Dermatology Online Journal

Surrounding ipsilateral eruptive seborrheic keratosis as a warning sign of intraductal breast carcinoma and Paget's disease (Leser Trelat sign)
Sadollah Shamsadini MD¹, Masood Baghaei Wadji MD², Ayeh Shamsadini³
Dermatology Online Journal 12 (6): 27

1. Department of Dermatology, Kerman university of Medical Sciences, Kerman Iran. shamsadini@yahoo.com2. Department of Surgery, KUMS, Kerman Iran 3. Bardsir Hospital, Kerman university of MS. Iran

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Abstract

Paget disease of the breast, most often occurs in middle-aged women. Leser-Trelat sign is a rare cutaneous manifestation of internal malignancy that is usually associated with visceral-type adenocarcinoma. We report a patient with Paget disease of the nipple and intraductal carcinoma who presented with ipsilateral, eruptive grouped seborrheic keratoses of the areloa and nipple of the breast.

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Ductal carcinoma in-situ and Paget disease of the nipple is a rare form of breast cancer. This type of cancer starts in the breast ducts and extends to the skin of the nipple, especially on the areola around the nipple [1, 2]. Eruptive seborrheic keratoses associated with an internal malignancy, the sign of Leser-Trelat, is a rare cutaneous paraneoplastic manifestation. Adenocarcinoma is the most common malignant neoplasm associated with the sign of Leser-Trelat [3, 4]. We report what we believe to be the first case of intra-ductal adenocarcinoma of the nipple associated with this sign on the ipsilateral breast. Usually the sign of Leser-Trélat describes the concomitant occurrence of visceral malignancy and the sudden onset of eruptive seborrheic keratoses but has also been described in association with pulmonary leiomyoma and human immunodeficiency virus (HIV) infection [3, 5]. The validity of this sign has been questioned [6].

Clinical synopsis

Figure 1
Nipple retraction and velvety brown papules of the areola and breast

A 48 year-old woman was referred to the dermatology clinic for consultation due to the sudden onset of multiple pigmented papules on and around the right breast 3 months prior to presentation . One month later the ipsilateral nipple retracted (Fig. 1). Upon skin examination many superficial, pigmented papules, consistent with seborrheic keratoses, were found around the nipple. No similar lesions were found on other areas of her skin.

One eruptive papule was excised; histopathology showed marked hyperkeratosis and acanthosis in a church spire pattern, consistent with seborrheic keratosis (Fig. 2). An additional incisional biopsy from the margin of the retracted nipple showed intraductal carcinoma in-situ (Fig. 3).

Figure 2	Figure 3
Figure 2. Biopsy of an eruptive papule demonstrating hyperkeratosis and pseudohorn cysts Figure 3. Biopsy from the margin of the nipple demonstrating a nest of Pagetoid cells

Discussion

The association of eruptive seborrheic keratoses with underlying malignancy has been termed the sign of Leser-Trelat. We conclude that the abrupt appearance of multiple seborreic keratoses on and around the breast of our patient afflicted with intraductal breast carcinoma represents Leser-Trelat sign.

Seborrheic keratosis is a very common pigmented growth seen mostly among the elderly population [7]. Although benign, showers of seborrheic keratoses may erupt concomitantly with internal malignancies [1, 6]. This entity has also been described in a patient with HIV infection [5]. Paget disease of the breast is a rare form of breast cancer. In our patient this malignancy was heralded by eruptive seborrheic keratoses on the same breast.

References

1. Curry S.S and King L.E The sign of Leser-Trelat. Report of a case with adenocarcinoma of the duodenum. Arch Dermatol. 1980 Sep;116(9):1059-60 PubMed

2. Mayo C, Lo YC, Fitzgerald TJ, Urie M. Forward-planned, multiple-segment, tangential Fields with concomitant boost in the treatment of breast cancer Med Dosim.2004 Winter. 29(4): 265-70.PubMed

3. Baghaei Vadji M Shamsadini S . Leser trelat, as a sign of lung leiomyoma Kerman University of Medical Sciences, Journal (internal Iranian journal, abstract in English) 1997;4(4): 190-194.

4. Schwartz RA. Sign of Leser-Trélat. J Am Acad Dermatol 1996; Jul 35: 88 95. PubMed

5. Smoller BR, Graham G. Benign neoplasms of the epidermis. In: Cutaneous Medicine and Surgery. An Integrated Program in Dermatology (Arndt KA, LeBoit PE, Robinson JK, Wintroub BU, eds), Vol. 2. Philadelphia: W.B. Saunders Co., 1996; 1441 9.

6. MacKie RM. Epidermal skin tumours. In: Textbook of Dermatology (Champion RH, Burton JL, Burns DA, Breathnach SM, eds), 6th edn, Vol. 2. Oxford: Blackwell Science, 1998; 1651 93. PubMed

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