Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 23  |  Issue : 1  |  Page : 88-91

Cutaneous nodules as a first presentation in triple-negative breast cancer


1 Radiology Department, Ahmadu Bello University and Teaching Hospital, Zaria, Nigeria
2 Department of Oncology, Ahmadu Bello University and Teaching Hospital, Zaria, Nigeria
3 Dermatology Unit, Department of Medicine, University College Hospital, Ibadan Oyo State, Nigeria

Date of Submission05-Jun-2020
Date of Decision09-Aug-2020
Date of Acceptance03-Feb-2021
Date of Web Publication28-Apr-2021

Correspondence Address:
Dr. Sefiya Olarinoye-Akorede
Radiology Department, Ahmadu Bello University and Teaching Hospital, Zaria
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jomt.jomt_23_20

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  Abstract 


Out of all skin neoplasms, metastasis accounts for only about 2%, and breast cancer is the second commonest malignancy to metastasize to the skin after malignant melanoma. Although triple-negative breast cancer patients tend to have metastatic disease at presentation, cutaneous metastasis is unusual. In this report, we present a 47-year-old asymptomatic woman whose attention was drawn by her hairdresser to a scalp swelling 2 months prior to presentation. Similar swellings were noticed on the back, arms, and thighs. One month later, a left breast lump was noticed during a clinical breast examination by a physician. She was in good physical condition but had generalized cutaneous nodules. Further investigations revealed canon ball metastasis to the lungs, and histopathology with immunohistochemistry confirmed triple-negative invasive ductal carcinoma with cutaneous metastasis. Skin involvement in breast cancer signifies advanced disease. Therefore, high index of suspicion is necessary so as not to overlook early sinister nodules as benign dermatological condition.

Keywords: breast cancer, nodules, skin, triple negative


How to cite this article:
Olarinoye-Akorede S, Jimeta D, Olarinoye GM, Adewuyi S. Cutaneous nodules as a first presentation in triple-negative breast cancer. J Med Trop 2021;23:88-91

How to cite this URL:
Olarinoye-Akorede S, Jimeta D, Olarinoye GM, Adewuyi S. Cutaneous nodules as a first presentation in triple-negative breast cancer. J Med Trop [serial online] 2021 [cited 2021 Nov 30];23:88-91. Available from: https://www.jmedtropics.org/text.asp?2021/23/1/88/314845




  Introduction Top


Breast cancer is a heterogeneous disease with diverse biological, pathological, and clinical characteristics. Triple-negative breast cancer (TNBC) is a term applied to cancers that fail to express estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER-2). In Nigeria and Senegal, TNBC accounts for 30%, Ghana 82%, and Mali 46% of all breast cancer cases.[1],[2],[3]

TNBC accounts for approximately 20% of breast cancers diagnosed worldwide, and it is more common among African women.[4],[5],[6] It is frequently seen in women younger than 40 years old, compared with hormone-positive breast cancers.[7] Other risk factors associated with TNBC include: positive BRCA1 and BRCA2 gene mutation, increase parity, younger age at first-term pregnancy, shorter duration of breastfeeding, and elevated hip-to-waist ratio.[7] Although the skin is not a common site of spread in breast cancer (unlike the lungs), breast cancer is the second commonest primary tumor associated with cutaneous metastases, usually in a previously diagnosed patient with breast cancer. Cutaneous metastases as first presentation occurs in only about 7% of breast cancer, with a wide range of clinical appearance with nodules or papules.[8] Metastatic breast cancer can be fatal with treatments limited to palliation.[9],[10]


  Case presentation Top


The index patient was a 47 year old peri-menopausal teacher who presented to us 2 months after her hairdresser noticed a swelling on her scalp. The swelling was gradually increasing, firm, painless with no associated ulceration or discharge, and it was followed by similar swellings which were noticed on the back, arms, and thighs. There were no cardiopulmonary or neurological symptoms. She had a normal appetite and no history of weight loss. She was a known asthmatic and has been on prolonged steroid therapy.

However, her father had prostate cancer while her mother had cervical cancer, both of whom died of the disease.

Her first child birth was at 27 years and last childbirth was 18 years ago. She had been taking oral contraceptives in the past but had no previous history of breast disease.

