Cutaneous metastases in a case of adenocarcinoma cervix with atypical presentation

Sandeep Arora; Rajeshwari Dabas; Eeshaan Ranjan; Aradhana Rout

doi:10.4103/ijdpdd.ijdpdd_76_20

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CASE REPORT

Year : 2021 | Volume : 8 | Issue : 1 | Page : 17-19

Cutaneous metastases in a case of adenocarcinoma cervix with atypical presentation

Sandeep Arora¹, Rajeshwari Dabas², Eeshaan Ranjan³, Aradhana Rout⁴
¹ Department of Dermatology, Army College of Medical Sciences & Base Hospital Delhi Cantt, New Delhi, India
² Department of Dermatology, Command Hospital, Udhampur, Jammu & Kashmir, India
³ Department of Dermatology, Military Hospital, Jammu, Jammu & Kashmir, India
⁴ Department of Dermatology, Command Hospital Air Force, Bengaluru, Karnataka, India

Date of Submission	30-Jun-2020
Date of Decision	08-Oct-2020
Date of Acceptance	06-Mar-2021
Date of Web Publication	11-Aug-2021

Correspondence Address:
Rajeshwari Dabas
Department of Dermatology, Command Hospital, Udhampur, Jammu & Kashmir.
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/ijdpdd.ijdpdd_76_20

Abstract

Cutaneous metastasis of carcinoma cervix is quite uncommon, with a reported incidence of 0.1%–4.4%, with zosteriform or dermatomal distribution being a rare presentation. Although zosteriform cutaneous metastases have been reported with other malignancies, namely lung carcinoma, breast carcinoma, and malignant melanoma, there are no reports of dermatomal cutaneous metastases with adenocarcinoma cervix. We report a case of adenocarcinoma cervix who developed cutaneous metastases in an unusual dermatomal distribution mimicking herpes zoster.

Keywords: Adenocarcinoma cervix, cutaneous metastasis, dermatomal

How to cite this article:
Arora S, Dabas R, Ranjan E, Rout A. Cutaneous metastases in a case of adenocarcinoma cervix with atypical presentation. Indian J Dermatopathol Diagn Dermatol 2021;8:17-9

How to cite this URL:
Arora S, Dabas R, Ranjan E, Rout A. Cutaneous metastases in a case of adenocarcinoma cervix with atypical presentation. Indian J Dermatopathol Diagn Dermatol [serial online] 2021 [cited 2023 Apr 1];8:17-9. Available from: https://www.ijdpdd.com/text.asp?2021/8/1/17/323705

Introduction

Cutaneous metastasis is an indicator of tumor progression and at times the first sign of an internal malignancy. The incidence of skin metastasis in carcinoma cervix is very low and ranges between 0.1% and 4.4%.^[1] We present a case of adenocarcinoma cervix who developed cutaneous metastases in an unusual dermatomal distribution mimicking herpes zoster. To our knowledge, this is the first case of dermatomal cutaneous metastases arising from adenocarcinoma cervix. One other case of zosteriform cutaneous metastases in a patient with squamous cell carcinoma of the cervix has been reported.^[1]

Case Report

A 54-year-old female, a known case of adenocarcinoma cervix Stage II B, was referred as a suspected case of persistent genital herpes infection of 3 months duration and herpes zoster over the abdomen for 1 month not responding to multiple courses of acyclovir.

She was initially treated with external beam radiation (45 Gy in 25 fractions), intracavitary brachytherapy (7 Gy in 2 fractions), and chemotherapy with injection cisplatin followed 3 months later by salvage surgery in the form of total abdominal hysterectomy and bilateral salpingo-oophorectomy and pelvic lymph node dissection for persistent residual disease in the cervix and uterus. She was also given adjuvant chemotherapy after surgery with four cycles of injection paclitaxel and injection carboplatin. After about a year of follow-up, she developed multiple red raised lesions over the right side of the vulva followed 2 months later by similar lesions over the abdomen which was not associated with pain, itching, blistering, or vesiculation. She also gave a history of swelling over both the legs, difficulty in passing urine, and chronic constipation with the absence of constitutional symptoms. On examination, she had bilateral pitting pedal edema and her vital parameters were within normal limits. Dermatological examination revealed multiple, shiny, grouped, firm papules over an erythematous base in a dermatomal distribution at the level of T10 dermatome bilaterally [Figure 1]. Similar lesions were also seen over the labia majora and labia minora on the right side [Figure 2].

