Case Report: Care Report: Primary malignant melanoma of the breast

Introduction

Malignant melanoma is the carcinoma of skin melanocytes. Primary malignant melanoma of the breast (P.M.M.B.) is a rare cancer with a minute number of cases reported in the literature. Around 95% of malignant melanomas arise primarily from the skin and 5% from the nonskin sites, including the choroid, the meninges, and the lining epithelium of the gastrointestinal tract.¹ Breast metastasis amounts to around 2% of breast tumors.² An extensive literature search by Ref. 1 found only six patients’ with P.M.M.B. from the parenchyma breast and less than 190 cases arising from breast skin.

We present a case of P.M.M.B. with skin involvement arising from breast parenchyma. As this is a sporadic tumor, clinical and pathological features are not fully established, leading to difficulty in arriving at the correct diagnosis. Early diagnosis and proper surgical intervention with adjuvant therapy are the denominators for improving this dreaded disease’s survival.²

Case report

A 40 year old man presented with a painless lump in the left breast for four months (since January 2023). He was Palaeo-Mediterranean and a farmer as his occupation. His Medical and family history was not significant, and psycho-social history including relevant genetic information not contributory. He had not undergone any past treatment or interventions.

Mode of progress was rapid and, on clinical examination, suggested a mass of size 3×4-cm hard in consistency occupying the central part of the breast just behind of nipple and areola left breast. There was evidence of retraction of the nipple with involvement of skin (Figure 1). Left axillary palpation revealed the presence of lymphadenopathy. Fine needle aspiration cytology was suggestive of secondary deposits in lymph nodes. High-Resolution Computed Tomography (H.R.C.T.) revealed no evidence of lung and pleural metastases. A positron emission tomography (P.E.T.) scan of the whole body revealed metastasis in thoracic vertebrae. The patient underwent a lumpectomy of the left breast; histopathology confirmed the diagnosis of melanoma (Figure 2).

Figure 1. Evidence of skin involvement in the form of nipple and skin retraction.

Figure 2. Histopathological and immunohistochemistry suggest tumor cell pleomorphism and nuclear atypia on Hematoxylin and eosin-stained sections.

No modifications have been made to this image.

Histopathological examination and immunohistochemical findings suggested a malignant melanoma. A complete physical examination did not reveal it at sites other than the breast. Hence this patient could be considered a P.M.M.B. with skeletal metastasis. The patient was not willing for further treatment. Three months later, the patient died, possibly due to metastases.

Discussion

Malignant melanomas arising from the breast are categorized into three types: (1) P.M.M.B. arising from the breast parenchyma, (2) Arising from the breast skin, and (3) Secondary deposits of primary melanomas of other skin sites. P.M.M.B. affecting the breast skin or parenchyma is not common worldwide, but the third type is variable in incidence.¹ We here report one case of P.M.M.B. with skin involvement in the form of nipple and skin retraction.

Koh J et al.¹ presented two cases of P.M.M.B.; one arose from the breast tissue and the second from the breast skin. Both had extensive distant metastasis with poor survival, similar to the present case. He Y et al.,² in his research, a young lady was presented with a malignant melanoma of the breast. She was also associated with extensive metastasis. Unfortunately, she refused further treatment and died after two and half months of Diagnosis, similar to the present case. Sagrario Galiano et al.³ presented a 72-year old woman with malignant melanoma of the left nipple and areola. The diagnosis was obtained by excisional biopsy. The histopathologic examination suggested that malignant melanoma was not associated with distant metastasis. She underwent a successful excision as the skin’s invasion depth was about 1 mm. A PET scan of the whole body was ruled out distant metastasis. Negative margins were obtained after surgery. The patient underwent an axillary sentinel biopsy with negative results. The prognosis was excellent, not similar to the present case. Dorothee Drueppel et al.⁴ reported a middle-aged woman with giant melanoma of the breast that is more than 10 cm in diameter. She underwent successful removal by surgery. Similar to the present case, Singh J et al.⁵ presented a case of P.M.M.B. and underwent a decision of a right breast lumpectomy; the histopathological examination was suggestive of malignant melanoma. She underwent further treatment in the form of monoclonal antibodies and chemotherapy. Even after these therapies, the prognosis was not good.

The strength of this report lies in its ability to provide detailed and nuanced insights into the topic at hand as it is a rare case report. The information presented is clear, concise, and easy to understand, making it an invaluable resource for anyone looking to learn more about this subject. The patient was not willing to undergo the treatment and subsequently died. Providing more context around the patient’s decision not to pursue treatment could help readers to understand the limitations of the case report. Mentioning any potential ethical considerations or personal factors that may have influenced the patient’s decision could provide valuable insight into the complexities of cancer treatment.

Conclusion

P.M.M.B. of the breast is a rare disease with a bad prognosis. Its diagnosis needs careful physical examination, histopathology, immunohistochemistry, and imaging like a P.E.T. scan. Early Diagnosis and proper surgical intervention with adjuvant therapy are the denominators to improve survival in this dreaded disease.

Consent

Written informed consent for publication of their clinical details and clinical images was obtained from the patient.