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Koh NH, Oh HY. Case report: Unusual breast cancer metastasis manifesting as a scalp lesion in a patient with invasive lobular carcinoma. Front Oncol 2024; 14:1361333. [PMID: 38646434 PMCID: PMC11026626 DOI: 10.3389/fonc.2024.1361333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Accepted: 03/13/2024] [Indexed: 04/23/2024] Open
Abstract
Breast cancer is the most prevalent cancer in women globally, often leading to distant metastasis in the lung, liver, or bones. Cutaneous metastasis represents an uncommon pattern in breast cancer, but when observed, it tends to manifest in the thorax and upper abdomen, primarily due to lymph node involvement. Therefore, occurrences of cutaneous metastasis on the scalp and extremities are infrequent. Moreover, invasive lobular carcinoma metastasizing to remote skin is rare among the breast cancer. This report presents a case of cutaneous metastasis of invasive lobular carcinoma to the scalp in a patient treated for breast cancer six years ago, with no signs of local recurrence or metastasis to other organs.
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Affiliation(s)
| | - Ha Yeun Oh
- Department of Radiology, Kangwon National University Hospital, Chuncheon, Republic of Korea
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Lee J, Kim JH, Liu M, Bang A, Olson R, Chang JS. Five-Fraction High-Conformal Ultrahypofractionated Radiotherapy for Primary Tumors in Metastatic Breast Cancer. J Breast Cancer 2024; 27:91-104. [PMID: 38529591 PMCID: PMC11065499 DOI: 10.4048/jbc.2024.0004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 02/13/2024] [Accepted: 03/14/2024] [Indexed: 03/27/2024] Open
Abstract
PURPOSE To report on the local control and toxicity of 5-fraction, high-conformal ultrafractionated radiation therapy (RT) for primary tumors in patients with metastatic breast cancer (MBC) who did not undergo planned surgical intervention. METHODS We retrospectively reviewed 27 patients with MBC who underwent 5-fraction high-dose ultrafractionated intensity-modulated RT for their primary tumors between 2017 and 2022 at our institution. A median dose of 66.8 Gy (range, 51.8-83.6 Gy) was prescribed to the gross tumor, calculated in 2-Gy equivalents using an α/β ratio of 3.5, along with a simultaneous integrated boost of 81.5%. The primary endpoint of this study was local control. RESULTS The median tumor size and volume were 5.1 cm and 112.4 cm3, respectively. Treatment was generally well tolerated, with only 15% of the patients experiencing mild acute skin toxicity, which resolved spontaneously. The best infield response rate was 82%, with the objective response observed at a median time of 10.8 months post-RT (range, 1.4-29.2), until local progression or the last follow-up. At a median follow-up of 18.3 months, the 2-year local control rate was 77%. A higher number of prior lines of systemic therapy was significantly associated with poorer 2-year local control (one-two lines, 94% vs three or more lines, 34%; p = 0.004). Post-RT, 67% of the patients transitioned to the next line of systemic therapy, and the median duration of maintaining the same systemic therapy post-RT was 16.3 months (range, 1.9-40.3). CONCLUSION In our small dataset, 5-fraction, high-conformal ultrahypofractionated breast RT offered promising 2-year local control with minimal toxicity. Further studies are warranted to investigate the optimal dose and role in this setting.
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Affiliation(s)
- Jeongshim Lee
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
- Department of Radiation Oncology, Inha University Hospital, Inha University School of Medicine, Incheon, Korea
| | - Jee Hung Kim
- Division of Medical Oncology, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Mitchell Liu
- British Columbia Cancer Agency - Vancouver Centre, Vancouver, Canada
| | - Andrew Bang
- British Columbia Cancer Agency - Vancouver Centre, Vancouver, Canada
| | - Robert Olson
- British Columbia Cancer Agency - Centre for the North, Prince George, Canada
| | - Jee Suk Chang
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea.
