Cutaneous Metastatic Carcinoma from Breast with Lymphangioma Circumscriptum-like Presentation in Zosteriform Distribution

Dear Editor, A 55-year-old woman presented with one-month history of cutaneous nodules over the anterior and lateral chest wall and haemorrhagic blisters on both sides of the neck. One year back, she was diagnosed with mucinous carcinoma of right breast (TNM stage 2) for which she underwent radical mastectomy and received radiation therapy 40 Gy (2.67 Gy × 15 fractions). Subsequently, the patient developed multiple painless grouped papulo-vesicular lesions on the ipsilateral (right) side of neck, present for the past nine months. She developed a lump in the left breast three months back which after histopathological examination (HPE) was found to be metastatic breast carcinoma and underwent mastectomy. Of late, she developed grouped haemorrhagic vesicles over the left neck which was similar to the morphology of lesions already present in the right side of neck. Examination revealed multiple, infiltrated, tender nodules of size 1–2 cm around the mastectomy area and lateral aspect of chest. And, there were asymptomatic coalescent haemorrhagic vesicles resembling lymphangioma circumscriptum (LC) on both the sides of neck with zosteriform distribution along C4 dermatome [Figure 1a and b]. Dermoscopy of the vesicular lesions revealed haemorrhagic spots, blue-grey areas, white structureless areas, telangiectasia and red-brown periphery [Figure 2]. There was no visceral metastasis. Skin biopsy from two sites, one from the lesion over the neck and other from the nodule in the chest, showed epithelium with an underlying neoplasm composed of nests of tumour cells in a pool of mucin suggestive of metastatic carcinomatous deposits. HPE of the vesicles in addition had haemorrhagic areas underneath the epithelium [Figure 3a-c]. Immunohistochemistry was negative for oestrogen and progesterone receptors (oestrogen receptor/progesterone receptors/human epidermal growth factor 2 negative) with overexpression of GATA3. High GATA3 expression indicates the tumour is well differentiated and has good prognosis.Figure 1: (a) Clinical images of the patient showing cutaneous nodules around the post-mastectomy area and bilaterally distributed LC-like lesions. (b) LC-like lesions in zosteriform pattern seen over the right side of the neck. LC = Lymphangioma circumscriptumFigure 2: Dermoscopic images of the LC-like lesions showing blue-grey areas, white structure-less areas, telangiectasia and haemorrhagic spots within the LC-like lesion and reddish-brown periphery around the lesions (Heine Delta 30 Dermatoscope, polarised ×10). LC = Lymphangioma circumscriptumFigure 3: (a) HPE with H and E staining of LC-like lesions—epithelium with underlying neoplasm composed of small nests of tumour cells with a pool of mucin (×4). (b) At high power, the cells are cuboidal having abundant granular cytoplasm exhibiting nuclear atypia with vesicular nuclei and increased mitosis (×40). (c) HPE of cutaneous nodules showing epithelium with underlying neoplasm composed of nests of tumour cells with abundant mucin. Purple areas around tumour cells indicate mucin stained with alcian blue (×4). HPE = Histopathological examinationMetastatic skin cancer is a rare complication of internal malignancies, commonly presented as nodules, less commonly as carcinoma erysipeloides, carcinoma en cuirasse, carcinoma telangiectoides and bullous variant.[1] Cutaneous metastasis (CM) can also resemble a wide range of benign skin conditions. CM with Zosteriform pattern is rare. A meta-analysis by Savoia et al. showed 56 cases with zosteriform cutaneous metastases from primary malignant tumours of which seven cases had primary breast carcinoma, mostly adenocarcinoma.[2] According to Hu et al., there are variations in the survival of CM resulting from various internal cancers, and CM from breast has a comparatively better prognosis than other cancers.[3] Mucinous breast carcinoma represents 1.5%–5% of all primary breast cancers. There are very few documented cases of secondary mucinous carcinoma of the skin, and almost all these cases had solitary lesion.[4] Neither LC-like lesions nor zosteriform distribution is documented previously. However, there is a case reported with LC-like presentation of CM, from a primary adenocarcinoma of breast.[5] In our case, the secondary deposits presented with two distinct morphologies, as cutaneous nodules and LC-like lesions with zosteriform distribution. This case report highlights the importance of considering LC-like presentation in zosteriform pattern as one of the dermatological manifestations of metastatic skin cancer and also, the possibility of two different manifestations of CM occurring in the same individual. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.