Monday, April 06, 2020

68 year-old woman with subcutaneous lesions

Presented by Dr. A.R. Pito, Retired, Volunteer Dermatologist
Queens Memorial Medical Center
New York, New York

This 68-year-old woman presented for evaluation of painful lesions under the skin that have been present for 3-4 months. She has a history of psoriasis, which is in remission, fibromyalgia, hypertension.  There is no personal history of malignancy.  No exotic travel.  She had smoked over two ppd for decades.

EXAMINATION: The examination shows a woman who appears slightly older than her stated age. She has 6-8 freely movable subcutaneous smooth-surfaced lesions on the back, posterior nuchal area, and the upper chest. The largest is ~ 5 mm in diameter. The remainder of the exam plus breast palpation was unremarkable.  No adenopathy appreciated.

INITIAL MPRESSION: Subcutaneous skin lesions, present for only a short period of time. Etiology is unclear.

PLAN: An excisional biopsy was taken today from the lesion on the right upper back.

The first two are H&E of nodule in the fat, showing atypical cells with duct-like vacuoles. The second two are representative immunoperoxidase stains. GATA 3 is the nuclear one (dot-like pattern) and mammoglobin is the cytoplasmic staining.
These darkly beautiful photomicrographs were taken by Dr. Lynne Goldberg at the Boston University School of Medicine's Department of Dermatopathology.

Plan:  Mammography and breast ultrasound. Referral to oncologist.
Mammography shows masses in r. breast.  Ultrasound guided biopsy planned and specimen will be sent for Estrogen receptor, progesterone receptor and Her-2 (human epidermal growth factor receptor).

Note:  In this age of "Social Distancing" it is unlikely that this disgnosis would have been make expeditiously in a woman with no history of an underlying malignancy.  We will add more as her case progresses.

Your thoughts will be appreciated.

1. Mammaglobin, a Valuable Diagnostic Marker for Metastatic Breast Carcinoma Zhiqiang Wang1, et. al. Int J Clin Exp Pathol (2009) 2, 384-389
Abstract:  Identification  of  metastasis  and  occult  micrometastases  of  breast  cancer  demands  sensitive  and  specific  diagnostic  markers.  In  this  study,  we  assessed  the  utility  of  a  mouse  monoclonal  antibody  to  human  mammaglobin  for  one  such  purpose.  Immunohistochemical  stains  were  performed  on  paraffin-embedded  sections  from  a  total  of  284  cases,  which  consisted  of  primary  breast  invasive  carcinomas  (41  cases)  with  matched metastases to ipsilateral axillary lymph nodes, metastatic breast carcinoma to liver (1 case) and kidney (1 case), non-breast neoplasms (161 cases), and normal human tissues (39 cases). The results showed 31 of the 41 cases of primary breast cancer with axillary lymph node metastases were positive for mammaglobin (76%). In the meantime, we documented expression of mammaglobin in occasional cases of endometrial carcinoma (17%). Our data further validated that mammaglobin is a valuable diagnostic marker for metastatic carcinoma of breast origin, although endometrial carcinoma should be considered as a major differential diagnosis. 

2. GATA3 Expression in Common Gynecologic Carcinomas: A Potential Pitfall. Tatjana Terzic  et. al.  Int J Gynecol Pathol, 38, 485-492 2019
Abstract: GATA binding protein 3 (GATA3) immunohistochemistry is primarily used as a marker of breast and urothelial differentiation, particularly in metastatic settings. In the gynecologic tract it also serves a robust marker for mesonephric and trophoblastic tumors. Full Abstract: PMID: 30059453


  1. Professor Sharquie from Baghdad: "This case represents picture of metastatic breast adenoma carcinoma but I have seen similar case with metastatic adenoma carcinoma but the source was kidney tumor?But in this case malignant cells are coming from breast."

  2. from Dato Ong Cheng Leng, Malaysia:"She has multiple skin secondaries from either lung or breast cancers. Sorry my histology is very poor.
    I have seen skin secondaries before, usually single large lesions, eg lung cancer.
    In her case, her heavy smoking a likely cause, which is not associated with small cell carcinoma of the lungs. The pathologists should be able to determine the origin from the skin secondary itself.

    Whatever the origin of the skin secondaries, prognosis is poor. We should try not do anything painful..."


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