Indian Journal of Dermatology, Venereology and Leprology Medknow Publications on behalf of The Indian Association of Dermatologists, Venereologists and Leprologists (IADVL) ISSN: 0378-6323 EISSN: 0973-3922 Vol. 76, Num. 2, 2010, pp. 215-215

Indian Journal of Dermatology, Venereology, and Leprology, Vol. 76, No. 2, March-April, 2010, pp. 215

Net letter

Carcinoma en cuirasse of the breast with zosteriform metastasis

Chembolli Lakshmi, Suma B. Pillai¹, Chetna Sharma¹, C. R. Srinivas

Department of Dermatology, ¹Pathology, PSG Hospitals & PSGIMSR, Peelamedu, Coimbatore - 641 004, India

Correspondence Address: Dr. Chembolli Lakshmi, Department of Dermatology, PSG Hospitals, Peelamedu, Coimbatore - 641 004, Tamil Nadu, India, cl_coimbatore@yahoo.co.in

Code Number: dv10064

PMID: 20228567

DOI: 10.4103/0378-6323.60544

Sir,

En cuirasse metastatic carcinoma is characterized by diffuse morphea-like induration of the skin. It is a fibrotic process resembling the encasement in an armor of a curassiere (cavalry soldier). ^[1],[2] It evolves from firm papules and nodules overlying an erythematous base to a sclerodermoid plaque. ^[3] Pain and pruritus may be the associated features, unlike cutaneous metastases, which usually present as asymptomatic, painless, firm or doughy skin-colored papules or nodules. Carcinoma en cuirasse in a dermatomal distribution has not been reported.

A 62-year-old postmenopausal lady who had undergone mastectomy for adenocarcinoma of the right breast two months back, presented with painful erythematous lesions over the right side of her chest, of one-month duration. There were no palpable lymph nodes in both the axillae or palpable nodules in the opposite breast. Numerous firm-to-hard erythematous papules and few indurated coalescent plaques with superficial ulceration and crusting were present over the right side of the chest in a dermatomal distribution (spread over the dermatomes T5 - T7). The evolution of lesions was from a papule that coalesced in few areas to form an indurated plaque. The underlying skin was erythematous, woody hard, and unpinchable [Figure - 1]. There was a burning pain along the distribution of the lesions, which on closer examination were papules, although they gave the impression of being papulovesicular.

Biopsy from a papule confirmed a metastatic adenocarcinomatous deposit. The dermis showed infiltration by tumor cells arranged in cords (Indian-file pattern) [Figure - 2]a and groups between the dense broad collagen bundles [Figure - 2]b. An occasional glandular pattern was also seen. Tumor emboli were seen in the superficial dermal lymphatics [Figure - 2]c. Perineural infiltration by tumor cells was also seen [Figure - 2]d.

Cutaneous metastases from solid primary tumors are rare. Eight clinicohistopathological types of skin involvement are seen with metastatic breast cancer, which include carcinoma en cuirasse, inflammatory telangiectatic and nodular types of metastatic carcinoma, alopecia neoplastica, carcinoma of the inframammary crease, metastatic mammary carcinoma of the eyelid with histiocytoid histology, and Paget′s disease. ^[4]

Targetoid metastasis has also been reported. ^[5] Carcinoma en cuirasse is characterized histologically by dense fibrosis and decreased vascularity, making it highly resistant to chemotherapy.

Perineural invasion of the nerves could account for the burning pain associated with the lesions. The induration could be related to chronic lymphatic obstruction as proposed by Hanley. ^[6] Tumor emboli within the superficial lymphatics were seen in our patient.

The mechanism for the zosteriform appearance of the metastatic disease is not known. It has been postulated to occur as a Koebner response to recent herpes zoster.^[7] However, our patient did not report any skin lesions over the area prior to the development of the present lesions.

Perineural lymphatic metastatic dissemination has also been suggested, ^[8] and is likely to be the cause of our patient having dermatomal distribution of skin lesions associated with burning pain.

To our knowledge, carcinoma en cuirasse in a dermatomal distribution has not been reported.

References

1.	Siddiqui MA, Zaman MN. Primary carcinoma en cuirasse. J Am Geriatr Soc 1996;44;221-2.  Back to cited text no. 1
2.	Lookingbill DP, Spangler N, Helm KF. Cutaneous metastasis in patients with metastatic carcinoma: a retrospective study of 4020 patients. J Am Acad Dermatol 1993;29:228-36.  Back to cited text no. 2  [PUBMED]
3.	Schwartz RA. Cutaneous metastatic disease. J Am Acad Dermatol 1995;33:161-82.  Back to cited text no. 3  [PUBMED]
4.	Rolz-Cruz G, Kim CC. Tumor invasion of the skin. Dermatol Clin 2008;26:89-102.  Back to cited text no. 4  [PUBMED]
5.	Singh G, Mohan M, Srinivas C, Valentine P. Targetoid cutaneous metastasis from breast carcinoma. Indian J Dermatol Venereol Leprol 2002;68:51-2.  Back to cited text no. 5  [PUBMED]
6.	Mullinax K, Cohen JB. Carcinoma en cuirasse presenting as keloids of the chest. Dermatol Surg 2004;30:226-8.  Back to cited text no. 6  [PUBMED]
7.	Manteaux A, Cohen PR, Rapini RP. Zosteriform and epidermotropic metastasis. Report of two cases. J Dermatol Surg Oncol 1992;18:97-100.   Back to cited text no. 7
8.	Matarasso SL, Rosen T. Zosteriform metastasis: case presentation and review of literature. J Dermatol Surg Oncol 1988;14:774-8.   Back to cited text no. 8  [PUBMED]

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