made the final diagnosis of SH.
Correspondence: Hiroo Hata, M.D., Ph.D., Department of Dermatology, Hokkaido University Graduate School of Medicine, N15 W7, Kita-ku, Sapporo 060-8638, Japan. Email: [email protected]
© 2014 Japanese Dermatological Association
1123
3 Storch CH, Hoeger PH. Propranolol for infantile haemangiomas: insights into the molecular mechanisms of action. Br J Dermatol 2010; 163: 269–274.
4 Chiu YE, Drolet BA, Blei F et al. Variable response to propranolol treatment of kaposiform hemangioendothelioma, tufted angioma, and Kasabach-Merritt phenomenon. Pediatr Blood Cancer 2012; 59: 934–938.
Primary breast carcinoma en cuirasse derived from invasive lobular carcinoma: The first case report Dear Editor, Carcinoma en cuirasse (CEC) preferentially arises in association with the cutaneous involvement of breast carcinomas. A large percentage of cases of breast CECs are secondary (recurrent) lesions following a breast operation, while 0.6– 10% of the cases are primary lesions, i.e., the first manifestation of the breast carcinoma.1 Herein we report an unusual case of primary breast CEC and discuss the importance of E-cadherin immunohistochemistry for their histopathological classification. A 60-year-old Japanese woman with no remarkable medical history visited our hospital complaining of an unusual eruption
(a)
on her right breast that slowly increased in size over 35 years. A physical examination revealed a keloid-like erythematous plaque around the right nipple (Fig. 1a). An MRI scan demonstrated an irregular mass on the right mammary gland directly extending to the overlying skin. No other neoplastic lesions were found by CT screening. The findings of the skin biopsy corresponded histologically to the “Indian file” pattern, which consists of dermal changes with a proliferation of thickened collagen bundles and infiltration of a small number of atypical neoplastic cells with linear arrangement between collagen bundles (Fig. 1b,c). Immunohistochemistry showed that the atypical cells were positive for the estrogen receptor (Fig. 1d) and
(b)
(d)
(c)
(e)
Figure 1. (a) Clinical picture of the eruption. Hard, thickened, irregular-shaped, keloid-like erythematous plaque, 10 9 8 cm in size, was observed around the right nipple. (b, c) Histopathology of the skin biopsy specimen taken from the keloid-like lesion revealed dermal changes marked by proliferation of thickened collagen bundles and infiltration of a small number of atypical neoplastic cells with large nuclei arranged in cords and strands between collagen bundles. (b) Low magnification (HE, 9200). (c) High magnification (HE, 9400). (d, e) Immunohistochemical examination demonstrated that the atypical cells were positive for estrogen receptor (d, 9400) but were negative for E-cadherin (e, 9400).
Correspondence: Yuta Kurashige, MD, PhD, Department of Dermatology, Tokai University School of Medicine, 143 Shimokasuya, Isehara-shi, Kanagawa 259-1193, Japan. Email: [email protected]
1122
© 2014 Japanese Dermatological Association
Letters to the Editor
progesterone receptor, but negative for HER2 (scored as 1) and E-cadherin (Fig. 1e). Given these facts, we diagnosed primary breast CEC derived from invasive lobular carcinoma (ILC). Invasive lobular carcinoma originates from the lobules within the mammary gland and is the second most prevalent type (5–15%) of invasive breast carcinoma, the most common (40–70%) being invasive ductal carcinoma (IDC).2 Regarding breast histopathology, “classical” ILC, a representative subtype of ILC, and some cases of IDC, can exhibit features consistent with the “Indian file” pattern, namely, stromal invasion of neoplastic cells within a linear arrangement. These two types of breast carcinomas are distinguished by immunohistochemistry; E-cadherin, a cell-to-cell adhesion molecule involved in carcinoma cell metastasis, is usually expressed in a large percentage of IDC cases, but is rarely expressed in ILCs.3 In previous English-language publications, only “secondary” cases of ILC-related CEC have been reported. To our knowledge, the present case is the first report of “primary” breast CEC derived from classical ILC. In the present case, the lack of E-cadherin expression successfully led to the diagnosis of ILC. Nevertheless, previous cases of primary breast CEC have rarely been examined for E-cadherin expression. Although ILC-related
primary breast CEC seems to be a rare entity, E-cadherin immunohistochemistry may be an important agent for detecting other similar cases.
