RakPiersi metaDoSkory, Medycyna
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Case report/
Opis przypadku
Massive isolated breast carcinoma metastases
to the skin. A case report
Masywne izolowane przerzuty raka piersi do skóry. Opis przypadku
Marta Tazbir
1
, Grażyna Broniarczyk-Dyła
1
, Piotr Pluta
2
1
Klinika Dermatologii Ogólnej, Estetycznej i Dermatochirurgii Uniwersytetu Medycznego w Łodzi,
kierownik Kliniki: prof. dr hab. n. med. Grażyna Broniarczyk-Dyła
2
Klinika Chirurgii Onkologicznej Uniwersytetu Medycznego w Łodzi,
kierownik Kliniki: prof. dr hab. n. med. Arkadiusz Jeziorski
Post Dermatol Alergol 2009; XXVI, 6: 547–549
Abstract
A 61-year-old patient with a history of left breast carcinoma, after mastectomy and pre- and post-surgical radiotherapy,
presented to the Department of General Aesthetic Dermatology and Dermatosurgery in Lodz with metastatic spread
to the skin in the form of multiple nodules and tumours located on the trunk. Imaging diagnostics did not reveal
metastases to other organs. The patient was subjected to five cycles of chemotherapy, an attempt at hormone
therapy, and palliative surgical removal of the most bothersome cutaneous lesions. Despite applying various methods
of treatment, disease progression was not inhibited. The patient died within 6 months of the appearance of massive
lesions on the skin of the trunk.
Key words: breast carcinoma, skin metastases, skin invasion.
Streszczenie
Do Kliniki Dermatologii Ogólnej, Estetycznej i Dermatochirurgii zgłosiła się 61-letnia chora na raka piersi lewej po am-
putacji piersi oraz chemioterapii przedoperacyjnej, pooperacyjnej i radioterapii z powodu rozsianych przerzutów do skó-
ry o typie guzków i guzów umiejscowionych na tułowiu. W badaniach obrazowych nie stwierdzono przerzutów do in-
nych narządów. U chorej zastosowano trzy linie chemioterapii, próbę hormonoterapii oraz paliatywne wycięcie
najbardziej uciążliwych zmian skórnych. Mimo zastosowania różnych metod leczenia, nie spowodowały one zatrzy-
mania progresji choroby. Chora zmarła 6 mies. od czasu pojawienia się pierwszych zmian skórnych na tułowiu.
Słowa kluczowe: rak piersi, przerzuty do skóry, zajęcie skóry.
Introduction
Breast carcinoma is the most frequent malignancy in
females in Poland and other countries all over the world.
A higher prevalence of this neoplasm has been observed
since the beginning of the 1960s [1].
Metastatic breast carcinoma can spread to lymphatic
nodes (via lymphatics), as well as to distant organs (via
blood circulation) [2]. Metastases from breast carcinoma
most frequently develop in the lungs, the central nervous
system, the liver and bones. This disease can also spread
to the skin, although this concerns only a small percentage
of cases (approx. 5%) [3]. Usually, metastases to the skin
are accompanied by the involvement of internal organs
[4, 5]. We present a case of a patient with multiple isolated
breast carcinoma metastases to the skin, in whom rapid
disease progression occurred in spite of the treatment
applied.
Case report
In 2004, a 60-year-old woman with a negative family
history of neoplastic diseases presented to the Surgical
Oncology Department at the Medical University of Lodz
with a painless tumour (4 cm in diameter) of the left
breast (Figure 1). Numerous movable lymphatic nodes
of the left armpit were found. A fine needle aspiration
biopsy of the tumour and the lymph nodes revealed
the presence of cancerous cells. No metastases were
found in the chest X-ray examination or the ultrasound
of the abdominal cavity. The patient received neoadjuvant
Address for correspondence: lek. med. Marta Tazbir, Klinika Dermatologii, Dermatologii Dziecięcej i Onkologicznej II Katedry Uniwersytetu
Medycznego w Łodzi, ul. Kniaziewicza 1/5, 91-347 Łódź, tel. +48 42 251 60 92/+48 42 251 61 92, e-mail: marta-majewska@wp.pl
Postępy Dermatologii i Alergologii XXVI; 2009/6
547
Marta Tazbir, Grażyna Broniarczyk-Dyła, Piotr Pluta
Fig. 1. Early skin lesions in the appearance of breast carci-
noma metastases to the skin of the trunk (February, 2008)
hormone therapy, in spite of a negative receptor state.
She was given tamoxifen at a dose of 20 mg 1 × 1 for
6 weeks. Due to lack of improvement and the patient’s
malaise, the treatment was discontinued. In Feb-
ruary 2008, the patient reported to the Department of
General Aesthetic Dermatology and Dermatosurgery in
Lodz with massive spread of the cancerous process in
the form of multiple nodules located on the skin
of the trunk. The clinical examination revealed nodules
and tumours covered with erosions and ulcerations
located within dark brown extensive spots. Some
of the erosions were covered with bloody purulent crusts.
