Extensive ulcerated pigmented nodules
Authors: Adam Friedman, Marc Jacobson, Ranon Mann
Journal: Journal of the American Academy of Dermatology (2011)

To the Editor: Pigmentation of cutaneous metastases is a rare phenomenon. We report a case of a woman with breast carcinoma that presented as ulcerated and pigmented metastatic nodules.A 57-year-old African American woman with a medical history significant for diabetes and asthma presented to the emergency room with worsening chronic lower back pain in March 2007. Upon admission, she was found to have “necrotic masses” involving both breasts and her chest wall. The patient attributed the lesions to poorly healing burns she had sustained while cooking 2 years earlier. A chest radiograph revealed right-sided pleural thickening and effusion and a small opacity overlying the right fourth rib. A computed tomographic scan of her chest revealed extensive right breast scarring, a soft tissue mass in the right pole, and right axillary and left posterior cervical lymphadenopathy. The dermatology department was asked to consult. The physical examination revealed extensive ulcerated brown-black nodules and tumors deforming the chest and superior abdominal wall (Fig 1). A punch biopsy was performed, showing neoplastic cellular aggregations between collagen bundles throughout the dermis and pigmented nests within the epidermis (Fig 2, A-C). Immunohistochemical stain for CK7 was consistent with epidermotropic metastatic adenocarcinoma of the breast (Fig 2, D).Fig 2A, Neoplastic aggregates between collagen bundles throughout the dermis. B, Neoplastic cells within the dermis and as pigmented nests within the epidermis. C, Intraepidermal collections of atyipical pigmented epithelial cells simulating nests of atypical melanocytes. D, Immunohistochemical stain for CK7 decorates epidermotropic metastatic adenocarcinoma of the breast. (A-C, Hematoxylin–eosin stain; D, CK7 immunostain; original magnifications: A, ×20; B, ×100; C, ×400; D, ×200.)View Large Image Figure ViewerDownload Hi-res image Download (PPT)Cutaneous metastases represent a relatively rare phenomenon in patients with internal malignancy, with a reported overall incidence of 0.7% to 9%. The most common site of origin for epidermotropic metastases is breast carcinoma in women and lung carcinoma in men.1Krathen R.A. Orengo I.F. Rosen T. Cutaneous metastasis: a meta-analysis of data.South Med J. 2003; 96: 164-167Crossref PubMed Scopus (328) Google Scholar Although cutaneous metastases often present during advanced stages of malignancies, they occasionally may be the first sign of a visceral carcinoma.Cutaneous breast metastases may have multiple clinical presentations. Dermal nodules represent the most common clinical presentation, occurring in approximately 10% of patients. In rare cases, pigmented metastases have been described—with few reports since the initial description by Jacoby et al2Jacoby R. Roses D.F. Valensi Q. Carcinoma of the breast metastatic to the skin and simulating malignant melanoma.in: Ackerman A.B. Pathology of malignant melanoma. Masson, Chicago1981: 263-267Google Scholar nearly 30 years ago. This unusual epidermotropic pigmented clinical subtype makes clinical, dermascopic,3Wyatt A.J. Agero A.L. Delgado R. Busam K.J. Marghoob A.A. Cutaneous metastatic breast carcinoma with melanocyte colonization: a clinical and dermoscopic mimic of malignant melanoma.Dermatol Surg. 2006; 32: 949-954Crossref PubMed Scopus (18) Google Scholar and histologic4Requena L. Sánchez Yus E. Núñez C. White Jr., C.R. Sangueza O.P. Epidermotropically metastatic breast carcinomas: rare histopathologic variants mimicking melanoma and Paget's disease.Am J Dermatopathol. 1996; 18: 385-395Crossref PubMed Scopus (52) Google Scholar differentiation from melanoma challenging.Several mechanisms of pigmentation of epidermotropic breast metastases have been proposed. In one case, molecular analysis of tumoral clusters revealed colonization by melanocytes and high levels of melanocyte chemotactic factor. This suggests that secreted homing molecules may play a role in the pathogenesis of pigmentation of cutaneous metastases.5Konomi K. Imayama S. Nagae S. Terasaka R. Chijiiwa K. Yashima Y. Melanocyte chemotactic factor produced by skin metastases of a breast carcinoma.J Surg Oncol. 