Chemotherapy With CMF for Triple-Negative Breast Cancer With Carcinoma Erysipelatoides | Breast Cancer | JAMA Dermatology | JAMA Network
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November 2016

Chemotherapy With CMF for Triple-Negative Breast Cancer With Carcinoma Erysipelatoides

Author Affiliations
  • 1Department of Dermatology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
  • 2Department of General Surgery, MacKay Memorial Hospital, Taipei, Taiwan
JAMA Dermatol. 2016;152(11):1281-1282. doi:10.1001/jamadermatol.2016.2502

An obese woman with underlying triple-negative breast cancer (TNBC) was diagnosed as having carcinoma erysipelatoides (CE) and was treated successfully with cyclophosphamide, methotrexate, and fluorouracil combination chemotherapy (CMF). To our knowledge, there have been no other cases of TNBC with CE responding to CMF.

Report of a Case

A woman in her 30s had a history of right breast cancer, stage IIIa (cT2N2M0), with negative immunohistochemical findings for estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2). She was initially administered neoadjuvant chemotherapy with 4 cycles of docetaxel (75 mg/m2) and cisplatin (60 mg/m2) followed by 4 cycles of combination chemotherapy with cyclophosphamide (500 mg/m2), liposomal doxorubicin (40 mg/m2), and fluorouracil (500 mg/m2) and subsequently underwent right modified radical mastectomy. Postoperative radiotherapy was administered as 28 fractions (total, 5040 cGy) to the right chest wall and 5 booster fractions (total, 1000 cGy) to the right axilla in a span of 6 weeks. After undergoing postoperative radiotherapy, the patient noticed a pruritic erythema lesion with multiple nodules over the operation site of the right breast. The lesion was initially treated as postradiotherapy dermatitis with a combination of topical betamethasone valerate and fradiomycin sulfate, but there was no response to these topical treatments.

Three months later (1 year after her initial cancer diagnosis), she presented to the dermatology clinic for evaluation skin erythema over her right breast. On examination, a well-demarcated, warm, erythematous plaque, 15 × 12 cm, was seen over the right side of the anterior chest wall around her operation scar. Scattered within the erythema were multiple palpable small nodules (Figure, A). A skin biopsy specimen obtained from the plaque showed multiple emboli of carcinoma cells in dermal and subcutaneous lymphatic vessels. On immunohistochemistry evaluation, the tumor cells were found to be negative for ER, PR, and HER2, and the diagnosis of CE arising from TNBC was made. She subsequently received vinorelbine (80 mg/m2) for 2 cycles and combination paclitaxel (70 mg/m2) and bevacizumab (10 mg/kg) for 11 cycles with no response and progressive skin involvement. She then received 5 cycles of combination chemotherapy with CMF (100 mg/m2 of cyclophosphamide, 30 mg/m2 of methotrexate, and 400 mg/m2 of fluorouracil) and experienced a clinically significant response with nearly complete remission of all skin lesions (Figure, B).

Figure.  Postmastectomy Clinical Images of a Patient With Triple-Negative Breast Cancer With Carcinoma Erysipelatoides Before and After CMF Treatment
Postmastectomy Clinical Images of a Patient With Triple-Negative Breast Cancer With Carcinoma Erysipelatoides Before and After CMF Treatment

A, Right mastectomy scar with a large well-defined area of erythema and multiple, scattered small nodules. B, Nearly complete remission of skin lesions after 5 cycles of cyclophosphamide, methotrexate, and fluorouracil combination chemotherapy (CMF).

Discussion

Carcinoma erysipelatoides has poor prognosis: the average life expectancy is less than 2.5 years from the time of diagnosis.1 Furthermore, in patients with TNBC and CE, disease-free survival is poorer than in those other subtypes of breast cancer, even with multimodality treatment including chemotherapy, radiotherapy, and surgery.2

In the past 10 years, chemotherapy regimens containing taxanes and anthracyclines have substituted for CMF for breast cancer. However, some studies suggested that CMF might have a role in the treatment of TNBC.3,4 This raises the possibility that regimens including antimetabolites, such as methotrexate and fluorouracil, and high cumulative doses of alkylating agents, such as cyclophosphamide, may be more effective than anthracycline-containing regimens in TNBC.4

In the present case, the patient had CE with underlying TNBC; vinorelbine followed by a combination of paclitaxel and bevacizumab were administered with no response and progressive skin involvement. Traditional CMF was then administered owing to her underlying TNBC and was followed by nearly complete remission of skin lesions. To our knowledge, this is the first report of successful CMF treatment of CE in a patient with TNBC. There is no clear evidence to suggest that CMF has a particular activity against CE with underlying TNBC. However, we believe that our case could potentially encourage documentation of cutaneous-specific responses from CMF even when there is no response to chemotherapy regimens containing anthracyclines and taxanes in patients with TNBC and CE.

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Article Information

Corresponding Author: Hung-Bun Lam, MD, Department of General Surgery, MacKay Memorial Hospital, No. 92, Sec. 2, Zhongshan N Road, Zhongshan Dist, Taipei City 10449, Taiwan (lamhungbun@gmail.com).

Published Online: July 27, 2016. doi:10.1001/jamadermatol.2016.2502.

Conflict of Interest Disclosures: None reported.

References
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Colleoni  M, Cole  BF, Viale  G,  et al.  Classical cyclophosphamide, methotrexate, and fluorouracil chemotherapy is more effective in triple-negative, node-negative breast cancer: results from two randomized trials of adjuvant chemoendocrine therapy for node-negative breast cancer.  J Clin Oncol. 2010;28(18):2966-2973.PubMedGoogle ScholarCrossref
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