CANCER MAMAR LOBULAR INVAZIV CU METASTAZE · PDF filecauzã de deces, dupã cancerul pulmonar, în þãrile dezvoltate ºi principala cauzã de deces în þãrile slab dezvoltate

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Rezumat

Introducere: Neoplasmul mamar se situeazã peprimul loc în patologia oncologicã la femei. În þara noastrãincidenþa a crescut de la 25 la sutã de mii de femei în 1988,la 50,56 la suta de mii de femei în 2006.

La femei, metastazele cutanate sunt determinate celmai frecvent de cancerul de sân, incidenþa fiind cu aproape20% mai mare comparativ cu celelalte tipuri de tumori.

Prezentare de caz: Prezentãm cazul unei paciente învârstã de 58 de ani, diagnosticatã în 2012 cu neoplasmmamar lobular invaziv drept. Aceasta s-a internat înclinica noastrã în Mai 2015, prezentând un placarderitemato-infiltrativ,sclerodermiform, fixat pe planurileprofunde, cu papule pe suprafaþã, însoþit de durere cucaracter de arsurã ºi impotenþã funcþionalã, localizat lanivelul regiunii cervicale ºi toracelui. În urma examenuluihistopatologic ºi în baza aspectului clinic, am stabilitdiagnosticul de metastaze cutanate “în cuirasã”,determinate de un carcinom mamar lobular. Pacienta a fostîndrumatã la Clinica de Oncologie, unde a urmattratament cu inhibitori ai receptorilor de estrogen, evoluþiafiind parþial favorabilã.

Discuþii: Cancerul mamar reprezintã, la nivelmondial, cel mai frecvent neoplasm la femei, fiind a douacauzã de deces, dupã cancerul pulmonar, în þãrile dezvoltateºi principala cauzã de deces în þãrile slab dezvoltate. Acestareprezintã totodatã ºi neoplasmul care metastazeazã cel maifrecvent la nivel cutanat.

Summary

Introduction: Breast cancer is the most common typeof cancer that affects women. In Romania, the incidence hasgrown from 25/100.000 women in 1988 to 50,56/100.000women in 2006.

In women, the most frequent type of cancer known todetermine skin metastasis is breast cancer, it’s incidencebeing almost 20% higher than any other type of cancer.

Case report: We present the case of a 58 years oldfemale patient diagnosed with breast cancer in 2012. Shewas admitted into our clinic in June 2015 with erythemato-infiltrative, sclerous placards, with papules on the surface,accompanied by burn-like pain and functional impotence,localized in the cervical and trunk area, progressingtowards the abdominal wall. Based on the clinical aspectsand the histopathological exam, she was diagnosed with „encuirasse” cutaneous metastases of a lobular breastcarcinoma. The patient was discharged from our clinic andguided to the Oncology Clinic, where she received hormonaltherapy (Anastrozole). Her evolution was partiallyfavorable.

Discussions: Worldwide, breast cancer is the mostfrequent type of cancer to affect women. It is the secondcause of death, after pulmonary cancer, in developedcountries and the first cause of death in less developedcountries.

The histopathological types of breast carcinoma:infiltrative ductal carcinoma, invasive lobular carcinoma,

CANCER MAMAR LOBULAR INVAZIV CU METASTAZECUTANATE „ÎN CUIRASÃ” - PREZENTARE DE CAZ

INVASIVE LOBULAR BREAST CANCER WITH “ENCUIRASSE” CUTANEOUS METASTASES - CASE REPORT

BIANCA CISMARU-IANCU*, RALUCA NICULINA CIUREA**, VIRGIL PÃTRAªCU***

CAZURI CLINICECLINICAL CASES

* Clinica Dermatologie, Spitalul Judeþean Craiova, România / Dermatology Clinic, County Hospital, Craiova, Romania** Universitatea de Medicinã ºi Farmacie, Departamentul de Anatomie Patologicã, Craiova, România / University of Medicine

and Pharmacy, Pathology Department, Craiova, Romania*** Universitatea de Medicinã ºi Farmacie, Departamentul de Dermatologie, Craiova, România / University of Medicine and

Pharmacy, Dermatology Department, Craiova, Romania

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DermatoVenerol. (Buc.), 61: 181-190

IntroducereNeoplasmul mamar se situeazã pe primul loc

în patologia oncologicã la femei. În UniuneaEuropeanã are o incidenþã de 109,8/100.000femei/an ºi o mortalitate de 38,4/100.000femei/an. În þara noastrã, incidenþa a crescut dela 25 la suta de mii de femei în 1988, la 50,56 lasuta de mii de femei în 2006 [1].

Incidenþa metastazelor cutanate în cadrulneoplaziilor interne este de aproximativ 5,3% [2].La femei, metastazele cutanate sunt determinatecel mai frecvent de cancerul de sân, incidenþafiind cu aproape 20% mai mare comparativ cucelelalte tipuri de tumori [3].

