Cutaneous Angiosarcoma in a Site of Healed Herpes Zoster

The Association between Herpes Zoster and Increased Cancer Risk: A Nationwide Population-Based Matched Control Study

Background: Herpes zoster (HZ) is strongly associated with decreased immune function, a factor of cancer development. Previous studies suggested inconsistent results regarding the association between HZ and increased cancer risk. We aimed to analyze the association between HZ and specific cancer risk. Methods: Of 134,454 patients diagnosed with HZ between 2002 and 2015, 81,993 HZ patients were matched 1:1 with non-HZ individuals by age, sex, and Charlson comorbidity index. Both groups were examined at 1, 3, and 5 years for cancer diagnosis. A Cox proportional hazard regression model was used to estimate cancer risk in both groups. The postherpetic neuralgia (PHN) and non-HZ groups were compared for specific cancer risk. Results: The HZ group showed a slightly decreased overall cancer risk compared with the non-HZ group (hazard ratio [HR] 0.94, 95% confidence interval [CI] 0.90–0.97, p = 0.002). The HRs for specific cancer risk were 0.41 (95% CI, 0.33–0.50, p < 0.001); 0.86 (95% CI, 0.81–0.91, p < 0.001); 0.87 (95% CI, 0.78–0.97, p = 0.014); 0.80 (95% CI 0.73–0.87, p < 0.001); 1.20 (95% CI, 1.07–1.34, p = 0.001); and 1.66 (95% CI, 1.35–2.03, p < 0.001) for cancers of the lips, mouth, and pharynx; digestive system; respiratory system; unknown secondary and unspecified sites; thyroid and endocrine glands; and lymphoid and hematopoietic systems, respectively. The HZ with PHN group showed higher HR for specific cancer risk, such as lymphoid and hematopoietic systems (95% CI, 1.27–2.39, p < 0.001). Conclusion: HZ was associated with increased or decreased incidence of specific cancers. PHN further increased the risk of developing certain cancers in HZ patients.

Plexus and peripheral nerve metastasis

Cancer in the form of solid tumors, leukemia, and lymphoma can infiltrate and metastasize to the peripheral nervous system, including the cranial nerves, nerve roots, cervical, brachial and lumbosacral plexuses, and, rarely, the peripheral nerves. This review discusses the presentation, diagnostic evaluation, and treatment options for metastatic lesions to these components of the peripheral nervous system and is organized based on the anatomic distribution. As skull base metastases (also discussed in Chapter 14) result in cranial neuropathies, these will be covered in detail, as well as cancers that directly infiltrate the cranial nerves. Particular emphasis is placed on the clinical, imaging, and electrodiagnostic features that differentiate neoplastic plexopathies from radiation-induced plexopathies. Neurolymphomatosis, in which malignant lymphocytes invade the cranial nerves, nerve roots, brachial and lumbosacral plexuses, and peripheral nerves, is a rare manifestation of lymphoma and leukemia. Diagnoses of neurolymphomatosis are often missed or delayed given its varied presentations, resulting in poorer outcomes. Thus this disease will also be discussed in depth.

Herpes Zoster and Risk of Cancer in the Elderly U.S. Population

BACKGROUND

Herpes zoster (HZ) arises in older people due to age-related decline in immunity. We assessed whether HZ, as a marker of immune suppression, is associated with increased cancer risk.

METHODS

We conducted a case-control study in U.S. adults with ages ≥ 65 years using the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database. Cases (n = 1,108,986) were people with first cancers identified in cancer registries (1992-2005). Controls (n = 100,000) were cancer-free individuals frequency matched to cases on age, sex, and year of selection. We identified HZ diagnosis using Medicare claims. Logistic regression models were constructed to determine adjusted associations between cancer and HZ.

RESULTS

HZ prevalence was modestly higher in cases than controls (1.4% vs. 1.2%). We identified significant associations between HZ and oral cavity/pharyngeal [adjusted OR (aOR) = 1.21], colon (aOR = 1.10), lung (aOR = 1.11), and non-melanoma skin (aOR = 1.46) cancers; myeloma (aOR = 1.38); diffuse large B-cell lymphoma (aOR = 1.30); lymphoplasmacytic lymphoma (aOR = 1.99); and chronic lymphocytic leukemia/small lymphocytic lymphoma (aOR = 1.55). Among solid cancers, HZ was mostly associated with regional and/or distant stage tumors. Associations were strongest when HZ was diagnosed 13 to 35 months before cancer diagnosis/selection; they were significant for some cancers in the 36 to 59 months period, and 60+ months for lymphoplasmacytic lymphoma (OR = 1.99).

