Carcinoma en cuirasse with Zosteriform Metastasis-A Rare Presentation ofBreast CarcinomaAfiya Shafi and Jangbhadur Singh*

Shere Kashmir Institute of Medical Sciences Medical College Hospital, Pathology, Ram Bagh, Srinagar, India*Corresponding Author: Jangbhadur Singh, Shere Kashmir Institute of Medical Sciences Medical College Hospital, Pathology, Ram Bagh, Srinagar, India, Tel: +919419032757; E-mail: jangbhadursinghsarna@gmail.com

Received date: December 30, 2015; Accepted date: February 18, 2016; Published date: February 22, 2016

Copyright: © 2016 Shafi A, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricteduse, distribution, and reproduction in any medium, provided the original author and source are credited.

Abstract

Carcinoma en cuirasse is a form of cutaneous metastasis of breast carcinoma. Although a rare condition, it ismost commonly associated with breast carcinoma with local recurrence after mastectomy and metastasis occurs afew months to years after primary has been diagnosed. Less frequently a metastasis is diagnosed at the same timeas primary tumour is diagnosed. We report a case of carcinoma en cuirasse in a 60 year old female who presentedwith elevated nodular indurated skin lesions on anterior and posterior left chest wall and axillary region. FNAC oflesions was performed. It was diagnosed as metastatic deposits of Duct Cell Carcinoma. It was followed byhistopathology and the diagnosis was confirmed. Hence it is very important to investigate thoroughly keloid like orindurated patches on skin of long duration.

Keywords: Carcinoma en cuirasse; Carcinoma Breast; CutaneousMetastasis; Zosteriform

IntroductionCarcinoma en cuirasse (Ca en cu) is a form of metastatic cutaneous

carcinoma [1]. Cutaneous metastasis occurs infrequently and is rarelypresent at the time, when cancer is initially diagnosed. Incidence variesfrom 0.6- 10% [2]. Skin metastasis is presenting signs of disease in 37%of men and 6% of women [3]. Carcinoma cells disseminate along tissuespaces or through lymphatics. Usually it appears in cases of localrecurrence after mastectomy. It very rarely presents as a first feature ofcarcinoma breast. Our case is rare in the context that the firstpresenting feature of our patient was the cutaneous metastasis, whichwas initially diagnosed clinically as Herpes Zoster.

Case reportA 60 year old post-menopausal woman presented to our

dermatology OPD with painful erythematous lesions over left side ofher chest for the last six months (Figure 1). There was nolymphadenopathy. Numerous firms to hard erythematous papules andfew indurated coalescent plaques with superficial ulceration andcrusting were present in the dermatomal distribution. She was treatedfor herpes zoster for a few months and there was no symptomaticrelief. There was burning pain along the distribution of lesions. Thelesions did not disappear and became more prominent. FNAC wasperformed from multiple sites. Giemsa stained smears revealed similarmorphological features in the aspirate from all slides. Smears werehighly cellular and arranged in clusters, sheets, acini and as well asdiscrete. There was moderate to severe pleomorphism andanisonucleosis. Nuclei were large hyper chromatic with coarseclumped chromatin and prominent nucleoli. Cytodiagnosis was madeas suggestive of metastatic deposits of duct cell carcinoma which waslater confirmed by histopathology.

Figure 1: Cutaneous metastasis of breast carcinoma.

DiscussionCarcinoma en cuirasse is a very rare condition. En cuirasse

metastatic carcinoma is characterized by diffuse morphea- likeinduration of skin [4]. It is a fibrotic process resembling a encasementin an armour of a cuirassier (cavalry soldier) [5]. It evolves from firmpapules and nodules overlying an erythematous base to asclerodermoid plaque. Pain and pruritus may be associated features.This may be explained on the basis of perineural involvement ofnerves. Induration could be related to chronic lymphatic obstructionas proposed by Hanley [6]. It is of diagnostic importance as it may befirst manifestation of an unknown primary malignancy or firstindication of metastasis of treated malignancy.

