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Hindawi Case Reports in Oncological Medicine Volume 2018, Article ID 5302185, 4 pages https://doi.org/10.1155/2018/5302185 Case Report Basal Cell Carcinoma of the Female Breast Masquerading as Invasive Primary Breast Carcinoma: An Uncommon Presentation Site 1 1 1 Mark B. Ulanja , Mohamed E. Taha, Arshad A. Al-Mashhadani, 2 1 1 Marwah Muaad Al-Tekreeti, Christie Elliot, and Santhosh Ambika Department of Internal Medicine, University of Nevada Reno, School of Medicine, 1155 Mill Street, Reno, NV 89502, USA American Public University System, 111 West Congress Street, Charles Town, WV 25414, USA Correspondence should be addressed to Mark B. Ulanja; email@example.com Received 28 April 2018; Accepted 19 June 2018; Published 3 July 2018 Academic Editor: Katsuhiro Tanaka Copyright © 2018 Mark B. Ulanja et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Skin cancer as a single entity is the most common malignancy in North America, accounting for half of all human cancers. It comprises two types: melanoma and nonmelanoma skin cancers. Of the nonmelanomas, basal cell carcinoma (BCC) constitutes about 80% of the cancers diagnosed every year. BCC usually occurs in sun-exposed areas such as the face and extremities. Occurrence in the nipple areolar complex is very rare. We present a case of a Caucasian woman who presented with what was initially thought to be invasive carcinoma of the breast involving the nipple areolar complex (NAC); however, the diagnosis was revealed to be a basal cell carcinoma after histopathological examination. The tumor was treated with modiﬁed radical mastectomy, with negative margins. The importance of this case lies in the rare site of presentation of basal cell carcinoma and the importance of early detection. 1. Introduction a Caucasian woman, involving the nipple areolar complex (NAC) which was initially thought to be invasive carci- Skin cancer as a single entity is the most common malig- noma of the breast, but was subsequently diagnosed to nancy in North America . They account for half of all be BCC. human cancers. Generally, they could be divided into two types: melanoma and nonmelanoma skin cancers. The non- 2. Case Report melanoma type, which is the most common form, includes basal cell carcinoma and squamous cell carcinoma. Of the A 64-year-old Caucasian female presented to our emergency 3.5 million cases of nonmelanoma skin cancer (NMSC) diag- department (ED) with a two-day history of bleeding from her nosed each year, 80% are basal cell carcinomas (BCCs), left breast. She has had a slowly enlarging growth on her left which makes BCCs the most common skin cancer . It is breast for the past two years, which initially started as a small most common among fair-skinned persons, with a lifetime papular lesion in the nipple areolar complex. Most recently, risk of 33% to 39% in white men and 23% to 28% in white the mass became ulcerated with active serous discharge; how- women in the United States . ever, due to the lack of health insurance, the patient did not The most important environmental risk factor is ultra- seek any medical attention. For the past two days prior to violet (UV) light exposure, hence BCC usually occurs in presentation, she developed signiﬁcant bleeding and oozing sun-exposed areas . The occurrence of BCC in unex- from the ulcerated mass, forcing her to report to the ED. posed areas such as in the nipple areolar complex (NAC) There was associated localized breast pain, but no weight is very rare [4, 5]. We present a case of breast cancer in loss, fever, nausea, vomiting, abdominal pain, back pain, 2 Case Reports in Oncological Medicine abdominal pain, shortness of breath, cough, blurry vision, nor headaches. She had no prior personal or family history of skin and breast cancers. She had no history of excessive exposure to sunlight, radiation exposure, arsenic ingestion, or a history of immunosuppression. Physical examination reveals an elderly female in no apparent distress. Vital signs were stable apart from an ele- vated blood pressure of 164/85 mmHg. Examination of the left breast revealed a large fungating mass of >10 cm in size, occupying most of the mid and outer breast with a distortion Figure 1: Left breast basal cell carcinoma showing ulcerations and of the nipple areolar complex (Figure 1). There were several bleeding. open wounds with active bleeding and a foul smell. The area of erythema was noted. There were palpable left axillary lymph nodes. The rest of the physical examination was unremarkable. equator, like Hawaii, was twice as that of the Midwestern The provisional diagnosis was breast cancer with possi- regions [7, 8]. ble metastasis. Subsequently, the patient underwent The most important risk factor for BCCs is ultraviolet workup to further characterize the mass and assess for (UV) light