CONCLUSION

HZ is associated with modestly increased risk of a few cancers, particularly hematologic malignancies. Associations were strongest at short latency intervals for many cancers, and for regional/distant stages among solid cancers, perhaps reflecting reverse causality.

IMPACT

Age-related immune decline does not play a major role in cancer development in older people, but it may be important for some lymphomas.

The immunocompromised district in dermatology: A unifying pathogenic view of the regional immune dysregulation

Besides the systemic immune deficiency, a sectorial default in immune control may occur in immunocompetent subjects. This regional immune defect can appear and remain confined to differently damaged skin areas, lately labeled immunocompromised districts (ICDs). An ICD is a skin area more vulnerable than the rest of the body for genetic or acquired reasons. Its vulnerability mainly consists in a local dysregulation of the immune control, which often facilitates (but sometimes hinders) the local onset of immunity-related eruptions or skin disorders. The factors responsible for localized immune dysregulation are multifarious, being represented by chronic lymphatic stasis, herpetic infections, ionizing or ultraviolet (UV) radiations, burns, all sorts of trauma (especially amputation), tattooing, intradermal vaccinations, and others of disparate nature (eg, paralytic stroke, poliomyelitis). Whatever the cause, in time an ICD may become a vulnerable site, prone to developing opportunistic infections, tumors, or dysimmune reactions (often of granulomatous type), strictly confined to the district itself; however, the opposite may also occur with systemic immune disorders or malignancies that selectively spare the district. In any case, the immunologic behavior of an ICD is different from that of the rest of the body. The pathomechanisms involved in this sectorial immune destabilization may reside in locally hampered lymph drainage that hinders the normal trafficking of immunocompetent cells (eg, chronic lymphedema, posttraumatic lymph stasis) or in a damage to sensory nerve fibers that release immunity-related peptides (eg, herpetic infections, carpal tunnel syndrome), or in both conditions (eg, amputation stump, radiation dermatitis). The ICD is a conceptual entity with no definite shape or dimension. It may take an extremely variable form and extent depending on the causative agent, ranging from a minimal area (eg, intradermal vaccination) or a small area (eg, herpes simplex infection), through a wide area (eg, radiotherapy), a bandlike segment (eg, skin mosaicism, herpes zoster infection), or an acral area (eg, carpal tunnel syndrome), up to a whole limb (eg, Stewart-Treves syndrome) or even an entire half body (eg, brain stroke). Varied newly coined terminology can be used to indicate the specific cause each time that it is responsible for a regional immune dysregulation. The advantage of the umbrella term ICD is that it encompasses all the possible causes involved in a local immune destabilization. An ICD may have a congenital or a postnatal origin, and interesting similarities between the two forms exist. An ICD may also take place in patients with a preexisting systemic immune deficiency, thus creating a more vulnerable site in an already vulnerable patient. Identifying a cutaneous ICD in a given patient is an important standpoint for both diagnostic and prevention purposes. This can be proven by the educative clinical examples that are reported here.

Wolf's post-herpetic isotopic response: Infections, tumors, and immune disorders arising on the site of healed herpetic infection

Herpes simplex viruses (HSV-1/HSV-2) and varicella-zoster virus (VZV) have several characteristics in common. Both are epidermoneurotropic, cause skin eruptions accompanied by sensory symptoms (itch, pain), damage peripheral sensory nerve fibers and cutaneous nerve endings, and interfere with neuromediator release, which can alter local mechanisms of immune control. For this reason, herpes-infected areas may become a preferential location for the subsequent onset of immunity-related skin disorders (infections, tumors, and dysimmune reactions), an event first reported by a neurologist and focused on by two brothers, a dermatologist and a pediatrician. The phenomenon therefore named Wolf's post-herpetic isotopic response (PHIR) refers to the occurrence of a new skin disorder at the site of a previous and already healed herpetic eruption (herpes zoster in most cases). Until now, we have been able to gather 189 well-documented cases of PHIR (all reported in the reference section), but our list is far from being complete. Some of the most emblematic cases are briefly described here. In some circumstances, the opposite of PHIR occurs, with diffuse skin disorders or eruptions that selectively spare herpes-infected areas (Wolf's post-herpetic isotopic nonresponse). Experimental investigations with patch testing have been performed in seven patients who were sensitized to nickel and had had herpes zoster in the past years. The tests were carried out bilaterally on the affected dermatomes and on the unaffected contralateral ones. The uneven immune responses we obtained have shown that the immune behavior of an herpes zoster-affected dermatome can be different from that of the corresponding contralateral dermatome, thus supporting the existence of immune dysregulation in herpes-infected areas.