Bill et al in his study of 7316 patients with internal malignancy 5%were found to have skin involvement [7]. The most common sources of

Journal of Medical & SurgicalPathology Shafi and Singh, J Med Surg Pathol 2016, 1:2

Case Report OMICS International

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DOI: 10.4172/2472-4971.1000107

cutaneous metastasis in males includes lungs (24%), large intestine(19%), melanoma (13%), squamous cell of oral cavity (12%), kidney(6%) and stomach (6%). In females, primary tumour site is breast(69%) while other sites include gastrointestinal (9%), ovaries (4%) andcervix (2%).

Eight clinicohistopathological types of skin involvement are seenwith metastatic breast carcinoma which includes carcinoma encuirasse, inflammatory telengiactactic, and nodular type, alopecianeoplastica, carcinoma of infra mammary crease, metastatic carcinomaof eyelid with histiocytoid histology and pagets disease [8].

Mechanism of zosteriform appearance of metastatic disease hasbeen postulated to occur as a koebner phenomenon to recent herpeszoster [9]. Peri-neural lymphatic metaststatic dissemination has alsobeen suggested and is likely to be the cause of our patient havingdermatomatal distribution of skin lesions associated with burning pain[10]. Skin lining with underlying cells showing metastatic deposits areshown in figure 2.

Figure 2: Skin lining with underlying cells showing metastaticdeposits od DCC: 20X.

Mordenti et al studied 164 cases of cutaneous metastasis fromcarcinoma breast, clinically presented as papules and nodules in 80% ,telegentatic carcinoma 11.2%, carcinoma encuraise in 3 andzoosteriform in 0.8%. All these lesions were not seen as first sign ofdisease in any patients.

Breast carcinoma is common in women and its metastasis involvingwith skin in one-quarter of patients, accordingly metastatic breastcancer shown to be cutaneous through histologically must bedifferentiated from other neoplasms as well as the diverse morphologicvariants of breast cancer itself [11]. Cutaneous metastasis of cancer areencountered in 0.7%-0.9% of all the patients in general [12]. Thelocation of skin metastasis depends on location of primary malignancy,mechanism of metastasis spread and gender of the patient. Some skinmetastasis may mimic benign dermatological conditions likehaemangioma, alopecia patches, erysipelas and herpes zoster eruptionas in our case.

Cutaneous metastases from the internal malignancy or primary skincancers are uncommon and zosteriform patterns are very rare [13]. 39cases were revived from literature to illucidate the characteristics of

zosteriform metastasis. The most frequent site of primary tumour wasthe breast (7 cases) and the most common site of skin metastasis waschest wall (21 cases). This review highlights the importance ofincluding cutaneous metastasis within the differential diagnosis ofzosteriform metastasis. Skin metastasis should be considered and askin biopsy is necessary to confirm the diagnosis [14].

Chisti et al concluded that the breast cancer is the second mostcommon cancer in women after non-melanoma skin cancers andexcluding melanoma, the most common tumour to metastasis to skinin women [15]. Cutaneous metastasis of breast carcinoma has variedpresentations but there is no well-established classification whichincludes them all.

Prognosis of the patients with cutaneous metastasis depends on type& biological behaviour of underlying tumour. In breast carcinoma withskin metastasis presents as advanced tumour and show very poorprognosis, hence skin duration of long duration (months to years) areto be thoroughly investigated particularly in elderly patients (Figures3A and 3B).

Figure 3A: Tumour cells in the sub epidermal region; 20X.

Figure 3B: Tumour cells in the sub epidermal region; 40X.

Citation: Shafi A, Singh J (2016) Carcinoma en cuirasse with Zosteriform Metastasis-A Rare Presentation of Breast Carcinoma. J Med SurgPathol 1: 107.

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Citation: Shafi A, Singh J (2016) Carcinoma en cuirasse with Zosteriform Metastasis-A Rare Presentation of Breast Carcinoma. J Med SurgPathol 1: 107.

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