Caz clinicPacientã în vârstã de 58 de ani, din mediul

urban, se prezintã în clinica noastrã în Mai 2015pentru apariþia unui placard eritemato-infiltrativ,sclerodermiform, cu papule pe suprafaþã, însoþitde durere cu caracter de arsurã ºi impotenþãfuncþionalã, localizat la nivelul regiunii cervicaleºi toracelui, extinzându-se la nivelul abdo-menului (fig. 1, fig. 2,fig. 3). Leziunile au apãrutîn urmã cu aproximativ 3 ani la nivelul regiuniicervicale, extinzându-se progresiv.

Antecedente heredo-colaterale: Mama-carcinom hepatic.

Antecedente personale patologice: Tiroiditãautoimunã (1985), Apendicectomie (1989), Cole-cistectomie (1996), Steatozã hepaticã (2012), HTAgrad III (2012), Neoplasm mamar drept operat(2012).

Introduction

Breast cancer is the most common type ofcancer that affects women. In the EuropeanUnion, the incidence of breast carcinoma is109,8/100.000 women/year and the mortality isup to 38,4/100.000 women/year. In Romania, theincidence has grown from 25/100.000 women in1988 to 50,56/100.000 women in 2006 [1].

The incidence of cutaneous metastasisdetermined by internal carcinoma is 5,3% [2]. Inwomen, the most frequent type of cancer knownto determine skin metastasis is breast cancer, it’sincidence being almost 20% higher than anyother type of cancer [3].

Case report

A 58 years old female patient presented witherythemato-infiltrative, sclerous placards, withpapules on the surface, accompanied by burn-like pain and functional disability, localized in thecervical and trunk area, progressing towards theabdominal wall (fig. 1, fig. 2, fig. 3). The lesionsfirst appeared 3 years ago in the cervical region,slowly extending to the other areas.

Family history: the patient’s mother had livercancer.

Personal pathological history: AutoimmuneThyroiditis (1985), Apendicectomy (1989),Colecistectomy (1996), Hepatic Steatosis (2012),Stage 3 Artherial Hypertension (2012), Surgicallytreated for a breast carcinoma (2012).

Tipurile histopatologice de carcinom mamar sunt:carcinom ductal infiltrativ, carcinom lobular invaziv,carcinom medular, mucinos, tubular, inflamator, papilar,mataplastic ºi boala Paget mamarã. Carcinomul lobularinvaziv reprezintã 15 % din cancerele mamare, fiind aldoilea tip histopatologic de neoplasm mamar, în ordineafrecvenþei. Acesta se caracterizeazã prin prezenþa recep-torilor pentru estrogen.

Concluzii: Principalul neoplasm care determinãmetastaze cutanate la femei este cancerul de sân.

Metastazele cutanate se prezintã sub forme variate, acãror recunoaºtere creºte rata de supravieþuire printratament adecvat ºi rapid instituit.

Cuvinte cheie: neoplasm mamar, metastaze cutanate,carcinom mamar lobular invaziv.

medullary carcinoma, mucinous carcinoma, tubularcarcinoma, inflammatory carcinoma, papillary carcinoma,metaplastic carcinoma and mammary Paget disease.Invasive lobular carcinoma represents 15% of all breastcancers and it’s the second most frequent histopathologicaltype of carcinoma. It usually presents estrogen receptors.

Conclusions: The main type of cancer known tometastasise in women is breast cancer. Cutaneousmetastases present under various forms. Knowing the exactappearances of these forms can facilitate the fast diagnosisof the primary tumor.

Keywords: breast cancer, cutaneous metastasis,invasive lobular carcinoma.

Intrat în redacþie: 22.04.2016Acceptat: 22.06.2016

Received: 22.04.2016Accepted: 22.06.2016

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Condiþii de viaþã ºi muncã: Expunere pre-lungitã la vapori de diluanþi ºi vopsele.

Istoricul bolii

Boala neoplazicã a fost diagnosticatã în 2012,când pacienta a prezentat o tumorã la nivelulglandei mamare drepte, în cadranul infero-internºi adenopatii laterocervicale ºi axilare bilaterale.Pacientei i s-a practicat mastectomie dreaptã culimfadenectomie axilarã dreaptã incompletã. Înurma biopsiei, examenul histopatologic a relevatdiagnosticul de carcinom mamar lobular invazivcu metastaze ganglionare masive. Ulterior a fostluatã în evidenþa Clinicii de Oncologie, unde aurmat tratament polichimioterapic cu Epi-rubicinã 100 mg, Taxotere 140 mg, Endoxan 500mg ºi Zarzio (4 ºedinþe), Paclitaxel (4 ºedinþe),terapie molecularã þintitã (Avastin) ºi radio-terapie (45 de fracþii). Manifestãrile cutanate auapãrut în urmã cu aproximativ trei ani, sub formãde plãci eritemato-infiltrative, sclerodermiforme,

Lifestyle: The patient had a history of pro-longed exposure cu paint vapors.

