Journal of Cytology
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CASE REPORT  
Year : 2015  |  Volume : 32  |  Issue : 1  |  Page : 68-70
Papular skin lesions: Clue to a recurrence of breast cancer on fine needle non-aspiration cytology (FNNAC)


1 Department of Pathology, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
2 Department Radiotherapy, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India

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Date of Web Publication16-Apr-2015
 

   Abstract 

Cutaneous metastasis from underlying carcinoma is relatively uncommon in clinical practice. A high index of suspicion is required to diagnose these lesions, as these lesions can mimic benign skin lesions and clinical findings may be subtle. Fine needle aspiration cytology (FNAC) is commonly employed for diagnosing these skin lesions. However, it is often difficult to aspirate adequate material from small papular lesions. In these clinical situations, fine needle non-aspiration cytology (FNNAC) is proposed as an alternative procedure. FNNAC eliminates the negative suction pressure employed in FNAC and decreases the dilution of tumor cells by blood and hence yields adequate diagnostic material. We report here a case in which FNNAC was used in place of FNAC in diagnosing papular skin lesions. This procedure was carried out in a treated patient of carcinoma breast who was on regular follow-up and presented to us with a 20-day history of papular skin lesions over the chest and back. This article enlightens the clinicians about the utility of FNNAC, which is a relatively uncommon procedure.

Keywords: Breast cancer; fine needle non-aspiration cytology; papular skin lesions

How to cite this article:
Afrose R, Akram M, Siddiqui SA. Papular skin lesions: Clue to a recurrence of breast cancer on fine needle non-aspiration cytology (FNNAC). J Cytol 2015;32:68-70

How to cite this URL:
Afrose R, Akram M, Siddiqui SA. Papular skin lesions: Clue to a recurrence of breast cancer on fine needle non-aspiration cytology (FNNAC). J Cytol [serial online] 2015 [cited 2019 Apr 23];32:68-70. Available from: http://www.jcytol.org/text.asp?2015/32/1/68/155245



   Introduction Top


Cutaneous metastasis (CM) from underlying carcinoma is relatively uncommon in clinical practice, 5.3%. [1] Breast carcinoma (69%) is the most common cause of CM in women, followed by carcinoma of the large intestine (9%), lungs and ovaries (4%). [2] These lesions often mimic benign skin lesions and present as localized nodules (most common), cicatricial plaques, fibrotic plaques, alopecia neoplastica, zosteriform eruptions and bullous lesions. [3],[4],[5],[6] A high index of suspicion is required to diagnose these lesions as clinical findings may be subtle. Fine needle aspiration cytology (FNAC) is commonly employed for diagnosing these skin lesions. However, it is often difficult to aspirate adequate material from small papular lesions. In these clinical situations, fine needle non-aspiration cytology (FNNAC) is proposed as an alternative procedure. FNNAC eliminates the negative suction pressure employed in FNAC and decreases the dilution of tumor cells by blood and hence yields adequate diagnostic material.

We report here a case in which FNNAC was used in place of FNAC in diagnosing papular skin lesions. This procedure was carried out in a treated patient of carcinoma breast who was on regular follow-up and presented to us with a 20-day history of papular skin lesions over her chest and back.


   Case Report Top


A 48-year-old woman was diagnosed with invasive ductal carcinoma of the left breast 4 years ago. She received neoadjuvant chemotherapy, followed by left modified radical mastectomy. After that, she underwent adjuvant chemotherapy and radiotherapy. She was put on hormone therapy and was on regular follow-up for the last 4 years.

From the last 20 days, she was complaining of painful erythmatous papular skin lesions over her chest and back.

Physical examination revealed multiple round-oval papulovescicular, tender cutaneous lesions ranging in size from 0.2 cm to 0.5 cm in the background of diffuse erythema, scattered over the left side of the chest wall, anterior abdominal wall and back [Figure 1]. The remainder of the physical examination was unremarkable.
Figure 1: Clinial photograph showing papulovescicular lesions over the anterior chest wall (arrow)

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A high index of suspicion for recurrence was made and the patient was advised for FNAC by the clinician.

Fine needle aspiration was not successful in this case as the lesions were very small, difficult to fix and yielded inadequate material. Alternatively, FNNAC was performed from the chest wall and back lesions to get adequate material.

