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Special Feature
July 2012

Image of the Month—Quiz Case

Author Affiliations


Author Affiliations: Department of Surgical Oncology, Curie Centre of Oncology, M. S. Ramaiah Medical College, Bangalore, India.

Arch Surg. 2012;147(7):679. doi:10.1001/archsurg.2011.907

A 60-year-old woman presented with an irregular lesion in the skin over the midline of her chest of 3 months' duration (Figure 1). There was recent onset of pain. The patient had undergone coronary artery bypass surgery 8 years earlier. On examination, we found an irregular-shaped nodular lesion, with some areas of ulceration measuring 10 cm vertically and 5 cm horizontally. There was restricted mobility of the lesion over the sternum. The single axillary node was palpable in both axillae and measured 3 cm× 3 cm on the right side and 2.5 cm × 2.5 cm on the left side. Supraclavicular nodes were not palpable, and there were no clinical or radiologic signs of metastasis elsewhere. A computed tomographic scan of the chest with contrast revealed the lesion in the midline extending to both breasts but more evident on the right side (Figure 1). The sternum was not involved with the disease; however, a biopsy revealed moderately differentiated carcinoma (Figure 2A). Immunohistochemistry was performed to confirm the diagnosis of breast cancer. Immunohistochemistry was positive for CK7, CK20 (Figure 2B and C), and gross cystic disease fluid protein positive (Figure 2D).

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Figure 1. A lesion in the midline over the sternum with small areas of ulceration. The inset of a computed tomographic scan of the thorax shows the lesion in the midline with extension into both breasts (more on the right). Note that the sternum is not infiltrated.

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Figure 2. Hematoxylin-eosin and immunohistochemisty-positive stainings. A, Hematoxylin-eosin staining of a biopsy showing pleomorphic cells in clusters and cords infiltrating the stroma, suggesting the possibility of a moderately differentiated carcinoma. B, Immunohistochemistry-positive staining for CK7. C, Immunohistochemistry-positive staining for CK20. D, Immunohistochemistry-positive staining for gross cystic disease fluid protein. Original magnification ×100 (A-D).

What Is the Diagnosis?

A.  Marjolin ulcer

B.  Breast carcinoma

C.  Infected keloid

D.  Basal cell carcinoma