CONFLICT OF INTEREST:
None declared.
Yuta KURASHIGE,1,2 Kumiko KURASHIGE,2 Tetsuo NAGATANI,2 Mitsuhiro HAYASHI3 1 Department of Dermatology, Tokai University School of Medicine, Kanagawa, Departments of 2Dermatology, and 3Breast Oncology, Hachioji Medical Center of Tokyo Medical University, Tokyo, Japan
doi: 10.1111/1346-8138.12671
REFERENCES 1 Mordenti C, Peris KM, Fargnoli C et al. Cutaneous metastatic breast carcinoma. Acta Dermatovenerol 2000; 9: 143–148 (e-edition). 2 Lakhani SR, Ellis IO, Schnitt SJ et al. WHO Classification of Tumours of the Breast, 4th edn. Skin Tumours. Lyon, France: IARC Press, 2012. 3 Rosen PP. Rosens Breast Pathology, 3rd edn. Invasive Lobular Carcinoma. Philadelphia: Lippincott Williams & Wilkins (Wolters Kluwer), 2009.
“Sprinkle brightness lesion” appearance in ultrasound B-mode findings of sinusoidal hemangioma Dear Editor, Sinusoidal hemangioma (SH) is an uncommon benign vascular tumor that is a distinctive subset of a group of lesions known as cavernous hemangiomas, first described in 1991 by Calonje and Fletcher.1 It commonly develops in middle-aged adults, predominantly in women, and presents as a solitary, painless, bluish subcutaneous or deep dermal mass on the trunk or the limb. Referring to the current classification of vascular tumors and malformations proposed by the International Society for the Study of Vascular Anomalies, SH does not fall into any of the categories; however, we could regard SH as some rare “dermatological” vascular anomaly.2 It is histopathologically characterized by the typical feature of gaping, markedly dilated and congested, thin-walled, “back-toback” vascular spaces in a sieve-like or sinusoidal arrangement.3 Thrombosis, hyalinization, dystrophic calcification and even areas of infarction can be seen in older lesions.4 Herein, we report a case of SH in which we were able to detect diffuse calcification from the “sprinkle brightness lesion” of the ultrasound B-mode findings. A 28-year-old man referred to us reported a bluish subcutaneous nodule that had been present for 10 years on his left
dorsal hand and that had gradually enlarged. Physical examination revealed a bluish, soft, mobile and regularly bordered nodule of 56 mm 9 40 mm 9 15 mm on the left dorsal hand (Fig. 1a). The patient underwent ultrasound scanning with the HI VISION 900 (Hitachi Medical, Tokyo, Japan). A conventional linear probe with a 5–13-MHz transducer was used in all scans, including B-mode, color Doppler test and elastography. Ultrasound B-mode examination revealed that the subcutaneous nodule contained numerous hyperechoic foci distributed diffusely, some of which cast an acoustic shadow, that resembled multiple stars in the sky (Fig. 1b). Color Doppler test showed poor blood flow within the tumor (data not shown). A surgical specimen showed multiple lobules in the subcutaneous area, with a lump of them coated by a thick fibrous membrane that was filled with red blood cells and blood clots. Each lobule was composed of thin-walled interconnecting vascular channels forming sinusoidal and pseudopapillary pattern (Fig. 1c). Focal calcification was seen intermittently throughout the tumor (Fig. 1d; red arrows). Each lobule was composed of thin-walled interconnecting vascular channels forming a sinusoidal pattern. Based on the histological findings, we made the final diagnosis of SH.
Correspondence: Hiroo Hata, M.D., Ph.D., Department of Dermatology, Hokkaido University Graduate School of Medicine, N15 W7, Kita-ku, Sapporo 060-8638, Japan. Email: [email protected]
© 2014 Japanese Dermatological Association
1123