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Shrivastava N, Balasubramanian A. Cutaneous Metastasis in Breast Cancer: A Case Series. Cureus 2023; 15:e40109. [PMID: 37425494 PMCID: PMC10329202 DOI: 10.7759/cureus.40109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2023] [Indexed: 07/11/2023] Open
Abstract
The most frequent reason for cutaneous metastases is breast cancer in females. Breast cancer patients can present with cutaneous manifestations of breast disease at the time of their initial diagnosis; however, cutaneous metastases more often present well after the initial diagnosis and treatment of the breast disease. We described three cases of carcinoma of breast metastasis to the skin of the breast and the chest wall, each with a unique dermatological presentation. A 52-year-old woman presented with a cutaneous erythematous papule for the past month. She underwent a modified radical mastectomy one year before. On presentation, she was diagnosed to have erythematous papule near the operative scar and surrounding chest wall and referred to the dermatology outdoor department, where a skin biopsy was done, which confirmed erysipeloides carcinoma. The second case includes a 38-year-old premenopausal lady who was diagnosed with carcinoma of the right breast with a locally advanced stage. She was treated with neoadjuvant chemotherapy (NACT) followed by modified radical mastectomy and subsequently presented with biopsy-proven multiple skin nodules on the chest wall at the same side. She was discussed in a multidisciplinary tumor board and planned for palliative chemotherapy followed by hormonal therapy. In the third case, a 42-year-old perimenopausal woman diagnosed with locally advanced left breast carcinoma presented in the surgical oncology outdoor patient department (OPD) with multiple skin erythema over the left breast. Biopsy was done from the skin erythema site showing metastasis to the skin. She was discussed in a multidisciplinary tumor board and planned for systemic chemotherapy followed by assessment for surgery. Skin erythema and erythematous papules are rare manifestations of cutaneous metastasis in patients with carcinoma of the breast; typically, patients present with a chest wall nodule. Careful examination and early detection of these uncommon skin lesions can lower morbidity and slow the progression of diseases in these patients.
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Affiliation(s)
- Neelesh Shrivastava
- Surgical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, IND
| | - A Balasubramanian
- Surgical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, IND
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Li ZH, Wang F, Zhang P, Xue P, Zhu SJ. Diagnosis and guidance of treatment of breast cancer cutaneous metastases by multiple needle biopsy: A case report. World J Clin Cases 2022; 10:345-352. [PMID: 35071538 PMCID: PMC8727255 DOI: 10.12998/wjcc.v10.i1.345] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 09/16/2021] [Accepted: 11/25/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Breast cancer patients have a high skin metastasis rate. However, reports on treatment of cutaneous metastases of breast cancer are scarce.
CASE SUMMARY We report the treatment process for one breast cancer case with bone, lung, and skin metastases. The patient was a 43-year-old woman with advanced breast cancer and skin metastasis. She underwent pathological diagnosis by needle biopsy to guide the treatment. When the disease progressed, a new pathological diagnosis was determined by needle biopsy to guide the treatment. The patient received chemotherapy, endocrine therapy, and photodynamic dynamic therapy, followed by sonodynamic therapy.
CONCLUSION Repeated puncture should be performed for advanced breast cancer with skin metastasis, in order to obtain the pathology and directly determine diagnosis when the disease progresses. The treatment should focus on controlling the systemic metastasis, rather than the local disease.
