malignant melanoma rarely affects the breast , accounting for less than 5% of all malignant melanomas .
malignant melanoma of the breast has various manifestations : primary cutaneous melanoma , primary glandular melanoma , metastatic melanoma , and in - transit metastases to the breast .
primary cutaneous malignant melanoma of the breast shows similar clinical features to melanomas arising from other cutaneous areas .
it follows different metastatic patterns than do primary carcinomas of the breast and require a different therapeutic approach .
wide local excision with sentinel lymph node ( sln ) biopsy is the most important therapeutic modality in preventing local recurrence .
malignant melanoma is an immunogenic tumor and adjuvant immunotherapy is indicated in high risk patients .
common metastatic sites are brain , lung , liver and overall prognosis is very poor in metastasis .
herein , we report a case of primary cutaneous malignant melanoma of the breast in a 59-year - old woman and discuss the clinicopathologic features and treatments in correlation to the literature data .
a 59-year - old woman was admitted with a black pigmented skin lesion in the right breast .
she mentioned that the lesion had appeared at birth but grew rapidly and bled recently .
the lesion was 2.0  1.5 cm in size and located on the periareolar skin in the upper inner quadrant of the right breast which is not associated any breast mass ( fig .
the axillary lymph node was not palpated and there was no nipple discharge or retraction .
she underwent incisional biopsy a week earlier at a local breast clinic and was diagnosed with malignant melanoma .
the specimen was an ulcerative , pigmented lesion , measuring 1.0  0.6 cm in size and 0.25 cm in thickness ( pt3b ) .
careful examination of the other skin and mucous membranes revealed no areas suggestive of a malignant melanoma .
brain computed tomography ( ct ) and positron emission tomography - ct showed no evidence of metastasis .
she underwent wide local excision of the lesion , including removal of normal appearing skin and underlying subcutaneous tissue to provide a safety margin ; and subsequent sentinel lymph node biopsy ( slnbx ) using the technetium ( tc)-99 m phytate was performed .
grossly , the specimen revealed a sharply defined , black pigmented lesion , measuring 1.9  1.6 cm in size including normal skin 2 cm apart from the tumor margin and subcutaneous tissue ( fig .
microscopic findings showed intraepidermal tumor cells and nests that were laterally spreading in a pagetoid manner and tumor nests invaded the superficial dermis 0.12 cm in thickness ( pt2a ) ( fig .
tumor cells often had large nuclei and nucleoli and abundant cytoplasm with brown - black pigments ( fig .
the resection margins were free of tumor cells and there was no regional lymph node metastasis ( pn0 ) .
the final pathologic stage considering incisional biopsy report was iib ( t3bn0m0 ) according to the 7th edition of the american joint committee on cancer classification .
three years after surgery , the patient is alive and shows no signs of local recurrence or distant metastasis .
the incidence of malignant melanoma has risen sharply over the last decade and can occur anywhere on the body .
it occurs most commonly on the extremities in females and on the trunk in males .
malignant melanoma of the breast is classified into primary melanoma of the breast skin or gland , and metastatic melanoma to the breast from an extramammary site .
cutaneous malignant melanoma of the breast is a rare tumor , accounting for less than 5% of all malignant melanomas and primary cutaneous malignant melanoma of the breast is particularly rare .
reported that cutaneous malignant melanoma showed different manifestations in the breast not only at initial presentation but also during the follow - up periods of each patient .
to date , several cases of primary cutaneous malignant melanoma of the breast have been reported in the west but have not yet been reported in korea .
exposure to solar ultraviolet radiation is the major environmental risk factor and the presence of host factors including skin pigmentation , sensitivity to the sun and large numbers of nevus are strongly associated .
bono et al .   reported cutaneous malignant melanoma prefers the upper inner quadrant of the breast and this finding is consistent with an etiologic role for sun exposure . in the present case ,
the lesion was also located in the upper inner quadrant of the right breast . in comparison to primary cutaneous malignant melanomas arising from other areas , neither the symptoms nor the physical findings of primary cutaneous malignant melanoma of the breast present any characteristic pattern .
