| Introduction: |
| A 51 year old woman developed a firm red rash in a surgical scar on the left side of the chest. |
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| History: |
| Over 3 months the rash spread to the left arm pit and flank. Intense pruritus and burning were refractory to treatment with loratadine, cephalexin, caladryl, diphenhydramine, aloe lotion, topical hydrocortisone cream, and oral steroids.
Her past history was significant for stage IV intraductal breast carcinoma (4 cm primary tumor of left breast, multiple positive axillary nodes,and regional metastases to a left supraclavicular node) diagnosed in July, 2000. She received 4 cycles of neoadjuvant chemotherapy (adriamycin, taxotene, marimastat) and then underwent modified radical mastectomy followed by a radiation therapy. Chest, abdominal, and pelvic CT's and bone scans were normal during follow-up examinations, and there was no evidence of distant metastases. |
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| Clinical
Presentation: |
| Physical examination of the left anterior chest wall revealed areas of hyper- and hypopigmentation and atrophy that were localized to the area of irradation and felt to be consistent with chronic radiation dermatitis. However, superimposed on this and extending into the nonirradiated areas was extensive induration and multiple, large, erythematous, coalescing plaques with some central clearing. Similar lesions involving the left axillary region and left posterior chest wall were noted. All of these areas were warm and exquistely tender. |
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| Pathology: |
| Two 4 mm skin punch biopsies were obtained from the left flank and upper back. Pathology revealed extensive invasion of both the papillary and reticular dermis by atypical cells with large, pleimorphic, hyperchromatic nuclei forming gland-like structures. Dilated lymphatics containg groups of these atypical cells were also noted.
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| Question
1: |
| What percentage of patients with internal malignancies develop cutaneous metastasis?
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| Question
2: |
| What are the three most common malignancies associated with cutaneous metastases? |
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| Question
3: |
| In women, what percentage of cutaneous metastases are due to a primary breast carcinoma? |
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| Question
4: |
| At what point in the disease course do cutaneous metastases generally occur?
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| Question
5: |
| How does metastatic breast cancer present in the skin? |