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Affiliation(s)
- Zhong-Hui Li
- Department of Oncology, Wangjing Hospital, China Academy of Chinese Medical Sciences, Beijing 100102, Beijing Province, China
| | - Fang Wang
- Department of Oncology, Wangjing Hospital, China Academy of Chinese Medical Sciences, Beijing 100102, Beijing Province, China
| | - Ping Zhang
- Department of Pathology, Wangjing Hospital, China Academy of Chinese Medical Sciences, Beijing 100102, Beijing Province, China
| | - Peng Xue
- Department of Oncology, Wangjing Hospital, China Academy of Chinese Medical Sciences, Beijing 100102, Beijing Province, China
| | - Shi-Jie Zhu
- Department of Oncology, Wangjing Hospital, China Academy of Chinese Medical Sciences, Beijing 100102, Beijing Province, China
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Wang N, Li L, Xiong Y, Chi J, Liu X, Zhong C, Wang F, Gu Y. Case Report: Significant Efficacy of Pyrotinib in the Treatment of Extensive Human Epidermal Growth Factor Receptor 2-Positive Breast Cancer Cutaneous Metastases: A Report of Five Cases. Front Oncol 2022; 11:729212. [PMID: 34976791 PMCID: PMC8716402 DOI: 10.3389/fonc.2021.729212] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 11/23/2021] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Breast cancer (BC) is the most common tumor to develop cutaneous metastases. Most BCs with cutaneous metastasis are human epidermal growth factor receptor 2 (HER2)-positive subtypes. Although the molecular mechanisms of breast cancer metastasis to different sites and the corresponding treatment methods are areas of in-depth research, there are few studies on cutaneous metastasis. CASE PRESENTATION Five HER2-positive BC patients with extensive cutaneous metastases were treated with a regimen containing pyrotinib, a novel small-molecule tyrosine kinase inhibitor that irreversibly blocks epidermal growth factor receptor (EGFR), HER2, and human epidermal growth factor receptor 4 (HER4), then their cutaneous metastases quickly resolved at an astonishing speed and their condition was well controlled during the follow-up period. CONCLUSIONS This case series reports the significant therapeutic effect of pyrotinib on cutaneous metastases of HER2-positive BC for the first time. Based on this, we recommend that pyrotinib can be used as a supplement to trastuzumab for HER2-positive BC patients with cutaneous metastases. In addition, we should consider that the pan-inhibitory effect of pyrotinib on EGFR, HER2, and HER4 may provide a dual therapeutic effect against HER2 and mucin 1.
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Affiliation(s)
- Nan Wang
- Department of Breast Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Lin Li
- Department of Breast Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Youyi Xiong
- Department of Breast Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jiangrui Chi
- Department of Breast Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xinwei Liu
- Department of Breast Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Chaochao Zhong
- Department of Plastic Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Fang Wang
- Department of Breast Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yuanting Gu
- Department of Breast Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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Kar S, Sawant A, Patrick S, Gangane N. Puzzling Papules on the neck: Cutaneous metastasis from the breast. JOURNAL OF CANCER RESEARCH AND PRACTICE 2020. [DOI: 10.4103/jcrp.jcrp_4_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Bose C, Singh SP, Igid H, Green WC, Singhal SS, Lee J, Palade PT, Rajan A, Ball S, Tonk V, Hindle A, Tarbox M, Awasthi S. Topical 2'-Hydroxyflavanone for Cutaneous Melanoma. Cancers (Basel) 2019; 11:cancers11101556. [PMID: 31615091 PMCID: PMC6826616 DOI: 10.3390/cancers11101556] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 10/03/2019] [Accepted: 10/11/2019] [Indexed: 12/14/2022] Open
Abstract
2′-hydroxyflavanone (2HF) is a dietary flavonoid with anticancer activity towards multiple cancers. Here, we report that topically applied 2HF inhibits the growth of intradermal implants of melanoma in immunocompetent mice. 2HF induced apoptosis and inhibited the growth of the human SK-MEL-24 as well as murine B16-F0 and B16-F10 melanoma cell lines in vitro. Apoptosis was associated with depletion of caspase-3, caspase-9, and PARP1 in B16-F0 and SK-MEL-24 cells. Caspase-9 and MEKK-15 were undetected even in untreated B16-F10 cells. Signaling proteins TNFα, and phospho-PDGFR-β were depleted in all three cell lines; MEKK-15 was depleted by 2HF in SK-MEL-24 cells. 2HF enhanced sunitinib (an MEK and PDGFR-β inhibitor) and AZD 2461 (a PARP1 inhibitor) cytotoxicity. 2HF also depleted the Ral-regulated, stress-responsive, antiapoptotic endocytic protein RLIP76 (RALBP1), the inhibition of which has previously been shown to inhibit B16-F0 melanoma growth in vivo. Functional inhibition of RLIP76 was evident from inhibition of epidermal growth factor (EGF) endocytosis by 2HF. We found that topically applied 2HF–Pluronic Lecithin Organogel (PLO) gel inhibited B16-F0 and B16-F10 tumors implanted in mice and caused no overt toxicity despite significant systemic absorption. 2HF treatment reduced phospho-AKT, vimentin, fibronectin, CDK4, cyclinB1, and BCL2, whereas it increased BIM and phospho-AMPK in excised tumors. Several cancer signals are controlled by endocytosis, a process strongly inhibited by RLIP76 depletion. We conclude that 2HF–PLO gel may be useful for topical therapy of cutaneous metastases of melanoma and could enhance the antineoplastic effects of sunitinib and PARP1 inhibitors. The mechanism of action of 2HF in melanoma overlaps with RLI76 inhibitors.
