Case and Research Letter
Pigmented Cutaneous Metastasis of Breast Carcinoma Mimicking a Melanoma
Metástasis cutánea pigmentada de carcinoma de mama simulando un melanoma
N. Ubillos
, M. Vola, M.E. Mazzei, J. Magliano
Corresponding author
Cátedra de Dermatología Médico Quirúrgica, Hospital de Clínicas, Montevideo, Uruguay
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Ubillos, M. Vola, M.E. Mazzei, J. Magliano" "autores" => array:4 [ 0 => array:4 [ "nombre" => "N." "apellidos" => "Ubillos" "email" => array:1 [ 0 => "nubi212@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "M." "apellidos" => "Vola" ] 2 => array:2 [ "nombre" => "M.E." "apellidos" => "Mazzei" ] 3 => array:2 [ "nombre" => "J." "apellidos" => "Magliano" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Cátedra de Dermatología Médico Quirúrgica, Hospital de Clínicas, Montevideo, Uruguay" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Metástasis cutánea pigmentada de carcinoma de mama simulando un melanoma" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1372 "Ancho" => 902 "Tamanyo" => 166695 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A, Image of the black tumor with a keratotic surface on an erythematous base. B, Central hypopigmentation, radial projections, and peripheral globules. Tortuous vessels are visible at the lower pole.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Breast cancer is the malignant tumor with the highest incidence and mortality in women worldwide.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">These tumors can give rise to both systemic and skin metastases.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Skin metastases are defined as malignant tumors that affect the dermis or subcutaneous tissue but are not contiguous with the primary tumor of origin.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Skin metastases from internal tumors are uncommon; they can occur during the course of the neoplastic disease or be its initial manifestation.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case Description</span><p id="par0025" class="elsevierStylePara elsevierViewall">A 67-year-old woman diagnosed with an infiltrating ductal carcinoma of the right breast 20 years earlier, treated by radical mastectomy, radiotherapy, and chemotherapy, and disease free up to the time of consultation, was seen for a pigmented tumor in the area of the right breast.</p><p id="par0030" class="elsevierStylePara elsevierViewall">On physical examination there was a round tumor with well-defined borders on the mastectomy scar. The tumor had a black, keratotic surface and an erythematous base and measured approximately 1<span class="elsevierStyleHsp" style=""></span>cm in diameter (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). It was slightly indurated on palpation. Dermoscopy revealed central hypopigmentation with radial projections and peripheral globules. Tortuous vessels were observed at the inferior pole (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Histology of the lesion showed the dermis to be diffusely infiltrated by epithelial tumor cells with moderate cellular and nuclear pleomorphism. In some sectors the cells formed ductal structures, while in others the tumor cells were arranged in rows. The tumor infiltration affected the epidermis, showing marked epidermotropism. Pigment was observed in the superficial tumor cells and in the superficial dermis (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Immunohistochemistry was positive for cytokeratin (CK) 7 and negative for S100, HMB45, Melan-A, and CK20 (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). There was focal positivity for estrogen and progesterone receptors, and the Hercep test was negative.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Based on the histopathology and immunohistochemistry findings, the patient was diagnosed with pigmented metastases from her breast carcinoma.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Discussion</span><p id="par0050" class="elsevierStylePara elsevierViewall">The pigmented epidermotropic form of breast carcinoma is a rare and atypical clinical presentation first described by Azzopardi and Eusebi in 1977.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4,5</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">There are several theories about the origin of the pigment in this type of lesion. One of these theories suggests an increase in the number of melanocytes and in melanin synthesis in the lesion.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5,6</span></a> Other theories maintain that there is a transfer of melanin from the melanocytes into the carcinoma cells or even that the tumor cells themselves can produce melanin.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Clinically, the tumor presents as an indurated black lesion that usually arises in or close to the mastectomy scar.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> The most important differential diagnosis is with melanoma, which this tumor can mimic both clinically and histologically.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4,7</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Dermoscopy can be a useful diagnostic tool, although the literature has few data on the dermoscopic findings in skin metastases; the pigmented forms are one of the rarest.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">The histopathology of metastases from breast cancer shows the dermis to be affected by the tumor cells, which can be organized as individual cells, in rows between bundles of collagen, or forming cords, nests, glandular structures, or solid aggregates. At higher magnification, the cells have polygonal, pleomorphic, hyperchromatic nuclei. Pigmented metastases from breast cancer show a connection with the epidermis and a pagetoid ascent both of individual cells and of irregular nests. The intraepidermal and dermal tumor cells contain melanin in their cytoplasm, and numerous dermal melanophages are also seen.