Segmental immune disorders resulting from neurologic injuries

The immunocompromised cutaneous district (ICD) is a novel pathogenic concept that refers to the occurrence of opportunistic skin disorders (such as infections, malignancies, and immune diseases) at a cutaneous site previously marked by a damaging event, usually involving the local lymph network or peripheral sensory nerves. In addition to herpetic infections, which are notoriously harmful for sensory nerve fibers and therefore already included among the potential causes of ICD, there are a large and variegate group of further neurologic diseases, both peripheral (carpal tunnel syndrome, facial nerve palsy, and trigeminal trophic syndrome) and central (poliomyelitis and brain stroke), which may be added to the wide and expanding spectrum of injuring events resulting in an ICD. The neural compartment of skin immunity plays a key role in immune homeostasis, and this assertion is confirmed by the fact that any neurologic injury, whatever the origin (peripheral or central) or the cause (infection, trauma, ischemia), can give rise to immune destabilization of the innervated area, which becomes a site prone to the occurrence of opportunistic skin disorders. A neural-driven process may be responsible for the cutaneous immune dysregulation ensuing from some neurologic diseases.

Wolf's Isotopic Response: Report of a Case and Review of Literature

“Wolf's isotopic response” refers to the occurrence of a new dermatosis at the site of previously healed dermatosis. A number of factors including viral, neural, vascular, and immunologic factors have been implicated in the causation of this peculiar response but none has been proven conclusively. Here, we report a case where lichen planus developed at the site of dermatofibrosarcoma protruberans that had been previously treated with surgery and radiotherapy. We also put forth a hypothesis on the genesis of isotopic response considering the above mentioned factors.

Dermatological and immunological conditions due to nerve lesions

Some syndromes are of interest to both neurologists and dermatologists, because cutaneous involvement may harbinger symptoms of a neurological disease. The aim of this review is to clarify this aspect. The skin, because of its relationships with the peripheral sensory nervous system, autonomic nervous system and central nervous system, constitutes a neuroimmunoendocrine organ. The skin contains numerous neuropeptides released from sensory nerves. Neuropeptides play a precise role in cutaneous physiology and pathophysiology, and in certain skin diseases. A complex dysregulation of neuropeptides is a feature of some diseases of both dermatological and neurological interest (e.g. cutaneous and nerve lesions following herpes zoster infection, cutaneous manifestations of carpal tunnel syndrome, trigeminal trophic syndrome). Dermatologists need to know when a patient should be referred to a neurologist and should consider this option in those presenting with syndromes of unclear etiology.

Literature meta-analysis of zosteriform cutaneous metastases from melanoma and a clinico-histopathological report from India

Cutaneous metastases in patients with malignant tumours are an important clue to tumour progression or even the first manifestation of malignancy. Among the various topographic patterns of cutaneous metastasis, the zosteriform pattern of metastasis is rare, and very few cases have been published. Various theories have been proposed for this zosteriform pattern of metastases, but none have been proved. We collected the available PubMed articles on zosteriform skin metastasis from cutaneous melanoma published since 1970 and reviewed the cases, including our own case. Melanoma presents with cutaneous metastasis in up to 44% of patients. Clinicians treating oncology patients should consider zosteriform skin metastasis in the differential diagnosis of zosteriform lesions to avoid inadequate diagnosis and management.

Wolf Isotopic Response Manifesting as Postherpetic Granuloma Annulare: A Case Series

Context.— Wolf isotopic response has infrequently been reported in the literature, mainly as isolated case reports.

Objective.— To aid in recognition of the occurrence of postherpetic granuloma annulare for accurate histologic interpretation of granulomatous dermatitides.

Design.— We report 5 cases of patients with Wolf isotopic response manifesting as granuloma annulare, developing in a site of previous herpes zoster, and discuss the clinicopathologic findings.

Results.— Previous infection with herpes zoster or herpes simplex virus was found in 5 of 5 cases reported. The differential diagnosis of a dermal lymphohistiocytic infiltrate with multinucleated giant cells includes postherpetic granuloma annulare.

