e358
Correspondence
Zosteriform cutaneous metastasis of breast carcinoma in a male patient
Editor, A 62-year-old man was referred to our outpatient clinic for the evaluation of a gradually enlarging papulonodular asymptomatic eruption of six months duration involving the right lower part of the trunk. Clinical examination revealed the presence of multiple coalescent, red to violaceous, indurated nodules and papules in a dermatomal distribution, along the T4–T7 neurotomes, at the lower right side of the thorax (Fig. 1a). A full body examination uncovered a subtle ipsilateral retraction of the nipple, firmly attached to a palpable tumor located beneath the areola. Furthermore, ipsilateral palpable axillary and supraclavicular lymph nodes were detected. The patient’s medical history was unremarkable. Under the clinical suspicion of metastatic skin disease, we performed an incisional skin biopsy. Histological examination showed the dermal invasion of adenoid neoplastic cells compatible with metastatic carcinoma of the breast (Fig. 1b). Subsequent fine needle aspiration cytology of the breast mass was consistent with carcinoma of the breast. Further laboratory examination revealed bone and lung metastases; the patient was diagnosed with stage IV breast cancer and treated accordingly. Cutaneous metastasis from an internal malignancy is a relatively frequent manifestation and is reported to occur in 5–10% of malignancies. In the vast majority of cases,
(a)
it represents a sign of disease progression and is characterized by a wide array of clinical presentations. Breast cancer is the neoplasia most commonly associated with skin metastases. However, the arrangement of skin lesions in a dermatomal distribution is highly unusual: only 10 cases of zosteriform cutaneous metastasis related to breast carcinoma have been published in the literature.1–4 To the best of our knowledge, this is the first reported case of a dermatomal cutaneous metastasis originating from breast carcinoma in a male patient. From a morphological perspective, dermatomal metastatic skin disease usually (in seven of 10 published cases) manifests with solid papulonodular lesions, as in our patient. Vesicobullous lesions have been reported in only three individuals. In addition to breast carcinoma, other primary malignancies associated with zosteriform patterns of skin metastases include melanoma, systemic and cutaneous B cell and T cell lymphomas, respiratory, gastrointestinal, and urinary tumors, and angiosarcoma and Kaposi’s sarcoma.1 Possible explanations for the zosteriform spread of cancer cells in the skin include vascular (lymphatic or hematogenous) spread, neural spread, the surgical implantation of malignant cells in the skin, and Koebnerization at the site of previous herpes zoster. Given that our patient had not undergone any surgical procedures before the development of the cutaneous metastasis, and his medical history was negative for herpes zoster, we suggest that
(b)
Figure 1 (a) Clinical examination reveals multiple coalescent, red to violaceous, indurated nodules and papules in a dermotomal distribution, along the T4–T7 neurotomes. Subtle ipsilateral retraction of the nipple is also apparent. (b) Histopathology shows dermal invasion of adenoid neoplastic cells compatible with metastatic carcinoma of the breast. (Hematoxylin and eosin stain; original magnification 910) International Journal of Dermatology 2014, 53, e347–e366
ª 2014 The International Society of Dermatology
Correspondence
vascular or neural routes represent the most plausible underlying mechanisms for the occurrence of this phenomenon. In our patient, zosteriform cutaneous involvement was the first clinical sign of an undiagnosed primary breast carcinoma. The unusual zosteriform distribution of cutaneous metastases, in conjunction with the relatively low incidence of breast malignancies in males,5 may result in delayed diagnosis, inadequate management, and prolonged morbidity in this group of patients. Increased awareness among physicians of the significance of such findings and the early recognition of cutaneous metastases are mandatory for the provision of an optimal treatment strategy. Zoe Apalla, MD, PhD Valeria Chassioti, MD, PhD Demetrios Ioannides, MD, PhD State Clinic Hospital of Skin and Venereal Diseases Thessaloniki Greece E-mail: [email protected] Elena Sotiriou, MD, PhD Despina Papadopoulou, MD, PhD Department of Dermatology (A) Aristotle University of Thessaloniki
Coexistence of psoriasis vulgaris and vitiligo with bullous pemphigoid: a case report
The coexistence of psoriasis and bullous pemphigoid (BP) was described in the literature as early as 1929. Since then less than 100 cases were described worldwide. Almost exclusively, psoriasis precedes the eruption of BP. Interestingly, BP seems to occur in patients with psoriasis at a younger age than sporadic BP. Most previously reported cases attributed the occurrence of BP in psoriasis to topical treatment with anthralin or tar but also phototherapy, such as psoralen + ultraviolet A (PUVA) or narrowband UVB, or to the use of anti-tumor necrosis factor antibodies.1–4 Here we report a case of BP eruption in a psoriatic patient apparently not related to antipsoriatic systemic or topical treatment. Additionally, in this patient, BP and psoriasis coexisted with vitiligo. A 47-year-old Polish woman with a 28-year history of psoriasis vulgaris presented with an extensive eruption that had started three weeks previously with disseminated erythematosquamous plaques, tense bullae, and erosions partially superimposed on pre-existing psoriatic plaques in the sacral area (Fig. 1) and on unaffected skin. In addition, this patient had typical psoriatic plaques on the ª 2014 The International Society of Dermatology
Thessaloniki Greece Aimilios Lallas, MD, PhD Skin Cancer Unit Arcispedale Santa Maria Nuova IRCCS (Istituto di Ricovero e Cura a Carattere Scientifico) Reggio Emilia Italy
References 1 Savoia P, Fava P, Deboli T, et al. Zosteriform cutaneous metastases: a literature meta-analysis and a clinical report of three melanoma cases. Dermatol Surg 2009; 35: 1355–1363. 2 Rao R, Balachandran C, Rao L. Zosteriform cutaneous metastases: a case report and brief review of literature. Indian J Dermatol Venereol Leprol 2010; 76: 447. 3 Bassioukas K, Nakuci M, Dimou S, et al. Zosteriform cutaneous metastases from breast adenocarcinoma. J Eur Acad Dermatol Venereol 2005; 19: 593–596. 4 Virmani NC, Sharma YK, Panicker NK, et al. Zosteriform skin metastases: clue to an undiagnosed breast cancer. Indian J Dermatol 2011; 56: 726–727. 5 Ly D, Forman D, Ferlay J, et al. An international comparison of male and female breast cancer incidence rates. Int J Cancer 2013; 132: 1918–1926.