Disease history

In 2012, the pacient discovered a tumor in theinferior internal quadrant of the right mammarygland and laterocervical and axillarylimphadenopathy. She had a right mastectomywith incomplete right axillary limphadenectomy.After performing a tumor biopsy, the histo-pathological exam revealed the diagnosis ofinvasive lobular breast carcinoma with massivelymph-node metastasis. She underwent poly-chemotherapy with Epirubicine 100 mg, Taxotere140 mg, Endoxan 500 mg, Zarzio (4 sessions),Paclitaxel (4 sessions), targeted moleculartherapy with Avastin and radiotherapy (45fractions). The first cutaneous lesions appeared 3years ago as erythemato-infiltrative, sclerousplaques with papules on the surface but in timethey evolved into placards that extended all over

Fig. 1. Plãci eritemato-infiltrative,scleroase, cu papule pe suprafaþã,regiunea cervicalãFig. 1. Erythemato-infiltrative,sclerous plaques, with papules onthe surface, cervical area

Fig. 3. Placard eritemato-infiltrativ, scleros,cu papule pe suprafaþã, la nivelul toraceluianterior ºi extindere spre peretele abdominalFig. 3. Erythemato-infiltrative, sclerousplacard, with papules on the surface, on theanterior chest wall, progressing towards theabdominal wall

Fig. 2. Placard eritemato-infiltrativ,scleros, situat în regiunea cervicalãºi la nivelul toracelui posteriorFig. 2. Erythemato-infiltrative,sclerous placard, found in thecervical area and posterior chest wall

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cu papule pe suprafaþã, însoþite de durere cucaracter de arsurã ºi impotenþã funcþionalã.Iniþial plãcile au apãrut la nivelul zonei cervicale,ulterior extinzându-se la nivelul întreguluitrunchi ºi flancului drept abdominal, formândplacarde. Pentru leziunile cutanate, pacienta aurmat tratament radioterapic (15 fracþii).

Examen clinic general

Pacientã supraponderalã (IMC 28,72), cufacies edematos ºi tegumente discret palide, cuedem generalizat la nivelul sânului stâng,predominant în cadranul inferior ºi placãeritematoasã localizatã submamar stâng.Limfedem la nivelul braþului drept. Blocuriganglionare laterocervicale bilaterale de 2/1 cm,fixate pe planurile profunde ºi sensibile lapalpare. TA 150/80 mmHg. Ficat cu margineainferioarã la 1 cm sub rebordul costal.

Explorãri paraclinice

Examen ecografic de bilanþ ºi elastografie aurelevat: adenopatie imagistic malignã axilarãstângã cu limfedem mamar stâng; modificãri deradiodermitã; celulitã ºi miozitã radicãcervicocefalicã dreaptã ºi presternalã dreaptã.

CT gât, torace, abdomen ºi pelvis relevã infiltraredifuzã a tegumentului, grãsimii subcutanate ºimusculaturii din regiunea nucalã, adenopatiesubmandibularã stângã de 10 mm, adenopatieaxilarã stângã de 14 mm, infiltrare difuzã ategumentului glandei mamare stângi ºi a grãsimiiretromamare ºi adenopatii inghinale drepte de 9ºi 14 mm.

Imaginile scintigrafice ale întregului corp nupun în evidenþã determinãri secundare osoase,doar o hipercaptare la nivelul articulaþieiscapulo-humerale stângi, posibil artrozicã ºihipertrofia glandei mamare stângi.

Antigen carbohidrat (CA 15-3) a avut valoareade 107,6 U/mL (valori normale ≤ 25 U/mL).

Radiografie pulmonarã: fãrã leziuni pulmonareactive; cord cu arcul inferior stâng alungit.

Ecografia abdomino-pelvinã a fost de aspectnormal, cu excepþia ficatului, care a prezentatdimensiuni uºor mãrite.

Examen HP: Am practicat excizia a treifragmente cutanate de la nivelul zonei scapularedrepte, toracelui anterior ºi flancului drept, iar

the trunk and right abdominal flank. The lesionswere accompanied by a burn-like pain andfunctional impotence. The patient then under-went 15 fractions of radiotherapy.

Clinical exam

Overweight patient (BMI 28,72), with oedemaof the face and the left breast, predominantly inthe inferior quadrant, erythematous plaqueunder the left breast and pale skin. We also foundright arm lymphedema and bilateral lymph nodeblocks of 2/1 cm, fixated to the subjacentstructures. Blood pressure was 150/180 mmHgand the liver had the inferior margin 1 cm underthe costal margin.

