86 yo lady presented with 6 month history of asymptomatic nodules and plaques. Biopsy of the skin lesions revealed metastatic carcinoma.

Investigations

FBC/ LFT / FBS: normal
ESR: 84
CR: 128
Tumour markers:
CA 125 : 35.1 (<35.0)
CEA: 8.8 (<5.0)
CA 15.3: 83.3 (<31.4)
aFP: 4.78 (1.09-9.04)

1: Ultrasound scan Neck: Multinodular goiter
2. Ultrasound scan Breast:No mass seen.There is skin thickening of the breasts
3. Mammogram :No mass seen.There is skin thickening of the breasts. No evidence of malignancy
4. CT Neck/Thorax/Abdomen/Pelvis: Enlarged right axillary lymph nodes. Solitary right lung nodule. Left thyroid nodules
5. MRI Breast: Not done as patient refused on the grounds that she will not be able to lie prone for the length of time required

Histopath Report

Section shows malignant cells infiltrating the dermis and subcutaneous fat. The malignant cells are characterised by small cells which lack of cohesion and appeared individually dispersed through a fibrous connective tissue and some arranged in single linear cords. The cells have a rounded-to-ovoid nuclei and a thin rim of cytoplasm. The epidermis appeared unremarkable.

The immunohistochemistry study shows the cells are immunoreactive to CK7, ER and PR. CK20, CD3, CD20 amd vimentin are negative

Skin biopsy: carcinoma most likely metastatic

Note: Primary from breast need to be considered in view of IHC findings. The immunoprofile does not support the diagnosis of lymphoma

Low power (H&E stain)

High Power (H&E stain)

Immunohistochemical Study
CK7 (cytokeratin)

ER (Estrogen receptor)

PR (Progesterone receptor)

Cutaneous metastases secondary to occult breast cancer ? with possible lung and lymph node metastases

Gynaecology team opinion
Scan done.No evidence to suggest pelvis mass. Advised that gynaecological malignancies seldom metastasize to the skin without any prior manifestations

Surgical team opinion
Occult Breast Carcinoma with skin metastases. Patient commenced on Letrozole 2.5mg od (oral non-steroidal aromatase inhibitor ) with a follow up appointment in 4 months time

Discussion with patient and family:
Not keen for further investigations. Conselled re: lung and lymph node biopsy to ascertain possible metastasis but refused. Happy to continue as per surgical team advice and will attend dermatology clinic for regular review

Our issues of concern are:

1. Is the diagnosis acceptable?

2. Are there other opinions with regards to the histopathology findings?

3. Are there any further investigations that we may do for this patient?

4. Any further opinions in terms of management?

Stephen Stone M.D. Professor of Dermatology, Southern Il University, Springfield, IL, USA on February 19, 2010

Excellent case presentation. The photomicrographs are very good. I would suggest the breast is only a presumptive source for these mets, and the search for a primary should be continued.

Ashok Sharma MD, Formerly Professor of Dermatology, Dr RP Government Medical College, Tanda, Kangra, HP, India on February 19, 2010

1. Considering the clinical presentation, history, physical examination and the histopath the diagnosis is quite valid.

2. Although I am not an expert pathologist however the histopath supported by special stains and markers does suggest presence of malignant cells.

3. I must complement you on your very thorough investigations in this patient (whatever she would permit). I don't see what else can be investigated.

4. An Oncologist's opinion is required. Considering her age, I am not sure if radiotherapy would help or prove intolerable. Also all management has to be as per her informed consent.

David Elpern MD, Dermatologist, Williamstown, MA, USA on February 19, 2010

A general dermatologist sees only occasional patients with cutaneous mets. These patients usually have more serious internal lesions. At 86 yo, I would not be aggressive. There is a role for palliation and not giving toxic meds nor incurring major expenses for the patient or her family. I would recommend an opinion from a dermatologic oncologist and a general oncologist and proceed slowly. Of course, the patient may not even want treatment at this point.

Khalid Al Hawsawi MD, Paediatric Dermatology Fellow,Sickkids' Hospital Toronto/Canada on February 19, 2010

Excellent case. I think this patient should be treated by oncologist.

Jag Bhawan M.D., Professor, Department of Dermatology and Pathology, Boston University School of Medicine, Boston, MA, USA on February 23, 2010

I agree that this is likely to be metastatic carcinoma. Breast is most likely the primary.

Ibrahim Misk MD, Dermatologist, Amman, Jordan on March 6, 2010

Thanks for the very nice case presented. I would refer him to an oncologist.