Cutaneous Metastasis of Breast Carcinoma Presenting as Alopecia Neoplastica:

Diagnosis and Management of Scalp Metastases: A Review

Scalp metastases (SMs) are particularly noteworthy, representing around 4-7% of cutaneous neoplasms in this region of the body, possibly due to its rich blood supply. Diagnosis of SMs involves a systematic approach encompassing oncologic history, clinical examination, dermoscopy, imaging, and histopathological assessment. Clinical presentations of SM can vary, but dermoscopy reveals unique vascular patterns aiding in diagnosis. Imaging, particularly MRI and CT, and histopathological evaluation are mandatory for definitive diagnosis. Treatment strategies vary depending on tumor characteristics and staging, ranging from surgical excision to systemic therapies like chemotherapy or radiotherapy. Multimodal approaches tailored to individual cases yield optimal outcomes. The diagnostic tools available do not always allow SMs to be diagnosed, and often the lack of knowledge on the part of oncologists in suspecting SMs can delay an early diagnosis. This review provides clinicians with a practical guide for the timely diagnosis and management of SM, emphasizing the importance of a multidisciplinary approach and personalized treatment strategies for improved patient outcomes.

Clinical, Pathological, and Molecular Features of Breast Carcinoma Cutaneous Metastasis

Cutaneous metastases (CMs) account for 2% of all skin malignancies, and nearly 70% of CMs in women originate from breast cancer (BC). CMs are usually associated with poor prognosis, are difficult to treat, and can pose diagnostic problems, such as in histopathological diagnosis when occurring long after development of the primary tumor. In addition, the molecular differences between the primary tumors and their CMs, and between CMs and metastases in other organs, are not well defined. Here, we review the main clinical, pathological, and molecular characteristics of breast cancer CMs. Identifying molecular markers in primary BC that predict CM and can be used to determine the molecular differences between primary tumors and their metastases is of great interest for the design of new therapeutic approaches.

Breast Cancer-Related Neoplastic Alopecia: A Case Report and Review of the Literature

Neoplastic alopecia (NA) is defined as an organized hair loss in single or multiple areas of the scalp caused by a primary tumor that has metastasized to the skin of the scalp. Due to its localization and clinical appearance, NA should be placed in differential diagnosis with alopecia areata or other entities. To date, pathognomonic dermoscopic criteria of NA have not yet been described: the absence of classical criteria of other scalp diseases in addition to a major neovascularization with on-focus arborizing vessels and erosions or ulcerations may help the clinician to suspect a diagnosis of secondary alopecia. Dermatologists should pay more attention to these rare forms of secondarism because in exceptional cases, a simple alopecia of the scalp can hide a new, relapsing or metastatic neoplasia.

Cutaneous Metastatic Cancer: Carcinoma Hemorrhagiectoides Presenting as the Shield Sign

Cutaneous metastases can be either the initial presentation of an unsuspected internal neoplasm in a cancer-free individual, or the harbinger of recurrent malignancy in an oncology patient who had achieved remission of his cancer, or a sign of progressive disease in a cancer patient who is currently receiving antineoplastic treatment. The cutaneous presentation of skin metastases is pleomorphic and can mimic not only benign conditions and tumors of the skin but also infections and inflammation of the skin. Carcinoma erysipelatoides, carcinoma hemorrhagiectoides, and carcinoma telangiectoides are the three subtypes of inflammatory cutaneous metastatic cancer. The former masquerades as a cutaneous streptococcal infection whereas the latter mimics idiopathic telangiectasias. In contrast, the morphology of carcinoma hemorrhagiectoides is distinctive: it appears similar in shape to a medieval knight's shield and its presence is referred to as a positive shield sign. To the best of our knowledge, carcinoma hemorrhagiectoides has been reported in four oncology patients whose skin metastases presented with the shield sign: two men with salivary duct carcinoma and two women with breast cancer. In conclusion, the shield sign may not only be a pathognomonic clinical feature of carcinoma hemorrhagiectoides but also reflect a common genomic aberration of these metastatic tumors.

