|Year : 2020 | Volume
| Issue : 1 | Page : 65-68
Rapid progression of carcinoma en cuirasse breast dermal metastases on18F-fludeoxyglucose positron emission tomography–computed tomography
Colin Raymond Young1, Mallini Harigopal2, Darko Pucar1
1 Department of Radiology, Yale New Haven Hospital, New Haven, CT, USA
2 Department of Pathology, Yale New Haven Hospital, New Haven, CT, USA
|Date of Submission||18-May-2019|
|Date of Acceptance||01-Jul-2019|
|Date of Web Publication||07-Nov-2019|
Dr. Colin Raymond Young
Department of Radiology, Yale New Haven Hospital, 20 York Street, New Haven, CT 06510
| Abstract|| |
Cancer in the dermis of the breast has a poor prognosis. The breast dermis can become malignantly involved primarily in inflammatory breast cancer, through the direct extension of locally advanced breast cancer, or metastatically from an underlying breast mass or a distant primary malignancy (e.g., gastric adenocarcinoma). Breast dermal metastases have the shortest median survival among them. Breast dermal metastases are classified into eight clinicohistopathologic groups, one of which is carcinoma en cuirasse. We present a case of a 52-year-old female with a history of invasive ductal carcinoma, Stage IIIC (pT2N3a), treated with lumpectomy, axillary node dissection, and chemoradiation therapy that recurred as carcinoma en cuirasse breast dermal metastases. Through18F-fludeoxyglucose positron emission tomography–computed tomography (18F-FDG PET-CT) and clinical images, the case illustrates the rapid progression and devastating consequences of carcinoma en cuirasse breast dermal metastases over a 4-month period despite optimal therapy. Furthermore, the case emphasizes the sensitivity of18F-FDG PET-CT to detect pathology in the breast dermis. Finally, the case highlights the crucial role that nuclear medicine physicians play in helping clinical colleagues differentiate between the various breast dermal malignant manifestations and benign mastitis, a common confounder in postradiation patients.
Keywords: 18F-fludeoxyglucose positron emission tomography–computed tomography, breast dermal metastases, carcinoma en cuirasse, inflammatory breast cancer, locally advanced breast cancer
|How to cite this article:|
Young CR, Harigopal M, Pucar D. Rapid progression of carcinoma en cuirasse breast dermal metastases on18F-fludeoxyglucose positron emission tomography–computed tomography. World J Nucl Med 2020;19:65-8
|How to cite this URL:|
Young CR, Harigopal M, Pucar D. Rapid progression of carcinoma en cuirasse breast dermal metastases on18F-fludeoxyglucose positron emission tomography–computed tomography. World J Nucl Med [serial online] 2020 [cited 2020 Jul 10];19:65-8. Available from: http://www.wjnm.org/text.asp?2020/19/1/65/271135
Disclaimer: The views expressed in this manuscript are those of the author and do not reflect the official policy of the Department of Navy, Department of Defense, or U.S. Government.
Copyright Statement: The first author is a military service member. This work was prepared as part of the authors' official duties. Title 17 U.S.C 105 provides that 'Copyright protection under this title is not available for any work of the United States Government.' Title 17 U.S.C. 101 defines a U.S. Government work as a work prepared by a member or employee of the U.S. Government as a part of that person's official duties.
| Case Report|| |
A 52-year-old female with a 4.6 cm left breast invasive ductal carcinoma (no special type) was treated with a lumpectomy and axillary lymph node dissection. Pathologic analysis of surgical specimens revealed wide negative surgical margins on the primary mass, and 19 of 25 lymph nodes were metastatically involved, overall consistent with Stage IIIC (pT2N3a) disease. No left breast dermal involvement was initially present. Subsequently, she received adjuvant chemotherapy with Adriamycin, Cytoxan, and paclitaxel and 66 Gy of radiation to the left breast and axilla.
About 1 year later, she represented with fibrosis of the left breast [Figure 1]a, white short arrows], and palpable right axillary adenopathy. While biopsy of the right axillary adenopathy indicated recurrent malignancy, the left breast fibrosis was initially clinically favored to represent radiation mastitis, partially attributable to initial punch biopsy results. However, an18 F-fludeoxyglucose positron emission tomography–computed tomography (18 F-FDG PET-CT) demonstrated an intense hypermetabolic activity associated with the right axillary adenopathy [Figure 1]b, black arrows] and broad areas of moderate hypermetabolic activity throughout the left breast dermis and parenchyma [Figure 1]c, white arrows]. This indicated that the changes in the left breast represented a site of aggressive recurrence as opposed to benign inflammation. This was confirmed with a repeat punch biopsy. The skin changes in the left breast were subsequently identified as carcinoma en cuirasse breast dermal metastases. Despite aggressive salvage chemotherapy with paclitaxel and carboplatin, an18 F-FDG PET-CT scan performed 4 months later revealed the progression of metastatic disease with spread to the right breast, with clinical images showing widespread cutaneous ulcerations and excoriations [Figure 1]d, [Figure 1]e, [Figure 1]f. Metastatic spread to the right breast dermis was confirmed by punch biopsy which demonstrated invasion of lymphovascular spaces by tumor emboli [Figure 2], black short arrows] in a background of fibrous connective tissue.
|Figure 1: (a-c) Pre-salvage chemotherapy (d-f) Post-salvage chemotherapy|
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| Discussion|| |
Cancer in the dermis of the breast has a poor prognosis. The breast dermis can become malignantly involved primarily in inflammatory breast cancer, through direct extension of locally advanced breast cancer, or metastatically from an underlying breast mass or a distant primary malignancy (e.g., gastric adenocarcinoma). [Table 1] describes the differences between these entities. Dermal metastases have the shortest median survival., Dermal metastases from underlying breast cancer occur infrequently, with an estimated incidence between 0.6% and 10%. First described by Velpeau in 1838, carcinoma en cuirasse is a particularly aggressive clinicohistopathologic variant of breast dermal metastases with a contractile fibrous texture resembling the metallic chest plate in antique Spanish cavalry armor. Carcinoma en cuirasse accounts for approximately 3% of dermal metastases from underlying breast cancer. Carcinoma en cuirasse is rarely the presenting feature of underlying breast cancer but rather tends to occur later in the course of the disease development or as a sign of recurrence., It is also known as scirrhous carcinoma, pachydermia, or Acarcine eburnee. While others have presented18 F-FDG PET-CT images of this entity,, this case report represents the first depiction of the rapid progression and devastating consequences. Furthermore, the case emphasizes the sensitivity of18 F-FDG PET-CT to detect pathology in the breast dermis. Finally, the case highlights the crucial role that nuclear medicine physicians play in helping clinical colleagues differentiate between various breast dermal malignant manifestations and benign mastitis, a common confounder in postradiation patients. Physicians interpreting18 F-FDG PET-CT images must routinely scrutinize the breast dermis for thickening or hypermetabolism. Such findings warrant recommending direct physical examination with tissue sampling as indicated.
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Conflicts of interest
There are no conflicts of interest.
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