Cutaneous metastasis to the scalp from squamous cell carcinoma of the cervix

Cutaneous metastasis from cervical cancer to the scalp and trunk: a case report and review of the literature

BACKGROUND

An estimated 119,300 new cases of cervical cancer occur annually in China, accounting for 372,00 deaths. Cutaneous metastasis from cervical cancer is a rare event, with an incidence of 0.1-1.3% and typically a preterminal occurrence. Scalp metastasis from cervical cancer is exceptionally anecdotal, with only a dozen examples well documented.

CASE PRESENTATION

The patient is a 33-year-old Chinese woman who was diagnosed with International Federation of Gynecology and Obstetrics stage IVB cervical cancer in November 2021. From December 2021 to April 2022, the patient was enrolled in the clinical trial of sintilimab combined with chemotherapy and radiotherapy for treatment of stage IV cervical cancer and underwent six cycles of immunotherapy and chemotherapy (sintilimab plus paclitaxel liposome and cisplatin). Treatment was well tolerated and led to a partial response. The masses adjacent to the spine and iliac bone was largely reduced. Thus, radiotherapy of the metastatic residues was carried out and followed by radiotherapy to the primary tumor at the cervix uteri. However, by the time of the radiotherapy completion in October 2022, the patient noticed painless nodules at the left scapular region and the right hypochondrium. The following month, more nodules occurred on the scalp and trunk, including the left axilla, anterior abdomen, and left back, along with a lesion invading the sternum that caused acute bone pain. The cutaneous masses were white, discrete with a rubbery consistency, and fixed to the skin. Several nodules increased in size and eventually ulcerated. Fine‑needle aspiration cytology of the left back swellings revealed metastatic squamous cell carcinoma, P16 positive. No visceral or brain metastasis was observed at this point.

CONCLUSIONS

Cervical cancer metastases to the scalp are extremely uncommon. When a scalp metastasis is present, it might be the only symptomatic sign of disease progression or widespread metastatic lesions. So far, there is no clear guideline regarding skin metastases treatment. Such skin lesions warrant a thorough radiologic and pathologic workup to form a comprehensive management plan.

Alopecia neoplastica as a sign of visceral malignancies: a systematic review

Alopecia neoplastica (AN) from visceral tumours is a rare form of cutaneous metastasis in which internal malignancies spread to the scalp. The diagnosis of AN may be very challenging, especially when its onset precedes the diagnosis of the primary tumour. We aimed to improve the knowledge on AN, highlighting that in case of scarring localized alopecia, a differential diagnosis with metastasis should always be considered. We performed a systematic review to describe the main demographic and clinical features associated with AN from visceral malignancies; a survival analysis was also performed. In 118 reports, accounting for 123 patients, we found that women were more affected by AN than men (53.7% vs. 46.3%). The most frequent site of the primary tumour was the gastrointestinal tract (24.4%), followed by breast (17.9%), kidney (8.1%), lung (7.3%), thyroid (7.3%), uterus (6.5%), central nervous system (6.5%), liver (3.3%) and other anatomic areas for 18.7% of cases. Furthermore, in more than half of the cases (66.1%), AN lesions were single and were mainly diagnosed after the primary visceral tumour (71.5%). Finally, survival analysis highlighted a lower progression-free survival in men; while, no significant differences in overall survival were reported among genders. In conclusion, metastatic skin disease should always be taken into consideration when dealing with patients with localized scarring alopecia.

Skin metastases of cervical cancer: two case reports and review of the literature

BACKGROUND

Although cervix carcinoma is one of the most common malignancies in women, hematogenous metastases are relatively not common. Cutaneous metastases, in particular, are unusual even at an advanced stage of disease. Their presence is a predictor of poor prognosis.

