Background: Cutaneous metastases from internal cancer are relatively uncommon in clinical practice, but they are very important to recognize. Metastases of skin may be a herald sign in the diagnosis of internal malignancy. Scalp metastasis from breast carcinoma is reported but it is rare. We describe a 42-year-old woman who presented with three foci of alopecia on her scalp resembling alopecia areata. She was a known case of breast carcinoma 10 years prior. Radical mastectomy and total chemotherapy was done 8 years prior. An incision biopsy of an alopecic patch was done revealing metastases of breast carcinoma to the scalp. Her workup failed to find metastatic involvement of other organs. This represents a case of breast carcinoma metastatic to the scalp mimicking alopecia areata, almost 10 years after radical mastectomy, and 8 years after chemotherapy. It is important for dermatologists to be alert for atypical features of alopecia areata, such as induration, and to maintain a low threshold for biopsy in atypical cases.
The usual origins of cutaneous metastases are cancers of breast, stomach, lung, uterus, large intestine, and kidneys. Cancers that have the highest propensity to metastasize to the skin include melanoma (45 % of cutaneous metastases), breast (30 %), nasal sinuses (20 %), larynx (16 %), and oral cavity (12 %) [1, 2]. Primary metastases of breast carcinoma to the scalp resulting in focal hair loss mimicking alopecia areata are rare. Cutaneous metastases may herald the diagnosis of internal malignancy; early recognition can lead to accurate and prompt diagnosis and timely treatment [3, 4]. Because breast cancer is so common, cutaneous metastasis of breast cancer is the most frequently encountered type of cutaneous metastasis, but primary metastases to the skin are relatively uncommon and those mimicking alopecia areata on scalp are even more rare [5]. They are very important to recognize in order to undertake proper evaluation of the primary lesion and to search for metastases involving other organs [6, 7, 8]. Diagnosis of cutaneous metastases can dramatically alter therapeutic plans, especially when metastases signify persistence of cancer originally thought to be cured. Some tumors metastasize with predilection to specific areas. Recognition of these patterns can be useful in directing the search for an underlying tumor. Four patches of alopecia areata were the primary metastases of breast cancer to the scalp in this case. She was a known case of breast carcinoma and metastases appeared 8 years after chemotherapy following radical mastectomy when she was clinically free of any lesions and without metastases to other organs.
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A 42-year-old woman presented with four patches of scalp hair loss. Her past history included breast carcinoma at 10 years prior. Radical mastectomy was done, followed by routine chemotherapy over the subsequent 2 years, and no problem was found over the last 8 years. The hair loss was diagnosed presumptively as alopecia areata. A scalp biopsy of one patch, however, indicated the presence of metastatic breast carcinoma. Further evaluation (with special emphasis on the lungs, liver, abdomen, and lymphatic ganglions) failed to find metastases involving other organs,. Only one uncertain round dense opaque focus was found on left area of parahilar region on a chest CT scan, but further workup and scans were negative.
This case illustrates that breast cancer metastases can occur in the skin even 10 years after mastectomy. Alopecia from breast metastases has been reported, but this is the first presentation of scalp metastases almost 10 years after mastectomy. The clinical clue to the presence of neoplastic alopecia is the presence of induration and the refractory nature of the alopecia [3]. In a series of 2,200 autopsies, skin metastases were present in 58 cases. Between 2 percent and 9 percent of the visceral malignancies are responsible for cutaneous or subcutaneous metastases [1, 2, 3, 4]. Although our patient was known to have breast carcinoma, the metastases appeared 10 years after diagnosis and 8 years after chemotherapy following radical mastectomy when she had no other complaints and was considered disease free.
© 2006 Dermatology Online Journal