exposure, particularly intermittent, intense UVB metastasis. Computer tomography (CT) scan of the chest, light exposure; hence, BCCs most commonly occur in sun- abdomen, and pelvis was positive for a large, partially enhanc- exposed areas . Other risk factors include radiation ther- ing heterogeneous mass in the left breast and a calciﬁed gran- apy, chronic arsenic exposure, and long-term immunosup- uloma in the right lung ﬁeld, in addition to mildly enlarged pression. In patients with early-onset or numerous BCCs, a left axillary lymph nodes. No evidence of metastasis was syndromic manifestation of a genetic cause (e.g., basal cell identiﬁed in the abdomen and pelvis. Magnetic resonance nevus syndrome) should be considered . imaging (MRI) of the brain with and without contrast was The occurrence of BCC in the skin of the breast such as negative for brain lesions. There was no evidence of osseous the nipple areolar complex (NAC) is very rare [4, 5]. It was metastatic disease as evident by the negative nuclear medicine ﬁrst reported in 1893  and as of September 2016, BCCs bone scintigraphy. of the areolar and nipple have been described in 55 individ- Trucut excisional biopsy of the mass was performed. The uals of which 35 were males and 20 were females and the initial histopathological exam was suggestive of an epidermal onset age ranged from 35 to 86 years [10, 11]. In a study by origin of the cancerous cells, raising the possibility of an Betti et al., they found that 74% of the BCCs were located adnexal primary such as basal cell carcinoma (Figures 2 and on the head and neck area, 26% were involved in the covered 3). Immunohistochemical (IHC) proﬁle also favored a pri- sites of the body, and only two cancers were involved in the mary skin disorder over a breast primary (Figures 4 and 5). nipple and areolar . A histogenic relationship has been Utilizing NeoGenomics®, the cells were consistent with cuta- noted between pilosebaceous units and the development of neous basal cell carcinoma. BCC . The NAC is deﬁcient in pilosebaceous units and Post diagnosis, the patient underwent left modiﬁed radi- this may explain the paucity of BCCs in this area . In regard to the etiology of BCC in the NAC, some stud- cal mastectomy with axillary lymph node dissection. After histopathological exam for the dissected tissue and lymph ies have suggested that ultraviolet (UV) irradiation might be nodes, a ﬁnal diagnosis of invasive cutaneous basal cell the main etiological factor. In one study, a history of exten- carcinoma was made. The margins were tested negative for sive sun exposure was evident in three out of six cases with carcinoma. All the dissected 16 lymph nodes were negative multiple BCC lesions in the NAC [13, 14]. Other potential for cancer. Subsequent treatment and oncological follow-up risk factors include genetic predisposition, immunosuppres- were scheduled with oncology. sion, ionizing radiation exposure, arsenic exposure, injuries such as burns or trauma, light-colored skin, previous BCCs at another site, and sunburns . Similar to the majority 3. Discussion of the cases of BCC, as well as in our case, no history of risk factors is identiﬁed. Basal cell carcinomas (BCCs) are nonmelanoma skin can- Diﬀerential diagnosis of a BCC lesion in the NAC includes Paget’s disease, eczema, adenoma of the nipple, papilloma of cers arising from the basal layer of the epidermis and its appendages. They constitute eighty percent of skin cancers. lactiferous ducts, syringomatous adenoma, invasive ductal They are slow-growing tumors and very rarely metastasize; carcinoma, and melanoma. Therefore, it is crucial to perform histopathological examination to establish the diagnosis . however, if left untreated, they tend to grow and invade nearby tissues . In the NAC, BCC is considered to behave more aggressively than other anatomical sites, but other nonaggressive histolog- Geographically, there is profound variation in the inci- dence of BCCs due to the eﬀect of ultraviolet light on its ical subtypes exist, and tumor recurrence is uncommon after development. In the USA for instance, in 1990, the incidence the successful treatment of the primary cancer [15, 16]. In a previous study, a report of 3 out of 31 cases of BCC in the of BCCs in the states which are in close proximity to the Case Reports in Oncological Medicine 3 Figure 2: Histological ﬁndings on excisional biopsy H&E Figure 5: IHC stain (SMA—smooth muscle actin) 20x shows the (hematoxylin and eosin stain) 2x, demonstrate nests of tumor cells normal epidermis to be negative (which is what is expected), but arising from the surface epidermis. the tumor cells show strong cytoplasmic positivity. The circles that are also staining is smooth muscle in normal blood vessels (positive internal control). high compared to the rate of 0.01–0.028%  noted by Elder et al. The