Rapid progression of carcinoma en cuirasse breast dermal metastases on ¹⁸F-fludeoxyglucose positron emission tomography–computed tomography

Abstract

Cancer in the dermis of the breast has a poor prognosis. The breast dermis can become malignantly involved primarily in inflammatory breast cancer, through the direct extension of locally advanced breast cancer, or metastatically from an underlying breast mass or a distant primary malignancy (e.g., gastric adenocarcinoma). Breast dermal metastases have the shortest median survival among them. Breast dermal metastases are classified into eight clinicohistopathologic groups, one of which is carcinoma en cuirasse. We present a case of a 52-year-old female with a history of invasive ductal carcinoma, Stage IIIC (pT2N3a), treated with lumpectomy, axillary node dissection, and chemoradiation therapy that recurred as carcinoma en cuirasse breast dermal metastases. Through ¹⁸F-fludeoxyglucose positron emission tomography–computed tomography (¹⁸F-FDG PET-CT) and clinical images, the case illustrates the rapid progression and devastating consequences of carcinoma en cuirasse breast dermal metastases over a 4-month period despite optimal therapy. Furthermore, the case emphasizes the sensitivity of ¹⁸F-FDG PET-CT to detect pathology in the breast dermis. Finally, the case highlights the crucial role that nuclear medicine physicians play in helping clinical colleagues differentiate between the various breast dermal malignant manifestations and benign mastitis, a common confounder in postradiation patients.

Keywords

¹⁸F-fludeoxyglucose positron emission tomography–computed tomography - breast dermal metastases - carcinoma en cuirasse - inflammatory breast cancer - locally advanced breast cancer

Disclaimer: The views expressed in this manuscript are those of the author and do not reflect the official policy of the Department of Navy, Department of Defense, or U.S. Government.

Copyright Statement: The first author is a military service member. This work was prepared as part of the authors' official duties. Title 17 U.S.C 105 provides that 'Copyright protection under this title is not available for any work of the United States Government.' Title 17 U.S.C. 101 defines a U.S. Government work as a work prepared by a member or employee of the U.S. Government as a part of that person's official duties.

Case Report

A 52-year-old female with a 4.6 cm left breast invasive ductal carcinoma (no special type) was treated with a lumpectomy and axillary lymph node dissection. Pathologic analysis of surgical specimens revealed wide negative surgical margins on the primary mass, and 19 of 25 lymph nodes were metastatically involved, overall consistent with Stage IIIC (pT2N3a) disease. No left breast dermal involvement was initially present. Subsequently, she received adjuvant chemotherapy with Adriamycin, Cytoxan, and paclitaxel and 66 Gy of radiation to the left breast and axilla.

About 1 year later, she represented with fibrosis of the left breast [Figure 1a], white short arrows], and palpable right axillary adenopathy. While biopsy of the right axillary adenopathy indicated recurrent malignancy, the left breast fibrosis was initially clinically favored to represent radiation mastitis, partially attributable to initial punch biopsy results. However, an ¹⁸F-fludeoxyglucose positron emission tomography–computed tomography (18 F-FDG PET-CT) demonstrated an intense hypermetabolic activity associated with the right axillary adenopathy [Figure 1b], black arrows] and broad areas of moderate hypermetabolic activity throughout the left breast dermis and parenchyma [Figure 1c], white arrows]. This indicated that the changes in the left breast represented a site of aggressive recurrence as opposed to benign inflammation. This was confirmed with a repeat punch biopsy. The skin changes in the left breast were subsequently identified as carcinoma en cuirasse breast dermal metastases. Despite aggressive salvage chemotherapy with paclitaxel and carboplatin, an ¹⁸F-FDG PET-CT scan performed 4 months later revealed the progression of metastatic disease with spread to the right breast, with clinical images showing widespread cutaneous ulcerations and excoriations [Figure 1d], [Figure 1e], [Figure 1f]. Metastatic spread to the right breast dermis was confirmed by punch biopsy which demonstrated invasion of lymphovascular spaces by tumor emboli [Figure 2], black short arrows] in a background of fibrous connective tissue.

