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Cedirian S, Rapparini L, Sechi A, Piraccini BM, Starace M. Diagnosis and Management of Scalp Metastases: A Review. Diagnostics (Basel) 2024; 14:1638. [PMID: 39125514 PMCID: PMC11311314 DOI: 10.3390/diagnostics14151638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2024] [Revised: 07/26/2024] [Accepted: 07/28/2024] [Indexed: 08/12/2024] Open
Abstract
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.
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Affiliation(s)
- Stephano Cedirian
- Dermatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (S.C.); (B.M.P.); (M.S.)
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Luca Rapparini
- Dermatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (S.C.); (B.M.P.); (M.S.)
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Andrea Sechi
- Dermatology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
| | - Bianca Maria Piraccini
- Dermatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (S.C.); (B.M.P.); (M.S.)
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Michela Starace
- Dermatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (S.C.); (B.M.P.); (M.S.)
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
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2
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Cohen PR. Comment on: "Eyebrow and Eyelash Alopecia: A Clinical Review". Am J Clin Dermatol 2023; 24:485-486. [PMID: 37058214 DOI: 10.1007/s40257-023-00771-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2023] [Indexed: 04/15/2023]
Affiliation(s)
- Philip R Cohen
- Department of Dermatology, Davis Medical Center, University of California, Sacramento, CA, USA.
- Touro University California College of Osteopathic Medicine, Vallejo, CA, USA.
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3
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Borg Grech S, Pisani D, Degaetano J, Boffa MJ. A sinister case of alopecia in a middle-aged woman. Clin Exp Dermatol 2023; 48:276-279. [PMID: 36763698 DOI: 10.1093/ced/llac031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 10/02/2022] [Accepted: 10/19/2022] [Indexed: 01/22/2023]
Abstract
We present the case of a middle-aged woman who presented with multiple indurated areas of hair loss on her scalp. Closer dermoscopic inspection of these patches revealed multiple arborizing vessels on an erythematous background. On further inspection nodules were also noted on the nape of the neck and right breast. Punch biopsies showed diffuse infiltration of the dermis by a neoplastic population of cells with moderate nuclear pleomorphism, abundant eosinophilic cytoplasm and brisk mitotic activity.
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Affiliation(s)
| | - David Pisani
- Department of Histopathology, Mater Dei Hospital, Msida, Malta
| | - James Degaetano
- Department of Histopathology, Mater Dei Hospital, Msida, Malta
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Flanagan KE, Burns LJ, Pathoulas JT, Walker CJ, Pupo Wiss I, Cornejo KM, Senna MM. Primary Alopecia Neoplastica: A Novel Case Report and Literature Review. Skin Appendage Disord 2021; 7:499-509. [PMID: 34901185 PMCID: PMC8613616 DOI: 10.1159/000516650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 02/16/2021] [Indexed: 11/19/2022] Open
Abstract
Alopecia neoplastica (AN) is caused by neoplastic cells damaging hair follicles, resulting in patchy hair loss like cicatricial alopecia and alopecia areata. AN has predominantly described cutaneous metastasis to the scalp from primary visceral malignant tumors. Less frequently, AN results from a primary scalp neoplasm. Compared to "secondary AN," there is a paucity of literature on "primary AN." Herein, we present a comprehensive literature review of primary AN and introduce a unique case of amelanotic melanoma causing primary AN. Including our presented case, 11 cases of primary AN have been reported with causative scalp neoplasms including angiosarcoma, hemangioendothelioma, syringomatous carcinoma, ectopic extramammary Paget's disease, and primary desmoplastic melanoma. 27.3% (3 of 11) of cases were misdiagnosed and treated for a primary alopecia, and 36.4% (4 of 11) of lesions were present for multiple years or an unknown amount of time, likely due to difficulty in recognizing scalp lesion or misdiagnosis. All patients required surgical excision with 36.4% (4 of 11) requiring chemotherapy, radiation, or photodynamic therapy. Two patients with scalp angiosarcoma died from their aggressive disease. Due to the risks of malignant primary AN if allowed to progress, primary AN should be considered in patients presenting with scarring alopecia.