Dermatologic sequelae of breast cancer: From disease, surgery, and radiation

The care of breast cancer patients is important to dermatologists. Breast cancer's initial presentation, clinical progression, and its associated treatments can result in a variety of cutaneous complications. Dermatologists may be the first to identify a breast cancer diagnosis, as a subset of patients first present with direct extension of an underlying tumor or with a cutaneous metastasis. The surgical treatment of breast cancer also begets a variety of skin sequelae, including postoperative lymphedema, soft tissue infections, seromas, pyoderma gangrenosum, and scarring disorders. Moreover, breast cancer radiation treatment commonly results in skin changes, which can range from mild and temporary dermatoses to chronic and disfiguring skin ulceration, fibrosis, and necrosis. Radiation may also precipitate secondary malignancies, such as angiosarcoma, as well as rarer dermatologic diseases, such as radiation-induced morphea, lichen planus, and postirradiation pseudosclerodermatous panniculitis. Finally, breast cancer is also associated with an array of paraneoplastic phenomena, including Sweet's syndrome and the rarer intralymphatic histiocytosis. Herein, we review the dermatological manifestations of breast cancer, including conditions associated with its presentation, progression, and treatment sequelae. Chemotherapy-induced cutaneous side effects are beyond the scope of this review. This article provides a comprehensive review for dermatologist to be able to identify, diagnose, and manage breast cancer patients from initial presentation to treatment monitoring and subsequent follow-up.

Alopecia as a systemic disease

Alopecia is a skin condition of great social and psychologic impact. Primary alopecia originates from the hair follicles and usually does not have systemic manifestations; however, secondary alopecia can affect the hair follicles in the setting of systemic diseases, medications, and external trauma. Connective tissue diseases, granulomatous diseases, bullous diseases, infections, and tumors are some of the systemic diseases that will be covered in this review. Trichoscopy is a useful noninvasive tool that can help with the diagnosis in the office and can guide the selection of the optimal site for the scalp biopsy. Histopathology is the ultimate tool for the diagnosis in most cases of secondary alopecia and can be performed on vertical and horizontal sections. In most cases, treating the underlying condition is the single most important strategy, but topical treatments for the alopecia are also applied.

Cutaneous Metastasis of Internal Tumors

Cutaneous metastasis portends a poor prognosis. Therefore, a high clinical index of suspicion is necessary so that a clinician knows how to recognize the presentation of a cutaneous metastasis, while the pathologist must know the appropriate stains to order. In this review, the authors summarize the common and uncommon ways that these tumors will present. Frequently a metastatic cancer will present as a firm red nodule or as a plaque, ulcer, or papule. Less commonly they will present with a clinical clue that can alert a clinician to a likely diagnosis; these manifestations include alopecic, vesicular, blue color, sclerodermoid, acrochordon-, or pellagra-like.

Alopecia neoplastica as a sign of visceral malignancies: a systematic review

Alopecia neoplastica (AN) from visceral tumours is a rare form of cutaneous metastasis in which internal malignancies spread to the scalp. The diagnosis of AN may be very challenging, especially when its onset precedes the diagnosis of the primary tumour. We aimed to improve the knowledge on AN, highlighting that in case of scarring localized alopecia, a differential diagnosis with metastasis should always be considered. We performed a systematic review to describe the main demographic and clinical features associated with AN from visceral malignancies; a survival analysis was also performed. In 118 reports, accounting for 123 patients, we found that women were more affected by AN than men (53.7% vs. 46.3%). The most frequent site of the primary tumour was the gastrointestinal tract (24.4%), followed by breast (17.9%), kidney (8.1%), lung (7.3%), thyroid (7.3%), uterus (6.5%), central nervous system (6.5%), liver (3.3%) and other anatomic areas for 18.7% of cases. Furthermore, in more than half of the cases (66.1%), AN lesions were single and were mainly diagnosed after the primary visceral tumour (71.5%). Finally, survival analysis highlighted a lower progression-free survival in men; while, no significant differences in overall survival were reported among genders. In conclusion, metastatic skin disease should always be taken into consideration when dealing with patients with localized scarring alopecia.

Alopecia in Association with Malignancy: A Review

The interaction between hair and malignancy is complicated. Various hair abnormalities can manifest in oncology patients as a clinical manifestation, the result of cancer therapy, or due to a paraneoplastic condition. The mechanisms of these changes remain unclear. Alopecia is one of the common clinical presentations occurring in oncology patients that affects their quality of life. The condition can concomitantly develop during the course of malignancy or when patients undergo cancer treatment. It is important for physicians to understand alopecia in association with malignancy as it may be an important associated finding or provide the clues to aid diagnosis. The aim of this review is to summarize the clinical characteristics of alopecia that occur in cancer patients and their relationship with the type of malignancy and its treatment.

