Primary Malignant Melanoma of the Breast: a case report

doi:10.21203/rs.3.rs-4680197/v1

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Case Report

Primary Malignant Melanoma of the Breast: a case report

https://doi.org/10.21203/rs.3.rs-4680197/v1

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Introduction

Primary malignant melanoma of the breast (PMMB) is a rare type of malignancy, and only a few case reports have been published.

Case presentation

We report the case of a 44-year-old Thai woman with PMMB. She was treated with wide local excision and sentinel axillary lymph node biopsy. She then underwent second-stage nipple reconstruction, and a 2-year follow-up conducted after the surgery showed satisfactory nipple architecture and tip projection and no evidence of the disease.

Conclusion

This case illustrates the importance of early diagnosis and effective treatment of PMMB for patient survival, as well as the importance of satisfactory breast reconstruction.

Melanoma

Malignant melanoma

Primary malignant melanoma of the breast

Wide local excision

Case report

Malignant melanoma is a malignant disease that usually arises in the skin, but it can occur in epithelial and mucosal locations, albeit rarely. Although it accounts for less than 10% of skin cancer cases, it is the deadliest form of skin cancer because of its aggressive nature and high mortality rate (1). Primary malignant melanoma of the breast (PMMB) is even rarer, accounting for less than 0.5% of breast cancer cases and 3–5% of malignant melanoma of all tissue types (2, 3).

In one of most comprehensive studies of PMMB in women describing 115 cases of cutaneous melanomas affecting the breast, with 14 cases exclusively involving the nipple-areolar complex (NAC), mastectomy did not offer any advantage over local excision of the primary lesion. However, regional axillary lymph node dissection was recommended (4).

Internal mammary lymph node dissection may be unnecessary according to a study by Lee et al. conducted in 1977, in which a condensed series comprising 12 PMMB cases revealed no occurrences of lymph node metastasis in internal mammary nodes (5).

PMMB is a rare disease with a poor prognosis. Surgery is the main treatment modality, involving radical local excision and axillary sentinel lymph node dissection in selected cases. Adjuvant and primary advanced treatment strategies for women with PMMB follow the guidelines applied to melanoma (3).

The clinical and pathological features, diagnosis, treatment, and follow-ups are discussed in context with the literature.

A 44-year-old Thai woman without a significant medical history or family history of cancer presented to Chulabhorn Hospital (Bangkok, Thailand) in July 2021 with a hyperpigmented skin lesion on her left breast (Fig. 1). The patient indicated that she had noticed the patch 10 years prior, but it had been expanding over the last 2 years. Clinical examination revealed a 1.7×1.3 cm hyperpigmented patch in the inner lower quadrant of the left breast. There was no change in the appearance of the local skin, and no discharge from or retraction of the nipple. The right breast appeared normal and had no palpable mass. No palpable nodules or masses in the axillary, cervical, and supraclavicular lymph nodes on both sides were evident. A thorough examination of other sites of skin and mucous membranes showed no signs of malignant lesions. Incisional biopsy was performed in the clinic, and the tissue was sent to the laboratory for a pathological report. The report showed a malignant melanoma, superficial-spread type, Clark Level IV with maximal depth of 2 mm, no ulcerative lesion, and mitotic activity 0–1/HPF. Computed tomography (CT) scan with intravenous contrast of the chest showing no evidence of metastasis. Therefore, primary malignant melanoma of the left breast was the most likely principal diagnosis.

The patient underwent wide local excision with a 2-cm margin extended to involve the left NAC, and left axillary sentinel lymph node biopsy assisted by peritumoral injection of 5 ml Isosulfan Blue 10 min prior to the excision (Fig. 2). The excision left the skin with a 4×4 cm rhomboid-shaped defect that was then corrected by local Limberg flap.

Pathology of the primary breast lesion revealed malignant melanoma, superficial-spreading type, Breslow thickness 1 mm, and no angiolymphatic invasion, and all margins were uninvolved by the malignant melanoma. Axillary lymph nodes were two-out-of-two negative for metastatic melanoma. The patient was then staged as T1bN0M0, which is equivalent to stage IB of the 8th edition of American Joint Committee on Cancer (AJCC) (6). Therefore, no adjuvant therapy was indicated according to national and international guidelines (7, 8).

At the 7-month follow up, the patient noticed a new 1-cm lump at her left axilla. Fine needle aspiration of the nodule was performed, revealing a benign lymphoid hyperplasia. The patient was then sent for MRI of both breasts and axillae, revealing extreme fibroglandular tissues of both breasts. These were likely benign findings, BI-RADS III. A whole-body FDG-PET/CT scan was also performed and revealed no sign of malignancy.

At 14 months postoperatively, the patient underwent nipple reconstruction (Fig. 3; prior to reconstruction). Follow up at 1 month later is shown in Figs. 4–5.

We followed up the patient for 2.5 years postoperatively (9 months post-nipple reconstruction). The shapes of both breasts were nearly identical, the projection of the reconstructed nipple pointed a little lower than the contralateral breast, and there was approximately 5% loss of the superficial skin flap (Figs. 6,7). A whole-body FDG PET/CT scan was undertaken at 30 months postoperatively, and neither local recurrence nor FDG avid cutaneous lesions were found. The patient is alive with no signs of the disease and is satisfied with her breasts and nipples.

