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Erysipeloid cutaneous metastasis from bladder carcinoma

European Journal of Dermatology. Volume 17, Number 6, 534-6, November-December 2007, Clinical report

DOI : 10.1684/ejd.2007.0271

Summary

Author(s) : Arianna Zangrilli, Rosita Saraceno, Loredana Sarmati, Augusto Orlandi, Luca Bianchi, Sergio Chimenti , Department of Dermatology, University of Rome Tor Vergata, Viale Oxford 81, 00133 Rome, Italy, Department of Infectious Diseases, University of Rome Tor Vergata, Rome, Italy, Department of Pathology, University of Rome Tor Vergata, Rome, Italy.

Summary : Cutaneous metastases from bladder cancer are uncommon, especially in the female population. Although their clinical presentation may vary, the erysipelas-like appearance and the lower extremities location represent exceptional features. We describe a 56-year-old female with a history of bladder adenocarcinoma (T3N0M0) who presented erythematous plaques with an erysipelas-like appearance located on the groins and thighs. Histopathology and immunohistochemistry from skin lesions were consistent with metastases from bladder carcinoma. We report this case for the unusual clinical features and because an early recognition of cutaneous metastases from genitourinary malignancies is important in clinical practice.

Keywords : bladder cancer, cutaneous metastases, erysipelas-like eruption

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ARTICLE

Auteur(s) : Arianna Zangrilli¹, Rosita Saraceno¹, Loredana Sarmati², Augusto Orlandi³, Luca Bianchi¹, Sergio Chimenti¹

¹Department of Dermatology, University of Rome Tor Vergata, Viale Oxford 81, 00133 Rome, Italy
²Department of Infectious Diseases, University of Rome Tor Vergata, Rome, Italy
³Department of Pathology, University of Rome Tor Vergata, Rome, Italy

accepté le 7 Juillet 2007

Cutaneous metastases from bladder carcinoma are rare and occur in 0.84% of patients with this malignancy [1]. Bladder carcinoma metastases are more frequent in men in accordance with the higher incidence of this cancer in the male population. Metastatic lesions in the skin are typically multiple, more rarely single and well-circumscribed nodules [2, 3]. The clinical recognition is mandatory because cutaneous involvement may represent the initial sign of a widespread disease [4]; for this reason misdiagnosis must be avoided. To the best of our knowledge only a few cases have been reported in the world literature. We present an extremely rare case of a woman with cutaneous metastases from bladder carcinoma with an inflammatory erysipelas-like appearance.

Case report

In January 2006, a 56 year-old woman was referred to our institution from the Internal Medicine Department for the evaluation of erythematous plaques with an erysipelas-like appearance bilaterally on the groins and thighs. The patient had been hospitalized in the Internal Medicine Department for an episode of macroscopic hematuria associated with edema of the left thigh. Clinical notes revealed a surgical excision (performed in another hospital) of a bladder adenocarcinoma in March 2004 (T3N0M0), followed by bacillus Calmette-Guérin (BCG) vaccine as an adjuvant chemotherapy that was discontinued after 6 months due to the appearance of cystitis associated with high fever. In December 2004, a first episode of edema of the left lower extremity led to further investigations by abdomen CT scan, bone scintigraphy, and MRI. Imaging revealed the presence of pelvic lymph nodal involvement and the stage was up-graded to T3N1M0. Consequently, the patient underwent cisplatinum therapy (once monthly for six months) with a good response and no evidence of disease progression. Cisplatinum chemotherapy is considered the mainstay of treatment for urothelial cancer; however further cycles of therapy are generally contraindicated for the associated renal toxicity. For this reason, paclitaxel (175 mg/m², every 3 weeks) was started as single agent therapy in October 2005. On hospitalization for the infusion of the second cycle of paclitaxel, a new episode of edema on the same lower extremity was observed. In November 2005, cutaneous lesions appeared. At that time, imaging staging did not show any evidence of tumor progression from the T3N1M0 stage.