Erysipelatoid Carcinoma

Erysipelatoid Carcinoma (EC), also known as Inflammatory Metastatic Carcinoma, is a rare form of cutaneous metastasis, secondary to an internal malignancy, more often related to breast cancer. Clinically, the lesion has a well-marked, bound erythematous appearance, much like an infectious process, such as erysipelas and cellulitis, these being the most common differential diagnoses. It is characterized by an acute or subacute appearance with an erythematous plaque, sometimes hot and painful, being more often situated in the primary tumor vicinity, especially in the thorax wall in the region of a mastectomy due to breast cancer. Here we present the case of a 75-year-old patient with ductal infiltrated carcinoma for 3 years, who presented an acute erythematous and infiltrated plaque in the region of a previous mastectomy, with a final diagnosis of EC.

Composite Tumor Associating Trichoblastoma and Seborrheic Keratosis

Seborrheic keratosis is a common benign epidermal tumor histologically composed of basaloid and squamous cells. It mainly occurs on the face, scalp, and trunk, and presents clinically as a well-circumscribed, brownish to black papule, nodule, or plaque. Trichoblastoma is a relatively rare benign, slow-growing tumor showing differentiation toward the primitive hair follicle. It clinically manifests as a solitary, skin to erythematous colored, well-circumscribed dermal nodule located predominantly on the head and neck with a predilection for the scalp. Histologically, a well-demarcated mass of follicular germinative cells that show various degrees of differentiation, arranged in lobules, sheets, and nests, is located in the dermis or subcutaneous fat layer. We report the case of a 28-year-old female patient with a solitary, 2.0×4.0-cm black plaque with a 0.7-cm skin-colored nodule on the scalp. Histologically, the entire black plaque had prominent hyperkeratosis, acanthosis, and papillomatosis with horn cysts. The central nodule showed well-circumscribed, various-sized dermal tumor lobules without a connection to the overlying epidermis. The lobular aggregation was composed of numerous basaloid epithelial nests and multiple primitive papillary structures with distinct peripheral palisading of nuclei. According to these findings, the scalp lesion was diagnosed as a composite tumor associating trichoblastoma and seborrheic keratosis.

Alopecia Neoplastica due to Gastric Adenocarcinoma Metastasis to the Scalp, Presenting as Alopecia: A Case Report and Literature Review

Alopecia neoplastica is defined as hair loss secondary to a visceral malignancy that has metastasized to the scalp. The scalp is a relatively common site of cutaneous metastasis, usually presenting as a single or multiple firm scalp nodules. Alopecia neoplastica is a well-recognized but rare presentation, and its pathogenesis is incompletely understood. Atrophy of the hair follicles due to tumor invasion of the scalp plays a role in the development of alopecia. Herein, we describe a 33-year-old woman with gastric adenocarcinoma who developed alopecia neoplastica while receiving cancer chemotherapy. Scalp biopsy revealed metastatic adenocarcinoma cells interspersed between collagen bundles and around hair follicles. Immunohistochemical analysis indicated that the tumor cells originated from the primary gastric adenocarcinoma. Therefore, she was diagnosed with alopecia neoplastica due to gastric adenocarcinoma. The findings from this report may be helpful for understanding the mechanism of alopecia neoplastica.

Cutaneous metastases from internal malignancies: a clinicopathologic and immunohistochemical review