CASE PRESENTATION

Case 1: A 63-year-old postmenopausal Moroccan woman was diagnosed as having cervical squamous cell carcinoma. She was treated with radical concurrent chemotherapy and radiation therapy followed by low-dose brachytherapy. Six months after finishing the therapy, multiple skin nodules appeared on her abdomen and chest wall. An excision biopsy was performed and showed metastatic squamous cell carcinoma. Her disease progressed and she died before completing her fourth course of palliative chemotherapy. Case 2: A 48-year-old Moroccan woman was diagnosed as having cervical squamous cell carcinoma; she was treated with concurrent chemoradiation. Before a planned high-dose brachytherapy, she noticed many nodular lesions on her arms, thighs, and chest wall. An excision biopsy was performed and showed metastatic squamous cell carcinoma. She then underwent a series of imaging examinations, including computed tomography of her chest, abdomen, and pelvis, and a whole body bone scan that showed disseminated disease involving her lungs and bones. She died after two courses of palliative chemotherapy, 2 months after the appearance of the skin lesions.

CONCLUSION

We report two cases to illustrate a rare localization of metastasis from cervical carcinoma that is highly aggressive requiring early detection and aggressive management.

Cutaneous metastasis in cancer of the uterine cervix: A case report and review of the literature

Carcinoma of the uterine cervix is a common neoplasm among Indian women; in fact, it is the commonest malignancy among rural Indian women. Uterine cervical cancer spreads mainly to the regional lymph nodes, with distant metastasis rarely occurring. Major sites of distant metastasis are lung, bone, and liver. Skin metastasis from carcinoma of the uterine cervix is a very rare event. The reported incidence ranges from 0.1 to 2%. Here we describe a 60-year-old woman with cervical cancer who developed metastatic lesions on the lower abdominal wall and also over the inner aspects of thigh.

Scalp metastasis from leiomyosarcoma of the inferior vena cava sign as the first clinical sign: a case report

The presentation of scalp metastases from leiomyosarcoma of the vena cava is an extremely infrequent event. There are no other publications that describe such finding and very few of leiomyosarcoma in vessels. About this event we have reviewed the English literature describing studies on scalp metastases and skin metastases in general: their incidence, origin, clinical appearance, meaning, and diagnosis. The case we describe would be the second one presented worldwide because, as far as we know, it has been only one more published in 2005.

Vulval metastasis from squamous cell carcinoma of the cervix clinically presenting as lymphangioma circumscriptum

Patients with cervical cancer may develop local recurrence or distant metastasis, and the rate of these events is increased in proportion to the clinical stage. Cutaneous metastasis of cervical cancer is very rare and only a few cases have been reported in Korean literature. It is common at the abdominal wall, vulva, and anterior chest wall and mainly presents as an asymptomatic dermal or subcutaneous nodule, ulcer or plaque. We herein report on an interesting case of vulval metastasis from squamous cell carcinoma of the cervix with an unusual clinical manifestation resembling lymphagioma circumscriptum.

Cutaneous metastases from internal malignancies

Cutaneous metastases of internal malignancies still seem to occur infrequently, although medical publications report an incidence rate of up to 10.4%. Common sense, however, fosters suspicion that we might underdiagnose the problem distracted by harder striking facets of an advanced disease. With contemporary knowledge, morphology and behavior of cutaneous metastases resemble each other regardless of the site of origin. This article itemizes clinical presentations according to organ systems, specific features, and differential diagnoses. In general, the survival turned out to be less than 12 months. But incremental awareness of cutaneous metastases proclaims this paradigm insufficient. Although excision is the local treatment of choice, investigations attempt to propose tumor-specific chemotherapeutic/immunological approaches. This paper endeavors to critically review the state of the art concerning the clinic, prognosis, and therapeutic concepts.

Cutaneous metastatic disease in cervical cancer: a case report

BACKGROUND

Cervical cancer metastasizes to skin in < 2% of patients. Cutaneous metastases can be confused with dermatitis. Their presence signals a poor prognosis.