Paraclinic exam

Ultrasound exam and elastography revealed: leftaxillary malignant adenopathy with left breastlymphedema; radiodermatitis; cellulitis andradiation myositis of the right cervicocephalicand presternal areas.

Neck, thorax, abdomen and pelvis CT revealeddiffuse infiltration of the skin, subcutaneous fatand nuchal muscles, a 10 mm left sub-mandibulary lymphadenopathy, 14 mm leftaxillary lymphadenopathy, diffuse infiltration ofthe left mammary gland and retromammary fatand 9 and 14 mm inguinal lymphadenopaties.

Scintigraphy images of the whole body showedno secondary bone carcinoma, just a hyper-caption in the left scapulohumeral joint, possiblyof arthrosic etiology and left mammary glandhypertrophy.

Carbohydrate antigen (CA 15-3) level was 107,6U/mL (normal level ≤ 25 U/mL).

Chest x-ray shows no active pulmonarylesions and a prolonged left inferior heart arch.

Echografic exam of the abdomen and pelvisshowed a slightly enlarged liver.

Histopathological examination: We performedthe excision of three skin fragments from theright scapular region, anterior thorax and rightflank areas. The result of the histopathologicalexam revealed epidermal atrophy, with manyisles and trabecules with malignant cells,sustaining diagnosis of cutaneous metastasisfrom a lobular breast carcinoma (fig. 4, fig. 5).

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rezultatul examenului HP a relevat epidermatrofic subiacent, cu numeroase insule ºitrabecule cu celule carcinomatoase, susþinânddiagnosticul de metastaze cutanate determinatede un carcinom mamar lobular (fig. 4, fig. 5).

Investigaþiile biologice au fost în limitenormale, cu excepþia VSH-ului, care a avut ovaloare de 30/56 mm (1h/2h).

Prin coroborarea rezultatelor acestor investi-gaþii am stabilit urmãtoarele diagnostice: CARCI-NOM MAMAR LOBULAR INVAZIV DREPT(T2N3Mx), METASTAZE CUTANATE „ÎNCUIRASÃ”.

Pacienta a fost externatã din Clinica deDermatologie ºi îndrumatã spre Clinica deOncologie Medicalã, unde a urmat o curã dehormonoterapie (Anastrozole), evoluþia fiindparþial favorabilã.

Discuþii

Cancerul mamar reprezintã, la nivel mondial,cel mai frecvent neoplasm la femei, fiind a douacauzã de deces, dupã cancerul pulmonar, în þãriledezvoltate ºi principala cauzã de deces în þãrileslab dezvoltate [4].

Incidenþa acestei afecþiuni creºte directproporþional cu vârsta, de la 1,5 cazuri la 100.000de femei cu vârsta cuprinsã între 20 ºi 24 de ani,la 421,3 cazuri la 100.000 de femei cu vârsta de

Laboratory tests were normal, except for theerythrocytes sedimentation rate, which had alevel of 30/56 mm (1h/2h).

By corroborating the results of these investi-gations we established the next diagnosis:INVASIVE LOBULAR CARCINOMA OF THERIGHT BREAST (T2N3Mx), „EN CUIRASSE”CUTANEOUS METASTASIS.

The patient was discharged from our clinicand guided to the Oncology Clinic, where shereceived hormonal therapy (Anastrozole). Herevolution was partially favorable.

Discussions

Worldwide, breast cancer is the most frequenttype of cancer to affect women. It is the secondcause of death, after pulmonary cancer, indeveloped countries and the first cause of deathin less developed countries [4].

The incidence of breast cancer is higher withage, growing from 1,5 cases/100.000 women at anage between 20 and 24 years, to 421,3cases/100.000 women at an age between 75 and79 years. Approximately 95% of the cases arefound in women over 40 years of age. The meanage of debut is 61 [5]. Our patient fits into the agecategory with the highest risk for developingbreast cancer.

Fig. 4. Epiderm atrofic, insule de celule carcinomatoaseinvadând dermul profund, Col. HE, ob x40 Fig. 4. Atrophic epidermis, islands of carcinomatous cellsinvading the deep dermis, HE stain, x40

Fig. 5 Insule de celule tumorale maligne, cu atipii marcate,invadând dermul profund Col. HE, ob x100Fig. 5. Islands of malignant tumor cells with marked atypia,invading the deep dermis, HE stain, x100

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75-79 de ani. Aproximativ 95% din cazuri se în-registreazã la femei cu vârsta de peste 40 de ani.Vârsta medie de debut este de 61 de ani [5].Pacienta noastrã se încadreazã în grupa de vârstãcu cea mai mare frecvenþã a apariþiei canceruluimamar.