Figure 1: Multiple, shiny, grouped, firm papules over an erythematous base present over bilateral T10 dermatome

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Figure 2: Multiple shiny, grouped, firm papules over the labia majora and labia minora on the right side

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On investigations, her hematological parameters were within normal limits. Her renal function tests were deranged (blood urea – 50 mg/dL and serum creatinine – 3.15 mg/dL), but other biochemical parameters were normal. On repeat positron emission tomography–computed tomography scan, she had local recurrence along with multiple bilateral pulmonary nodules, few lesions in the liver and L3 vertebral body, and metastases to various lymph nodes (aortocaval, left external iliac, left inguinal, and left prevascular region in the mediastinum). She was also detected to have bilateral mild-to-moderate hydroureteronephrosis (right more than left) due to encasement of bilateral lower ureters by the vaginal stump lesion. Skin biopsy from one of the lesions revealed tumor cells that were arranged in an ill-defined glandular pattern in the dermis. The tumor cells had a high nuclear–cytoplasmic ratio with moderately eosinophilic to vacuolated cytoplasm and pleomorphic nuclei with few showing nucleoli suggestive of metastatic adenocarcinoma deposit (Stage IV) [Figure 3]A and B. Immunohistochemistry (IHC) was done, and p16 was negative. In view of her clinical presentation and investigations, she was diagnosed to have vault recurrence and progressive metastatic disease with cutaneous metastases in a dermatomal distribution. She was reviewed by the urologist, and cystoscopy followed by meatal dilatation and right double J stenting under general anesthesia was carried out. She was then planned for palliative radiotherapy by the oncology team.

Figure 3: (A) Photomicrograph showing normal epidermis. Dermis shows cells arranged in an ill-defined glandular pattern (H and E, x100). (B) Photomicrograph showing tumor cells arranged in fused glandular pattern with high N:C ratio, moderately eosinophilic to vacuolated cytoplasm, and pleomorphic nuclei (H and E, x400)

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Discussion

Cutaneous metastases from various internal malignancies have an incidence ranging from 0.6% to 10.4%. The common malignancies which spread to the skin in females have their origin in the breast, ovary, oral cavity, lung, and large intestine.^[2] Metastases to the skin from cancer cervix are rare as it spreads mainly to the lungs, lymph nodes, gastrointestinal tract, liver, and spine. They generally occur in patients with advanced disease or those with recurrence and multiple distant metastases, and are associated with a poor prognosi.^[1]

Skin metastases may have a varied morphological spectrum with papules and nodules being the most common manifestation. Other presentations include ulcerations, sclerotic, vesiculobullous, telangiectatic, or other inflammatory lesions.^[3] Skin metastases in a zosteriform pattern or dermatomal distribution are quite uncommon. The zosteriform pattern has been reported with breast carcinoma,^[4] malignant melanoma,^[5] lung carcinoma,^[6] urinary bladder carcinoma,^[7] few hematological and vascular malignancies,^[8] and one case of squamous cell carcinoma cervix.^[1] Often they have been misdiagnosed and treated as herpes zoster.

The exact mechanism of occurrence of zosteriform or dermatomal metastases is not known. There are various theories which include spread of malignant cells to perineural lymphatics, hematogenous spread through fenestrated vessels of dorsal root ganglia, direct neural spread, surgical implantation, orkoebnerization at the site of prior herpes zoster infection.^[9]

In our case, the cutaneous metastases were present on the abdominal wall in a bilateral dermatomal distribution at the level of T10 dermatome masquerading as herpes zoster, and the lesions on the vulva were grouped and unilateral mimicking genital herpes simplex virus infection. The histology was suggestive of the primary malignancy, but the IHC marker p16 was negative which is possible as mentioned in other studies on cancer cervix. Vedula et al. in their study found p16 to be negative in 12% cases of carcinoma cervix.^[10] IHC serves as an ancillary aid in the diagnosis of skin metastases. It can play an important role in differentiating primary skin neoplasms from cutaneous metastasis and also indicate the primary site of tumor if it is unknown.^[11]

Our patient had responded poorly to onco-therapeutic and surgical interventions. The mean interval between the diagnosis of the primary tumor and the development of skin metastasis in her was about 2 years which is similar to that mentioned in other case reports. The appearance of an eruption in a dermatomal distribution of long duration with the absence of vesiculation or blistering should alert the clinician of nonherpetic disorders. Early diagnosis in these cases would help in instituting appropriate therapy by the treating physician.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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