CASE

A 66-year-old postmenopausal woman with a diagnosis of stage IVa cervical carcinoma was treated with radical concurrent chemotherapy and radiation. Two months after completing treatment, the patient noted maculopapular skin lesions in the lower abdomen. These were confirmed on biopsy as metastases from the cervical cancer. The cutaneous metastases progressed rapidly to involve the inguinal regions, vulva, and perineum. Further assessment ruled out metastases to other organs. Despite six courses of palliative combination chemotherapy, the patient's disease progressed, and she died six months after the appearance of the cutaneous metastases.

CONCLUSION

We reviewed the details of 47 reported cases of cutaneous metastases of cervical carcinoma. In the majority of these cases, patients presented within 10 years of initial diagnosis and died within a mean of 8.5 months from cutaneous metastasis.

Skin metastasis: a pathologist's perspective

Skin metastasis is defined as the spread of malignant cells from a primary malignancy to the skin. It is one manifestation of systemic spread of cancer. The tumor cells originate either from an internal malignancy or from a primary skin cancer. This study presents a literature review concerning these issues as well as this author's experience encountered throughout 19 years of surgical pathology and dermatopathology practice. Several conclusions are evident. Generally, skin metastases are encountered in 0.7-9% of all patients with cancer and as such the skin is an uncommon site of metastatic disease when compared to other organs. There is usually a long-time lag between the diagnosis of the primary malignancy and the recognition of the skin metastases. However, these metastases may be the first indication of the clinically silent visceral malignancies. The regional distribution of the skin metastasis, although not always predictable, is related to the location of the primary malignancy and the mechanism of metastatic spread. The relative frequency of skin metastasis correlates with the type of primary cancer, which occurs in each sex. For instance, lung and breast carcinomas are the most common primaries that send skin metastasis in men and women, respectively. The head and neck region and the anterior chest are the areas of greatest predilection in men. The anterior chest wall and the abdomen are the most commonly involved sites in women. Skin metastases usually appear as non-specific groups of discrete firm painless nodules that emerge rapidly without any explanation. They vary in size from so tiny as to be of 'miliary lesions' to as large as 'Hen's egg size'. Some skin metastasis may mimic specific dermatological conditions such as cutaneous cyst, dermatofibroma, pyogenic granuloma, hemangioma, papular eruptions, herpes zoster eruptions, rapidly infiltrating plaques, alopecic patches, cellulitis and erysipelas. Histologically, the skin metastases usually show features reminiscent of the primary malignancy, but with variable degrees of differentiation. Molecularly, skin metastasis is an organized, non-random and organ-selective process orchestrated by interaction among several heterogeneous molecules, which are largely unknown. Metastasis to the skin is often a pre-terminal event that heralds poor outcome.

Cutaneous metastases of visceral tumours: a review

BACKGROUND

Up to 10% of all visceral malignancies develop cutaneous metastases. As cutaneous metastases are underestimated and underdiagnosed they can be a clinical challenge. The clinical appearance and patterns of distribution of cutaneous metastases, the characterisation of clinical outcomes and available therapeutic options are compiled.

PATIENTS AND METHODS

Literature (over the last 6 years) MESH in terms of cutaneous metastases was comprehensively evaluated. Characteristics from 92 available cases are elaborated and adjusted with terms (time unlimited) of published epidemiological reviews to single organs.

RESULTS

The broad clinical spectrum with differential diagnoses is displayed. An allocation of cutaneous metastases and a particular organ is not reliable. In 22% of all cases cutaneous metastases can lead to the diagnosis of an internal malignoma. The majority of cases reveal cutaneous metastases to emerge in a tumour-free interval in about 36 months, after a successful treatment of the primary tumour, most commonly along with other organ metastases. Probable survival turned out to be less than 12 months. Consistently with this end-stage condition, treatment aligns with rules of palliation. Local treatment of choice is excision. Only a minority of investigators attempted to come up with tumour-specific treatment strategies, and almost no randomised therapy studies can be presented.

CONCLUSION

A reference guide of cutaneous metastases is given; the clinical spectrum is adjusted to an actual status; state of the art of the treatment is accomplished. An epidemiological, improved registration and diagnostic work-up for targeted therapies in conjunction with dermatologists are favoured.