Conclusions.— All cases of postherpetic Wolf isotopic response reported in this series revealed granuloma annulare, with a perineurovascular or perifollicular pattern of lymphohistiocytic infiltration including multinucleated giant cells, and occurred following herpes zoster or herpes simplex infection, although herpes viral infection was not always associated with a subsequent isotopic eruption. Awareness of this entity can aid in the clinicopathologic diagnosis of granuloma annulare occurring at the site of prior herpes viral infection.

Zosteriform skin involvement of nodal T-cell lymphoma: a review of the published work of cutaneous malignancies mimicking herpes zoster

A 77-year-old Japanese woman initially presented with non-Hodgkin's lymphoma involving her neck, axillary and inguen lymph nodes. She had edematous erythema and nodules limited to the skin in zosteriform distribution on the left side chest wall along the T4-5 dermatome. In addition, since 1970, we have mainly been collecting English-language articles on malignant skin tumors and skin metastasis described as zosteriform in the title, and we have reviewed a total of 29 cases, including our own. It should be mentioned that 59% of the cases reported had been diagnosed with herpes zoster at the time of the initial examination and that many of them had received drug therapy (e.g. acyclovir). We wish to add the dermatomic eruption mimicking zoster sine herpete to the list of possible presentations of cutaneous malignancies.

Early detection of cutaneous angiosarcoma of the face and scalp and treatment with placitaxel

Cutaneous angiosarcoma (AS) of the face and scalp of the elderly is a rare malignant tumour with a very poor prognosis. The variable presentation and the benign appearance of the cutaneous AS may often delay the correct diagnosis. Because it is extremely aggressive, only early detection and treatment can modify the prognosis. We describe a case of an old man who was diagnosed of AS of the face and scalp 1 month after developing the cutaneous lesion. After treatment with placitaxel, the lesion completely diminished. Unfortunately, he developed pulmonary fibrosis and died 6 months after diagnosis. Predisposing factors of this entity are also discussed.

Granuloma annulare in a site of healed herpes zoster: Wolf's isotopic response

A case of granuloma annulare that developed in a site of healed herpes zoster is reported. Polymerase chain reaction failed to detect VZV DNA in a biopsy specimen. The occurrence of different types of cutaneous reactions in a body area previously affected by herpes virus infection is known as Wolf's isotopic response. Pathogenesis may be due to a local neuroimmune dysregulation set off by herpesvirus-induced lesions of dermal sensory nerve fibres.

Isotopic response after herpesvirus infection: an update

The term postherpetic isotopic response describes the occurrence of a new, unrelated disease that appears at the same location as a previously healed herpetic infection. When dealing with the pathogenetic mechanism involved in the isotopic response, several possibilities should be considered: a viral origin, an immunologic origin, a vascular origin, and a neural origin. The aim of this article is to review and discuss the different pathogenetic mechanisms with particular attention to new information related to the possible neural origin of this abnormal response of the skin.

Cutaneous reactions at sites of herpes zoster scars: an expanded spectrum

Several types of cutaneous lesions have previously been described at the sites of herpes zoster scars. We describe 16 patients with cutaneous lesions which had developed on herpes zoster scars. Biopsies were taken from these lesions, and a polymerase chain reaction assay was used to detect the viral genome in paraffin-embedded specimens. Histopathological findings enabled diagnosis of nonspecific granulomatous dermatitis in five patients, granulomatous vasculitis in two patients, lichen sclerosus in two patients, and pseudolymphoma, keloid, sarcoidal granuloma, granuloma annulare, granulomatous folliculitis, lichen planus and cutaneous Rosai-Dorfman disease, each in one patient. Varicella-zoster virus DNA was not identified in any of the patients. Granulomatous folliculitis, lichen sclerosus and cutaneous Rosai-Dorfman disease have not previously been described in herpes zoster scars, but they are three new cutaneous reaction patterns that may have developed within these scars. Our investigations indicate that the cutaneous reactions appearing in herpes zoster scars are not due to the persistence of varicella-zoster virus DNA within the lesions.

Zosteriform metastases in melanoma

Zosteriform metastasis is a rare form of tumor spread to the skin that most often arises from an internal carcinoma or a hematologic malignancy. We describe a 29-year-old woman with malignant melanoma of the back in whom zosteriform metastases developed along the fifth thoracic dermatome.

