Year : 2010 | Volume
: 53 | Issue : 2 | Page : 351--358
Carcinoma en cuirasse : A rare presentation of breast cancer
Sadhana D Mahore, Kalpana A Bothale, Anjali D Patrikar, Archana M Joshi
Department of Pathology, NKP Salve Institute of Medical Sciences & Research Centre, Wanadongri, Hingna Road, Nagpur-440 019, India
Kalpana A Bothale
28, Shastri layout, Khamla, Nagpur-440 025
Carcinoma en cuirasse is a form of cutaneous metastasis. Although this condition is rare, it is most commonly associated with breast carcinoma with local recurrence after mastectomy. Cutaneous metastasis presents most commonly a few months or years after the primary has been diagnosed. Less frequently a metastasis is diagnosed at the same time as the primary tumor or presents as the first manifestation of the disease. We report a case of carcinoma en cuirasse in a 50-year-old female who presented with elevated, finely nodular, indurated skin lesions on left anterior chest wall, axillary region and keloid - like patch on left upper arm. On further examination a breast mass was detected. Fine needle aspiration of all the lesions was performed. Cytodiagnosis was given as infiltrating duct carcinoma of breast with metastatic carcinoma involving left anterior chest wall, axilla and left upper arm. We should not disregard keloid-like or indurated patches on skin which should be investigated thoroughly.
|How to cite this article:|
Mahore SD, Bothale KA, Patrikar AD, Joshi AM. Carcinoma en cuirasse : A rare presentation of breast cancer.Indian J Pathol Microbiol 2010;53:351-358
|How to cite this URL:|
Mahore SD, Bothale KA, Patrikar AD, Joshi AM. Carcinoma en cuirasse : A rare presentation of breast cancer. Indian J Pathol Microbiol [serial online] 2010 [cited 2020 Jul 15 ];53:351-358
Available from: http://www.ijpmonline.org/text.asp?2010/53/2/351/64346
Carcinoma en cuirasse is a form of metastatic cutaneous carcinoma. Cutaneous metastasis occurs infrequently and is rarely present at the time cancer is initially diagnosed. Its incidence varies from 0.6 to 10 %. Skin metastases are the presenting signs of the disease in 37% of men and six per cent of women.  Skin metastasis from breast carcinoma initially presents as nodule, telangiectatic carcinoma, en cuirasse, alopecia neoplastica, or zosteriform pattern. Carcinoma en cuirasse is relatively rare. In this condition the thoracic wall is studded with carcinomatous indurated plaque and the skin is infiltrated as if it has been likened to a coat of armor. Carcinoma cells disseminate along tissue spaces or through lymphatic vessels. Usually carcinoma en cuirasse appears in cases of local recurrence after the mastectomy. It may rarely appear as a presenting feature of carcinoma of the breast. 
A 50-year-old female presented with finely nodular, indurated, itchy, painful skin lesions on left anterior chest wall of six months duration. On examination, shiny, elevated, finely nodular, indurated skin lesions were found on the left side of anterior chest wall, measuring 7x4 cm and extending into the axillary region over an area of 4x4 cm which was elevated, erythematous and nodular. After further work-up, similar shiny, keloid-like, discrete, indurated, nodular patches were noticed on the left upper arm, measuring 4x4 cm. [Figure 1]. On further examination, a deep seated hard lump was palpated in the left breast, measuring 2x2 cm. Axillary lymph nodes could not be palpated due to indurated painful skin lesions.
Fine needle aspiration of breast lump, lesion on left anterior chest wall, left axilla and left upper arm was performed. Hematoxylin and eosin (H and E) and Papanicolaou stained smears revealed similar morphological features in the aspirate from all the sites. Aspirate from the breast mass revealed moderate cellularity. The cells were arranged in sheets, clusters, acinar pattern and scattered single cells. There was moderate pleomorphism and anisonucleosis. The cells revealed scanty to moderate amount of cytoplasm and large hyperchromatic nuclei with coarsely clumped chromatin and prominent nucleoli [Figure 2]. Smears from indurated plaque revealed scanty cellularity. Very few sheets and singly scattered cells were seen. Cytodiagnosis was given as infiltrating duct carcinoma of breast with metastatic carcinoma involving left anterior chest wall, axilla and left upper arm.
Cutaneous metastasis is relatively rare. Cutaneous metastasis is of diagnostic importance because it may be the first manifestation of an undiscovered internal malignancy or the first indication of metastasis of supposedly adequately treated malignancy.
In a study of 7316 patients with internal cancer, 367 (five per cent) were found to have skin involvement.  In another study of 4020 patients with metastatic disease 420 (10%) had cutaneous metastasis.  The most common sources of cutaneous metastases in males include the lungs (24%), large intestine (19%), melanoma (13%), squamous cell carcinoma of the oral cavity (12%), kidney (six per cent), stomach (six per cent) and esophagus (three per cent). In females the primary tumor site is most often the breast (69%), while other sources include the large intestine (nine per cent), melanoma (five per cent), ovaries (four per cent) and uterine cervix (two per cent). 
Breast carcinoma is the most common malignancy to metastasize to skin. The incidence of various tumors that metastasize to skin correlate well with the frequency of occurrence of the primary tumor. 
Mordenti et al. studied 164 cases of cutaneous metastasis from breast carcinoma. Clinical features included papules and /or nodules in 131 (80%), telangiectatic carcinoma in 19 (11.2%), erysipeloid carcinoma in five (three percent), carcinoma en cuirasse in five (three per cent), alopecia neoplastica in three (two per cent) and zosteriform pattern in one (0.8%). Metastatic lesions were located at the site of mastectomy in 50 patients and elsewhere on the anterior aspect of chest wall in 75, axilla in eight, back in eight, scalp in five, preauricular area in five, supraclavicular area in four, face in two, neck in two, upper extremity in three and lower extremity in two patients. These cutaneous lesions did not occur as first sign of disease in any patient examined. 
Mullinax et al. reported a case of carcinoma en cuirasse presenting as keloid-like nodule on the chest without tumor mass in deep breast tissue.  Carcinoma en cuirasse with sclerodermatomyositis-like clinical appearances has also been described.  In nodular carcinoma and en cuirasse carcinoma the tumor cells disseminate largely along tissue spaces and only to a minor degree through lymphatic vessels. 
The prognosis of patients with cutaneous metastasis depends upon the type and biological behavior of the underlying primary tumor. As breast carcinoma with skin metastasis is usually associated with advanced cancer, they represent poor prognosis. In our case, cytological diagnosis of carcinoma en cuirasse was not difficult as the breast lump was also present. But the initial clinical presentation of carcinoma breast as carcinoma en cuirasse is unusual. Clinical presentation as keloid-like patch on left upper arm showing presence of malignant cells microscopically, was the interesting feature. So we should not disregard such keloid-like patches which should be investigated thoroughly, particularly in elderly patients.
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