Malignant melanoma is known to be aggressive because of its high incidence of metastasis and high mortality rate. Although primary malignant melanoma of the breast (PMMB) is relatively rare compared with other malignant diseases, its aggressive nature and high mortality rate make early diagnosis and effective treatment at a stage when a cure is readily achievable the most important success factors (7).

Malignant melanoma of breast skin is more difficult to correctly diagnose because the location may strongly point to primary breast cancer. If the tissue sample is inconclusive, the immunostaining of proteins such as HMB45, Melan A, MITF, S-100, and Sox10 may help to label and support the diagnosis of malignant melanoma (9).

The treatment of PMMB is the same as that for other malignant melanomas located elsewhere on the body (10). The primary surgical method is wide local excision, with a recommended margin of 2 cm to ensure surgical reliability. Aligning with the ESMO consensus on the guidelines for cutaneous melanoma, the predicted rate of sentinel lymph node metastasis for 8th AJCC’s stage T1b is between 5% and 10%, and hence it is sufficient to discuss sentinel lymph node biopsy with the patient (7). Mastectomy does not enhance the patient's prognosis, and only performing sentinel lymph node biopsy alone can reduce the need for unnecessary lymph node dissection, which then lowers the risk of developing lymphedema. A comprehensive axillary lymph node dissection becomes necessary when preoperative axillary lymph node metastasis is identified and confirmed, or a positive lymph node status is obtained from the biopsy (2, 10).

We evaluated the patient's breast following wide excision. Because there was only a minor change to the left breast contour, the use of a skin flap for nipple reconstruction was adequate. We made an arrow flap nipple on the left breast with the size and location based on the contralateral breast.

We followed the patient for 2.5 years post-excision and nipple reconstruction. The patient was satisfied with the nipple contour and tip projection. Follow-up is still being conducted to monitor for recurrence and to further assess the nipple contour in the long term.

In conclusion, PMMB is rare but very aggressive. Early diagnosis and effective treatment are the most important factors to increase survival. Finally, reconstructing the breast to its near-original contour is no less important than the treatment itself because it improves both the physical appearance and overall well-being of the patient.

PMMB Primary malignant melanoma of the breast

NAC Nipple-areolar complex
HPF High-power field

CT Computed tomography

ESMO European Society for Medical Oncology

NCCN National Comprehensive Cancer Network

MRI Magnetic resonance imaging

BI-RADS Breast Imaging Reporting and Data System

FDG-PET 18-Fluoro-deoxyglucose positron emission tomography

HMB45 Human melanoma black-45

MITF Microphthalmia-associated transcription factor

SOX10 Sex-determining region Y box transcription factor-10

Acknowledgements
We thank H. Nikki March, PhD, from Edanz (https://jp.edanz.com/ac) for editing a draft of this manuscript.

Authors’ contributions
IK drafted the manuscript. SS and ST treated the patient. ST helped to draft the manuscript. All authors have read and approved the manuscript for submission.

Funding
The authors declare that no funding was received for this study.

Availability of data and materials
No additional dataset was used for creation of this manuscript. All information was available from standard documentation in the patient’s electronic medical record.

Ethics approval and consent to participate
The Chulabhorn Royal Academy ethics committee approved this study. The patient was assigned an informed written consent form.

Consent for publication
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Competing interests
The authors declare that they have no competing interests.

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Drueppel, D., et al. Primary malignant melanoma of the breast: case report and review of the literature. Anticancer Res. 2015;35:1709–13.
Papachristou, D. N., et al. Cutaneous melanoma of the breast. Surgery 1979;85:322–8.
Lee, Y. T., et al. Primary melanoma of skin of the breast region. Ann Surg. 1977;185:17–22.
Keung, E. Z. and J. E. Gershenwald. The eighth edition American Joint Committee on Cancer (AJCC) melanoma staging system: Implications for melanoma treatment and care. Expert Rev Anticancer Ther. 2018;18:775–84.
Michielin, O., et al. ESMO consensus conference recommendations on the management of locoregional melanoma: under the auspices of the ESMO Guidelines Committee. Ann Oncol. 2020;31:1449-61.
National Comprehensive Cancer Network. Melanoma: Cutaneous (version 2.2024). https://www.nccn.org/guidelines/guidelines-detail?category=1&id=1492. Accessed 19 Jun 2024.
Miettinen, M., et al. Microphthalmia transcription factor in the immunohistochemical diagnosis of metastatic melanoma: comparison with four other melanoma markers. Am J Surg Pathol. 2001;25:205–11.
He, Y., et al. Primary malignant melanoma of the breast: A case report and review of the literature. Oncol Lett. 2014;8:238–40.

No competing interests reported.

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Primary Malignant Melanoma of the Breast: a case report

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Abstract

Introduction

Case presentation

Conclusion

Figures

Background

Case presentation

Discussion and Conclusions

Abbreviations

Declarations

References

Additional Declarations

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