knees and scalp as well as vitiliginous macules for 40 years duration on the dorsal aspects of hands and ankles confirmed by histopathological examination. She had a family history of psoriasis with her daughter and siblings of her mother being affected. She had never received PUVA or narrowband UVB therapy. She reported experiencing severe psychic stress a few days before the onset of this bullous eruption. During the current hospitalization, skin biopsies were taken for histopathological and immunofluorescent examinations. Histopathology showed subepidermal blistering with an infiltrate mainly of neutrophils and lymphocytes and a small number of eosinophils. Direct immunofluorescence (DIF) from the perilesional skin revealed neither immunoglobulin nor C3 deposits along the basement membrane zone. However, when DIF (split) was repeated with antibodies against IgG isotypes, the results were negative for IgG1, IgG2, IgG3, and IgM but clearly positive for IgG4 (Fig. 2a). Indirect immunofluorescence assay conducted on monkey esophagus as a substrate demonstrated circulating IgG autoantibodies (titer 1 : 640) against the dermal– epidermal junction (Fig. 2b). ELISA assay confirmed high International Journal of Dermatology 2014, 53, e347–e366
e359
Correspondence
Zosteriform cutaneous metastasis of breast carcinoma in a male patient
Editor, A 62-year-old man was referred to our outpatient clinic for the evaluation of a gradually enlarging papulonodular asymptomatic eruption of six months duration involving the right lower part of the trunk. Clinical examination revealed the presence of multiple coalescent, red to violaceous, indurated nodules and papules in a dermatomal distribution, along the T4–T7 neurotomes, at the lower right side of the thorax (Fig. 1a). A full body examination uncovered a subtle ipsilateral retraction of the nipple, firmly attached to a palpable tumor located beneath the areola. Furthermore, ipsilateral palpable axillary and supraclavicular lymph nodes were detected. The patient’s medical history was unremarkable. Under the clinical suspicion of metastatic skin disease, we performed an incisional skin biopsy. Histological examination showed the dermal invasion of adenoid neoplastic cells compatible with metastatic carcinoma of the breast (Fig. 1b). Subsequent fine needle aspiration cytology of the breast mass was consistent with carcinoma of the breast. Further laboratory examination revealed bone and lung metastases; the patient was diagnosed with stage IV breast cancer and treated accordingly. Cutaneous metastasis from an internal malignancy is a relatively frequent manifestation and is reported to occur in 5–10% of malignancies. In the vast majority of cases,
(a)
it represents a sign of disease progression and is characterized by a wide array of clinical presentations. Breast cancer is the neoplasia most commonly associated with skin metastases. However, the arrangement of skin lesions in a dermatomal distribution is highly unusual: only 10 cases of zosteriform cutaneous metastasis related to breast carcinoma have been published in the literature.1–4 To the best of our knowledge, this is the first reported case of a dermatomal cutaneous metastasis originating from breast carcinoma in a male patient. From a morphological perspective, dermatomal metastatic skin disease usually (in seven of 10 published cases) manifests with solid papulonodular lesions, as in our patient. Vesicobullous lesions have been reported in only three individuals. In addition to breast carcinoma, other primary malignancies associated with zosteriform patterns of skin metastases include melanoma, systemic and cutaneous B cell and T cell lymphomas, respiratory, gastrointestinal, and urinary tumors, and angiosarcoma and Kaposi’s sarcoma.1 Possible explanations for the zosteriform spread of cancer cells in the skin include vascular (lymphatic or hematogenous) spread, neural spread, the surgical implantation of malignant cells in the skin, and Koebnerization at the site of previous herpes zoster. Given that our patient had not undergone any surgical procedures before the development of the cutaneous metastasis, and his medical history was negative for herpes zoster, we suggest that
(b)
Figure 1 (a) Clinical examination reveals multiple coalescent, red to violaceous, indurated nodules and papules in a dermotomal distribution, along the T4–T7 neurotomes. Subtle ipsilateral retraction of the nipple is also apparent. (b) Histopathology shows dermal invasion of adenoid neoplastic cells compatible with metastatic carcinoma of the breast. (Hematoxylin and eosin stain; original magnification 910) International Journal of Dermatology 2014, 53, e347–e366
