International Journal of Surgery Case Reports 114 (2024) 109119

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International Journal of Surgery Case Reports

journal homepage: www.elsevier.com/locate/ijscr

Case report

Simultaneous cutaneous melanoma and ipsilateral breast cancer with

metastasis to the same axilla. A case report with a focus on a
multidisciplinary approach
Margit Leonie Riis a, *, Linnea Augestad b, Vidar Gordon Flote c, Aase Tangerud d, Lars Frich e
a
Section of Breast and Endocrine Surgery, Department of Cancer Treatment, Oslo University Hospital, Oslo, Norway
b
Locum Consultant for Melanoma, Department of Oncology, Oslo University Hospital, Norway
c
Department of Oncology, Oslo University Hospital, Oslo, Norway
d
Department of Radiology, Oslo University Hospital, Oslo, Norway
e
Section of Oncologic Plastic Surgery, Department of Plastic and Reconstructive Surgery, Oslo University Hospital Radiumhospitalet, Oslo, Norway

A R T I C L E I N F O A B S T R A C T

Keywords: Introduction and importance: Treatment of simultaneously occurring primary malignancies with separate
Breast cancer lymphatic drainage is a surgical and medical challenge. We present a patient in which multidisciplinary man­
Melanoma agement of coexisting melanoma and breast cancer was mandatory for optimal results.
Axillary metastasis
Case presentation: A 67-year-old female had a primary surgical resection for a skin lesion on the back. Histology
Case report
revealed melanoma with a Breslow thickness of 4.8 mm. According to guidelines, a wide local excision was
scheduled. Prior to the surgery, routine mammography revealed simultaneous ipsilateral breast cancer. A pre­
operative work-up revealed a pathological lymph node in the left axilla. Biopsies found metastasis from ma­
lignant melanoma. She had combined surgery with breast-conserving therapy, wide local excision of the skin on
the back, and extended axillary clearance of levels I-III. Final histology revealed axillary metastases both from
melanoma and breast cancer. Adjuvant therapy was decided based on a multidisciplinary approach.
Clinical discussion: To our knowledge, cases of synchronous primary cutaneous melanoma with biopsy-verified
axillary metastases and independent, ipsilateral primary breast carcinoma have not been described. The surgi­
cal approach was done according to guidelines. The breast cancer was re-staged based on the histology of the
surgical specimen. Adjuvant treatment was a combination of treatment strategies for the two primary
malignancies.
Conclusion: This case highlights the need for a multidisciplinary approach in treating simultaneous breast cancer
and melanoma both with axillary metastasis. The optimal treatment approach was based on close collaboration
between surgeons, oncologists, radiologists, and pathologists. Multidisciplinary meetings are mandatory for
optimal results.

1. Introduction both primaries was present in lymph nodes in the left axilla.

We present a case with cutaneous melanoma on the left back and
simultaneous ipsilateral cancer of the breast. Preoperative work-up
revealed metastasis from melanoma to the left axilla. The breast
tumor was initially perceived to be a stage N0 cancer.
In cases without metastases to the axilla, sentinel node diagnostics
could be performed with dual tracer, with one injection of tracer at the
site of the primary melanoma, and a separate injection of tracer at the
site of the primary breast cancer. However, in this case, metastasis from
2. Presentation of case
The patient is a 67–year–old female who presented with a skin lesion
on the left side of the back. An excision biopsy was performed, and
histology revealed nodular melanoma with a Breslow thickness of 4.8
mm with no ulceration and 15 mitoses per mm2. The lesion was removed
with a side margin of 5 mm and a depth margin of 8.5 mm. According to
national guidelines for the treatment of melanoma, wide local excision

* Corresponding author.
E-mail addresses: margit.l.riis@gmail.com (M.L. Riis), linaug@ous-hf.no (L. Augestad), aastan@ous-hf.no (A. Tangerud).

