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E-IJD® - CORRESPONDENCE |
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| Year : 2022 | Volume
: 67
| Issue : 6 | Page : 838 |
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| Carcinoma en cuirasse with vesicular Eruptions: A Pitfall in Diagnosis by Tzanck Smear |
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Yin-Shuo Chang1, Kuo-Hsien Wang1, Hsiou-Hsin Tsai1, Ting-Hua Yang2
1 Department of Dermatology, Taipei Medical University Hospital, No. 252; Department of Dermatology, School of Medicine, College of Medicine, Taipei Medical University, No. 250, Wu Hsing St., Taipei City, Taiwan
2 Department of Dermatology, Taipei Medical University Hospital, No. 252, Wu Hsing St., Taipei City, Taiwan
| Date of Web Publication | 23-Feb-2023 |
Correspondence Address:
Yin-Shuo Chang
Department of Dermatology, Taipei Medical University Hospital, No. 252; Department of Dermatology, School of Medicine, College of Medicine, Taipei Medical University, No. 250, Wu Hsing St., Taipei City
Taiwan
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ijd.IJD_101_17
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How to cite this article:
Chang YS, Wang KH, Tsai HH, Yang TH. Carcinoma en cuirasse with vesicular Eruptions: A Pitfall in Diagnosis by Tzanck Smear. Indian J Dermatol 2022;67:838 |
How to cite this URL:
Chang YS, Wang KH, Tsai HH, Yang TH. Carcinoma en cuirasse with vesicular Eruptions: A Pitfall in Diagnosis by Tzanck Smear. Indian J Dermatol [serial online] 2022 [cited 2023 Mar 29];67:838. Available from: https://www.e-ijd.org/text.asp?2022/67/6/838/370271 |
Sir
Cutaneous metastases of breast cancer with vesicles may sometimes be mistaken for herpes infection.[1] Tzanck smear may be the first tool for differential diagnosis. In tumoural disease, atypical tumour cells may aggregate together and form a multinuclear giant cell-like cluster, which may be misdiagnosed by inexperienced clinicians as herpes virus infection. Herein, we report a case of carcinoma en cuirasse with vesicular eruptions which was first misdiagnosed as herpes infection.
A 60-year-old female was diagnosed with infiltrating ductal carcinoma of the right breast. The patient underwent a modified radical mastectomy and two stages of breast reconstruction. One month after the breast reconstruction, the patient started to notice skin rashes that gradually progressed to the right chest wall with multiple vesicle formations. Physical examination showed multiple erythematous papules coalescing into well-demarcated indurated plaques with grouped vesicles spread to the right chest wall in a dermatomal distribution [Figure 1]. The underlying erythematous patch was caused by allergic contact dermatitis induced by alcohol pads. | Figure 1: (a and b) Multiple erythematous papules and nodules coalesce into thickened well-demarcated indurated plaques on the right anterior chest wall, like a cuirasse. The lesions spread to the right lateral chest wall in a dermatomal distribution. The underlining erythematous patch was caused by allergic contact dermatitis. (c) Multiple grouped vesicles and erosions with clear discharge and crusts were noted
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Tzanck smear revealed multiple multinuclear giant cell-like clusters [Figure 2]a and [Figure 2]b, which were first interpreted as multinucleate giant cells in herpetic infection. Nevertheless, the clinical diagnosis of cutaneous metastases of breast cancer was more favoured than herpetic infections in view of the clinical pattern and the large, atypical cells under the Tzanck smear. | Figure 2: (a) Under low-power view, the Tzanck smear revealed multiple multinuclear giant cell-like clusters, which was first interpreted as multinucleate giant cells in herpes zoster or herpes simplex infection. (b) Under high-power view, the large atypical cells have a high nuclear–cytoplasmic ratio and hyperchromatic nuclei. The atypical cells also aggregate together to form a multinuclear giant cell-like cluster, combined with the grouped vesicles and erosions clinically, which may mislead the clinician to the diagnosis of herpetic infection
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Skin incisional biopsy revealed carcinoma cell infiltration in the dermis [Figure 3]a and [Figure 3]b and tumour emboli in lymphatic vessels [Figure 3]c. The tumour cells showed positive staining for GATA-3 [Figure 3]d. The varicella-zoster virus antibody and herpes simplex virus type 1 and type 2 antibodies showed negative results. Virus culture of the blister fluid revealed no isolated virus in 30 days. The diagnosis of carcinoma en cuirasse with vesicular eruptions was made. The patient then received salvage chemotherapy. | Figure 3: (a and b) Histopathological examination showed carcinoma cell infiltration in the dermis, arranged in cords, nested growth pattern, and separated by dense fibrosis. The carcinoma cells display pleomorphic nuclei with prominent nucleoli. (H&E; original magnification, ×40 and × 200). H and E = haematoxylin and eosin. (c) Tumor emboli in lymphatic vessels (arrow) in the superficial dermis were seen (H&E; original magnification, ×200) (d) Carcinoma cells were immunosensitive to GATA3 (GATA3; original magnification, ×40)
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Carcinoma en cuirasse generally presents after mastectomy.[2] Perineural lymphatic spread along the cutaneous nerve and accidental surgical implantation might be the possible mechanism for zosteriform metastases. Tumoral lymphatic embolization may obstruct the lymph duct in the superficial dermis and cause subclinical lymphedema.[3] This may be the possible mechanism for vesicle formations.
Tzanck smear may be the first tool to differentiate herpes zoster from zosteriform metastases to give the right and timely treatment. In typical multinucleate giant cells caused by herpetic infections, the border is usually smooth and nuclei tend to be crowded and moulded together. There is also peripheral margination of the chromatin and a ground-glass appearance of the nuclei.[4],[5] On the contrary, the border of the multinuclear giant cell-like cluster by atypical tumour cells is irregular and the nuclei tend to spread sporadically in the cytoplasm. The atypical malignant cells also have a high nuclear–cytoplasmic ratio and hyperchromatic nuclei.
In patients with vesicular lesions who do not respond to antiviral treatment, clinicians should always put tumoral skin involvement into differential diagnosis, especially when the skin lesion occurs after operation in malignancy patients. Although Tzanck smear is cost-effective and convenient in clinical usage, it should be interpreted with caution to not fall into the pitfall of diagnosis.
Level of evidence: Level III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of the expert committee
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
 References | |  |
| 1. | Virmani NC, Sharma YK, Panicker NK, Dash KN, Patvekar MA, Deo KS. Zosteriform skin metastases: Clue to an undiagnosed breast cancer. Indian J Dermatol 2011;56:726-7.  [ PUBMED] [Full text] |
| 2. | Oliveira GM, Zachetti DB, Barros HR, Tiengo A, Romiti N. Breast carcinoma en Cuirasse--case report. An Bras Dermatol 2013;88:608-10. |
| 3. | Bassioukas K, Nakuci M, Dimou S, Kanellopoulou M, Alexis I. Zosteriform cutaneous metastases from breast adenocarcinoma. J Eur Acad Dermatol Venereol 2005;19:593-6. |
| 4. | Koranda FC. Images in clinical medicine. Use of multinucleated giant cells to diagnose a viral eruption. New Engl J Med 2004;350:e6. doi: 10.1056/ENEJMicm010775. |
| 5. | Gupta G, Athanikar SB, Pai VV, Naveen KN. Giant cells in dermatology. Indian J Dermatol 2014;59:481-4. [ PUBMED] [Full text] |
[Figure 1], [Figure 2], [Figure 3] |
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