Cutaneous Metastasis in Breast Cancer: A Case Report

Introduction

Breast cancer (BC) is the most common malignancy among women globally and the second leading cause of cancer-related death worldwide. One of the most concerning aspects in BC is metastasis. Although breast cancer typically spreads to lymph nodes, bone, liver, and lungs, there have been reports of BC metastasis to less common sites [1].

Brain metastases from BC is considered rare. However, because of the improved diagnosis and a longer illness course, the incidence rate has progressively increased. Brain metastasis is more common in BC subgroups such as HER2-positive and triple-negative breast cancer [2]. BC metastases to the ovaries is also uncommon, but it is clinically significant since it can mimic main ovarian cancers, making the diagnosis difficult. Abdominal discomfort, bloating, and increased abdominal girth are common clinical manifestations. It is common in advanced BC and is associated with a poor prognosis [3,4]. Gastric metastasis is rare. It often presents as a gastric ulcer or gastrointestinal hemorrhage. Invasive lobular carcinoma is more commonly associated with gastric metastases than invasive ductal carcinoma [5].

BC skin metastasis, also known as cutaneous metastasis, occurs in around 20% of all advanced BC patients. It usually presents as a skin nodule, plaque, or erythematous lesion, and its clinical appearance can be similar to that of benign skin conditions.

A review of the literature showed that the incidence of cutaneous metastases varies between 0.7% and 10.0% for all types of carcinomas. Likewise, a more recent meta-analysis [6] showed that the overall incidence was 5.3%. Women with breast cancer are more likely than those with other malignancies to develop metastatic cutaneous lesions, followed by lung, colon, rectal, renal, ovarian, and bladder cancer [6].

Because of the existence of dermal lymphatic invasion, inflammatory BC has a greater risk of skin metastases [5,7]. Metastases often present as skin-colored nodules on the anterior chest wall, typically from lymphatic extension to the overlying skin. Adenocarcinoma has the greatest risk of skin metastases among the histologic subtypes of breast cancer, ranging from 77% to 82% of cases. BC has been linked to a variety of well-described clinical manifestations, including carcinoma erysiploides, carcinoma telangiectoides, carcinoma en cuirasse, and alopecia neoplastica [8–10].

This case report emphasizes the importance of follow-up and surveillance in patients with a history of BC, as the cancer can recur and spread many years after treatment. Early detection of recurrence essential for patient survival and prognosis.

Case Report

DIAGNOSIS:

Stage 4 breast cancer, Luminal A.

TREATMENT PLAN:

The patient was started on anti-hormone therapy and capecitabine based on immunohistochemistry findings after discussion of the Breast Tumor Board. Follow-up after 3 months showed regressing tumor and stable lung metastasis.

Discussion

BC is the most common cancer in women worldwide. In 2020, there were about 2.26 million new cases of BC, accounting for 11.7% of all cancer cases in women [11], making for approximately 8 million women alive who were diagnosed with breast cancer in the last 5 years. BC accounts for 0.5–1% of cancers in men [12].

BC is the most common cancer among women in the Kingdom of Saudi Arabia, where, in the last decade, it has accounted for 14.8% of all cancer cases in women and 8.5% of all cancer-related deaths. According to the Ministry of Health of Saudi Arabia, 2022, over 50% of breast cancer cases are detected at a later stage, compared to only 20% in other wealthy countries. As a result, Saudi Arabia has a higher mortality rate and higher annual treatment costs for BC than the United States across all stages of the disease [12]. Data on breast cancer incidence and patterns in the Saudi population are scarce, and this is also true in our city, Jeddah, in the western region of Saudi Arabia. A 2019 retrospective study by Alotaibi et al included 3 tertiary hospitals in Jeddah and showed that two-thirds of BC patients were diagnosed at advanced stage [13]. This is higher than the internationally reported figures and is also higher than for other regions in the country, such as the eastern province. Unfortunately, patients with advanced stage are more prone to have greater morbidity and lower survival rates compared to early-diagnosed cases [14]. The most common types of cancer that metastasize to the skin are breast, colon, lung, ovary, and bladder cancer, with an overall prevalence of 5.3% [12].

Skin metastasis typically appears late in the course of the disease, after the primary cancer has been diagnosed [15]. It is estimated that 0.7–9% of patients with cancer will develop skin metastasis at some point during their treatment [15,16]. The prevalence of cutaneous metastases has increased as cancer survival rates have increased, and therapy options have become more diverse. Because of the wide range in clinical course, identifying both the skin cancer and the original tumor can be challenging [17]. Metastasis can be the earliest indicator of relapse after cancer treatment and can be a predictor of poor survival. It is more prevalent among the elderly. A skin biopsy should be taken in cancer patients with early or rapid onset, prolonged healing, bleeding, or vascular appearance of lesions that do not disappear following therapy [15]. The scalp, navel, chest wall, and abdomen are the most common locations of metastasis, and they occur on the chest and abdomen in 75% of women. BC is the most prevalent primary malignancy in women, and it tends to spread later to the anterior thoracic wall [16,18].

Although the clinical manifestation of metastasis can differ, it is frequently characterized by suddenly appearing, normochromic or brownish solid nodules. Lesions can either be associated with pain or not, and they may initially spread abruptly before stabilizing. They may appear sclerotic or inflammatory, and they may be single or numerous. They sometimes retract the skin [15,19]. Metastatic breast cancer that has spread extensively to the skin can resemble cellulitis or an armored breastplate (en cuirasse pattern) [16]. A previous study in 2000 reported that skin lesions from BC metastasis are often multiple, hard, dark, and painless nodules that suddenly appear and are about 2 cm in size. However, the appearance of the lesions can vary depending on the histological type of the cancer, such as erysipelas (redness and swelling of the skin), papules (small, raised bumps on the skin), widespread sclerosis (thickening and hardening of the skin), or eczema (red, itchy rash) [18]. Papules and/or nodules were the most common presentation, accounting for 80% of cases. Telangiectasic carcinoma ranked second with 11.2%, followed by erysipeloid carcinoma with 3%, “en cuirasse” carcinoma with 3%, alopecia neoplastica with 2%, and a zosteriform pattern with 0.8%. Rarely, cutaneous metastases appear as the initial sign of malignancy [14]. BC can spread to the skin either directly, by hematologic or lymphatic dissemination, or through surgical implantation [19].

A skin biopsy is always required to diagnose skin metastases. In most cases with cutaneous metastases, the primary cancer has become locally advanced beyond surgical management [20,21]. Treatment options include chemotherapy, radiation, and hormone therapy, based on immunohistochemistry characteristics [22,23]. Furthermore, local radiation can be considered in patients with large ulcerating breast tumors, in addition to debridement and dressing. Unfortunately, the prognosis is usually poor [24].

Studies indicate that many [6] individuals with inflammatory breast cancer and [25] even early-stage triple-negative breast cancer have a recurrence rate of 40–50%. Current guidelines recommend annual mammography after treatment, but there should be individualized extended surveillance to monitor for late recurrence [26,27].

Conclusions

In this case, a patient with metastatic BC presented with multiple new skin masses. The patient had previously been treated for left-sided BC 10 years prior, and the new masses were all found to be metastatic BC. She has begun chemotherapy and hormonal treatment, and her disease was responding at 3-monts follow-up.

This report highlights the importance of long follow-up for patients with a history of BC. Even after many years, the cancer can recur and spread to other parts of the body. Patients should be aware of the signs and symptoms of recurrence, and they should see their doctor right away if they experience any new or concerning symptoms.