Cutaneous metastases in a patient with no previous diagnosis of cancer: diagnostic challenge

Abstract

On rare occasions, skin lesions are the first local of metastatic manifestation of internal malignancies. In case of no previous diagnosis of these tumors, the approach of suspicious skin lesions becomes a challenge, especially in differentiating cutaneous metastases and adnexal primary neoplasms. Currently, besides epidemiologic, dermoscopic and histopathologic aspects, the evaluation also integrates immunohistochemical exams and cell markers such as p40 and p63, highly specific for skin metastases. This article describes the case of cutaneous metastases as the sole obvious sign of breast cancer in a previously asymptomatic woman. The diagnosis was made by the finding of neoplastic cells in the dermis and immunohistochemistry compatible with ductal carcinoma.

Cutaneous lesions as the first manifestation of breast cancer: a rare case

“…In 2013, a Brazilian study demonstrated that the most common sites of cutaneous metastases are the chest (31.94% of cases) followed by the abdomen (20.37%) and scalp (14.81%). In women, the most common primary malignancy was breast cancer (63.19%), intestines (10.41%) and lung (4.16%), which tends to metastasize later to the anterior thoracic wall [ 2 , 6 ]. Although cutaneous metastasis most frequently originates from breast cancer, it rarely occurs as the first manifestation of this malignancy [ 6 , 8 ].…”

“…Our case showed a sudden development of multiple erythematous patches that rapidly ulcerated. Cutaneous metastases from breast cancer are most commonly reported as multiple, firm, hyperpigmented, painless nodules, followed by papules, erysipelas-like, alopecic, and sclerotic plaques which may retract the skin [ 2 , 6 ]. In a review of 164 patients, the most frequent manifestations were papules and/or nodules (80%), followed by telangiectatic carcinoma (11.2%), erysipeloid carcinoma (3%), carcinoma en cuirasse (3%), alopecia neoplastica (2%) and zosteriform pattern (0.8%) [ 8 ].…”

“…The result on both sites showed identical findings, diffuse dermal nests of tumor cells infiltrating to the collagen bundles and fat tissue, which confirmed that cutaneous metastasis had reached to the upper arm region. Skin biopsy is the gold standard for diagnosis and should always be considered in case of early or sudden onset, delayed healing, bleeding tendency, or vascular appearance of the lesions that do not resolve after treatment [ 2 , 6 ]. Several histopathologic features may help to identify the source of the primary tumor.…”

“…An analysis of 124 cases of metastases revealed this characteristic in 76.6% cases. The most frequent subtypes for the primary malignancies of the breast are ductal and lobular [ 6 ]. Basic patterns of metastasis mechanisms from a breast cancer to the skin are reported to occur through direct extension, hematologic dissemination, or surgical implantation [ 8 ].…”

“…However, this can be a pitfall for clinicians when the clinical presentation is not the typical inflammatory nodule or mass. Identifying these manifestations in patients with no previous diagnosis of a primary neoplasia, as well as the appropriate management of these uncommon lesions, is a real challenge for the dermatologist [ 5 , 6 ]. Cutaneous metastases are associated with poor prognosis, higher staging of primary malignancies, recurrence, and, if they arise during therapy, indicate an inadequate response [ 7 ].…”