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Affiliation(s)
- Chhanda Bose
- Division of Hematology & Oncology, Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA;.
| | - Sharda P Singh
- Division of Hematology & Oncology, Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA;.
| | - Henry Igid
- Division of Hematology & Oncology, Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA;.
| | - William C Green
- Division of Hematology & Oncology, Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA;.
| | - Sharad S Singhal
- Department of Medical Oncology and Therapeutic Research, City of Hope National Medical Center, Duarte, CA 91010, USA.
| | - Jihyun Lee
- Division of Hematology & Oncology, Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA;.
| | - Philip T Palade
- Department of Pharmacology and Toxicology, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA.
| | - Aditya Rajan
- Division of Hematology & Oncology, Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA;.
| | - Somedeb Ball
- Division of Hematology & Oncology, Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA;.
| | - Vijay Tonk
- Department of Pediatrics, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA.
| | - Ashly Hindle
- Division of Hematology & Oncology, Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA;.
| | - Michelle Tarbox
- Department of Dermatology and Dermatopathology, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA.
| | - Sanjay Awasthi
- Division of Hematology & Oncology, Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA;.
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Sehrawat A, Kotwal SA, Parthasarathy KM. Metastatic Dermatosis in Breast Carcinoma on Adjuvant Trastuzumab: Is Skin a Sanctuary Site in Human Epidermal Growth Factor Receptor-2-Amplified Disease? Indian J Dermatol 2018; 63:424-426. [PMID: 30210167 PMCID: PMC6124245 DOI: 10.4103/ijd.ijd_234_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Cutaneous metastasis (CM) from internal malignancies is commonly seen. Sometimes, skin metastases can be the first sign of advanced cancer or an indicator of cancer recurrence. Cases of breast cancer with cutaneous progression after or during trastuzumab therapy have been described in the past, frequently associated with systemic disease progression. However, CM during adjuvant trastuzumab therapy is very rare. It has been hypothesized that cancer cells located in the skin survive and take proliferative advantage by virtue of an immune-tolerance mechanism that hampers trastuzumab-mediated antibody-dependent cell-mediated cytotoxicity. We describe a case of human epidermal growth factor receptor-2-overexpressing breast cancer presenting with diffuse CM during adjuvant trastuzumab therapy.
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Affiliation(s)
- Amit Sehrawat
- From the Department of Medical Oncology, Dharamshila Narayana Superspeciality Hospital, New Delhi, India
- Address for correspondence: Dr. Amit Sehrawat, Department of Medical Oncology, Dharamshila Narayana Superspeciality Hospital, Vasundhara Enclave, New Delhi - 110 096, India. E-mail:
| | - Sumedha A. Kotwal
- Department of Pathology, Dharamshila Narayana Superspeciality Hospital, New Delhi, India
| | - K. M. Parthasarathy
- From the Department of Medical Oncology, Dharamshila Narayana Superspeciality Hospital, New Delhi, India
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Ferreira VA, Spelta K, Diniz LM, Lucas EA. Exuberant case of cutaneous metastasis of breast cancer. An Bras Dermatol 2018; 93:429-431. [PMID: 29924228 PMCID: PMC6001113 DOI: 10.1590/abd1806-4841.20187157] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Accepted: 07/04/2017] [Indexed: 11/22/2022] Open
Abstract
Cutaneous metastasis is the main cause of morbidity and mortality of cancer patients, denoting a guarded prognosis. The clinical spectrum of the disease is broad and can mimic benign conditions. The diagnosis depends on thorough clinical examination and complementary exams, with emphasis on the histopathological study and immunohistochemistry. Because it indicates a systemic relapse, it is necessary to intervene with intravenous chemotherapy, to which local therapies can be associated. We report the case of a 65-year-old woman with cutaneous metastasis from breast cancer treated 14 years back, manifested by extensive firm and infiltrated red-purple plaques on the sides of the trunk, with a course of six months. After evaluation, she was referred to the regional cancer center. She passed away one month and a half later.
