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Breast cancer cutaneous metastases mimicking Papilloma Cutis Lymphostatica. Biopsy to avoid pitfalls

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InternationalJournalofSurgeryCaseReports46(2018)31–33

Contents lists available atScienceDirect

International

Journal

of

Surgery

Case

Reports

j o u r n a l h o m e p a g e :w w w . c a s e r e p o r t s . c o m

Breast

cancer

cutaneous

metastases

mimicking

Papilloma

Cutis

Lymphostatica.

Biopsy

to

avoid

pitfalls

Giuseppe

Giudice,

Michelangelo

Vestita,

Fabio

Robusto,

Paolo

Annoscia,

Francesco

Ciancio

,

Eleonora

Nacchiero

DepartmentofPlasticandReconstructiveSurgery,UniversityofBari,Italy

a

r

t

i

c

l

e

i

n

f

o

Articlehistory: Received8January2018 Accepted19March2018 Availableonline10April2018

Keywords: Breastcancer Lymphedema

PapillomaCutisLymphostatica Metastases

a

b

s

t

r

a

c

t

INTRODUCTION:Secondarylymphedemaisthemostfrequentlong-termcomplicationofaxillary lym-phadenectomy.Itcanresultincomplicationaserysipelas,warts,PapillomaCutisLymphostatica(PCL),or angiosarcomas.Moreover,inwomenaffectedbybreastcanceranaccuratedifferentialdiagnosisamong theseconditionsorcomplicationrelatedtoradiationdermatitisorcutaneousmetastasisisessential. PRESENTATIONOFCASE:Wereportthecaseofa60-year-oldpostmenopausalCaucasianwomanaffected bysecondarylymphedemafollowingcompletemastectomyforbreastcancer.Thepatientaftersurgery wastreatedwithradiotherapy,chemotherapyandhormonetherapy,developingalympedemaofleft armafterfewmonths.TheselesionshadclinicaltypicalfeaturesofPCL,buthistopathologicalanalysis revealeddermo-hypodermicmetastasisofbreastcarcinoma.

DISCUSSION:Thepresenceofskinlesionsinsecondarylymphedemaafteroncologicallymphadenectomy requiresanaccuratedifferentialdiagnosis.Infact,theselesionscanemulatedegenerativeorinfective skindiseases;anyway,inpatientsaffectedbysecondarylymphedemaotherlesscommonconditions– asPLC,nodular-typelichenmyxedematosusorGottron’scarcinoidpapillomatosis–shouldbetakeninto account.

CONCLUSION:Ourcasereportsthepossibilitythatmetastasesofbreastcancermightalsomimicthese conditions.

©2018TheAuthor(s).PublishedbyElsevierLtdonbehalfofIJSPublishingGroupLtd.Thisisanopen accessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction

Secondarylymphedema ofupper limbsisthemostfrequent long-term complication of axillary lymphatic tissue resections, withanincidencerangingbetween6%and30%[1].Mostfrequent sequelaoflymphedemaareerysipelasandwarts,butinveryrare casesit canresultin moreseverecomplications, suchas Papil-lomatosisCutis Lymphostatica(PCL)or angiosarcomas.PCLis a benign,usuallyasymptomaticandunderreportedcondition result-ingfromchroniclymphedema[2].Itwasmorefrequentlyreported inprimarylymphedemaorascomplicationofasecondary dam-ageoflymphaticvesselsduetodiabetes.Todate,fewcasesofPCL havebeendocumentedafteraiatrogenicsecondarylymphedema [3,4].Alsocarcinomasorangiosarcomasarisinginlimbsaffected bychroniclymphedemahavebeendocumented[5,6].Moreover, lesionsarisingin upper limbin women affectedby breast car-cinoma could be related to cutaneous metastases or radiation dermatitisfollowingradiationtherapy[7,8].Forthis reason,the

∗ Correspondingauthorat:DepartmentofPlasticandReconstructiveSurgery, UniversityofBari,CAP70124PiazzaGiulioCesare11,Bari,Italy.

E-mailaddress:francescociancio01@gmail.com(F.Ciancio).

presence ofskinlesionsoftheupperlimbsin patientsaffected bybreastcancerrequiresanaccuratedifferentialdiagnosisamong cancerrecurrencesormetastasis,therapeuticalcomplications,and dermatologicalconditions.Theworkhasbeenreportedinlinewith theSCAREcriteria[9].

2. Casereport

Wepresentthecaseofa60-year-oldpostmenopausalCaucasian woman affectedbysecondary lymphedema following complete mastectomyandaxillarydissectionforaLuminalBinvasivelobular carcinomaofleftbreast.Immunohistochemistrytestifiesnegativity forHER-2mutation.Patientunderwentmastectomyandcomplete lymphadenectomyofleftaxillaryregioninNovember2015.The patientrefusedthereconstructivesurgicaltreatmentofthebreast. After surgery, the case was presented to the multidisciplinary breastcancerboardofourinstitutionandthepatientunderwent localradiotherapyandadjuvantchemotherapybasedon anthracy-cline/taxaneregimenfollowedbyhormonetherapywithletrozole. InOctober2016,thepatientpresentedwithastageIIIleftupper limblymphedema[10]withtheappearanceofisochromicnodular lesionsoftheskin(Figs.1and2).Segmentallymphoscintigraphy ofupperlimbsdocumentedaseverelymphedemaoftheleftupper

https://doi.org/10.1016/j.ijscr.2018.03.025

2210-2612/©2018TheAuthor(s).PublishedbyElsevierLtdonbehalfofIJSPublishingGroupLtd.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://

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32 G.Giudiceetal./InternationalJournalofSurgeryCaseReports46(2018)31–33

Fig.1.Initialclinicalpresentationoflesions.