https://doi.org/10.1016/j.ijscr.2023.109119
Received 26 October 2023; Received in revised form 20 November 2023; Accepted 1 December 2023
Available online 6 December 2023
2210-2612/© 2023 The Author(s). Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY license
(http://creativecommons.org/licenses/by/4.0/).
M.L. Riis et al. International Journal of Surgery Case Reports 114 (2024) 109119

with a 2-cm margin and sentinel node biopsy were recommended.
Prior to the wide local excision of her melanoma, screening
mammography revealed a tumor in the left breast (Fig. 2a). Further
diagnostics for breast cancer included an ultrasound of the breast and
axilla with biopsies from both sites (Fig. 2b and c) and an equivalent MRI
(Fig. 2d and e). The tumor in the left breast measured 21 × 17 mm on
ultrasound. Biopsies from the breast tumor showed invasive carcinoma,
NST (no special type), grade 2, estrogen and progesterone receptor-
positive, and Ki67 57 %. Core needle biopsies from the tumor in the
left axilla showed metastasis from melanoma. As part of the staging
workup for melanoma, FDG PET/CT was performed which showed FDG
uptake in the left breast and the left axilla, but no distant metastases (fig
f).
After multidisciplinary discussion, a combined approach was per­
formed with simultaneous wide local excision at the site of the primary
melanoma, axillary lymph node dissection of levels I-III, and breast-
conserving surgery after guidewire marking of the tumor.
Histology of the surgical specimen from the left breast revealed
invasive breast carcinoma, NST, grade 3. The tumor size was 23 × 19
mm. There were clear margins. The tumor was estrogen and proges­
terone receptor positive and HER2 negative. Ki67 was 57 %. In the
surgical specimen from the axilla, there were 14 lymph nodes, two of
which had metastases from melanoma, and one with metastasis from
both primary malignancies (Fig. 1). Breast cancer was re-staged to
pT2N1 (1/14) M0, grade 3, stage IIb. The melanoma stage was pT4aN1b
(2/14) M0, stage IIIC [1]. The metastatic lymph nodes were BRAF-
positive.
The recommended chemotherapy regimen for her breast cancer was
based on TNM staging [1] and the molecular profile of the tumor [2,3].
The Prosigna test revealed a molecular B-type tumor [4,5] which ac­
cording to national guidelines recommends treatment with 4 cycles of
anthracycline/cyclophosphamide plus weekly paclitaxel for 12 admin­
istrations, followed by endocrine therapy and zoledronic acid.
Both malignancies were high-risk tumors with a significant risk of
recurrence and with strong indications for adjuvant treatment. The pa­
tient was informed about the multidisciplinary recommendations and
was involved in the treatment decisions. Adjuvant combination therapy
for stage III melanoma with the BRAF- and MEK-inhibitors dabrafenib
and trametinib was initiated six weeks after surgery. After five weeks
with BRAF- and MEK-inhibitor, 4 cycles of anthracycline/cyclophos­
phamide every third week were administered. Three weeks after
completion of the adjuvant chemotherapy for breast cancer, adjuvant
locoregional radiotherapy, 2,67 Gy × 15 towards residual breast tissue
and axilla, and concomitant endocrine therapy were administered ac­
cording to guidelines. Dabrafenib and trametinib were paused during
chemoradiation therapy.
Multidisciplinary discussions and concern for serious adverse events
due to interactions between two potentially aggressive regimens
entailed a treatment pause of BRAF- and MEK-inhibitor and omission of
paclitaxel. Although dabrafenib and trametinib can lead to discontinu­
ation of therapy due to intolerance, the therapy was administered
without any serious adverse advents that precluded the planned ther­
apy. However, a single dose reduction was made due to an instance of
pyrexia. The patient reported good quality of life during the treatment,
with an ECOG performance status of 0–1. After 8 months of follow-up,
no recurrences or new metastases occurred.
3. Discussion
Simultaneous primary cutaneous melanoma and ipsilateral primary
breast cancer with synchronous axillary metastasis from both malig­
nancies have to our knowledge not been described in the literature.