Factorii de risc pentru apariþia canceruluimamar sunt:

•• Vârsta ºi sexul feminin;•• Istoricul familial de cancer mamar – riscul

de a dezvolta un neoplasm mamar este de4 ori mai mare pentru persoanele care au orudã de gradul I diagnosticatã cu aceastãafecþiune. Mai mult de jumãtate dincancerele mamare moºtenite se datoreazãmutaþiilor de la nivelul genelor BRCA1 ºiBRCA2. Persoanele care prezintã acestemutaþii au un risc de 85% de a dezvolta uncarcinom mamar de-a lungul vieþii, risc de10-30 de ori mai mare comparativ cupopulaþia care nu prezintã aceste mutaþii;

•• Factorii hormonali – vârsta înaintatã laprima sarcinã, nuliparitatea, menstruaþiaprecoce ºi menopauza tardivã au fostasociate cu un risc crescut de apariþie acancerului mamar;

•• Antecedentele personale patologice – unistoric de carcinom mamar creºte de 3-4 oririscul de a dezvolta un neoplasm la sânulcontralateral; istoricul personal dehiperplazie, fibroadenom ºi papilomsolitar cresc riscul de apariþie a canceruluide sân;

•• Stilul de viaþã – fumatul, consumul dealcool;

•• Obezitatea;•• Factorii de mediu – carcinogenii din

mediu [6,7].În cazul pacientei noastre, factorii de risc cei

mai importanþi, precum istoricul familial decancer mamar, factorii reproductivi ºi hormonaliºi antecedentele personale de leziuni pre-canceroase localizate la nivelul glandei mamare,lipsesc.

Majoritatea cancerelor mamare suntasimptomatice în stadiile incipiente, iar în stadiileavansate se poate palpa un nodul nedureros, dur,neregulat, asimetric, fixat la planurile superficialesau profunde. Alte modalitãþi de debut pot fireprezentate de modificarea dimensiunii sau

The risk factors of breast cancer are:•• Age and gender – increasing age and

female sex is a risk factor for developingbreast cancer;

•• Family history of breast cancer – the riskof developing breast carcinoma is 4 timeshigher for people who have a first-degreerelative diagnosted with this disease. Morethan half of the inherited breast cancers aredue to mutations of the BRCA1 andBRCA2 genes. The women with thesemutations have an 85% risk of developingbreast cancer during their lifetime, 10-30times higher risk than people withoutthese mutations;

•• Hormonal factors – increased age duringthe first pregnancy, nulliparity, earlymenarche and late menopause have beenassociated with a high risk of developingbreast cancer;

•• Prior health history – a personal medicalhistory of breast cancer increases the risk ofdeveloping breast cancer in the oppositemammary gland 3-4 times; personalhistory of breast hyperplasia, fibro-adenoma and solitary duct papilloma alsoincrease the risk of developing breastcancer;

•• Lifestyle – smoking and alcoholism;•• Obesity;•• Environmental factors-pollution and

environmental carcinogens [6,7].In our patient’s case, the most important risk

factors, like personal and family history of breastcancer and hormonal factors, are missing.

The majority of breast cancers are asympto-matic at first but as they progress, a firm,irregular, asymmetrical, non painful nodule canbe palpated. The nodule is usually fixated to boththe superficial and profound structures. Othermeans of debut are represented by changes in theform and dimension of the breast, changes of theskin covering the mammary gland (erythema,oedema, thickening of the skin), ulceration, re-traction or mamelonary secretion and axillarynodule [8].

Histopathological types of breast carcinoma:1. Infiltrative ductal carcinoma-represents

75% of all breast cancers and has a hightendency of lymph-node metastasis;

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formei sânului, modificãri la nivelul tegu-mentului (eritem, edem, îngroºare a pielii),ulceraþie, retracþie sau secreþie mamelonarã ºinodul axilar [8].

S-au descris mai multe tipuri histopatologicede carcinom mamar:

1. Carcinomul ductal infiltrativ-reprezintã75% din cancerele mamare ºi are otendinþã crescutã de a metastaza prinintermediul ganglionilor limfatici;

2. Carcinomul lobular invaziv-reprezintã15% din cancerele mamare; se caracte-rizeazã prin prezenþa receptorilor pentruestrogen; carcinomul lobular in situreprezintã un marker pentru dezvoltareacarcinomului mamar lobular invaziv;

3. Carcinomul medular-apare mai frecventla femeile tinere;

4. Carcinomul mucinos;5. Carcinomul mamar tubular;6. Carcinom mamar inflamator;7. Carcinomul papilar-apare mai frecvent la

persoane de peste 60 de ani;8. Cancerul mamar metaplastic-afecteazã

frecvent femeile mai în vârstã ºi per-soanele de culoare;

9. Boalã Paget mamarã.Tipurile medular, mucinos, tubular, infla-

mator, papilar, metaplastic ºi boala Paget mamarãreprezintã împreunã aproximativ 10% dincarcinoamele mamare [9].

