PMC4847805_01
Response in patient 1. CT scan shows liver metastasis presentation at basal time (A and B), after 5 cycles (C and D) and after 12 cycles (E and F) of chemotherapy containing Trastuzumab/Pertuzumab. The target lesions are indicated by arrows.
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Unfortunately, 3 months later, red cutaneous plaques reappeared on her skin, in the site of previous excision, and a restaging CT scan showed secondary lesions in the liver (Fig. 1A-B). A clinical objective response was achieved on the cutaneous lesions during the treatment and a CT scan performed after 5 cycles revealed a partial response in liver (Fig. 1C vs A and D vs B).
Skin metastases during Trastuzumab/Pertuzumab treatment in patient 1. The red patches on the right oedematous breast resemble urticarial reaction. Nodules and plaques spread all over the left chest wall.
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Patient's right breast rapidly became oedematous and covered by little nodules resembling the plaques of the left chest wall that, in the meantime, increased in size and number, a clear sign of cutaneous cancer progression (Fig. 2).   
PMC4847805_02
Response in patient 2. RMI shows several metastatic lesions in all vertebra at basal time (A), after 6 cycles (B) and after 12 cycles (C) of chemotherapy containing Trastuzumab/Pertuzumab. Arrows indicate some target lesions.
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MRI confirmed neoplastic lesions in all vertebra and pelvic bones (Fig. 3A). Consistently, the MRI performed after 6 cycles demonstrated a dramatic reduction in number and size of bone metastases (Fig. 3B).   Nevertheless, disease remained in partial response in the bone and with no other site of metastatic spread as revealed by MRI (Fig. 3C) and CT scan, respectively.
Skin metastases during Trastuzumab/Pertuzumab treatment in patient 2. Edema of the right breast and reddening of the skin on the trunk up to the base of the neck with the presence of small, well-circumscribed, solitary nodules. Biopsy confirmed the malignant origin of the lesions.
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New small nodules appeared in the skin of the trunk and the pre-existing ones increased in size (Fig. 4).