Discussion

Figure 1 (a-c) Pre-salvage chemotherapy (d-f) Post-salvage chemotherapy

Figure 2 Postsalvage chemotherapy biopsy

Cancer in the dermis of the breast has a poor prognosis. The breast dermis can become malignantly involved primarily in inflammatory breast cancer, through direct extension of locally advanced breast cancer, or metastatically from an underlying breast mass or a distant primary malignancy (e.g., gastric adenocarcinoma). [Table 1] describes the differences between these entities. Dermal metastases have the shortest median survival.[11],[12] Dermal metastases from underlying breast cancer occur infrequently, with an estimated incidence between 0.6% and 10%.[13] First described by Velpeau in 1838, carcinoma en cuirasse is a particularly aggressive clinicohistopathologic variant of breast dermal metastases with a contractile fibrous texture resembling the metallic chest plate in antique Spanish cavalry armor.[14] Carcinoma en cuirasse accounts for approximately 3% of dermal metastases from underlying breast cancer.[15] Carcinoma en cuirasse is rarely the presenting feature of underlying breast cancer but rather tends to occur later in the course of the disease development or as a sign of recurrence.[13],[15] It is also known as scirrhous carcinoma, pachydermia, or Acarcine eburnee.[16] While others have presented ¹⁸F-FDG PET-CT images of this entity,[16],[17] this case report represents the first depiction of the rapid progression and devastating consequences. Furthermore, the case emphasizes the sensitivity of ¹⁸F-FDG PET-CT to detect pathology in the breast dermis. Finally, the case highlights the crucial role that nuclear medicine physicians play in helping clinical colleagues differentiate between various breast dermal malignant manifestations and benign mastitis, a common confounder in postradiation patients. Physicians interpreting ¹⁸F-FDG PET-CT images must routinely scrutinize the breast dermis for thickening or hypermetabolism. Such findings warrant recommending direct physical examination with tissue sampling as indicated.

Table 1 Differentiating malignant lesions of the breast dermis

Conflict of Interest

There are no conflicts of interest.

Financial support and sponsorship

Nil.

• References

• 1 Giuliano AE, Connolly JL, Edge SB, Mittendorf EA, Rugo HS, Solin LJ, et al. Breast cancer-major changes in the American Joint Committee on Cancer eighth edition cancer staging manual. CA Cancer J Clin 2017;67:290-303.
• 2 Yeh ED, Jacene HA, Bellon JR, Nakhlis F, Birdwell RL, Georgian-Smith D, et al. What radiologists need to know about diagnosis and treatment of inflammatory breast cancer: A multidisciplinary approach. Radiographics 2013;33:2003-17.
• 3 Garg PK, Prakash G. Current definition of locally advanced breast cancer. Curr Oncol 2015;22:e409-10.
• 4 Schwartz RA. Histopathologic aspects of cutaneous metastatic disease. J Am Acad Dermatol 1995;33:649-57.
• 5 Afiya S, Singh J. Carcinoma en cuirasse with zosteriform metastasis-a rare presentation of breast carcinoma. J Med Surg Pathol 2017;1:1-3.
• 6 Perez-Pinera P, Chang Y, Deuel TF. Pleiotrophin, a multifunctional tumor promoter through induction of tumor angiogenesis, remodeling of the tumor microenvironment, and activation of stromal fibroblasts. Cell Cycle 2007;6:2877-83.
• 7 Hayashi K, Matsuda S, Machida K, Yamamoto T, Fukuda Y, Nimura Y, et al. Invasion activating caveolin-1 mutation in human scirrhous breast cancers. Cancer Res 2001;61:2361-4.
• 8 Tsukamoto K, Ito N, Yoshimoto M, Kasumi F, Akiyama F, Sakamoto G, et al. Allelic loss on chromosome 1p is associated with progression and lymph node metastasis of primary breast carcinoma. Cancer 1998;82:317-22.
• 9 Calaf GM, Echiburú-Chau C, Zhao YL, Hei TK. BigH3 protein expression as a marker for breast cancer. Int J Mol Med 2008;21:561-8.
• 10 Ochiai A, Akimoto S, Shimoyama Y, Nagafuchi A, Tsukita S, Hirohashi S, et al. Frequent loss of alpha catenin expression in scirrhous carcinomas with scattered cell growth. Jpn J Cancer Res 1994;85:266-73.
• 11 Hance KW, Anderson WF, Devesa SS, Young HA, Levine PH. Trends in inflammatory breast carcinoma incidence and survival: The surveillance, epidemiology, and end results program at the national cancer institute. J Natl Cancer Inst 2005;97:966-75.
• 12 Schoenlaub P, Sarraux A, Grosshans E, Heid E, Cribier B. Survival after cutaneous metastasis: A study of 200 cases. Ann Dermatol Venereol 2001;128:1310-5.
• 13 Mahore SD, Bothale KA, Patrikar AD, Joshi AM. Carcinoma en cuirasse: A rare presentation of breast cancer. Indian J Pathol Microbiol 2010;53:351-8.
• 14 Savatard L. Cancer en cuirasse. Br J Dermatol Syph 1943;55:31-9.
• 15 Mordenti C, Peris KM, Fargnoli C, Cerroni L, Chimenti S. Cutaneous metastatic breast carcinoma. Acta Dermatovenerol 2000;9:143-8.
• 16 Tung L, Stone EC, Bhasin M, Sheth S, Nelson M, Sheth PA, et al. Breast carcinoma en cuirasse as a natural progression of untreated breast cancer. Case Stud Surg 2015;2:46-8.
• 17 Win AZ, Aparici CM. Carcinoma en cuirasse from recurrent breast cancer seen on FDG-PET/CT. J Clin Imaging Sci 2015;5:35.

Publication History

Received: 18 May 2019

Accepted: 01 July 2019

Article published online:
19 April 2022