Pacienta noastrã prezintã carcinom lobularinvaziv, acesta fiind a doua formã histopatologicãde carcinom mamar, în ordinea frecvenþei.

Diagnosticul cancerelor mamare se pune pebaza examenului fizic, testelor imagistice (eco-grafie, mamografie, RMN) ºi biopsiei. Dia-gnosticarea precoce ºi tratamentul prompt scadsemnificativ mortalitatea.

Neoplasmul mamar metastazeazã la nivelcutanat mai frecvent decât orice alt tip de cancer.Metastazele sunt observate de obicei într-unstadiu avansat al bolii, la mai mulþi ani dupãmastectomie. Doar în foarte puþine cazuriapariþia metastazelor precede sau coincide cudiagnosticul neoplasmului mamar [10].

Apariþia metastazelor cutanate semnificãextensia tumorii la nivelul pielii, capilarelor ºivaselor limfatice ºi un diagnostic tardiv.Supravieþuirea în cancerul de sân cu metastaze

2. Invasive lobular carcinoma-represents15% of all breast cancers; it usuallypresents estrogen receptors; in situ lobularcarcinoma is a risk factor for invasivelobular carcinoma;

3. Medullary carcinoma-is more frequent inyoung women;

4. Mucinous carcinoma;5. Tubular carcinoma;6. Inflammatory carcinoma;7. Papillary carcinoma-is more frequent in

women over 60;8. Metaplastic carcinoma-usually affects

younger women and black people;9. Mammary Paget disease.Mammary Paget disease and the medullary,

mucinous, tubular, inflammatory, papillary andmetaplastic types represent 10% of all breastcancers [9].

Our patient was diagnosed with invasivelobular carcinoma of the breast, the second mostfrequent histopathological type of breast cancer.

The diagnosis of breast cancer is based onphysical exam, imaging test (echography,mammography, MRI) and biopsy. The earlydiagnosis and prompt treatment significantlydecrease the mortality of breast cancer.

Breast carcinoma can cause cutaneousmetastasis more frequently than any other type ofcancer. The metastases are usually observed in alater stage of the disease, a few years after themastectomy. Only in rare cases the metastasesprecede or coincide with the diagnosis of thebreast cancer [10].

The presence of cutaneous metastases usuallymeans the extension of the tumor to the skin,capillaries and lymph vessels and a latediagnosis. The survival rate in breast cancer withcutaneous metastasis is approximately 36 months[11,12]. A particular aspect of our case is re-presented by the fact that our patient hasexceeded the 36 months limit, her evolutionbeing slightly favorable after the last treatmentshe received.

Cutaneous breast metastases are usuallylocalized at the thoracic wall. Other common sitesare represented by the neck and head, abdomenand upper extremities [13]. Our patient hadcutaneous breast metastases in the cervical area,thorax and right abdominal flank.

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este de aproximativ 36 de luni [11,12]. Un aspectparticular al cazului nostru este reprezentat defaptul cã pacienta a depãºit pragul de 36 de luni,evoluþia ei fiind uºor favorabilã în urmaultimului tratament.

Localizarea de elecþie a metastazelor cutanatedin neoplasmul mamar este la nivelul pereteluitoracic. Alte localizãri frecvente sunt la nivelulgâtului ºi capului, abdomenului, scalpului ºimembrelor superioare [13]. Pacienta noastrã pre-zintã metastaze cutanate localizate în regiuneacervicalã ºi la nivelul toracelui ºi flancului dreptabdominal.

Aspectul clinic variazã de la zone de pieleinduratã ºi infiltratã pânã la papule dedimensiuni mici ºi chiar noduli de dimensiunimai mari. De cele mai multe ori suntasimptomatice, dar în anumite cazuri pacienþiipot prezenta durere sau sensibilitate.Diagnosticul este de multe ori dificil datoritãasemãnãrii leziunilor cu celulita sau limfedemul[14]. În cazul prezentat de noi am întâlnit: zonede piele induratã, infiltratã, ce prezintã pesuprafaþã papule netede.

Din punct de vedere clinic, se cunoscurmãtoarele forme de metastaze cutanate:

•• Noduli dermo-hipodermici de culoareroºie-violacee ºi diametrul de 1-3 cm.Reprezintã forma cea mai frecventã, fiindîntâlnitã în 97,5 % din cazuri. Localizareainiþialã este în raport cu tumora primarã;

•• Forma erizipeloidã sau de limfangitãcarcinomatoasã;

•• Metastaze scleroase ce se manifestã prinplãci infiltrate, puþin scleroase sau infla-matorii, cu extindere lentã. Uneori supra-faþa este acoperitã cu noduli, având unaspect boselat. Prezintã douã variante:1. Alopecia neoplazicã de scalp, asociatã

frecvent cu un neoplasm mamar;2. Metastazã „în cuirasã” prin extensia

unui neoplasm mamar la nivelul pere-telui toracic.

