Cutaneous Metastasis from a Primary Vault Malignancy

Dear Editor,

A 68-year-old female was presented to skin out-patient department (OPD) with multiple lesions over the body for 15 days associated with pain and occasional itching. Patient was a diagnosed case of carcinoma vault with right iliac node metastasis 4 years back and had taken radiation therapy and chemotherapy (Methotrexate + Gemcitabine + Paclitaxel + Cyclophosphamide) for the same. Her positron emission tomography and Computed tomography (PET & CT) scan report showed multiple lymph node metastases involving pelvic and neck nodes. Metastatic lesions were also present in the psoas muscle, liver, and other sites.

Cutaneous examination showed multiple ill-defined, hypertrophic plaques and nodules over the lower abdomen, back, bilateral groins, and pubic region [Figures 1a and 1b]. Edema was present over the right inguinal region with overlying thick, sclerotic, non-pinchable skin. The left inguinal lymph node was palpable, tender, and enlarged. The oral cavity showed a diffuse, hyperpigmented patch over the soft palate and buccal mucosa [Figure 2]. Irregular pitting was seen over the right middle and ring fingernails.

Figure 1.

Multiple ill-defined, hypertrophic plaques and nodules over. (a) lower abdomen, and pubic region. (b) back

Figure 2.

Hyperpigmentation over soft palate and buccal mucosa

Skin biopsy was taken from the lesion over lower abdomen. Histopathology showed malignant epithelial cells arranged in a papillary and micropapillary pattern with central fibrovascular areas. The cells were moderately pleomorphic, round to oval malignant epithelial cells with vesicular chromatin, and minimal to moderate eosinophilic cytoplasm. Few cells showed prominent nucleoli. Adjacent stroma shows intense acute inflammatory infiltrates comprised predominantly, neutrophils [Figure 3]. Case was diagnosed as cutaneous metastasis secondary to carcinoma vault.

Figure 3.

Moderately pleomorphic, round to oval malignant epithelial cells with vesicular chromatin, and minimal to moderate eosinophilic cytoplasm, arranged in papillary and micropapillary pattern with central fibrovascular areas. (H and E, 10x)

Cutaneous metastases from internal malignancies are uncommon and suggests a poor prognosis. In men, the most common cancers with cutaneous metastasis are lung, colon, and melanoma, whereas in women they are breast, colon, and melanoma. Carcinomas of the cervix and vagina exhibiting skin metastases are very rare.[1]

Skin metastases occur in 0.6%–10.4% of all patients with cancer and only represent 2% of all skin tumors.[2] Cutaneous metastases occur generally within 1 to 2 years of resection of the primary cancer but, can occur at any time.

Skin metastases from internal malignancies are important for both dermatologists and dermatopathologists because of their variable clinical presentation, frequent delays, and failure in their diagnosis, affecting its morbidity, prognosis, and treatment. Many times, cutaneous metastasis may be the first sign of clinically silent visceral cancer or even a clue to tumor recurrence. Cutaneous metastases from vulvar cancers are very rare, and less than ten cases have been reported. Most of them are squamous cell carcinomas and epidermotropic metastases as rare event.[2]

Primary vaginal carcinomas account for about 1% of all gynecologic cancers, and cutaneous metastases from primary vault malignancies are extremely rare.[3] The common sites of metastasis in primary vaginal adenocarcinoma are the lung, colon, vaginal vault, paravaginal lesion, bone, and liver, with no case of cutaneous metastasis.[4]

Cutaneous metastases from different primary malignancies affect the skin of the abdomen including groins,[5] observed in our case also, where the first site involved was the skin of the lower abdomen which further progressed to involve bilateral groins, pubic region, and back.

Four major mechanisms of cutaneous metastasis from female genital cancer includes direct invasion from an underlying carcinoma, implantation from a surgical scar, hematogenous spread, and lymphatic spread. Lymph node metastases and distant metastases, which are also suspected in our instance, are generally associated with the progression of vaginal cancer. Cutaneous metastasis from cervical or vaginal cancer has been classified into the single ulcerated, multiple nodular, and diffuse pruritic eruption types.[1] Other less frequent clinical expressions are alopecia patches, morphea-like lesions, nodules resembling follicular cysts, dermatofibroma-like tumors, pyogenic granuloma-like or hemangioma-like lesions, herpes zoster-like eruption, cellulitis, and erysipelas. Our case accordingly can be considered as multiple nodular types.

Histopathologically, there are four main morphologic patterns of cutaneous metastases involving the dermis, namely, nodular, infiltrative, diffuse, and intravascular.[1] Cutaneous metastasis from a solid cancer is known to have a poor prognosis. Patient education plays a major role in this early detection, palliative care, and vigorous management to cure the metastatic disease and to prevent the occurrence of additional metastases.

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Conflicts of interest

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