Scalp metastases as the first sign of a breast carcinoma
In clinical practice, nodules are the most common presentation of cutaneous metastases of breast cancer, but a wide range of clinical manifestations are described. Therefore, differential diagnostics of cutaneous metastases suggestive of breast cancer are a challenge for the dermatologist, who is often the first person who may suspect this cancer or its recurrence. Early diagnosis of skin metastases often initiate treatment or dramatically change the previously used therapeutic regimens that can prolong the life of the patient. Authors present the rare case of cutaneous metastases which mimic mild skin changes, which are difficult to identify.

A 47-year-old woman with a history of hypothyroidism and supraventricular tachycardia who was besides in good health reported to the Dermatologic Outpatient Clinic due to a focal hair loss in the occipital area of the scalp. The lesion was 5 cm large, of irregular shape, pearly-pink coloured, painless and non-pruritic. The skin was palpably elevated and partially covered with yellowish scale. The patient firstly noticed small hair loss a couple months before the admission and it gradually became larger. She had no history of previous dermal diseases.

A punch biopsy was taken from the skin lesion which revealed metastatic adenocarcinoma. On immunohistochemistry (IHC) staining for estrogen receptors (ER, 90%) and progesterone receptors (PR, 70%), mammaglobin and gross cystic disease fluid protein (GCDFP) were positive, what suggests metastatic breast adenocarcino ma with HER2 negative expression and poorly differentiated, high-grade (G3) invasion. Computed tomography imaging has shown a primary tumour in the left mammary gland. The patient denied any personal or family history of prior breast or invasive ovarian cancer as well as radiation treatment.

She admits she has never done breast self-examination and clinical breast examination. She has never had any breast imaging, including mammography, magnetic resonance imaging (MRI), or ultrasound imaging. The patient was referred to the Oncology Department where she was prescribed doxorubicin with cyclophosphamide chemotherapy. After six cycles, the primary lesion is under control and skin lesions have regressed but not completely disappeared. At the moment, she is undergoing hormonal treatment, however her hair has regrown in the alopecia lesion.