Dermoscopy of Skin Metastases From Breast Cancer

Two Case Reports

Awatef Kelati; Salim Gallouj


J Med Case Reports. 2018;12(273) 

In This Article


All types of cancer may metastasize to the skin, with the frequency of occurrence ranging from 0.2 to 9% among autopsies carried out on patients with cancer. Skin metastases may occur synchronously or metachronously with the diagnosis of the primary tumor. Occasionally, skin metastases may represent an initial manifestation of an occult internal carcinoma. Breast and lung cancer are the most common primary types of cancer that metastasize to the skin.[4]

Patients with breast cancer require differentiation between skin metastasis and benign dermatological disease. Differences between cutaneous metastases and cellulitis or lymphedema were found most definitively on the histologic study of tissue biopsy.[5]

Advanced metastatic breast cancer is difficult to cure, and an eventual resistance to cytotoxic treatment is expected, progression of cutaneous metastases may lead to a fungating mass that would require skin and wound management.[5] Fungating wounds can decrease quality of life by negatively impacting psychological well-being and increasing social isolation.[6] This is why the recognition of cutaneous metastasis at an early stage is very important for the therapeutic approach, because surgery of limited lesions may be performed, which is not possible for advanced stages. For this reason, we think that dermoscopy may be of great help in recognizing these types of cutaneous metastasis.

To date, only a limited number of dermoscopic images of cutaneous metastatic solid tumors have been published.[4] Cutaneous metastatic breast cancer dermoscopy was recently described in two papers of three case reports; the first case reported nodular hyperpigmented metastatic breast cancer, with features of peripheral globules and blue–white veil mimicking a melanoma;[7] recently, in two other cases, findings of polymorphous vascular structures, whitish depigmentation, umbilicated pits with a tendency for forming linear fissure-like structures with small, lateral depressions were reported. These last features were also noticed in our two cases. As a result, a characterization of metastatic breast cancer may be performed based on these patterns; yellow areas were an additional feature in our cases.

Polymorphous and atypical vessels are the most frequent vascular structures characterizing malignancy;[8] they were also observed in these cases of cutaneous breast metastasis. However, these structures may be misdiagnosed as an angiosarcoma or a lymphangiosarcoma in Stewart–Treves syndrome after mastectomy where we can also find white lines as another sign of malignancy,[9] the other dermoscopic signs would be of great help, like the yellow-orange color and the fissure-like depressions that were described in our two cases.

These polymorphic vessels may also have a prognostic value: the greater the density of the vessels, the more the disease is invasive, which was observed in our second case where the vascularization is abundant and it was concordant with an advanced clinical stage; this deserves further investigation in prospective studies.