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E-IJD® - BASIC RESEARCH |
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| Year : 2022 | Volume
: 67
| Issue : 1 | Page : 93 |
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| Alopecia neoplastica inducing underlying lytic skull metastasis |
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Rubén Linares Navarro1, Héctor Perandones González1, Pedro Sánchez Sambucety1, Ana De La Hera Magallanes2, Manuel Ángel Rodríguez Prieto1
1 Dermatology Department, Hospital Universitario de León, León, Spain
2 Pathology Department, Hospital Universitario de León, León, Spain
| Date of Web Publication | 19-Apr-2022 |
Correspondence Address:
Rubén Linares Navarro
Hospital Universitario de León, Servicio de Dermatología, Calle Altos De Nava, S/N, 24008, León, +34648949658
Spain
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ijd.ijd_991_20
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 Abstract | | |
Alopecia neoplastica is a rare type of cutaneous metastasis. The most frequent presentation consists of red-violaceous nodular scarring alopecia located at the parietal area. The most frequent primary tumor locations are the breast and gastrointestinal tract. We report a case of alopecia neoplastica that induced an underlying lytic bone metastasis. After a rigorous literature search, we could not find another case showing this mechanism.
Keywords: Alopecia neoplastica, cutaneous metastasis, oncology
How to cite this article:
Navarro RL, González HP, Sambucety PS, Hera Magallanes AD, Rodríguez Prieto M&. Alopecia neoplastica inducing underlying lytic skull metastasis. Indian J Dermatol 2022;67:93 |
How to cite this URL:
Navarro RL, González HP, Sambucety PS, Hera Magallanes AD, Rodríguez Prieto M&. Alopecia neoplastica inducing underlying lytic skull metastasis. Indian J Dermatol [serial online] 2022 [cited 2023 May 29];67:93. Available from: https://www.e-ijd.org/text.asp?2022/67/1/93/343311 |
| Case Report | |  |
A 62-year-old woman with a history of recurrent breast cancer with hepatic, pelvic, and spinal metastases sought medical advice for a 2-cm indurated alopecic plaque with a telangiectatic surface on the right parietal scalp [Figure 1]a. The patient reported that this lesion had progressively grown during the last 3 months. | Figure 1: (a) A 2-cm indurated alopecic plaque with a telangiectatic surface on the right parietal scalp. (b) Skull radiography showed a lytic image exactly located under the cutaneous lesion
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Skull radiography [Figure 1]b and computed tomography showed a lytic image exactly located under the cutaneous lesion. Bone scintigraphy displayed signs of bone metastases in the said area as well as in the spine and pelvis. A punch biopsy of the plaque [Figure 2]a and [Figure 2]b revealed tumor cell clusters and Indian-file pattern in dermis and deep subcutaneous tissue, accompanied by fibrosis, adnexa invasion, and hair follicles atrophy. | Figure 2: (a) Tumor cell clusters and Indian-file pattern in the dermis and deep subcutaneous tissue, accompanied by fibrosis, adnexa invasion, and hair follicle atrophy. (b) Tumor cell clusters and Indian-file pattern in the dermis and deep subcutaneous tissue, accompanied by fibrosis, adnexa invasion, and hair follicle atrophy
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Immunohistochemistry results were 100% positive for estrogen and progesterone receptors and 20% positive for Ki67. Cadherin E was negative. These findings coincide with those obtained from the primary invasive lobular breast cancer.
The patient received treatment with fulvestrant, everolimus, and vinorelbine. Unfortunately, she passed away shortly after diagnosis of alopecia neoplastica.
| Discussion | | |
Cutaneous metastases may be the first clinical manifestation of internal malignancy or even a sign of relapse. Besides, they are generally associated with poor prognosis. Thus, their early detection is important.
Breast cancer is the most common underlying primary malignancy in cutaneous metastases in women. Typical presentation consists of skin-colored or pink-red nodules on the anterior chest wall or abdomen, via a direct or lymphatic extension to the overlying skin.[1] Other well-known manifestations of cutaneous metastases in breast cancer are carcinoma telangiectoides, carcinoma erysipeloides, carcinoma en cuirasse, and alopecia neoplastica. This latter entity could be compatible with our patient's clinical findings.
Alopecia neoplastica is a rare type of cutaneous metastasis, and it must be differentiated from other scarring and nonscarring alopecia causes. Although its pathogenesis remains unclear, hair follicle loss and atrophy may be secondary to direct tumor dermal invasion or due to stromal fibrosis induced by the neoplasm.[2],[3]
Paolino et al.[4] reported in a systematic review based on 123 patients that the most frequent presentation was red-violaceous nodular scarring alopecia with a mean diameter of 2.2 ± 1.2 cm, the parietal area being the most involved. The most frequent primary tumor locations were breast and gastrointestinal. Most alopecia neoplastica cases (72.7%) occurred after the diagnosis of the primary tumor, while 2.5% of cases occurred prior to it. Therefore, cutaneous metastases should be included in the differential diagnosis of localized alopecic scalp lesions, regardless of previous internal malignancy history.
In 2009, Cohen[5] proposed that alopecia neoplastica should be classified as primary if the cancer originates in the cutaneous scalp or as secondary if the malignancy originates from a visceral organ and has metastasized to the scalp skin.
We report an uncommon case of a secondary alopecia neoplastica that might have induced an underlying lytic skull metastasis. Taube et al.[6] proved that lytic bone metastases in breast cancer are mainly osteoclast-mediated and locally activated by tumor cells. This mechanism could explain our case.
In conclusion, alopecia neoplastica can generate underlying lytic bone lesions due to local osteoclast activation by tumor cells. After a rigorous literature search, we could not find another case showing this mechanism.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Choate EA, Nobori A, Worswick S. Cutaneous metastasis of internal tumors. Dermatol Clin 2019;37:545-54.  |
| 2. | Scheinfeld N. Review of scalp alopecia due to a clinically unapparent or minimally apparent neoplasm (SACUMAN). Acta Derm Venereol 2006;86:387–92. |
| 3. | Cohen I, Levy E, Schreiber H. Alopecia neoplastica due to breast carcinoma. Arch Dermatol 1961;84:490–2. |
| 4. | Paolino G, Pampena R, Grassi S, Mercuri SR, Cardone M, Corsetti P, et al. Alopecia neoplastica as a sign of visceral malignancies: A systematic review. J Eur Acad Dermatol Venereol 2019;33:1020-8. |
| 5. | Cohen PR. Primary alopecia neoplastica versus secondary alopecia neoplastica: A new classification for neoplasmassociated scalp hair loss. J Cutan Pathol 2009;36:917-8. |
| 6. | Taube T, Elomaa I, Blomqvist C, Beneton MNC, Kanis JA. Histomorphometric evidence for osteoclast-mediated bone resorption in metastatic breast cancer. Bone 1994;15:161–6. |
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