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    "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&#46;<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&#46;</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&#46;<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&#59; they can occur during the course of the neoplastic disease or be its initial manifestation&#46;<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&#44; treated by radical mastectomy&#44; radiotherapy&#44; and chemotherapy&#44; and disease free up to the time of consultation&#44; was seen for a pigmented tumor in the area of the right breast&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">On physical examination there was a round tumor with well-defined borders on the mastectomy scar&#46; The tumor had a black&#44; keratotic surface and an erythematous base and measured approximately 1<span class="elsevierStyleHsp" style=""></span>cm in diameter &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;&#46; It was slightly indurated on palpation&#46; Dermoscopy revealed central hypopigmentation with radial projections and peripheral globules&#46; Tortuous vessels were observed at the inferior pole &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41;&#46;</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&#46; In some sectors the cells formed ductal structures&#44; while in others the tumor cells were arranged in rows&#46; The tumor infiltration affected the epidermis&#44; showing marked epidermotropism&#46; Pigment was observed in the superficial tumor cells and in the superficial dermis &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Immunohistochemistry was positive for cytokeratin &#40;CK&#41; 7 and negative for S100&#44; HMB45&#44; Melan-A&#44; and CK20 &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; There was focal positivity for estrogen and progesterone receptors&#44; and the Hercep test was negative&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Based on the histopathology and immunohistochemistry findings&#44; the patient was diagnosed with pigmented metastases from her breast carcinoma&#46;</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&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4&#44;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&#46; One of these theories suggests an increase in the number of melanocytes and in melanin synthesis in the lesion&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5&#44;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&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Clinically&#44; the tumor presents as an indurated black lesion that usually arises in or close to the mastectomy scar&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> The most important differential diagnosis is with melanoma&#44; which this tumor can mimic both clinically and histologically&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4&#44;7</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Dermoscopy can be a useful diagnostic tool&#44; although the literature has few data on the dermoscopic findings in skin metastases&#59; the pigmented forms are one of the rarest&#46;<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&#44; which can be organized as individual cells&#44; in rows between bundles of collagen&#44; or forming cords&#44; nests&#44; glandular structures&#44; or solid aggregates&#46; At higher magnification&#44; the cells have polygonal&#44; pleomorphic&#44; hyperchromatic nuclei&#46; Pigmented metastases from breast cancer show a connection with the epidermis and a pagetoid ascent both of individual cells and of irregular nests&#46; The intraepidermal and dermal tumor cells contain melanin in their cytoplasm&#44; and numerous dermal melanophages are also seen&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4&#44;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&#44; differentiating it from other clinically similar diseases such as melanoma&#44; and it is also of prognostic significance&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Breast carcinomas usually have a CK7-positive and CK20-negative pattern&#46; Staining for proteins S100&#44; HMB45&#44; and Melan-A is negative in the majority of cases&#44; differentiating the lesion from melanoma&#44; which usually expresses these proteins&#46; Estrogen and progesterone hormone receptors can also be studied&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Another useful immunohistochemistry technique with prognostic and therapeutic implications is the Hercep test&#44; which analyzes protein HER2 overexpression in breast cancer tissues&#59; expression is associated with a poorer prognosis&#46;<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&#44; 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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
Autor para correspondencia
nubi212@gmail.com

Corresponding author.
, M. Vola, M.E. Mazzei, J. Magliano
Cátedra de Dermatología Médico Quirúrgica, Hospital de Clínicas, Montevideo, Uruguay
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    "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&#46;<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&#46;</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&#46;<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&#59; they can occur during the course of the neoplastic disease or be its initial manifestation&#46;<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&#44; treated by radical mastectomy&#44; radiotherapy&#44; and chemotherapy&#44; and disease free up to the time of consultation&#44; was seen for a pigmented tumor in the area of the right breast&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">On physical examination there was a round tumor with well-defined borders on the mastectomy scar&#46; The tumor had a black&#44; keratotic surface and an erythematous base and measured approximately 1<span class="elsevierStyleHsp" style=""></span>cm in diameter &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;&#46; It was slightly indurated on palpation&#46; Dermoscopy revealed central hypopigmentation with radial projections and peripheral globules&#46; Tortuous vessels were observed at the inferior pole &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41;&#46;</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&#46; In some sectors the cells formed ductal structures&#44; while in others the tumor cells were arranged in rows&#46; The tumor infiltration affected the epidermis&#44; showing marked epidermotropism&#46; Pigment was observed in the superficial tumor cells and in the superficial dermis &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Immunohistochemistry was positive for cytokeratin &#40;CK&#41; 7 and negative for S100&#44; HMB45&#44; Melan-A&#44; and CK20 &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; There was focal positivity for estrogen and progesterone receptors&#44; and the Hercep test was negative&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Based on the histopathology and immunohistochemistry findings&#44; the patient was diagnosed with pigmented metastases from her breast carcinoma&#46;</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&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4&#44;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&#46; One of these theories suggests an increase in the number of melanocytes and in melanin synthesis in the lesion&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5&#44;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&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Clinically&#44; the tumor presents as an indurated black lesion that usually arises in or close to the mastectomy scar&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> The most important differential diagnosis is with melanoma&#44; which this tumor can mimic both clinically and histologically&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4&#44;7</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Dermoscopy can be a useful diagnostic tool&#44; although the literature has few data on the dermoscopic findings in skin metastases&#59; the pigmented forms are one of the rarest&#46;<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&#44; which can be organized as individual cells&#44; in rows between bundles of collagen&#44; or forming cords&#44; nests&#44; glandular structures&#44; or solid aggregates&#46; At higher magnification&#44; the cells have polygonal&#44; pleomorphic&#44; hyperchromatic nuclei&#46; Pigmented metastases from breast cancer show a connection with the epidermis and a pagetoid ascent both of individual cells and of irregular nests&#46; The intraepidermal and dermal tumor cells contain melanin in their cytoplasm&#44; and numerous dermal melanophages are also seen&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4&#44;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&#44; differentiating it from other clinically similar diseases such as melanoma&#44; and it is also of prognostic significance&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Breast carcinomas usually have a CK7-positive and CK20-negative pattern&#46; Staining for proteins S100&#44; HMB45&#44; and Melan-A is negative in the majority of cases&#44; differentiating the lesion from melanoma&#44; which usually expresses these proteins&#46; Estrogen and progesterone hormone receptors can also be studied&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Another useful immunohistochemistry technique with prognostic and therapeutic implications is the Hercep test&#44; which analyzes protein HER2 overexpression in breast cancer tissues&#59; expression is associated with a poorer prognosis&#46;<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&#44; although restaging of the disease must be performed to determine the most suitable management&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">In conclusion&#44; we have presented a case of a pigmented skin metastasis from breast cancer that had been diagnosed 20 years earlier&#46; We highlight the importance of its clinical and histological differentiation from malignant melanoma&#46;</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&#46;</p></span></span>"
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