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Affiliation(s)
- Kelly E. Flanagan
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Laura J. Burns
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - James T. Pathoulas
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Chloe J. Walker
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Isabel Pupo Wiss
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kristine M. Cornejo
- Dermatopathology Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Maryanne M. Senna
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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5
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Vezzoni R, Toffoli L, Conforti C, Dri A, Retrosi C, di Meo N, Magaton Rizzi G, Signoretto D, Zalaudek I. Breast Cancer-Related Neoplastic Alopecia: A Case Report and Review of the Literature. Skin Appendage Disord 2021; 7:339-345. [PMID: 34604320 DOI: 10.1159/000514566] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 01/18/2021] [Indexed: 12/14/2022] Open
Abstract
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.
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Affiliation(s)
- Roberta Vezzoni
- Dermatology and Venereology Department, Maggiore Hospital of Trieste, University of Trieste, Trieste, Italy
| | - Ludovica Toffoli
- Dermatology and Venereology Department, Maggiore Hospital of Trieste, University of Trieste, Trieste, Italy
| | - Claudio Conforti
- Dermatology and Venereology Department, Maggiore Hospital of Trieste, University of Trieste, Trieste, Italy
| | - Arianna Dri
- Dermatology and Venereology Department, Maggiore Hospital of Trieste, University of Trieste, Trieste, Italy
| | - Chiara Retrosi
- Dermatology and Venereology Department, Maggiore Hospital of Trieste, University of Trieste, Trieste, Italy
| | - Nicola di Meo
- Dermatology and Venereology Department, Maggiore Hospital of Trieste, University of Trieste, Trieste, Italy
| | - Giovanni Magaton Rizzi
- Dermatology and Venereology Department, Maggiore Hospital of Trieste, University of Trieste, Trieste, Italy
| | - Diego Signoretto
- Department of Histopathology, Cattinara Hospital of Trieste, Trieste, Italy
| | - Iris Zalaudek
- Dermatology and Venereology Department, Maggiore Hospital of Trieste, University of Trieste, Trieste, Italy
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Scalp metastases as the first sign of a breast carcinoma. Postepy Dermatol Alergol 2021; 38:530-532. [PMID: 34377140 PMCID: PMC8330864 DOI: 10.5114/ada.2021.107942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 10/11/2019] [Indexed: 11/17/2022] Open
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Skafida E, Triantafyllopoulou I, Flessas I, Liontos M, Koutsoukos K, Zagouri F, Dimopoulos AM. Secondary Alopecia Neoplastica Mimicking Alopecia Areata following Breast Cancer. Case Rep Oncol 2020; 13:627-632. [PMID: 32774247 PMCID: PMC7383155 DOI: 10.1159/000507694] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 04/02/2020] [Indexed: 11/19/2022] Open
Abstract
Cutaneous metastases from visceral carcinomas are relatively uncommon, with an overall incidence ranging from 0.7 to 9%. Diagnosis of scalp metastases usually escapes clinicians and dermatologists due to the fact that these metastases are mimicking other benign dermatological conditions. Herein, we present an uncommon case of scalp alopecia neoplastica mimicking alopecia areata due to breast cancer; a 43-year-old woman diagnosed with lobular cancer 3 years previously presented with acute loss of hair in well-circumscribed areas of the scalp and was diagnosed with alopecia areata by a private-practice dermatologist. She was then reevaluated, and due to her history of breast cancer, a biopsy from the scalp was performed and revealed alopecia neoplastica. At the same time that the skin lesions were recognized as disease involvement, the patient presented with dyspepsia, and endoscopy of the upper and lower gastrointestinal tract also revealed metastasis to the stomach and bowel. Gastrointestinal metastasis may occur with several types of cancer, but the stomach and bowel are rare metastatic sites for breast cancer.
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Affiliation(s)
- Efthymia Skafida
- Haematology-Oncology Unit, Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Alexandra General Hospital, Athens, Greece
| | | | - Ioannis Flessas
- General and Breast Surgery Unit, General and Maternity Hospital "Helena Venizelou,", Athens, Greece
| | - Michael Liontos
- Haematology-Oncology Unit, Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Alexandra General Hospital, Athens, Greece
| | - Konstantinos Koutsoukos
- Haematology-Oncology Unit, Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Alexandra General Hospital, Athens, Greece
| | - Flora Zagouri
- Haematology-Oncology Unit, Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Alexandra General Hospital, Athens, Greece
| | - Athanasios-Meletios Dimopoulos
- Haematology-Oncology Unit, Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Alexandra General Hospital, Athens, Greece
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Abstract
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.