Fig. 1. Metastases from melanoma (a-c) and breast carcinoma (d-f) in the same axillary lymph node. Diffuse, cell-rich infiltration of melanoma (a) and breast
carcinoma (d) shows a trabecular arrangement with abortive gland formation in routine H&E stains. Positive staining is seen with immune markers for melanoma (b:
double immune stain with SOX-10/melan-A which shows brown nuclear staining for SOX-10 and red cytoplasmic reaction for melan-A). At the same time, there is no
staining seen in the same lymph node in the area with breast carcinoma cells (e). On the contrary, the AE1/AE3 (pan-cytokeratin) immunostaining shows no staining
in the area with melanoma (c), while it is positive in the metastatic breast carcinoma cells (f).

2
M.L. Riis et al. International Journal of Surgery Case Reports 114 (2024) 109119

Fig. 2. Mammography of the left breast shows a spiculated mass in the upper lateral quadrant in front and oblique view, suspicious of malignancy (blue arrow) (a).
Ultrasound of the left axilla demonstrates a pathological axillary lymph node with a cortical thickness of 5 mm (blue arrow), which is highly suspicious for metastasis
(b). Ultrasound of the left breast reveals a malignant irregular hypoechoic mass in the left breast (blue arrow) (c). MRI of the left axilla demonstrates a pathological
lymph node with cortical thickness (blue arrow) (d). MRI of the left breast shows a spiculated malignant contrast-enhanced mass in the left breast (blue arrow) (e).
PET/CT shows high FDG uptake in the tumor of the left breast and a lymph node in the ipsilateral axilla (blue arrow) (f).

