BILATERAL, NON-BONY METASTASES TO THE HAND FROM CERVICAL CARCINOMA

BACKGROUND

Hand metastases from carcinomas are very rare and account for just 0.1% of all metastases¹. When they occur, bony metastases are the typical presenting feature². We report an extremely rare case of bilateral non-bony metastasis to the hand of an 85 year-old woman from cervical cancer.

CASE PRESENTATION

An 85-year-old woman presented to us with nodular masses of various sizes on both palms and ulcerated bleeding nodule on her right thumb [Fig. 1]. Four months earlier she had been diagnosed with invasive squamous cell carcinoma of cervix. The histologic diagnosis of the cervical carcinoma was that of a poorly differentiated squamous cell carcinoma. A CT scan of the abdomen, showed multiple noncalcified nodules in the lung bases suggestive of pulmonary metastasis and mild right renal hydronephrosis making it a Stage IV disease.

Figure 1:

Bilateral palmar nodules (arrows) with an ulcerated nodule on the right thumb

She was treated with palliative external beam radiotherapy in a hospital in the United States of America. The patient was a known diabetic and hypertensive patient with no history of allergy, no recent additions to or changes in her medications and no pruritus. The remainder of her medical history was non-contributory.

Physical examination revealed multiple nodular lesions on the palms of both hands. They were more on the left palm and varied in size from 0.3cm to 1cm in diameter. The nodules were firm, tender and mobile. The nodule on the left thumb was ulcerated. The rest of the physical examination were unremarkable. A diagnosis of pyogenic granuloma of the left thumb and differential diagnosis of Dupuytrens nodules of the palm were made. Hematological investigations were normal. Chest X-ray and abdomino-pelvic - ultrasonography were unremarkable. She had excisional biopsies of the thumb and palmar lesions that revealed metastatic squamous cell carcinoma [Fig. 2]. She declined any further treatment and died four months after the diagnosis of the cutaneous metastasis to the palms.

Figure 2:

Hematoxylin and Eosin Stain (a): X40-Overlying squamous epithelium with thick stratum corneum and nests of metastatic cells in the dermis. (b): X400 Shows highly pleomorphic squamous cells with vesicular nuclei, scanty eosinophilic cytoplasm and brisk mitosis

DISCUSSION

Cutaneous metastases are seen in up to 10% of all malignancies⁴. Cancers with a predilection to metastasize to the skin are cancers from the breast, colorectum, melanoma, lung and oral cavity^3-6. The occurrence of cutaneous metastases suggests advanced disease and is associated with a poor prognosis^2-8. The clinical presentation however is variable and can mimic benign skin lesions^2,7 as seen in our case. A high index of suspicion therefore is required for its recognition.

Hand metastasis from a primary internal malignancy is very rare, seen only in about 0.1% of metastases¹. The metastatic lesions are found more commonly in the phalanges, metacarpal and carpal bones^1,2,6. Cutaneous hand involvement is therefore extremely rare and the diagnosis can be missed particularly when it is the only presenting feature^2,6. Subungal metastases have been reported in patients with primary internal malignancies arising from the lung, genitourinary system and the breast⁶.

Cutaneous metastases from cervical cancer are seen in less than 2% of patients and more commonly seen is metastasizes to the trunk, vulva and lower extremities^9-11. There has been only one previous report known to the authors of metastasis to the hand from cervical cancer by Elamurugen et al., in which they reported cervical cancer metastasis to the palm of one hand with frank features of a fungating lesion¹². Bilateral non-bony metastasis to the hands as seen in our case has not as far as we are aware been previously reported. The multinodular features and squamous cell pathology seen in our patient are in keeping with the typical presenting features of metastatic lesions from cervical cancer^9-11. Other morphological patterns seen in metastatic squamous cell carcinoma of the cervix could include, carcinoma en cuirrase, carcinoma telangiectaticum, Sister Mary Joseph's nodule, alopecia neoplastica, and cicatricial and bullous forms^10,11.

The prognosis of cutaneous metastases from cervical cancer is still extremely poor, and the median survival of patients is 3–8 months^7,10,11. Our patient died 4 months after the manifestation of the cutaneous lesions.

CONCLUSION

There should be a high index of suspicion in patients being managed for internal malignancies, particularly squamous cell carcinoma of the cervix, presenting with nodules on the hand. These lesions should undergo prompt skin biopsy to rule out cutaneous metastatic disease.