85‑year‑old female with history of infiltrating lobular carcinoma of the left breast, initially diagnosed in 2005, status post left modified radical mastectomy, adjuvant radiation and adjuvant endocrine therapy with arimidex for 5 years that she completed in 07/2010. At that time, the tumor size was 8 cm extending into the dermis and focally present in the inferior intercostal margin 9 out of 15 axillary lymph nodes positive for metastatic carcinoma. Her initial tumor was pT4 pN1 pMx, stage IIIB. The tumor was ER 90% positive, PR 10%, and HER‑2 negative. The patient was without any evidence of disease since then.
In April 2016, the patient noticed nodular erythematous rash over her left arm and new lesions noted on the left side of her back with some recent weight loss and back pain. Following this, the patient was evaluated and had a biopsy done by a dermatologist. The left upper back and lower lesions were biopsied and the findings were consistent with strong diffuse staining of the neoplastic cells for pankeratin, CK7, ER and no staining for PR confirming the diagnosis of recurrent metastatic adenocarcinoma of the breast. FISH studies for HER-2 were negative. Her Breast tumor markers CA 15-3 were also elevated to 40.
Patient then had a metastatic work up done with CT scan of the chest, abdomen, and pelvis, which did not show any evidence of visceral metastases. Patient also had bone scan done because of back pain and it was negative.
She was then started on hormonal therapy with monthly fulvestrant injections, to which she had an excellent response and all the nodular erythematous lesions faded away within a month.
Discussion:
Cutaneous metastases of a primary visceral malignancy are relatively uncommon, with an overall incidence ranging from 0.7 to 10.4%. The incidence of breast carcinoma cutaneous manifestation (BCCM) in patients with breast carcinoma is relatively high with 23.9% of cutaneous metastases diagnosed as breast cancer (1, 2). In the majority of cases where skin metastasis has occurred, the primary cancer is widespread and may be untreatable. Surprisingly, our patient did not have any internal disease and presented with only erythematous lesions.
Conclusions:
Our case is unique with the presence of multiple metastatic cutaneous lesions with no detectable visceral disease.
It’s important for Primary care provider or hospitalist to recognize these lesions earlier and send for appropriate dermatological evaluation and biopsy to reach the final diagnosis.
1) Schwartz RA. Cutaneous metastatic disease. J Am Acad Dermatol 1995: 33: 161–182.
2) Lookingbill DP, Spangler N, Helm KF. Cutaneous metastases in patients with metastatic carcinoma: a retrospective study of 4020 patients. J AmAcad Dermatol 1993: 29: 228–236.