Angiosarcoma in Japan. A review of 99 cases

BACKGROUND

Angiosarcoma is rare, and information about its clinical features are limited. Therefore, a large scale study of angiosarcoma was performed in Japan.

METHODS

Through a nationwide Japanese study, 99 cases of angiosarcoma were collected and their clinicopathologic findings were summarized relative to predisposing risk factors.

RESULTS

The patient age at diagnosis was 3-92 years, (mean, 62 years), with a two to one male to female ratio. The head and face were the most common primary site (29 cases); other sites were liver (17); trunk (13): pleural cavity (6), chest wall (2), abdominal wall (2), buttock (2), inguinal region (1); heart (12); and extremities (7). The proven predisposing risk factors included chronic pyothorax for angiosarcoma in the pleural cavity (six), thorotrast in the liver (five), radiotherapy to the abdominal wall and buttock (four), and chronic limb edema of the forearm (one). Irrespective of primary sites, the majority of cases had metastases to lung in 72 cases, bone in 42, liver in 36, regional lymph nodes in 30, and adrenal gland in 24. The 2-year survival rate was 17%.

CONCLUSIONS

This study describes a different etiology in the development of angiosarcoma in patients from Japan compared with that of patients from Western countries, though the frequency of angiosarcoma among all soft-tissue sarcomas was similar in both areas. In Japan, chronic pyothorax, radiotherapy, and thorotrast proved to be distinctive causative factors of angiosarcoma.

Zosteriform and epidermotropic metastasis. Report of two cases

We report two cases of zosteriform metastasis to the skin. One patient had epidermotropic papulovesicular metastases from a presumed cutaneous adnexal neoplasm. The second patient had painful zoster-like papulovesicles from metastatic breast cancer. Previously reported dermatomal or zosteriform metastases are reviewed.

Combined modality treatment of adult soft tissue sarcomas of the head and neck

Between 1975 and 1985, 16 adult patients high grade soft tissue sarcomas arising in the head and neck were treated with combined modality therapy at the National Cancer Institute. Fifteen patients underwent an attempt at gross resection, while only a biopsy was performed in 1 patient. All patients received conventionally fractionated, high-dose, post-operative irradiation. Twelve of 16 patients received adjuvant chemotherapy with cyclophosphamide and adriamycin, given concomitantly with radiation therapy. With a median follow-up of 43 months from diagnosis (range 11-116 months), 10 patients (64%) are disease-free. Of these 10 patients, 1 presented with pulmonary metastases and 2 patients later failed in the lung; all pulmonary disease was resected and these patients are disease-free at 80, 115, and 116 months following presentation. Local control was maintained in 12 patients (75%). An analysis of the iso-effect lines for local control shows a slope of 0.32. The median NSD for local control was 1720 ret. We conclude that aggressive local management of high grade sarcomas which combines gross resection and high-dose post-operative irradiation results in excellent local control. The role of adjuvant chemotherapy is less well defined in this small patient series. The acute and late complications of this combined modality approach are manageable.

Angiosarcoma of the face and scalp, prognosis and treatment

72 patients with angiosarcoma (AS) of the face and scalp have been analyzed with respect of various prognostic factors and the effects of different treatment regimes. This disease predominantly occurs in the elderly (age range, 56-92 years), and affects men rather more frequently than women (men: 44, women: 28). The clinical presentation varied, and included bruise-like lesions, dusky plaques, chronic edema or cellulitis, ulcerated nodules, pyoderma, and infected conditions. Due to lack of clinical awareness and problems with histologic assessment, delays in diagnosis were frequent. The majority of the tumors arose in the upper part of the face or scalp. Less commonly, the central part of the face was affected while only three tumors developed in the mandibular region. Overall the prognosis was poor; one half of the patients died within 15 months of presentation. Only 12% of the patients survived 5 years or more. Patients with lesions that were less than 10 cm in diameter responded better to treatment and statistically survived longer than those with larger lesions, emphasizing the crucial importance of early diagnosis. There is some indication that men, younger patients, patients with lesions on the central part of the face survived longer, but this was not of statistical significance. The histologic differentiation of the tumors at presentation also was of doubtful prognostic significance. Despite the overall poor prognosis, radical radiotherapy (mostly wide-field electron-beam therapy) in seven patients resulted in the apparent eradication of the local skin disease and prolonged survival of the patients. Pulmonary metastases developed 10 years later in two of those patients, however, but the face and scalp remained tumor-free.