Occult Invasive Lobular Carcinoma Presenting as an Axillary Skin Metastatic Lesion Underwent Neoadjuvant Endocrine Therapy and Surgical Resection: A Case Report and Review of Literature

Abstract

Introduction Invasive lobular carcinoma (ILC) is the second most common type of breast cancer accounting for 5–15% of all breast cancer cases. It usually presents with nonspecific signs and symptoms. Occult breast cancer presenting as an axillary mass is rare, with prevalence of 0.3–1%, less likely with isolated cutaneous breast metastasis as a first presentation. There are limited data in the literature on patients who underwent endocrine therapy and complete surgical resection. Case Presentation A 54-year-old woman with left axillary skin swelling that had been persisting for 6 years was diagnosed with ILC 18 months ago presenting with an ulcerated axillary skin lesion and was managed with letrozole in another facility as she was estrogen receptor (ER) and progesterone receptor (PR) positive. She received letrozole for 18 months and had a partial response in the form of healing of the ulcer with persistent subcutaneous nodules. Her breast mammogram, ultrasound, and magnetic resonance imaging findings were unremarkable; however, there were few prominent left axillary lymph nodes. A biopsy of the left axillary lymph node was positive for malignancy, consistent with ILC. A skin punch biopsy of the axillary skin lesion showed ILC extending to the dermis with no background breast tissue. The patient underwent left modified radical mastectomy with excision of the left axillary skin lesion. The breast specimen comprised 0.4 mm of ILC as the primary malignancy and nine positive axillary lymph node malignancies. The patient received adjuvant radiotherapy and continued to receive letrozole. There were no signs of complications or recurrence during the follow-up period. Conclusion Ulcerated skin lesions in the axilla should raise concerns regarding breast cancer metastasis. In cases of isolated cutaneous breast metastases, surgical excision can be considered in combination with endocrine therapy.

Case report: Cutaneous metastases as a first manifestation from breast cancer with concurrent gastric metastases

“…CMs of breast cancer are most common in the chest, followed by the head and neck, back, and abdomen. The most prevalent clinical manifestation is solitary erythematous invasive papules and nodules (80%) ( Prabhu et al, 2009 ), usually ranging from 1–3 cm in diameter ( Busbait et al, 2022 ). With disease progression, these nodules may ulcerate or undergo infection.…”

“…The sensitivity of certain diagnostic imaging modalities is low, with mammography and ultrasound showing sensitivity rates of 57%–81% and 68%–98%, respectively. Therefore, combining these with highly sensitive MRI (93%) may lead to a successful diagnosis ( Busbait et al, 2022 ). Moreover, individuals with a history of breast cancer ought to undergo comprehensive skin examinations, even years subsequent to breast cancer surgery and chemotherapy.…”

“…This may be because most patients with GMs are from ILC, and their hormone receptors are usually positive, mainly luminal-type, which is relatively sensitive to endocrine therapy. Endocrine therapy has been reported to play an important role in improving patient survival ( Busbait et al, 2022 ). Over an 8-year follow-up period, tamoxifen showed a disease-free survival (DFS) and OS of 66% and 74%, respectively, compared to 82% and 89% for letrozole ( Metzger Filho et al, 2015 ; Busbait et al, 2022 ).…”

“…Endocrine therapy has been reported to play an important role in improving patient survival ( Busbait et al, 2022 ). Over an 8-year follow-up period, tamoxifen showed a disease-free survival (DFS) and OS of 66% and 74%, respectively, compared to 82% and 89% for letrozole ( Metzger Filho et al, 2015 ; Busbait et al, 2022 ). There is a case report that CMs from ILC is rapidly and completely relieved with aromatase inhibitor ( Parietti et al, 2022 ), especially in ER+ ( Huang et al, 2022 ).…”

Metastatic Occult Primary Lobular Breast Cancer: A Case Report

“…Metastatic occult primary breast cancer is a rare but well-known entity [10], described in the literature, with the most common sites of metastatic spread being the axillary lymph nodes and bones. Cases of metastatic occult primary lobular breast cancer with GI tract and axillary lymph node spread have been previously published [11][12][13].…”