Physical examination performed at the moment of patient’s referral showed asymptomatic, indurate, and warm erythematous plaques on the groins and thighs. These lesions had a confluent tendency with an erysipelas-like appearance (figure 1). Numerous erythematous papules overlying the plaque lesions were also observed. Two 4 mm punch biopsies were performed from two different lesions. Histopathology showed a dense, diffuse infiltrate of neoplastic cells located in the upper dermis and subcutaneous tissue, with sparing of epidermis. Neoplastic cells, arranged in an Indian-file pattern, were characterised by abundant cytoplasm and nuclear anaplasia (figure 2A and figure 3). Lymphatic invasion by tumor cells was also observed. Immunohistochemistry revealed a positivity for cytokeratin (CK) 7 (figure 2B) and CK 19, negativity for CK 5, a borderline positivity for CEA, and negativity for vimentin. The morphological and immunohistochemical profile was considered compatible with a metastasis from a bladder primary malignancy. During staging procedures, our patient developed ascites and died in March 2006.

Discussion

There is a limited number of previously reported cases of bladder carcinoma with cutaneous metastases, especially in the female population in which this tumour is uncommon [1].

Furthermore, the erysipelas-like appearance and the lower extremities distribution represent exceptional features [2, 5, 6].

Cohen et al. reported a case of carcinoma erysipelatoides as the first manifestation of a transitional cell carcinoma of the bladder. Skin lesions began as erythematous nodules on the thighs, and were misdiagnosed as cellulitis; in contrast, the histology showed infiltrating strands and nests of poorly differentiated carcinoma cells in the lower dermis, consistent with cutaneous metastasis from bladder malignancy. Four months later the tumor spread extensively [5].

Furthermore, Elston et al. reported two cases of carcinoma erysipelatoides from transitional cell bladder carcinoma. Similarly to the aforementioned case, specific immunostainings were not performed and the diagnosis was made in accordance with the history of bladder cancer and the compatible histology [6].

We report a rare case of inflammatory carcinoma or erysipelatoides carcinoma due to a bladder adenocarcinoma as primary malignancy. Cutaneous metastases from this cancer could be defined as an exceptional event considering that more than 90% of bladder carcinomas are transitional cell carcinomas, 6-8% are squamous cell carcinomas, and only 2% adenocarcinomas [7]. The immunohistochemical studies supported the clinical correlation of the cutaneous metastasis with the primary malignancy showing positivity for cytokeratins expressed from the urothelial tissue.

Moreover, cutaneous involvement from internal carcinoma is a relatively rare event with a wide-range incidence (between 0.7 and 9%) reflecting the need for consensus in medical literature [8,9]. Excluding malignant melanoma, leukaemia and lymphoma, breast carcinoma represents the most common primitive neoplasm associated with cutaneous involvement, while the bladder cancer is one of the most rare [10, 11].

Furthermore, cutaneous lesions typically appear as multiple, more rarely single, well-circumscribed nodules, generally located at a single site, and more frequently on the abdominal skin [1]. In contrast, in our case, the patient had an uncommon erysipelas-like presentation located on the lower extremities associated with a lymphatic invasion typical of the carcinoma erysipelatoides [5]. The carcinoma erysipelatoides aspect has been reported in gastric cancer, anaplastic thyroid carcinoma, prostate cancer, breast cancer and lung cancer [2]. Metastases with this clinical appearance may mimic other dermatological disorders such as inflammation and infections that are common events in patients under chemotherapy; thus misdiagnosis with erysipelas or cutaneous drug reaction must be avoided. An early recognition of cutaneous metastases from bladder neoplasm is important because this metastatic type seems to be associated with a longer survival-time compared to other malignancies [3]. In fact, patients with cutaneous metastases from bladder carcinomas (treated with chemotherapy and triple therapy) have a survival time ranging between 13-24 months vs a median time of 6 months in untreated patients [1,3,7].

Acknowledgments

Financial support: none. Conflict of interest: none.

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