3
M.L. Riis et al.
However, a case has been reported with metastases to an axillary lymph
node from breast cancer and melanoma [6]. In this case, however, the
patient presented with primary breast cancer, and the metastasis from
melanoma was from a melanoma excised eight years previously.
Furthermore, a case has been presented with simultaneous occurrence of
melanoma and breast cancer, but without metastases to the axillary
lymph nodes [7]. In our case, the preoperative biopsy confirmed
metastasis from melanoma to the axilla, which indicated that her mel­
anoma was the most advanced cancer. Given the histology of the sur­
gical specimen of the melanoma, axilla, and breast further treatment
needed a multidisciplinary approach. If axillary metastasis from breast
cancer had been diagnosed preoperatively without the involvement of
melanoma, axillary clearance would not have been mandatory, as a
clinically negative (not palpable lymph node) axilla with metastasis
from breast cancer can be addressed with a sentinel node biopsy.
However, if axillary metastases from breast cancer are clinically
palpable, axillary clearance is advised. Thus, axillary clearance in the
case of metastases from breast cancer may not be as extensive as in the
case of axillary metastasis from melanoma. In the latter case, extended
surgery at level I-III is recommended, as it is considered a disease with
poor prognosis and without response to radiotherapy in contrast to
lymph node metastases from breast cancer.
The recommended treatment for breast cancer was primary surgery
followed by a combined adjuvant approach. For resectable stage III
melanoma, the standard of care at the time of treatment of this patient
was surgery followed by systemic therapy with either immunotherapy or
BRAF- and MEK-inhibitor. However, neoadjuvant immunotherapy is
emerging as the new standard of care for patients with regional metas­
tases from melanoma [8]. Consequently, if our patient with simulta­
neous metastasis from melanoma and breast cancer had received
neoadjuvant therapy instead of axillary clearance, the diagnosis and
treatment of the breast cancer would probably have been delayed. The
combination therapy of BRAF- and MEK-inhibitor dabrafenib and tra­
metinib was approved for adjuvant treatment of resected stage III mel­
anoma with BRAF mutation by the Food and Drug Administration (FDA)
in 2018 [9], and in Norway in 2019. Dabrafenib and trametinib were
preferred to immunotherapy because of their immediate response to
potential microscopic disease, and the reversibility of potential toxicity
upon discontinuation with a lower risk of interfering with the adjuvant
treatment of the breast cancer.
This case demonstrates how the order of treatment, and the type of
treatment, must be discussed at every level to optimize the prevention of
cancer recurrence and minimize the risk of adverse events. The guide­
lines for the different malignancies [10–12] separately cannot be
directly applied. The optimal treatment to avoid serious side effects and
prevent cancer recurrence is dependent on a multidisciplinary approach
and should be managed at a centralized unit [13].
This work has been reported in line with the SCARE 2020 criteria
[14].
4. Conclusion
We present a unique clinical case of synchronous primary breast
cancer and primary malignant melanoma, both with metastasis to ipsi­
lateral axillary lymph nodes. The optimal treatment approach was based
on close collaboration between plastic surgeons, breast surgeons and
medical oncologists. Multidisciplinary meetings are mandatory to ach­
ieve optimal results.
Ethical approval
Ethical approval for this case report was not required, as it solely
involves the presentation of a clinical case in which the patient has given
explicit written informed consent for the publication of their medical
history and related data. The patient's consent, obtained in accordance
with Oslo University Hospital's ethical guidelines and relevant
4
International Journal of Surgery Case Reports 114 (2024) 109119
regulatory requirements, serves as the basis for sharing this case.
Source of funding
The authors reported no proprietary or commercial interest in any
product mentioned or concept discussed in this article.
CRediT authorship contribution statement
Margit Riis: Margit Riis initiated the study, was directly involved in
the surgical treatment of the patient, and played a primary role in
writing the manuscript.
Lars Frich: Lars Frich, the plastic surgeon, was actively involved in
the patient's treatment and made significant contributions to the prep­
aration, editing, and review of the manuscript.
Linnea Augestad: Linnea Augestad as medical oncologist special­
izing in melanoma, was responsible for the patient's medical treatment
and made substantial contributions to editing and refining the
manuscript.
Vidar Flote: Vidar Flote as medical oncologist specialized in breast
cancer, was responsible for the patient's medical treatment and made
substantial contributions to editing and refining the manuscript.
Aase Tangerud: Aase Tangerud, a radiologist, played a key role in
editing the manuscript and was responsible for retrieving radiological
images and crafting figure legends.
Guarantor
Margit Riis is the guarantor of this study. In this role, Margit Riis
takes full responsibility for the integrity and accuracy of the case report
as a whole, from inception to publication. The guarantor ensures that all
aspects of the study, including its design, data collection, analysis,
interpretation, and the writing and review of the manuscript, meet the
highest standards of academic and ethical integrity.
Registration of research studies
N/A.
Declaration of competing interest
None.
Acknowledgments
Acknowledgment to the Patient:
I would like to extend my heartfelt gratitude to the patient whose
unwavering strength and cooperation made this study possible. Your
willingness to participate and share your medical journey has not only
contributed to the advancement of medical knowledge but has also
provided inspiration to all of us. Your resilience and bravery serve as a
reminder of the human spirit's remarkable capacity to overcome chal­
lenges. This research owes much of its value to your involvement, and
for that, we are deeply appreciative.
Acknowledgment to the Pathologist:
I wish to express my sincere appreciation to Dr. György Geza Csa­
naky, the pathologist responsible for retrieving histological images and
crafting the figure legends for this study. Your expertise, precision, and
dedication to your work have been instrumental in ensuring the accu­
racy and quality of our research. Your commitment to detail and your
ability to translate complex medical data into accessible figure legends
have greatly enhanced the clarity and comprehensibility of our findings.
Your invaluable contributions have made a significant impact on the
quality of this research, and we are grateful for your skill and dedication.
These acknowledgments are a testament to the collaborative effort
that goes into medical research and the significant roles that both
M.L. Riis et al.
patients and professionals play in advancing our understanding of health
and disease.
Declaration of generative AI and AI-assisted technologies in the writing
process
During the preparation of this work the author(s) used Grammarly in
order to correct grammar and spelling. After using this tool/service, the
author(s) reviewed and edited the content as needed and take(s) full
responsibility for the content of the publication.
Consent
Written informed consent was obtained from the patient for publi­
cation of this case report and accompanying images. A copy of the
written consent is available for review by the Editor-in-Chief of this
journal on request.
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