ª 2014 The International Society of Dermatology
Correspondence
vascular or neural routes represent the most plausible underlying mechanisms for the occurrence of this phenomenon. In our patient, zosteriform cutaneous involvement was the first clinical sign of an undiagnosed primary breast carcinoma. The unusual zosteriform distribution of cutaneous metastases, in conjunction with the relatively low incidence of breast malignancies in males,5 may result in delayed diagnosis, inadequate management, and prolonged morbidity in this group of patients. Increased awareness among physicians of the significance of such findings and the early recognition of cutaneous metastases are mandatory for the provision of an optimal treatment strategy. Zoe Apalla, MD, PhD Valeria Chassioti, MD, PhD Demetrios Ioannides, MD, PhD State Clinic Hospital of Skin and Venereal Diseases Thessaloniki Greece E-mail: [email protected] Elena Sotiriou, MD, PhD Despina Papadopoulou, MD, PhD Department of Dermatology (A) Aristotle University of Thessaloniki
Coexistence of psoriasis vulgaris and vitiligo with bullous pemphigoid: a case report
The coexistence of psoriasis and bullous pemphigoid (BP) was described in the literature as early as 1929. Since then less than 100 cases were described worldwide. Almost exclusively, psoriasis precedes the eruption of BP. Interestingly, BP seems to occur in patients with psoriasis at a younger age than sporadic BP. Most previously reported cases attributed the occurrence of BP in psoriasis to topical treatment with anthralin or tar but also phototherapy, such as psoralen + ultraviolet A (PUVA) or narrowband UVB, or to the use of anti-tumor necrosis factor antibodies.1–4 Here we report a case of BP eruption in a psoriatic patient apparently not related to antipsoriatic systemic or topical treatment. Additionally, in this patient, BP and psoriasis coexisted with vitiligo. A 47-year-old Polish woman with a 28-year history of psoriasis vulgaris presented with an extensive eruption that had started three weeks previously with disseminated erythematosquamous plaques, tense bullae, and erosions partially superimposed on pre-existing psoriatic plaques in the sacral area (Fig. 1) and on unaffected skin. In addition, this patient had typical psoriatic plaques on the ª 2014 The International Society of Dermatology
Thessaloniki Greece Aimilios Lallas, MD, PhD Skin Cancer Unit Arcispedale Santa Maria Nuova IRCCS (Istituto di Ricovero e Cura a Carattere Scientifico) Reggio Emilia Italy
References 1 Savoia P, Fava P, Deboli T, et al. Zosteriform cutaneous metastases: a literature meta-analysis and a clinical report of three melanoma cases. Dermatol Surg 2009; 35: 1355–1363. 2 Rao R, Balachandran C, Rao L. Zosteriform cutaneous metastases: a case report and brief review of literature. Indian J Dermatol Venereol Leprol 2010; 76: 447. 3 Bassioukas K, Nakuci M, Dimou S, et al. Zosteriform cutaneous metastases from breast adenocarcinoma. J Eur Acad Dermatol Venereol 2005; 19: 593–596. 4 Virmani NC, Sharma YK, Panicker NK, et al. Zosteriform skin metastases: clue to an undiagnosed breast cancer. Indian J Dermatol 2011; 56: 726–727. 5 Ly D, Forman D, Ferlay J, et al. An international comparison of male and female breast cancer incidence rates. Int J Cancer 2013; 132: 1918–1926.
knees and scalp as well as vitiliginous macules for 40 years duration on the dorsal aspects of hands and ankles confirmed by histopathological examination. She had a family history of psoriasis with her daughter and siblings of her mother being affected. She had never received PUVA or narrowband UVB therapy. She reported experiencing severe psychic stress a few days before the onset of this bullous eruption. During the current hospitalization, skin biopsies were taken for histopathological and immunofluorescent examinations. Histopathology showed subepidermal blistering with an infiltrate mainly of neutrophils and lymphocytes and a small number of eosinophils. Direct immunofluorescence (DIF) from the perilesional skin revealed neither immunoglobulin nor C3 deposits along the basement membrane zone. However, when DIF (split) was repeated with antibodies against IgG isotypes, the results were negative for IgG1, IgG2, IgG3, and IgM but clearly positive for IgG4 (Fig. 2a). Indirect immunofluorescence assay conducted on monkey esophagus as a substrate demonstrated circulating IgG autoantibodies (titer 1 : 640) against the dermal– epidermal junction (Fig. 2b). ELISA assay confirmed high International Journal of Dermatology 2014, 53, e347–e366
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