Key Clinical Message:
We report an original case of carcinoma en cuirasse associated with
zosteriform metastasis announced the developing of contralateral breast
cancer.We underline the importance of the knowledge of this rare
clinical entity to ensure an early diagnosis.
Funding: None.
Manuscript word count: 400
Breast cancer (BC) is the first internal malignancy associated with
cutaneous metastasis of different clinical presentations [1]. We
report a case of carcinoma encuirasse (CC) associated with
zosteriform metastasis (ZM) revealing a contralateral BC.
A 40-year-old woman presented with painful erythematous papules grouped
on the right side of the trunk of two-months duration. She had a history
of left infiltrating ductal carcinoma 3 years back, treated with
chemotherapy, mastectomy and radiotherapy. On examination, numerous firm
erythematous clustered papules were present over the right side of the
chest in a dermatomal distribution (T4–T6) with peau
d’orange appereance (Figure1). The underlying skin was indurated. Many
diffuse sclerodermiform erythematous plaques were also present. There
was a palpable mass in the right breast. Two biopsies were performed
from a papule and an indurated plaque revealing same histologic
features: a dense dermal infiltration of malignant epithelial cells
delimiting cribriform clusters with lymphangitic carcinomatosis.Collagen
densification was also seen (Figure2). Microbiopsy of the breast nodule
confirmed the malignant origin. No distant metastasis was detected.
Controlateral BC with CM was finally diagnosed. The patient was started
on palliative chemotherapy after a multidisciplinary team meeting.
CMs in patients with BC occur in 23,9% [2]. Erythematous papules
and nodules are the most common presentation (80% of cases) [3].
Less commonly, atypical variants of skin involvement in BC can mimic
common processes: erysipelas (carcinoma erysipeloides), lymphangioma
circumscriptum and cutaneous vasculitis (carcinoma teleangiectaticum)
[3]. CC and ZM, presented here, resembling morphea and herpes
zoster respectively are extremely rare. In those exceptional cases, only
histology can make the diagnosis which often resembles the primary
cancer.
CC is seen in only 3% of patients with CMs from BC [3]. It is
characterized by erythematous indurated plaques with diffuse
sclerodermatous induration of the chest wall skin [2]. It is most
commonly linked with local recurrence of BC following treatment, as in
our case, but it can also be a clinical presentation of a primitive
tumor [3]. CC is characterized histologically by dense fibrosis with
few neoplastic cells and decreased vascularity, making it highly
resistant to chemotherapy [2].
ZM is a rarely seen subtype with only a few hundred cases in the
literature, among them 12 cases due to BC.6 It may be
distributed along dermatomes in various clinical patterns, including
nodular, papulovesicular, or vesiculobullous [2]. Several theories
have been proposed to clarify the pathogenetic mechanism of zosteriform
dissemination. It has been postulated to occur as a Koebner response to
recent herpes zoster [4]. Our patient did not report any skin lesion
over the area previously. ZM may also be generated by the diffusion of
tumor cells from the perineural lymphatic vessels [2]. This is
likely to be the cause in our patient having lymphangitic carcinomatosis
in histology. Occurring in oncologic immunosuppressive patients, ZM can
be confused with herpes zoster infection. Definite diagnosis is made on
microscopic examination. In our case, ZM occurred in the contralateral
site, revealing a contralateral BC. Association of CC and ZM has not
been reported yet.
To conclude, CM should be included in the differential of potentially
benign lesions in patients with neoplastic disease history.