Fig.2. Detailofinitialnodularlesion.

Fig.3. Clinicalpresentationofmultiplenodularreddenedlesions.

limbwithahighvalueofTransportIndex(28),while lymphoscinti-graficexaminationwasnormal in thecontralateral upperlimb. Thepatientunderwenttherapywithphysiotherapy,bandagesand plasticdevices;inDecember2016,however,thepatientreported furtherdiffusionandreddeningof theskinlesionsaffectingthe leftupperlimb(Figs.3and4).Thephysicalexaminationrevealed thepresenceofpainlessnon-confluentovalnodularlesions, dis-tributedonthevolarsurfaceofleftarmand forearm.Clinically, theselesionshadthetypicalfeaturesoflymphostatic papillomato-sis;nonetheless, due tothepatient’s history, we performedan excisionalbiopsyofone ofthelesions.Histopathologicanalysis revealedthepresenceof0.7cm masscharacterizedbypresence ofpleomorphicspindlecellswithlargehyper-chromaticnucleiand denseeosinophiliccytoplasm.Immunohistochemistrywaspositive forproteinKi67andestrogenreceptor,confirmingthediagnosisof dermo-hypodermicmetastasisofinvasivebreastcarcinoma.The patientwasconsideredhormone-refractory and sheunderwent tofirstlinechemotherapywithanti-VEGFincombinationto

tax-Fig.4.Detailofreddenedlesions.

ane.Todate,shehasundergoneclinicalandimaging(chestX-ray, abdominalultrasound,andwhole-bodySPECT/CTscan)follow-up withnoevidenceoflymphaticorvisceralmetastases.

3. Discussion

Presenceofovalexophiticnon-pigmentedlesioninthe homo-lateralupper limb of womanwho underwent mastectomy and completelymphadenectomyofaxillaryregionforabreastcancer needanaccuratedifferentialdiagnosis,evenmoreinpresenceof lymphedema.

First of all,differential diagnosis includes degenerative skin conditions such as keratoacanthoma, pilomatricoma, pyoderma vegetans, and non-pigmented skin cancers; however the pres-enceofmultipleexophiticlesionsmakestheseunlikelydiagnoses. Infectivecomplicationsoflymphedemaaremoreplausibleinthis patient;infact,lymphedemaisthemostcommonlong-term com-plicationofaxillarylymphnodedissection[1]andassociationof reducedimmunesurveillanceandskindamageinthe lymphede-matousregions[11]mayleadtoskininfections.Inmoresevere cases,lymphedemacanresultinpapillomatosiscutis lymphostat-ica(PCL),characterizedbythepresenceofmultipleskin-colored, confluent,partlyhyperkeratotic,verrucouspapulesonlimbs[6].In suchcases,skininfections,aserysipelas,mayresultfromskinlossof continuity.Wartsandangiosarcomaswerealsoreportedinpatients affectedbyPCL[5,6]. Finally,nodular-type lichen myxedemato-susandGottron’s carcinoidpapillomatosis[12]skinshouldalso beconsideredincaseofmultipleexophyticlesionsonlimbs,but theabsenceofhypothyroidismandthenegativityforHPVserology assayexcludethesediagnoses.

Alloftheaboveconditionsarecompatibleswiththeskinlesions affectingtheleftupperlimbofourpatient;cutaneousmetastasesof breastcancer,ontheotherhand,havebeendocumentedinseveral studies,asevidencedbyourresearchatoneofthemost impor-tantdatabasesintheliterature[13].Thesecanbepolymorphous, mimickingwhealrash[14],erythemaannullarecentrifugum[15], nodules[16]orexophyticlesions[7].

Inanycase,excisionalbiopsyisindispensableforacorrectand precociousdiagnosisofskinmetastasisofbreastcancermimicking PCLinalimbaffectedbylymphedema.Furthermore,asinourcase, skinmetastasesmaybethefirstclinicalevidenceofrecurrenceand theirdetectionimpliestheadjustmentofchemotherapyregimen andthusholdsprognosticandtherapeuticsignificance.

Conflictsofinterest

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G.Giudiceetal./InternationalJournalofSurgeryCaseReports46(2018)31–33 33

Funding

Authorshavenotreceivedfundingorsponsorforpaper produc-tion.

Ethicalapproval

Tocarryoutthisscientificwork,therewasnoneedtoresort totheethicscommittee.Ethicalapprovalhasbeenexemptedfrom ourinstitution.

Consent

Writteninformedconsentwasobtainedfromthepatientfor publicationofthiscasereportandaccompanyingimages.Acopy ofthewrittenconsentisavailableforreviewbytheEditor-in-Chief ofthisjournalonreques.

Authorcontribution

Alltheauthorscontributedequallytothewritingofthepaper. Researchregistrationnumber

NA. Guarantor

FrancescoCiancioMD. References

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Fig. 4. Detail of reddened lesions.

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