Skin metastases occur in 0.6%-10.4% of all patients with cancer and represent 2% of all skin tumors. Skin metastases from visceral malignancies are important for dermatologists and dermatopathologists because of their variable clinical appearance and presentation, frequent delay and failure in their diagnosis, relative proportion of different internal malignancies metastasizing to the skin, and impact on morbidity, prognosis, and treatment. Another factor to take into account is that cutaneous metastasis may be the first sign of clinically silent visceral cancer. The relative frequencies of metastatic skin disease tend to correlate with the frequency of the different types of primary cancer in each sex. Thus, women with skin metastases have the following distribution in decreasing order of frequency of primary malignancies: breast, ovary, oral cavity, lung, and large intestine. In men, the distribution is as follows: lung, large intestine, oral cavity, kidney, breast, esophagus, pancreas, stomach, and liver. A wide morphologic spectrum of clinical appearances has been described in cutaneous metastases. This variable clinical morphology included nodules, papules, plaques, tumors, and ulcers. From a histopathologic point of view, there are 4 main morphologic patterns of cutaneous metastases involving the dermis, namely, nodular, infiltrative, diffuse, and intravascular. Generally, cutaneous metastases herald a poor prognosis. The average survival time of patients with skin metastases is a few months. In this article, we review the clinicopathologic and immunohistochemical characteristics of cutaneous metastases from internal malignancies, classify the most common cutaneous metastases, and identify studies that may assist in diagnosing the origin of a cutaneous metastasis.

Cutaneous metastases of internal tumors

Cutaneous metastases are relatively rare in clinical practice and their diagnosis requires a high index of suspicion because clinical findings can be subtle. These metastases reveal the presence of disseminated malignant disease and can lead to the diagnosis of unsuspected internal tumors or the spread or recurrence of an already diagnosed tumor. Early recognition of cutaneous metastases can facilitate prompt and accurate diagnosis resulting in early treatment; however, they are generally indicative of a poor prognosis. Some tumors have a predilection to metastasize to specific areas. Recognition of these patterns provides essential information that can guide the search for the underlying tumor.

Clinical manifestations of cutaneous metastases: a review with special emphasis on cutaneous metastases mimicking keratoacanthoma

Approximately 5% of oncology patients develop cutaneous metastases, with only a small number of these patients (less than 1%) having metastatic skin lesions as the first sign of their visceral cancer. Metastases tend to occur on skin surfaces in the vicinity of the primary tumor. However, any site may be affected by cutaneous metastases. Skin metastases can present with several morphologies including, albeit rarely, keratoacanthoma-like lesions. Keratoacanthoma is a keratinous tumor that morphologically appears as a nodule with a central keratin-filled crater. This article reviews the characteristics of oncology patients whose cutaneous metastases mimicked a keratoacanthoma, including illustrations from our patient, a 53-year-old Caucasian man whose metastatic esophageal adenocarcinoma not only presented with a keratoacanthoma-like tumor on his upper lip but also a forehead macule and a scalp nodule. We also report keratoacanthoma-like presentations from literature cases of breast cancer, chondrosarcoma, and pulmonary malignancies. The lesions were discovered 3-24 months after diagnosis of visceral cancer and led to the discovery of unsuspected lung cancer in two patients. Most of the patients (60%) died within 2 months of discovery of the keratoacanthoma-like cutaneous metastases. We also reviewed the literature and discuss other morphologies of cutaneous metastases in patients whose primary tumors were in the breast, lung, and esophagus. In addition, we review from the literature other examples of tumors that present as metastatic nodules on the scalp. The possibility of cutaneous metastasis should be entertained and pathologic evaluation should be considered in an oncology patient with underlying visceral malignancy who develops a keratoacanthoma-like lesion.

Metastatic breast carcinoma mimicking a sebaceous gland neoplasm: a case report

Introduction

Breast cancer is common in women and its metastases involve the skin in approximately one quarter of patients. Accordingly, metastatic breast cancer shown to be cutaneous through histology must be distinguished from a wide variety of other neoplasms as well as the diverse morphologic variants of breast cancer itself.

Case presentation

We report the case of a 61-year-old Caucasian woman with cutaneous metastases of a bilateral ductal breast carcinoma that in histopathological examination mimicked an adnexal neoplasm with sebaceous differentiation.

Conclusion

Against the background of metastatic breast carcinoma, dermatopathological considerations of sebaceous differentiation of skin lesions are presented and discussed focusing on the rare differential diagnosis of sebaceous carcinoma of the breast.

Cutaneous manifestations of breast carcinoma

The incidence of breast carcinoma cutaneous manifestation in patients with breast carcinoma is 23.9%. The most common sites of breast carcinoma cutaneous manifestation are the chest wall and abdomen, but they can occur at the extremities and in the head/neck region. Due the high incidence of breast carcinoma, these cutaneous manifestations are the most common metastases seen by dermatologists. In clinical practice, cutaneous metastases show a wide range of clinical manifestations. Nodules are the most common presentation, but several other patterns are described below.