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Affiliation(s)
- Sonali Nanda
- Dr. Philip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Valeria De Bedout
- Dr. Philip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Mariya Miteva
- Dr. Philip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA.
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Abstract
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.
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Erstine EM, Elwood HR, Westbrook KC, McCalmont TH, Shalin SC, Gardner JM. Desmoplastic melanoma presenting as primary alopecia neoplastica: a report of two cases. J Cutan Pathol 2016; 43:872-9. [DOI: 10.1111/cup.12758] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 02/15/2016] [Accepted: 03/31/2016] [Indexed: 11/27/2022]
Affiliation(s)
| | - Hillary R. Elwood
- Department of PathologyUniversity of New Mexico School of Medicine Albuquerque NM USA
| | - Kent C. Westbrook
- Department of SurgeryUniversity of Arkansas for Medical Sciences Little Rock AR USA
| | - Timothy H. McCalmont
- Departments of Pathology and DermatologyUniversity of California San Francisco CA USA
| | - Sara C. Shalin
- Departments of Pathology and DermatologyUniversity of Arkansas for Medical Sciences Little Rock AR USA
| | - Jerad M. Gardner
- Departments of Pathology and DermatologyUniversity of Arkansas for Medical Sciences Little Rock AR USA
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11
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Abstract
Many reports have described the presence of alopecia areata (AA) associated with other autoimmune diseases, which support the autoimmune nature of AA. Additionally, AA has been reported in association with malignancy as a paraneoplastic symptom. In this report, we describe three patients with diffuse large B-cell lymphoma, alveolar soft part sarcoma, and cavernous sinus arteriovenous fistula with embolization treatment, respectively, who characteristically presented with rectangular-patterned occipital AA.
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Affiliation(s)
- Jaeyong Shin
- Department of Dermatology and Cutaneous, Biology Research Institute, Yonsei University College of Medicine, Seoul, Korea
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12
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Rongioletti F, Christana K. Cicatricial (scarring) alopecias: an overview of pathogenesis, classification, diagnosis, and treatment. Am J Clin Dermatol 2012; 13:247-60. [PMID: 22494477 DOI: 10.2165/11596960-000000000-00000] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Cicatricial (scarring) alopecia forms a group of disorders in which the common final pathway is the destruction of the hair follicle unit that is replaced by fibrous tissue. Hair loss may occur as a primary event when the follicle is the main target of the disease process (primary cicatricial alopecias) or as a secondary event when the follicle act as an 'innocent bystander' in the course of a disease occurring outside of the follicular unit (secondary cicatricial alopecias). Permanent hair loss may also occur in the late phases of some nonscarring alopecias that are called 'biphasic alopecias.' Primary cicatricial alopecia accounts for 5% of all trichologic consultations at the Section of Dermatology, University of Genoa, Genoa, Italy. Considering that hair loss has a strong impact on patients' psychology and quality of life, and that cicatricial alopecias can be associated with underlying systemic implications, it is extremely important that every clinician is familiar with the diagnosis and treatment of the different types of cicatricial alopecia. An accurate clinical assessment integrated with (video) dermatoscopy and histopathologic studies permits a high standard performance of correct diagnoses. A brief review of our current knowledge of disease pathogenesis and the hypothetical disease mechanisms is presented. Some practical considerations for improving the 2001 North American Hair Research Society working classification of the primary cicatricial alopecias are suggested. The aim of treatment is to slow or stop the progression of the inflammatory waves and the scarring process at the earliest phase of involvement. Recommendations for therapy are based upon a literature review, personal experience, expected adverse effects, and some pragmatic considerations such as the cost and patient compliance.
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Riahi RR, Cohen PR. Clinical manifestations of cutaneous metastases: a review with special emphasis on cutaneous metastases mimicking keratoacanthoma. Am J Clin Dermatol 2012; 13:103-12. [PMID: 22229935 DOI: 10.2165/11590640-000000000-00000] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Ryan R Riahi
- Medical School, University of Texas Medical Branch, Galveston, TX, USA
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