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4,9</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Immunohistochemistry is another tool that helps us to make the etiologic diagnosis of the lesion, differentiating it from other clinically similar diseases such as melanoma, and it is also of prognostic significance.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Breast carcinomas usually have a CK7-positive and CK20-negative pattern. Staining for proteins S100, HMB45, and Melan-A is negative in the majority of cases, differentiating the lesion from melanoma, which usually expresses these proteins. Estrogen and progesterone hormone receptors can also be studied.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Another useful immunohistochemistry technique with prognostic and therapeutic implications is the Hercep test, which analyzes protein HER2 overexpression in breast cancer tissues; expression is associated with a poorer prognosis.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">The treatment of skin metastases is by excision, although restaging of the disease must be performed to determine the most suitable management.</p><p id="par0095" class="elsevierStylePara elsevierViewall">In conclusion, we have presented a case of a pigmented skin metastasis from breast cancer that had been diagnosed 20 years earlier. We highlight the importance of its clinical and histological differentiation from malignant melanoma.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of Interest</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Case Description" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Discussion" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflicts of Interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Ubillos N, Vola M, Mazzei ME, Magliano J. Metástasis cutánea pigmentada de carcinoma de mama simulando un melanoma. Actas Dermosifiliogr. 2016;107:699–701.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1372 "Ancho" => 902 "Tamanyo" => 166695 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A, Image of the black tumor with a keratotic surface on an erythematous base. B, Central hypopigmentation, radial projections, and peripheral globules. Tortuous vessels are visible at the lower pole.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 630 "Ancho" => 1706 "Tamanyo" => 273637 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Histopathology. A, Glandular structures of adenocarcinoma of the breast. Hematoxylin and eosin, original magnification<span class="elsevierStyleHsp" style=""></span>×10. B, Pigment can be observed in the superficial tumor cells and in the superficial dermis. Hematoxylin and eosin, original magnification<span class="elsevierStyleHsp" style=""></span>×10.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1047 "Ancho" => 1505 "Tamanyo" => 384244 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Immunohistochemistry. A, Cytokeratin positive. B, Cytokeratin7 positive. C, S100 negative. D, HMB45 negative.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Globocan 2012. Breast Cancer Estimated Incidence, Mortality and Prevalence Worldwide in 2012 [accessed 8 Aug 2015]. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 6 | 7 | 13 |
| 2024 October | 119 | 41 | 160 |
| 2024 September | 119 | 26 | 145 |
| 2024 August | 127 | 63 | 190 |
| 2024 July | 100 | 32 | 132 |
| 2024 June | 134 | 72 | 206 |
| 2024 May | 94 | 41 | 135 |
| 2024 April | 88 | 31 | 119 |
| 2024 March | 90 | 37 | 127 |
| 2024 February | 81 | 22 | 103 |
| 2024 January | 87 | 33 | 120 |
| 2023 December | 82 | 19 | 101 |
| 2023 November | 93 | 27 | 120 |
| 2023 October | 93 | 26 | 119 |
| 2023 September | 104 | 36 | 140 |
| 2023 August | 84 | 19 | 103 |
| 2023 July | 103 | 36 | 139 |
| 2023 June | 92 | 27 | 119 |
| 2023 May | 131 | 25 | 156 |
| 2023 April | 148 | 34 | 182 |
| 2023 March | 88 | 27 | 115 |
| 2023 February | 120 | 31 | 151 |
| 2023 January | 90 | 25 | 115 |
| 2022 December | 95 | 46 | 141 |
| 2022 November | 73 | 30 | 103 |
| 2022 October | 59 | 27 | 86 |
| 2022 September | 73 | 44 | 117 |
| 2022 August | 85 | 52 | 137 |
| 2022 July | 61 | 37 | 98 |
| 2022 June | 63 | 41 | 104 |
| 2022 May | 126 | 41 | 167 |
| 2022 April | 87 | 39 | 126 |
| 2022 March | 96 | 56 | 152 |
| 2022 February | 85 | 27 | 112 |
| 2022 January | 96 | 44 | 140 |
| 2021 December | 63 | 40 | 103 |
| 2021 November | 68 | 59 | 127 |
| 2021 October | 153 | 73 | 226 |
| 2021 September | 83 | 51 | 134 |
| 2021 August | 68 | 45 | 113 |
| 2021 July | 51 | 31 | 82 |
| 2021 June | 38 | 37 | 75 |
| 2021 May | 54 | 41 | 95 |
| 2021 April | 99 | 76 | 175 |
| 2021 March | 62 | 39 | 101 |
| 2021 February | 60 | 28 | 88 |
| 2021 January | 40 | 30 | 70 |
| 2020 December | 35 | 12 | 47 |
| 2020 November | 44 | 25 | 69 |
| 2020 October | 25 | 14 | 39 |
| 2020 September | 38 | 13 | 51 |
| 2020 August | 33 | 26 | 59 |
| 2020 July | 19 | 14 | 33 |
| 2020 June | 30 | 32 | 62 |
| 2020 May | 21 | 22 | 43 |
| 2020 April | 22 | 11 | 33 |
| 2020 March | 32 | 25 | 57 |
| 2020 February | 3 | 0 | 3 |
| 2019 December | 3 | 0 | 3 |
| 2019 September | 4 | 0 | 4 |
| 2019 June | 2 | 0 | 2 |
| 2019 April | 0 | 3 | 3 |
| 2019 March | 2 | 0 | 2 |
| 2019 January | 2 | 0 | 2 |
| 2018 October | 1 | 0 | 1 |
| 2018 September | 1 | 0 | 1 |
| 2018 February | 31 | 6 | 37 |
| 2018 January | 37 | 7 | 44 |
| 2017 December | 42 | 8 | 50 |
| 2017 November | 29 | 6 | 35 |
| 2017 October | 32 | 7 | 39 |
| 2017 September | 26 | 6 | 32 |
| 2017 August | 22 | 5 | 27 |
| 2017 July | 21 | 3 | 24 |
| 2017 June | 27 | 8 | 35 |
| 2017 May | 23 | 6 | 29 |
| 2017 April | 22 | 10 | 32 |
| 2017 March | 16 | 15 | 31 |
| 2017 February | 16 | 5 | 21 |
| 2017 January | 11 | 6 | 17 |
| 2016 December | 17 | 13 | 30 |
| 2016 November | 25 | 10 | 35 |
| 2016 October | 77 | 24 | 101 |
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