Zosteriform metastasis of endometrial cancer

ARTICLE

Auteur(s) : Siegfried Werchau, Wolfgang Hartschuh, Martin Hartmann

Department of Dermatology, University of Heidelberg, Germany

Zosteriform distributed metastases are rare cutaneous manifestations of malignancies. They have diagnostic relevance, as they often go along with poor prognosis and may be the first manifestation of an underlying malignancy. We report an unusual case of endometrial cancer developing segmental zosteriform distributed skin metastases on the left breast.

A 68-year-old Caucasian woman was referred to our clinic for therapy of herpes zoster. She had numerous serohematic blister formations in a zosteriform pattern on her left breast, left lateral thorax and left back, on a reddish background. The efflorescences were distributed in a typical zosteriform manner along the left thoracic dermatomes Th2-4, without crossing the median line (figure 1A). The patient described sensations of pain and itching on and around the efflorescences. The previous history revealed an endometrial cancer of the corpus uteri (pT1b, pNx, G2, FIGO 1b, ER 12/12, PR 9/12) first diagnosed three years previously. At the time of hospitalization the patient was not receiving any chemotherapy. She was first considered to have herpes zoster and received a systemic treatment with intravenous acyclovir. The primary vesicular skin changes disappeared and the surrounding erythema paled but became infiltrated and changed its distribution. Some vesicles transformed into more solid, indurated papules and nodules. As no therapeutic improvement was achievable by antiviral therapy, we performed two skin biopsies. They revealed an extensive infiltration under orthotopic epithelium, of irregular nests of pleomorphic epithelium cells, with many atypical mitoses. Immunohistopathological stains showed a cytokine expression profile (CK7++, CA125+ and negative for CK20, TTF-1, CDX-2, ER, PR, vimentin), similar to the primary tumor of the corpus uteri. Therefore the diagnosis of cutaneous metastases of an adenocarcinoma with lymphangiosis carcinomatosa was confirmed (figure 1B). Chemotherapy treatment was not appropriate due to the patient’s deteriorated general condition. The patient was referred to a palliative care unit.

The incidence of cutaneous metastases from all neoplasms reported in literature varies from 0.7 to 10.4 percent [1]. Although metastasis to the skin is not uncommon, a cutaneous zosteriform distribution is still very rare. Malignancies frequently developing skin metastases are malignant melanoma, followed by adenocarcinoma of the breast, lung, colon and ovary [2]. Typical locations are the chest wall, followed by the face and lower extremities [1]. Most skin metastases occurred in the fifth decade of life. In the literature, nearly equal prevalence of cutaneous metastasis is described in both sexes. Two thirds of the patients reported sensations of pain at the site where metastases developed. Without a clinical history, it is difficult to distinguish different types of malignancies. For this reason in particular, the original site of malignancy has prognostic and therapeutic relevance. In such cases, immunohistochemistry (e.g. cytokine staining), can be helpful to identify the primary [3]. In cases of skin metastases, prognosis is usually very poor, as this kind of distant metastasis seldom occurs in the absence of intra-abdominal disease progression. Median survival times of cutaneous metastasized malignancies have ranged from three months to ten years [1]. Although endometrial cancer is a common gynecological malignancy, currently, there are only a half dozen reports of skin metastases [4]. The main sites for metastatic endometrial cancer are usually local lymph nodes in the pelvic cavity [5].

This is the first literature report of zosteriform distributed cutaneous metastases from an endometrial adenocarcinoma. This can be a challenging situation for the treating physician so that a targeted therapy is delayed. Often patients are mistreated under the diagnosis of herpes zoster. Therefore, if patients seem to suffer from herpes zoster showing no signs of improvement despite systemic antiviral medication and especially having a positive history for a malignancy, additional, histological examination is essential to rule out neoplastic transformation.

Acknowledgements

References

2 Kikuchi Y, Matsuyama A, Nomura K. Zosteriform metastatic skin cancer: report of three cases and review of the literature. Dermatology 2001; 202: 336-8.

3 Claeys A, Pouaha J, Christian B, et al. Zosteriform cutaneous localizations of B-cell chronic lymphocytic leukaemia. Eur J Dermatol 2008; 18: 101-2.

4 Baydar M, Dikilitas M, Sevinc A, et al. Cutaneous metastasis of endometrial carcinoma with hemorrhagic nodules and papules. Eur J Gynaecol Oncol 2005; 26: 464-5.

5 Sorosky JI. Endometrial cancer. Obstet Gynecol 2008; 111: 436-47.