likely explanation is that the subareolar plexus is rich in a network of lymphatic capillaries and this might pro- vide high potential for metastasis of tumors in this area, hence this relative diﬀerence [16, 17]. Varying modalities of treatment are available for BCC in the NAC depending on the characteristics of the lesion. Options include medical treatment, photodynamic therapy, laser therapy, Mohs’ microsurgery, and simple surgical exci- sion with or without radiotherapy, as well as partial mastec- tomy with axillary dissection and surgical reconstruction of the breast [15, 16, 18]. This patient presented late because Figure 3: Histological ﬁndings on excisional biopsy H&E of the lack of health insurance, and oozing and bleeding were (hematoxylin and eosin stain) 10x show peripheral palisading of noted from the extensive ulcerated breast lesions. The initial the tumor cells at the periphery of the nests. histopathology report was not conclusive and had to be sent for further consultation. It was recommended that given the clinical impression and initial inconclusive histopathology report, mastectomy was most appropriate. It was conceivable that the patient will likely have persistently positive resection margins if reasonable attempts at excision and reexcision was made . Also based on the relatively high incidence of maxillary lymph node metastasis , mastectomy was rec- ommended as the best mode of treatment. Our case presented with a 2-year history of a slowly growing papular lesion in the breast not associated with sys- temic symptoms except for local breast pain when it began to ulcerate, involving most part of the left breast. It is important to be aware that BCCs can become locally aggressive, without systemic symptoms. Simple mastectomy with left axillary lymph node dissection was performed. Lymph nodes were negative as well as the rest of the metastatic workup. Regular Figure 4: Immunohistochemical (IHC) stain 20x shows tumor cells follow-up is very important to assess for recurrence or late to be negative for GATA3 (note: positive in breast primary). manifestation that might develop from micro metastasis. Unfortunately, follow-up was diﬃcult to establish due to NAC have developed apparent axillary lymphadenopathy health insurance constraints, but the patient was educated with histologically conﬁrmed cases . Takeno et al. found thoroughly regarding the examination of her skin and fea- that axillary lymph node metastasis of basal cell carcinoma tures of recurrence and advised regarding seeking medical help as early as possible. was about 11.5% in 26 patients , which was apparently 4 Case Reports in Oncological Medicine Rochester, Minnesota,” Journal of the American Academy of 4. Conclusion Dermatology, vol. 22, no. 3, pp. 413–417, 1990. For the past 125 years, only about 62 cases of BCC of the  H. Robinson, “Rodent ulcer of the male breast,” Philosophical NAC have been reported, which highlights the rarity of transactions of the Royal Society of London, vol. 44, pp. 147- this presentation. Clinicians should be aware of the occur- 148, 1893. rence of BCC in this unexposed region and should con-  R. Betti, C. Bruscagin, E. Inselvini, and C. Crosti, “Basal cell sider BCC as a diﬀerential diagnosis to other benign and carcinomas of covered and unusual sites of the body,” Interna- malignant disorders aﬀecting the NAC. Furthermore, given tional Journal of Dermatology, vol. 36, no. 7, pp. 503–505, the rich lymphatic nature of the NAC, this cancer has the 1997. high potential for distant metastasis, and hence it is of  M. Fujii, A. Harimoto, and T. Namiki, “Basalzellkarzinom des great importance to be recognized early enough to insti- Mamillen-Areola-Komplexes mit multiplen Läsionen: tute appropriate treatment. 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Al-Mashhadani, Marwah Muaad Al-Tekreeti, Christie lance of trends in cancer survival 2000–14 (CONCORD-3): Elliot, and Santhosh Ambika) declare that they have no analysis of individual records for 37,513,025 patients diag- nosed with one of 18 cancers from 322 population-based competing interests. registries in 71 countries,” The Lancet, vol. 391, no. 10125, pp. 1023–1075, 2018. Authors’ Contributions  A. Sinha and J. A. Langtry, “Secondary intention healing All authors (Mark B. Ulanja, Mohamed E. Taha, Arshad A. following Mohs micrographic surgery for basal cell carcinoma Al-Mashhadani, Marwah Muaad Al-Tekreeti, Christie Elliot, of the nipple and areola,” Acta Dermato-Venereologica, vol. 91, no. 1, pp. 78-79, 2011. and Santhosh Ambika) contributed equally to the work.  S. Takeno, N. Kikuchi, T. Miura et al., “Basal cell carcinoma of the nipple in male patients with gastric cancer recurrence: References report of a case,” Breast Cancer, vol. 21, no. 1, pp. 102–107,  D. L. Miller and M. 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