On general examination, she was a middle-aged lady with no respiratory or painful distress; she was not pale, anicteric, or dehydrated. There was a wide distribution of soft, painless, and mobile cutaneous nodules present on her scalp, trunk, left upper arm, anterior abdominal wall, and thighs, with the largest measuring 5 cm × 3 cm × 1 cm.

The left breast had a painless, mobile, and firm solitary lump. There was no skin dimpling or ulceration, no nipple deviation, retraction nor nipple discharge. However, there were multiple axillary lymphadenopathies. The difference in the mid-upper arm circumference of both arms was not significant. The other systems were normal.

Results of full blood count, urea and electrolyte, serum calcium and phosphate, urinalysis, retroviral screening, and abdominopelvic ultrasound scan were within normal ranges or negative. However, ultrasound scan of the breast and subcutaneous lesions [Figure 1] and [Figure 2] show multiple hypoechoic masses, of varying shapes and sizes. They have indistinct margins and were vascular on doppler interrogation. Multiple axillary lymph nodes were present bilaterally. In addition, chest X-ray showed multiple metastases. Fine needle aspiration cytology of the subcutaneous swelling and excisional biopsy of the breast lump was done which revealed metastatic ductal carcinoma and invasive ductal carcinoma, respectively. Immunohistochemistry studies of the tissue showed HER-2 negative and ER/PR negative receptor status.
Figure 1: High frequency ultrasound scan of the breast and axilla. (a) Showing a round hypoechoic mass (1.4 cm X1.3 cm) with indistinct margin at 2 O’clock position in the left breast. (b) Showing enlarged axillary lymph node with loss of reniform shape and absent fatty hilum

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Figure 2: Ultrasound scan of the skin nodules. (a) Showing irregular shaped hypoechoic masses with non-circumscribed indistinct margin. (b) Showing increased vascularity on doppler interrogation

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A definitive diagnosis of triple negative metastatic breast cancer was made. Cyclical chemotherapy with docetaxel was prescribed. She received I.V. docetaxel 140 mg 3 weekly. The cutaneous nodules regressed significantly after the second course of chemotherapy. After four courses of chemotherapy, she developed progressive breathlessness which was associated with cough. Emergency chest X-ray and echocardiography revealed bilateral pleural and pericardial effusions. She had pericardiocentesis, chest tube insertion, drainage, and pleurodesis. Both procedures yielded hemorrhagic effluents. Her condition, however, worsened progressively and she passed on 6 months after diagnosis.


  Discussion Top


TNBC patients present with aggressive tumors which show rapid growth and quick relapse as was the case with the index patient. These patients also have an increased tendency to present with lung metastases as against skin as initial presentation.[9],[11],[12] Even when the skin is involved, it is usually in a known or previously diagnosed patient, making this case unusual.

Cutaneous nodules as a first presentation of metastatic breast cancer signifies advanced disease, which alters the course of management with a poor prognosis.[13] The predominant mode of spread is by lymphatic embolization. Most skin metastases are within the vicinity of the primary malignancy. The skin lesions have varying appearances from nodules to papules which may be single or multiple.[14] Our patient had multiple nodules involving the head, trunk, and extremities. The triple-negative phenotype is identified in 90% of BRCA1-associated breast cancers and to a lesser extent in BRCA2-associated cancers. It is thought that genetic mutations related to BRCA1 and BRCA2 may be responsible for the high rate of TNBC in African women. Because of unavailability of genetic sampling in our environment, the patient and her relatives were not tested for BRCA mutation. This could have been the likely risk factor associated with the diagnosis. Her father (first degree relative) had histologically confirmed diagnosis of prostate cancer which is known to be associated with BRCA1 and BRCA2 gene mutation.

Hormone therapies and HER-2 targeted agents are ineffective in TNBC group of tumors. These tumors respond to conventional chemotherapy. Taxanes and anthracyclines are known to show effectiveness as first-line treatment in TNBC; they demonstrate a high pathologic response rate.[15] Platinum agents can be used for BRCA-associated TNBC in the neoadjuvant and metastatic setting.

Genetic instability seen in TNBC tumors probably results in an increased potential for the development of chemoresistance making their management even more challenging. The patient was on prolonged steroid therapy for asthma which can cause immunosuppression. Probable genetic instability and immunosuppression can be confounding factors for rapid relapse observed in the patient who initially showed remarkable response to chemotherapy as the cutaneous nodules regressed but later the disease progressed on treatment with development of pericardial effusion and worsening of pleural effusion.


