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

(1)

CASE

REPORT

–

OPEN

ACCESS

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.

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

(2)

CASE

REPORT

–

OPEN

ACCESS

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

(3)

CASE

REPORT

–

OPEN

ACCESS

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

[1]J.A.Petrek,M.C.Heelan,Incidenceofbreastcarcinoma-relatedlymphedema,

Cancer83(1998)2776–2781.

[2]R.S.Kasper,S.Nobbe,Imagesinclinicalmedicine.Papillomatosiscutis

lymphostatica,N.Engl.J.Med.370(January(1))(2014)69,http://dx.doi.org/

10.1056/NEJMicm1307463.

[3]D.Aydin,M.Heidenheim,Papillomatosiscutislymphostatica,Clin.CaseRep.

4(September(10))(2016)1012(eCollection2016Oct.).

[4]M.Guida,A.Cramarossa,E.Fistola,M.Porcelli,G.Giudice,K.Lubello,G.

Colucci,Highactivityofsequentiallowdosechemo-modulating

TemozolomideincombinationwithFotemustineinmetastaticmelanoma.A

feasibilitystudy,J.Transl.Med.8(November)(2010)115.

[5]H.H.Niederauer,U.Schultz-Ehrenburg,K.U.Tiedjen,Tumorformof

lymphostaticpapillomatosisoftheskin,Hautarzt42(August(8))(1991)

518–522(ArticleinGerman).

[6]J.I.Epstein,G.Mendelsohn,Squamouscarcinomaofthefootarisingin

associationwithlong-standingverrucoushyperplasiainapatientwith

congenitallymphedema,Cancer54(September(5))(1984)943–947.

[7]U.Handa,R.Kundu,K.Dimri,Cutaneousmetastasisastudyof138cases diagnosedbyﬁne-needleaspirationcytology,ActaCytol.(December)(2016),

http://dx.doi.org/10.1159/000453252.

[8]F.N.Bray,B.J.Simmons,A.H.Wolfson,K.Nouri,Acuteandchroniccutaneouss

reactionstoionizingradiationtherapy,Deematol.Ther.(Heidelb.)6(June(2))

(2016)185–206.

[9]R.A.Agha,A.J.Fowler,A.Saetta,I.Barai,S.Rajmohan,D.P.Rajmohan,The

SCAREGroup,TheSCAREstatement:consensus-basedsurgicalcasereport

guidelines,Int.J.Surg.34(October)(2016)180–186.

[10]InternationalSocietyofLymphology,Thediagnosisandtreatmentof

peripherallymphedema:2013ConsensusDocumentoftheInternational

SocietyofLymphology,Lymphology46(March(1))(2013)1–11.

[11]W.J.Stewart-Treves,Syndrome:alethalcomplicationofpostmastectomy

lymphedemaandregionalimmunedeﬁciency,Arch.Surg.(1979)11482.

[12]H.H.Niederauer,U.Schultz-Ehrenburg,K.U.Tiedjen,Tumorformof

lymphostaticpapillomatosisoftheskin,Hautarzt42(August(8))(1991)

518–522.

[13]LoRusso,G.Spolveri,F.Ciancio,F.A.Mori,Mendeley:aneasywaytomanage, share,andsynchronizepapersandcitations,Plast.Reconstr.Surg.131(6) (2013)946e–947e,http://dx.doi.org/10.1097/PRS.0b013e31828bd400.

[14]C.Damaskos,D.Dimitroulis,V.Pergialiotis,C.Doula,G.Koulermou,E.A.

Antoniou,M.Frangoulis,K.Stergios,K.Kontzoglou,Anunexpectedmetastasis

ofbreastcancermimickingwhealrush,G.Chir.37(May–June)(2016)

136–138.

[15]V.Sabater,F.Ferrando,A.Morera,L.Palomar,Cutaneousmetastasisof inﬂammatorybreastcarcinomamimickinganerythemaannulare centrifugum:asignoflocallyrecurrentcancer,Clin.Exp.Dermatol.41 (December(8))(2016)906–910,http://dx.doi.org/10.1111/ced.12953.

[16]S.Kamaraju,J.Depke,J.Povletich,A.Currey,E.Weil,Cutaneousmetastasis

duetoBreastcancerinapatientwithprimarybiliarycirrhosis:acasereport,

CaseRep.Oncol.9(November(3))(2016)718–725.

OpenAccess

ThisarticleispublishedOpenAccessatsciencedirect.com.ItisdistributedundertheIJSCRSupplementaltermsandconditions,which permitsunrestrictednoncommercialuse,distribution,andreproductioninanymedium,providedtheoriginalauthorsandsourceare credited.