Cutaneous metastases from different internal malignancies: a clinical and prognostic appraisal

BACKGROUND

Cutaneous metastases are perceived as a sign of advanced disease and are regarded as a grave prognostic indicator. In addition, few reports have focused on the cutaneous metastasis profiles of Asian patients.

OBJECTIVES

We seek to analyse the clinical and prognostic characteristics of cutaneous tumour metastases in a Taiwanese medical centre.

METHODS

Clinical records from Kaohsiung Medical University Hospital over the last 20 years (1986-2006) were reviewed, and cases of biopsy-proven cutaneous metastases from internal malignancies identified. Survival rates were evaluated using the Kaplan-Meier method and compared by the log-rank test. The Cox proportional hazards model was used for univariate analysis to determine the risk of mortality among different groups.

RESULTS

A total of 141 cases of cutaneous metastases were identified. The clinical profiles were similar to those from western countries, although the frequencies of primary tumours were different. The duration of survival was usually short following diagnosis of cutaneous metastases, but prognosis is significantly better in breast cancer patients with metastases. Moreover, the survival was even longer for breast cancer patients when the metastasis was confined to the skin.

CONCLUSIONS

The risk of skin metastases depends largely on the characteristics of tumour cells, which is similar among different ethnic groups. In terms of prognosis, a subset of breast cancer patients has superior prognosis, even among breast cancer patients with stage IV disease. Physicians should consider this finding in clinical situations to avoid possible misinformation about the prognosis of the disease.

Cellulitis-like cutaneous metastasis of uterine cervical carcinoma

Metastasis to the skin from cervical carcinoma is relatively uncommon. Herein we present a 41-year-old woman with a history of cervical carcinoma with severe facial erythematous swelling and telangiectasia. She was initially treated for cellulitis without improvement. A skin biopsy specimen revealed widespread intravascular tumor emboli in the dermis and subcutis, resembling the so-called inflammatory carcinoma of the breast. As this is an unusual clinical presentation for the metastasis of cervical carcinoma, this case is reported.

Cervical cancer metastasis to the scalp presenting as alopecia neoplastica

A 45-year-old Japanese woman was diagnosed in 1996 with squamous cell cancer of the cervix following an abnormal Papanicolaou smear and subsequent diagnostic conization. She underwent total abdominal hysterectomy with pelvic lymphadenectomy and was found to have poorly differentiated squamous cell carcinoma, International Federation of Gynecology and Obstetrics (FIGO) stage IB1. She remained asymptomatic until 2003 when she presented with obstructive uropathy with acute renal failure and hydronephrosis, suspected to be from the recurrence of cervical cancer. This was confirmed when computerized tomography (CT)-guided lymph node biopsy showed squamous cell carcinoma of the para-aortic lymph nodes histologically consistent with the cervical primary. In addition, there was evidence of lumbar spine metastasis by positron emission tomography (PET) and bone scans. She received several courses of chemotherapy with cisplatin and 5-fluorouracil (5FU), as well as radiation therapy. In July 2004, she was hospitalized for acute renal failure, nausea, vomiting, and anorexia. CT of the abdomen identified widespread metastases in the liver, pancreatic head, and lumbar spine. During this hospitalization, she complained of severe scalp tenderness and patchy hair loss first noticed 3 days prior to presentation. On examination of her scalp, two patches of alopecia were observed (Fig. 1). In the largest patch, there was a 5 x 2.5-cm, tender, erythematous plaque with atrophy. In the smaller patch, there was a 2 x 1.5-cm, erythematous, scaly plaque. A punch biopsy of the larger patch revealed atypical epithelial cells in nests with intravascular involvement and diminished numbers of focally miniaturized hair follicles (Fig. 2a). The scalp specimen was histologically identical with biopsy specimens of the cervical primary (Fig. 2b). There was also seborrheic dermatitis, with thick greasy scale, noted on the scalp, which resolved with fluocinolone solution. The patient decided against further treatment for her advanced cervical cancer but did accept hydromorphone for pain. She died 3 months after admission.