Cytology findings were similar from both sites and revealed sheets of pleomorphic cells with a high nucleo-cytoplasmic ratio and prominent nucleoli forming a glandular pattern [Figure 2]. Diagnosis of cutaneous metastases from breast carcinoma (CMBC) was suggested.
Figure 2: Loose clusters of malignant ductal epithelial cells. (H and E, x400). Inset showing gland formation (Pap, x400)

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   Discussion Top


CM from patients of breast carcinoma is not rare, and it is reported in around 23.9% of cases. In most of the cases, it appears within 5 years after the excision and is usually nodular. [6] They can be single or multiple and are usually 1.5-2.0 cm in size. [7] Our patient had CMBC of papulovesicular type in an erythematous background. Such metastases offer an easily accessible tissue sample for rapid cytopathological diagnosis. The peculiar feature in our patient was the presence of very small (<0.5 cm) and extensive papulovescicular skin lesions that were difficult to fix and aspirate. Consequently, only blood was found in the aspirated material on repeated attempts. Hence, an alternative technique of FNNAC was performed. FNNAC is also called cytopuncture or fine needle capillary sampling. It was first used in France in 1982 [8] for breast tumor and later for thyroid, orbital, periorbital and cutaneous tumors. FNNAC sampling eliminates the negative suction pressure employed in FNAC, resulting in less dilution by blood. [9] The important advantages of FNNAC sampling are easy operation and control over operating hand, especially for neck, breast, cutaneous or subcutaneous tissues. [10]

In our case, FNNAC provided an adequate sample for cytological diagnosis. Maurya et al. [10] in his study also found that non-aspiration sampling has more cellular material, less blood, less cellular trauma and better retention of architecture. However, he concluded that better diagnostic accuracy can be achieved by combining both the techniques.


   Conclusion Top


This article enlightens the clinicians about the utility of FNNAC, which is a relatively uncommon procedure. However, it is indicated in certain clinical situations like in this case.

 
   References Top

1.
Krathen RA, Orengo IF, Rosen T. Cutaneous metastasis: A meta-analysis of data. South Med J 2003;96:164-7.  Back to cited text no. 1
    
2.
Johnson WC. Metastatic carcinoma of the skin: Incidence and dissemination. In: Elder D, Elenitsas R, Jaworsky C, Johnson Jr. B, editors. Lever's Histopathology of the Skin. 8 th ed. Philadelphia: Lippincott-Raven;1997. p. 1011-8.  Back to cited text no. 2
    
3.
Lookingbill DP, Spangler N, Helm KF. Cutaneous metastases inpatients with metastatic carcinoma: A retrospective study of 4020 patients. J Am Acad Dermatol 1993;29:228-36.  Back to cited text no. 3
    
4.
Chisti MA, Alfadley AA, Banka N, Ezzat A. Cutaneous metastasis from breast carcinoma: A brief report of a rare variant and proposed morphological classification. Gulf J Oncolog 2013;1:90-4.   Back to cited text no. 4
    
5.
Gade JN, Kimmick G, Hitchcock MG, McMichael AJ. Generalized cutaneous metastases from breast adenocarcinoma. J Am Acad Dermatol 1997;37:129-30.  Back to cited text no. 5
    
6.
De Giorgi V, Grazzini M, Alfaioli B, Savarese I, Corciova SA, Guerriero G, et al. Cutaneous manifestations of breast carcinoma. Dermatol Ther 2010;23:581-9.  Back to cited text no. 6
    
7.
Gupta RK, Naran S. Fine needle aspiration cytology of cutaneous and subcutaneous metastatic deposits from epithelial malignancies. An analysis of 146 cases. Acta Cytol 1999;43:126-30.  Back to cited text no. 7
    
8.
Zajdela A, Zillhardt P, Voillemot N. Cytological diagnosis by fine needle sampling without aspiration. Cancer 1987;59:1201-5.  Back to cited text no. 8
    
9.
Santos JE, Leiman G. Nonaspiration fine needle cytology. Application of a new technique to nodular thyroid disease. Acta Cytol 1988;32:353-6.  Back to cited text no. 9
    
10.
Maurya AK, Mehta A, Mani NS, Nijhawan VS, Batra R. Comparison of aspiration vs non-aspiration techniques in fine-needle cytology of thyroid lesions. J Cytol 2010;27:51-4.  Back to cited text no. 10
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Correspondence Address:
Dr. Ruquiya Afrose
Department of Pathology, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh - 202 002, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9371.155245

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    Abstract
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