1992; 50: 62-66Crossref PubMed Scopus (41) Google ScholarIn addition, metastatic infiltrates within the epidermis may lead to a blockade of the normal transfer of melanin to keratinocytes. Phagocytosis of melanin from melanocytes by the epithelial cells of the carcinoma has been shown (most notably in pigmented adenocarcinoma of the rectum).To our knowledge, we present one of the most extensive and destructive cases recorded in the literature of an underlying breast carcinoma presenting as ulcerated and pigmented metastatic nodules. To the Editor: Pigmentation of cutaneous metastases is a rare phenomenon. We report a case of a woman with breast carcinoma that presented as ulcerated and pigmented metastatic nodules. A 57-year-old African American woman with a medical history significant for diabetes and asthma presented to the emergency room with worsening chronic lower back pain in March 2007. Upon admission, she was found to have “necrotic masses” involving both breasts and her chest wall. The patient attributed the lesions to poorly healing burns she had sustained while cooking 2 years earlier. A chest radiograph revealed right-sided pleural thickening and effusion and a small opacity overlying the right fourth rib. A computed tomographic scan of her chest revealed extensive right breast scarring, a soft tissue mass in the right pole, and right axillary and left posterior cervical lymphadenopathy. The dermatology department was asked to consult. The physical examination revealed extensive ulcerated brown-black nodules and tumors deforming the chest and superior abdominal wall (Fig 1). A punch biopsy was performed, showing neoplastic cellular aggregations between collagen bundles throughout the dermis and pigmented nests within the epidermis (Fig 2, A-C). Immunohistochemical stain for CK7 was consistent with epidermotropic metastatic adenocarcinoma of the breast (Fig 2, D). Cutaneous metastases represent a relatively rare phenomenon in patients with internal malignancy, with a reported overall incidence of 0.7% to 9%. The most common site of origin for epidermotropic metastases is breast carcinoma in women and lung carcinoma in men.1Krathen R.A. Orengo I.F. Rosen T. Cutaneous metastasis: a meta-analysis of data.South Med J. 2003; 96: 164-167Crossref PubMed Scopus (328) Google Scholar Although cutaneous metastases often present during advanced stages of malignancies, they occasionally may be the first sign of a visceral carcinoma. Cutaneous breast metastases may have multiple clinical presentations. Dermal nodules represent the most common clinical presentation, occurring in approximately 10% of patients. In rare cases, pigmented metastases have been described—with few reports since the initial description by Jacoby et al2Jacoby R. Roses D.F. Valensi Q. Carcinoma of the breast metastatic to the skin and simulating malignant melanoma.in: Ackerman A.B. Pathology of malignant melanoma. Masson, Chicago1981: 263-267Google Scholar nearly 30 years ago. This unusual epidermotropic pigmented clinical subtype makes clinical, dermascopic,3Wyatt A.J. Agero A.L. Delgado R. Busam K.J. Marghoob A.A. Cutaneous metastatic breast carcinoma with melanocyte colonization: a clinical and dermoscopic mimic of malignant melanoma.Dermatol Surg. 2006; 32: 949-954Crossref PubMed Scopus (18) Google Scholar and histologic4Requena L. Sánchez Yus E. Núñez C. White Jr., C.R. Sangueza O.P. Epidermotropically metastatic breast carcinomas: rare histopathologic variants mimicking melanoma and Paget's disease.Am J Dermatopathol. 1996; 18: 385-395Crossref PubMed Scopus (52) Google Scholar differentiation from melanoma challenging. Several mechanisms of pigmentation of epidermotropic breast metastases have been proposed. In one case, molecular analysis of tumoral clusters revealed colonization by melanocytes and high levels of melanocyte chemotactic factor. This suggests that secreted homing molecules may play a role in the pathogenesis of pigmentation of cutaneous metastases.5Konomi K. Imayama S. Nagae S. Terasaka R. Chijiiwa K. Yashima Y. Melanocyte chemotactic factor produced by skin metastases of a breast carcinoma.J Surg Oncol. 1992; 50: 62-66Crossref PubMed Scopus (41) Google Scholar In addition, metastatic infiltrates within the epidermis may lead to a blockade of the normal transfer of melanin to keratinocytes. Phagocytosis of melanin from melanocytes by the epithelial cells of the carcinoma has been shown (most notably in pigmented adenocarcinoma of the rectum). To our knowledge, we present one of the most extensive and destructive cases recorded in the literature of an underlying breast carcinoma presenting as ulcerated and pigmented metastatic nodules. CorrectionJournal of the American Academy of DermatologyVol. 65Issue 2PreviewFriedman A, Jacobson M, Mann R. Extensive ulcerated pigmented nodules. J Am Acad Dermatol 2011;64:994-6. Full-Text PDF