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LETTER TO EDITOR Table of Contents   
Year : 2009  |  Volume : 52  |  Issue : 4  |  Page : 587-588
A case of metastatic melanoma in the breast with unknown primary site, diagnosed by fine needle aspiration cytology


Department of Pathology, NKP Salve Institute of Medical Sciences, Digdoh Hills, Hingna, Nagpur 440 019, India

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Date of Web Publication1-Oct-2009
 

How to cite this article:
Wilkinson AR, Mahore SD, Bothale KA. A case of metastatic melanoma in the breast with unknown primary site, diagnosed by fine needle aspiration cytology. Indian J Pathol Microbiol 2009;52:587-8

How to cite this URL:
Wilkinson AR, Mahore SD, Bothale KA. A case of metastatic melanoma in the breast with unknown primary site, diagnosed by fine needle aspiration cytology. Indian J Pathol Microbiol [serial online] 2009 [cited 2014 Apr 24];52:587-8. Available from: http://www.ijpmonline.org/text.asp?2009/52/4/587/56133


Sir,

Metastatic breast tumors are rare. They usually present as painless discrete masses, which may be mobile and mimic fibroadenomas. They may be associated with axillary lymphadenopathy. We report a case of metastatic melanoma breast with an unknown primary site, diagnosed on fine needle aspiration cytology.

A 35-year-old married lady hailing from rural Madhya Pradesh presented with a left axillary mass noticed for two months and a right breast lump noticed for one and half months. She gave a past history of left inguinal region swelling six months prior to presentation for which she was treated with some oral and injectable medicines. The inguinal swelling subsided. Thereafter she noticed hypopigmented patches on the left inguinal region, forehead and perioral region.

On examination, a 5 x 4 cm lump was palpable in the left axillary region with a smooth surface and well-defined margins. The left breast was normal. The right breast revealed a 2 x 2 cm mobile lump in the lower outer quadrant. There were no axillary lymph nodes on the right side. The skin over both the palpable masses was normal. A clinical diagnosis of fibroadenoma right breast and possibly tuberculosis of left axillary lymph nodes was made and FNAC of both the masses was requested. Aspirate smears from both the sites were cellular [Figure 1] and showed clusters and isolated large cells with large pleomorphic nuclei showing prominent nucleoli. Few cells showed presence of brown pigment. Many bi- and multinucleate giant cells were seen [Figure 2]. A few lymphocytes were also present in the axillary node aspirate. A cytological diagnosis of an epithelial malignancy, probably malignant melanoma in right breast and left axillary lymph node was given.

Left axillary node excision biopsy and right breast lumpectomy was done. The right breast mass was noticed to be necrotic at surgery.

Gross examination: the left axillary mass measured 4 x 3.5 x 2 cm. Cut surface showed a lobulated appearance with a central area of necrosis. The right breast biopsy came in multiple pieces together measuring 2.5 x 0.7 x 0.6 cm.

Histopathological examination from the breast and axillary masses confirmed malignant melanoma [Figure 3]. Immunohistochemistry showed that the tumor cells expressed S-100 protein and HMB 45, which confirmed the diagnosis of melanoma.

Subsequently, an effort was made to find the primary site. No skin nodules were seen. Gynecological examination and rectal examination was normal. Baseline hematological investigations, chest X-ray and ultrasound abdomen were normal. Endoscopy was also normal. Bone scan showed findings suggestive of skeletal metastasis in the left sacroiliac joint and left femur. Asymmetrical involvement of the right breast, left axillary lymph node and skeletal metastasis possibly indicate an advanced stage of the disease at the time of presentation. As a primary site could not be found at the time the patient presented to us, a final diagnosis of metastatic malignant melanoma in the right breast and left axillary lymph node was made. Vitiligo was an associated clinical finding. The patient was referred to the oncologist for further treatment.

Malignant melanomas are known to undergo spontaneous regression. They may later present as metastatic melanoma with no demonstrable primary. To suspect such tumors and give a cytological diagnosis, especially when the site of presentation is rare, is challenging. Melanomas normally metastasize to regional lymph nodes and skin, whereas visceral metastases occur to lungs, liver and bone. Metastasis to the breast is rare.[1],[2] However, melanomas are the most commonly reported primary tumors to metastasize to the breast. The other primary tumors which metastasize to the breast are from ovary, thyroid, lung, oral cavity and kidney.[3]

The clinical presentation of melanomas metastasizing to the breast is usually as palpable masses without skin changes.[2] They can also masquerade as fibroadenomas.[4] The site of the primary tumor when known, may be in the upper extremities or trunk, and sometimes in the lower extremity.[1] The appearance of vitiligo-like patches in melanoma patients may be due to an immunologic phenomenon. It is suggested that spontaneous antihumoral immune response is responsible for the destruction of the malignant as well as the normal pigmented cells.[5]


   Acknowledgment Top


We thank Dr. D. N. Lanjewar, Professor of Pathology, Mumbai for reviewing this interesting case and S L Raheja Hospital, Mumbai for doing the immunohistochemistry.

 
   References Top

1.Ravdel L, Robinson WA, Lewis K, Gonzalez R. Metastatic melanoma in the breast: A report of 27 cases. J Surg Oncol 2006;94:101-4.  Back to cited text no. 1      
2.Loffeild A, Marsden Jr. Management of melanoma metastasis to the breast: Case series and review of the literature. Br J Dermatol 2005;152:1206-10.  Back to cited text no. 2      
3.Vaughan A, Dietz JR, Moley JF, DeBenedetti MK, Aft RL, Gillande WE, et al. Metastatic disease to the breast: The Washington University experience. World J Surg Oncol 2007;5:74.  Back to cited text no. 3      
4.da Silva BB, da Silva RG, Lopes Costa PV, Pitres CG, da Silva Pinheiro G. Melanoma metastasis to the breast masquerading as fibroadenoma. Gynecol Obstet Invest 2006;62:97-9.  Back to cited text no. 4      
5.Le Gal FA, Avril MF, Bosq J, Lefebvre P, Deschemin JC, Andrieu M, et al. Direct evidence to support the role of antigen specific CD8+ T cells in melanoma associated vitiligo. J Invest Dermatol 2001;117:1464-70.  Back to cited text no. 5      

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Correspondence Address:
Anne R Wilkinson
37 Chitnavis Layout, Byramji Town, Nagpur 440 013, Maharashtra
India
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DOI: 10.4103/0377-4929.56133

PMID: 19805989

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    Figures

  [Figure 1], [Figure 2], [Figure 3]

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