•• Metastaze „în mãtãnii” – reprezentate denoduli canceroºi diseminaþi limfatic sauneurotrop;

•• Nodulii Mary-Joseph sunt metastaze lanivelul ombilicului, cel mai adesea de la uncancer gastric, colic, pancreatic sau uterin.

The skin metastases have various aspects,from areas of indurated, infiltrated skin to smallpapules or large nodules. Most of the time, thelesions are asymptomatic, but sometimes theycan pe accompanied by pain of sensitivity. Thediagnosis is difficult because the lesions canresemble cellulitis or lymphedema [14]. In ourcase, we have encountered: placards ofindurated, infiltrated skin, with smooth papuleson the surface.

Clinical forms of cutaneous metastases:•• Red or purple dermo-hypodermic nodules

with a diameter between 1 and 3 cm. Thisis the most frequent form, encountered in97,5% of the cases. The initial localization isconnected to the primary tumor;

•• Erysipeloid form or carinomatouslymphangitis;

•• Sclerous metastases characterized byinfiltrative, sclerous or inflammatoryplaques, with slow extension. Sometimesthe surface is covered by nodules, giving ita bosselated appereance. It presents in twoforms:1. Neoplastic scalp alopecia, frequently

associated with breast carcinoma;2. „En cuirasse” metastases that appear

through the extension of breast cancer tothe chest wall.

•• Beads-like metastases-represented bynodules with lymphatic dissemination;

•• Mary-Joseph nodules are skin metastaseslocalized in the umbilical area. They aremost often determined by a gastric,pancreatic or uterine cancer.

The clinical aspect of the cutaneousmetastases is determined by factors such as: theprimary tumor, the extension mechanism (bloodor lymph-nodes) and local factors like traumaand radiotherapy which can facilitate thedeveloping of metastases on the affected area[15].

The cutaneous metastases treatment dependson their dimension and localization and implieschemotherapy and radiotherapy. Transitoryresults have been optained in the case of a pacientwith breast cancer and cutaneous metastasesafter using imiquimod 5% 3 times a week. Afterthree weeks the pain intensity diminished andthe aspect of the lesions improved, but 2 weeks

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Aspectul clinic al metastazelor este deter-minat de factori precum: organul de origine,mecanismul de extindere (limfatic sau sanguin) ºifactori locali ca traumatismele ºi radioterapia carepot favoriza apariþia metastazelor pe zoneleagresate [15].

Tratamentul metastazelor cutanate depindede dimensiunea ºi localizarea acestora, utili-zându-se în principal chimioterapia ºi radio-terapia. Rezultate tranzitorii s-au obþinut în cazulunei paciente cu neoplasm mamar metastazat lanivelul tegumentului, dupã administrarea deimiquimod 5% de 3 ori pe sãptãmânã. Dupã treisãptãmâni intensitatea durerii a scãzut, iaraspectul leziunilor s-a îmbunãtãþit, însã la 2sãptãmâni dupã întreruperea aplicãrii de imi-quimod, leziunile au reapãrut [16].

Tratamentul neoplasmului mamar includeintervenþie chirurgicalã, polichimioterapie, radio-terapie ºi hormonoterapie (în cazul supra-expresiei receptorilor pentru estrogen). Scopurileprincipale ale tratamentului sunt îmbunãtãþireasupravieþuirii ºi calitãþii vieþii, prin controlulsimptomelor ºi progresiei bolii.

Concluzii

1. Cancerul de sân este o afecþiune a cãreiincidenþã este din ce în ce mai ridicatã,fiind principalul neoplasm care determinãmetastaze cutanate la femei.

2. Metastazele cutanate se prezintã subforme variate; cunoaºterea exactã a aspec-tului acestora poate facilita diagnosticarearapidã a neoplasmului primar.

3. Un diagnostic rapid permite iniþiereatratamentului adecvat, crescând astfelcalitatea vieþii pacienþilor ºi rata desupravieþuire a acestora.

after finishing the treatment, they reappeared[16].

The treatment of breast cancer includessurgery, polychemotherapy, radiotherapy andhormonotherapy (if the estrogen receptors arepresent). The primary purposes of the treatmentare to improve the survival rate and the quality ofthe patient’s life by controlling the disease’ssymptoms progression.

Conclusions

1. The incidence of breast cancer isincreasing, becoming the main type ofcancer to determine cutaneous metastasesin women.

2. Cutaneous metastases present undervarious forms; knowing the exactappearances of these forms can facilitatethe fast diagnosis of the primary tumor.

3. A fast diagnosis allows the patients toreceive an adequate treatment, this wayimproving their survival rate and lifequality.