however , in cutaneous malignant melanoma of the breast , mmg and/or us should be obtained to reveal the breast lesion that is considered a metastatic lesion . in our case ,
if malignant melanoma occurs in the nipple - areolar area , phagocytosis of melanin by paget 's cells can distinguish the malignant melanoma from paget 's disease of the breast . in our case ,
however , incisional biopsy should never be performed to establish the diagnosis of cutaneous malignant melanoma because it would be confusing in determining the pathologic stage .
therefore , if a suspicious lesion is found , excisional biopsy should be performed . for an accurate diagnosis of primary cutaneous malignant melanoma , a comprehensive physical examination
also , any history of previous removal of pigmented lesions must be investigated and reviewed if present .
the management of primary cutaneous malignant melanoma of the breast requires special consideration in view of the rarity of the disease and the intricate anatomy of the breast .
surgery is the main therapeutic option and wide local excision with a margin containing normal appearing skin and underlying subcutaneous tissue is the standard of treatment .
adequate excision margin is considered a 1 to 2 cm clearance according to tumor thickness ; 1 cm clearance is adequate for lesions < 1 mm thickness and 2 cm for > 2 mm thickness . in our case ,
mastectomy does not improve the survival rate obtained by breast conserving surgery . because regional lymph node metastasis is the most important prognostic factor
it is rare for it to spread systemic metastasis without first passing through the sln .
reported that lesions located below 3 cm from clavicle metastasized to the axillary lymph nodes regardless of gender or location and lesions located above 3 cm , assessment on the cervical region has been recommended .
the incidence of lymph node metastases ranges from 6% for patients with 1 mm cutaneous malignant melanomas to 35% in patients with 4 mm .
a positive sln is associated with clark level iv depth , tumor regression and ulceration , young age , higher mitotic rate , male and axial location .
cutaneous malignant melanoma is an immunogenic tumor and high dose interferon alpha has gained approval for adjuvant treatment of malignant melanoma .
interferon has shown to improve relapse - free survival but a definitive benefit in overall survival is debatable . though radiotherapy decreases the locoregional failure from 30 - 50% to 10 - 20% , a survival benefit remains vague because of low radiosensitivity in melanoma cells .
in contrast to breast carcinoma , a significance of chemotherapy or hormonal therapy is unclear . despite various aggressive systemic treatments ,
cutaneous malignant melanoma is possibly a life - threatening disease in which regional or distant metastasis may develop .
the most common metastatic site is the brain , for which dacarbazine is considered the standard treatment .
the important prognostic factors are regional lymph node metastasis , primary tumor thickness , and ulceration . during follow - up visits ,
particular attention should be paid to the importance of breast examination . not only in visible in - transit metastasis , but also when there is evidence of mild breast skin abnormalities such as a light blue spot , histological confirmation should be performed .
the rarity of cutaneous malignant melanomas of the breast have made them difficult to evaluate . moreover , distinguishing whether a cutaneous malignant melanoma of the breast is primary or metastatic is important for the treatment strategies and the overall prognosis .
awareness of unusual cutaneous lesions of the breast is necessary to determine the optimal treatment modalities on this rare disease .
 cutaneous malignant melanoma of the breast can be divided into two categories : primary and metastatic lesions . 
 cutaneous malignant melanoma of the breast is a rare tumor , accounting for less than 5% of all malignant melanomas . 
 clinical features and diagnostic methods of primary cutaneous malignant melanoma of the breast are similar to those arising from other cutaneous areas . 
 treatment of choice is wide local excision with adequate resection margin according to tumor thickness . 
 sentinel lymph node biopsy should be performed because the presence of lymph node metastasis is the most important prognostic factor . 
 there have been only limited reports involving primary cutaneous malignant melanoma of the breast . 
 thus , we report a case of primary cutaneous malignant melanoma in a 59-year - old woman with a review of the recent literature . 