These lesions were not painful, but the patient
experienced strong itching. Rapid enlargement
of the tumours and the affected area prevented her from
being fully active. The patient was qualified for palliative
surgical treatment. The seven most bothersome tumours
(the largest size – 12 × 6 cm) were removed. Within
a month after the surgery, nodules and tumours
reappeared, enlarged rapidly, and underwent
decomposition (Figure 2). The patient’s imaging
examination (chest X-ray, abdominal USG, bone
scintigraphy) did not reveal the presence of breast
carcinoma metastases. The patient died in June 2008 due
to circulatory and respiratory insufficiency with symptoms
of pulmonary embolism (autopsy was not performed at
the request of the family).
chemotherapy including 4 cycles of Taxotere and
Adriblastine. A partial remission of the tumour size and
lymph nodes was achieved. The patient was qualified for
mastectomy. A modified radical mastectomy of the left
breast was carried out according to the Madden method.
Postoperative healing was uneventful. The histo-
pathological examination of the postoperative material
showed the presence of G-III infiltrative ductal carcinoma
in situ with a partial micropapillary component. In 11 of 17
lymph nodes carcinoma metastases of 1.6 cm in diameter
were detected. The extent of cancer spread according to
the TNM staging system was estimated as pT1cN3. The
degree of oestrogen and progesterone receptor expression
was negative (ER-0, PR = 0), but HER-2 receptor expression
was high (+2). The patient was subjected to postoperative
radiotherapy (50 Gy to the chest region + 50 Gy to lymph
node areas for 5 weeks), as well as adjuvant
chemotherapy according to the FAC scheme; 4 cycles were
applied. In May 2005, a relapse was diagnosed in
the vicinity of the scar after mammectomy. Following
the surgical removal of lesions, second-line chemotherapy,
including 4 cycles of Navelbine 40 mg + FU 800 mg, was
provided. One year later, a subsequent carcinoma relapse
in the scar in the form of multiple nodules and tumours
in the region of the chest was detected, and a surgical
biopsy confirmed the diagnosis. Third-line chemotherapy
(3 cycles of mitoxantrone in monotherapy, 20 mg each)
was applied. In April 2006, metastatic breast carcinoma
involved the chest skin; fourth-line chemotherapy, i.e.
cisplatin in monotherapy, 3 × 50 mg for 3 days, was
implemented. The treatment was carried out for 6 cycles
until lesion stabilization was achieved. The treatment
of skin lesions continued with subsequent fifth-line
chemotherapy with methotrexate at the dose of 50 mg
in monotherapy for 7 days (6 cycles). Next, oral
methotrexate (5 mg 60 tablets, 10 mg 100 tablets,
2.5 mg 250 tables) was administered. In May 2007, due
to progression of cutaneous lesions, the patient received
Discussion
Breast carcinoma metastasizes mainly to the lungs,
bones, central nervous system, and liver [1]. In
a retrospective study of 4020 patients with metastatic
disease, Lookingbill DP, Spangler N and Helm KF reported
that cutaneous metastatic breast carcinoma accounted
for 5% of cases. In the available literature, we have not
found any case report with massive metastases from breast
carcinoma to the skin unaccompanied by metastatic spread
to other organs symptomatically or visible in diagnostic
imaging examination. Therefore, in our opinion we present
the first case with such an atypical course of the disease.
French
et al.
described a case of a 39-year-old woman
with extensive metastatic breast carcinoma spreading to
the upper extremity with the signs and symptoms
of lymphoedema, and to the bones [6]. The patient had
been earlier treated at other institutions because
of recurrent invasive ductal adenocarcinoma manifested
by skin lesions. She had undergone neoadjuvant
chemotherapy followed by a modified radical mastectomy,
radiotherapy, and adjuvant chemotherapy. At the time
of presentation she had extensive necrosis and
lymphoedema of the upper limb caused by lymphatic
obstruction secondary to cancer cell invasion, and
underwent shoulder disarticulation for palliation with
chemotherapy. The survival time for the patient from
admission to the department was 18 months.
548
Postępy Dermatologii i Alergologii XXVI; 2009/6
Massive isolated breast carcinoma metastases to the skin. A case report
A
B
C
D
Fig. 2. Advanced neoplastic dissemination to the skin (June, 2008)
Furthermore, Daneshbod
et al.
presented a case
of cutaneous manifestation of breast carcinoma me-
tastases in a 47-year-old patient [7]. Cutaneous lesions
were initially observed in the scar after mammectomy and
later they disseminated to the whole upper extremity,
resulting in its intensive oedema and erythema. The skin
of the limb was thickened, with distinctly marked affected
posterior areas resembling cellulitis, and intensive
infiltration of fluid from the lesions. Radical excision
of the left breast had been performed 15 years earlier due
to infiltrating ductal carcinoma. A biopsy from the skin
lesions confirmed the presence of the disease. The levels
of oestrogen and progesterone receptors as well as Her2
receptors and p53 were negative, which the authors
associated with multiple cancer cell obstruction in
lymphatic vessels.
The median survival rate for patients with cutaneous
metastatic breast carcinoma is approximately 6 months
[8, 9]. However, our patient's survival was 3 years from
the first relapse of the disease in the scar following
mastectomy and 6 months from the patient's presentation
to our department with massive metastases to the skin.
All this confirms the observation of poor prognosis
of breast carcinoma metastases to the skin [10].
The project was financed by the resources of statutory
work No. 503-7064-1.
References
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