Bibliografie / Bibliography1. Rodica Anghel, Laurenþia Minea, Mircea Dediu, Xenia Bacinschi, Alexandru Eniu, Dan Eniu, Lucian Miron,

Brânduºa Aldea, Ghid de management al neoplasmului mamar, pag 1, publicat în Monitorul Oficial al României,Partea I, nr. 608 din 3 septembrie 2009.

2. Krathen RA, Orengo IF, Rosen T. Cutaneous metastasis: A meta-analysis of data. South Med J. 2003; 96: 164-7.3. Christina Yin Bin Wong, Meghan A. Helm, Robert E. Kalb, Thomas N. Helm, and Nathalie C. Zeitouni, The

Presentation, Pathology, and Current Management Strategies of Cutaneous Metastasis, North American Journal ofMedical Sciences, Sept 2013, (5)9: 499-504.

4. Torre LA, Bray F, Siegel RL, Ferlay J, Lortet-Tieulent J, Jemal A, Global cancer statistics, 2012, CA Cancer J Clin,2015 Mar;65(2):87-108. doi: 10.3322/caac.21262. Epub 2015 Feb 4.

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Conflict de interese Conflict of interestNEDECLARATE NONE DECLARED

Adresa de corespondenþã: Prof. univ. dr. Virgil Pãtraºcu, Universitatea de Medicinã ºi Farmacie din Craiova, str. Petru Rareº, nr. 2-4, cod 200345. tel. 0724273676, e-mail [email protected]

Correspondance address: Virgil Pãtraºcu, Professor, MD, PhD, University of Medicine and Pharmacy from Craiova,Petru Rareº Street, No 2-4, 200345; Craiova, Romaniaphone 004-0724273676; e-mail: [email protected]

5. American Cancer Society. Breast Cancer Facts & Figures 2011-2012. Available at http://www.cancer.org/Research/CancerFactsFigures/BreastCancerFactsFigures/breast-cancer-facts-and-figures-2011-2012.

6. DeVita, Hellman & Rosenberg's Cancer Principles and Practice of Oncology, 9th Edition, 2011, pag 1392, ISBN 978-1 -45 1 1-0545-2.

7. Stopeck T. Alison, Patricia A Thompson , Pavani Chalasani, Jules E Harris, Breast Cancer, Oct 20, 2015, Medscape,http://emedicine.medscape.com

8. Lucian Miron, Ingrith Miron, Cãtãlin Dãnãilã, Mihai Marinca, Angela Dãscãlescu, Terapia oncologicã. Opþiunibazate pe dovezi. Iaºi, 2008. ISBN: 978-973-611-538-7.

9. C I Li, D J Uribe and J R Daling, Clinical characteristics of different histologic types of breast cancer, British Journalof Cancer (2005) 93, 1046-1052. doi: 10.1038/sj.bjc.6602787.

10. Brianna Kalmykow MSN, ANP-BC, Suzanne Walker CRNP, MSN, Cutaneous metastases in breast cancer, ClinicalJournal of Oncology Nursing, 2011; 15 (1): 99-101.

11. Lund-Nielsen, B., Muller, K., & Adamsen, L. (2005). Malignant wounds in women with breast cancer: Feminineand sexual perspectives. Journal of Clinical Nursing, 14, 56-64. http://dx.doi.org/10.1111/j.1365-2702.2004.01022.x

12. Pal, S.K., Gupta, R., Somlo, G., Hurria, A., Chung, C.T., Luu, T.H., Bernstein L., Mortimer, J., Lack of survivalbenefit in metastatic breast cancer with new chemotherapeutic agents: The City of Hope experience, Journal ofClinical Oncology 2008; 26:s20. doi: 10.1200/JCO.2007.11.6905.

13. Hu, S.C., Chen, G.S., Lu, Y.W., Wu, C.S., & Lan, C.C. (2008). Cutaneous metastases from different internalmalignancies: A clinical and prognostic appraisal. Journal of the European Academy of Dermatology andVenereology, 22, 735-740.Hussein, M.R. (2010). Skin metastasis: A pathologist's perspective. Journal of CutaneousPathology, 37, E1-E20. http://dx.doi.org/10.1111/j.1600-0560.2009.01469.x

14. Nashan, D., Muller, M.L., Braun-Falco, M., Reichenberger, S., Szeimies, R.M., & Bruckner-Tuderman, L. (2009).Cutaneous metastases of visceral tumours: A review. Journal of Cancer Research and Clinical Oncology, 135, 1-14.

15. Virgil Pãtraºcu, Boli dermatologice ºi infecþii sexual transmisibile, ediþia a III-a, Sitech, Craiova 2014, ISBN 978-606-11-4091-6.

16. Lisa Henriques, Michael Palumbo, Marie-Pascale Guay, Boris Bahoric, Mark Basik, Petr Kavan, Gerald Batist,Imuquimod in the treatment of Breast Cancer skin metastasis, Journal of Clinical Oncology, March 10, 2014 vol.32, pag e22-e25.

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