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Affiliation(s)
- Vítor Angelo Ferreira
- Dermatology Service, Hospital Universitário Cassiano
Antônio Moraes, Universidade Federal do Espírito Santo (Ufes),
Vitória (ES), Brazil
| | - Karla Spelta
- Empresa Brasileira de Serviços Hospitalares (EBSERH) and
Dermatology Service, Hospital Universitário Cassiano Antônio Moraes,
Universidade Federal do Espírito Santo (Ufes), Vitória (ES), Brazil
| | - Lucia Martins Diniz
- Discipline of Internal Medicine/Dermatology, Universidade Federal
do Espírito Santo (Ufes), Vitória (ES), Brazil
- Medical Residency Program in Dermatology, Universidade Federal do
Espírito Santo (Ufes), Vitória (ES), Brazil
| | - Elton Almeida Lucas
- Dermatology Service, Hospital Universitário Cassiano
Antônio Moraes, Universidade Federal do Espírito Santo (Ufes),
Vitória (ES), Brazil
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Sammon J, Jain A, Bleakney R, Mohankumar R. Magnetic resonance imaging appearance of soft-tissue metastases: our experience at an orthopedic oncology center. Skeletal Radiol 2017; 46:513-521. [PMID: 28180954 DOI: 10.1007/s00256-017-2582-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 01/15/2017] [Accepted: 01/18/2017] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To assess the prevalence and magnetic resonance imaging appearance of metastasis presenting as a soft-tissue mass. MATERIALS AND METHODS A retrospective chart review was performed on 51 patients who presented to an orthopedic oncology center with soft-tissue masses, with a histology-proven diagnosis of soft-tissue metastasis, over a 14-year period. Their magnetic resonance imaging, primary origin, and follow-up have been assessed. RESULTS Soft-tissue metastasis was identified in patients ranging from 18 to 85 years old. Most (80%) of the masses were located deep to the deep fascia. In our cohort of patients, melanoma was the most common primary malignancy contributing to soft-tissue metastasis (21.8%). Among soft-tissue metastasis from solid organs, breast and lung were the most frequent (9.1% each). Five patients had soft-tissue metastases from an unknown primary. CONCLUSION Imaging diagnosis of soft-tissue metastases is challenging as it can demonstrate imaging appearances similar to primary soft-tissue sarcoma. The presence of a known malignancy may not be evident in everyone, and even if available, histopathology will be necessary for diagnosis if this is the only site of recurrence/metastasis to differentiate from a primary soft-tissue sarcoma. Moreover, soft-tissue metastasis may be the initial presentation of a malignancy. Primary malignancies with soft-tissue metastasis carry a poor prognosis; hence, prompt diagnosis and management in essential.
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Affiliation(s)
- Jennifer Sammon
- Division of Musculoskeletal Imaging, Joint Department of Medical Imaging, Mount Sinai Hospital and University of Toronto, 600 University Avenue, Toronto, Ontario, Canada, M5G 1X5
| | - Abhishek Jain
- Division of Musculoskeletal Imaging, Joint Department of Medical Imaging, Mount Sinai Hospital and University of Toronto, 600 University Avenue, Toronto, Ontario, Canada, M5G 1X5
| | - Robert Bleakney
- Division of Musculoskeletal Imaging, Joint Department of Medical Imaging, Mount Sinai Hospital and University of Toronto, 600 University Avenue, Toronto, Ontario, Canada, M5G 1X5
| | - Rakesh Mohankumar
- Division of Musculoskeletal Imaging, Joint Department of Medical Imaging, Mount Sinai Hospital and University of Toronto, 600 University Avenue, Toronto, Ontario, Canada, M5G 1X5.
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