  Conclusion Top


Cutaneous nodules must be distinguished from a wide range of benign and malignant conditions. The presence of significant risk factors for malignancy should arouse a suspicion for a more serious condition. Cutaneous metastatic breast cancer and a triple-negative receptor status confer a poor prognosis and a challenge in management, with the patients eventually succumbing to the disease within a relatively short time.

Financial support and sponsorship

Nil.

Conflicts of interest

The authors report no conflicts of interest.



 
  References Top

1.
Jonathan MUA, Yibala IO. Triple negative breast cancer in a private immunohistochemistry laboratory in Abuja Nigeria. Adv Biol Res 2016;10:58-64.  Back to cited text no. 1
    
2.
Stark A, Kleer CG, Martin I et al. African ancestry and higher prevalence of triple-negative breast cancer: findings from an international study. Cancer 2010;116:4926-32.  Back to cited text no. 2
    
3.
Ly M, Antoine M, Dembélé AK et al. High incidence of triple-negative tumors in sub-Saharan Africa: a prospective study of breast cancer characteristics and risk factors in Malian women seen in a Bamako university hospital. Oncology 2012;83:257-63. doi: 10.1159/000341541  Back to cited text no. 3
    
4.
Ferlay J, Soerjomataram I, Dikshit R et al. Cancer incidence and mortality worldwide: sources, methods and major patterns in GLOBOCAN 2012. Int J Cancer 2015;136:E359-86.  Back to cited text no. 4
    
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Trivers KF, Lund MJ, Porter PL et al. The epidemiology of triple-negative breast cancer, including race. Cancer Causes Control 2009;20:1071–82.  Back to cited text no. 5
    
6.
Millikan RC, Newman B, Tse CK et al. Epidemiology of basal-like breast cancer. Breast Cancer Res Treat 2008;109:123-39.  Back to cited text no. 6
    
7.
Gonzalez-Angulo AM, Timms KM, Liu S et al. Incidence and outcome of BRCA mutations in unselected patients with triple receptor-negative breast cancer. Clin Cancer Res 2011;17:1082-9.  Back to cited text no. 7
    
8.
Callen J, Jorizzo J, Zone J, Piette W, Rosenbach M, Vleugels A. Dermatological Signs of Systemic Diseases (2016). Faculty Bookshelf. 86 https://hsrc.himmelfarb.gwu.edu/books/86  Back to cited text no. 8
    
9.
Dongwei G, Jiajun D, Lei C, Qi L. Risk factors for initial lung metastasis from breast invasive ductal carcinoma in stages I-III of operable patients. Jpn J Clin Oncol 2009;39:97-104.  Back to cited text no. 9
    
10.
Pichon MF, Broet P, Magdelenat H et al. Prognostic value of steroid receptors after long-term follow-up of2257 operable breast cancer. Br J Cancer 1996;73:1545-51.  Back to cited text no. 10
    
11.
Lin NU, Claus E, Sohl J, Razzak AR, Arnaout A, Winer EP. Sites of distant recurrence and clinical outcomes in patients with metastatic triple-negative breast cancer: high incidence of central nervous system metastases. Cancer 2008;113:2638-45.  Back to cited text no. 11
    
12.
Ruiterkamp J, Ernst MF, van de Poll–Franse LV, Bosscha K, Tjan–Heijnen VC, Voogd AC. Surgical resection of the primary tumour is associated with improved survival in patients with distant metastatic breast cancer at diagnosis. Eur J Surg Oncol 2009;35:1146-5.  Back to cited text no. 12
    
13.
Kazeminejad A, Ghahari MJ, Mirabi A, Davoodi L, Tabarestani M. Unusual presentation of breast metastasis mimicking skin abscess. Tabari Biomed Stu Res J 2019;1:25-7.  Back to cited text no. 13
    
14.
Dent R, Trudeau M, Pritchard KI et al. Triple-negative breast cancer: clinical features and patterns of recurrence. Clin Cancer Res. 2007;13(15 Pt 1):4429-34.  Back to cited text no. 14
    
15.
Mordenti C, Peris K, Concetta Fargnoli M, Cerroni L, Chimenti S. Cutaneous metastatic breast carcinoma. Acta Dermatovenerol APA 2000;9:4.  Back to cited text no. 15
    


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