Inflammatory cutaneous metastasis from laryngeal carcinoma

ARTICLE

The frequency of cutaneous metastases from internal carcinomas ranges from 0.7 to 10% according to different authors [1-7]. It depends on inclusion criteria, that is, if melanoma metastases are considered [7] or if data come from autopsies [1-6] or from clinical records [7]. In women, breast carcinoma is the internal neoplasm that most frequently leads to skin metastasis, whereas in men lung carcinoma, carcinoma of large intestine and carcinoma of the oral cavity are the most common underlying tumours [7]. The clinical presentation may also be various [7-10]: nodular, inflammatory, telangiectatic, bullous, cicatricial or "en cuirasse". Inflammatory cutaneous metastases are frequently observed in patients affected by breast carcinoma [11, 12]; however this type of metastasis has also been reported in patients with carcinoma of pancreas [13], rectum [14, 15], lung [16], ovary [17], parotid gland [18, 19] and urinary bladder [20].

We report a patient with inflammatory skin metastasis from laryngeal carcinoma.

Case report

S. N., 64-year-old man, a retired cement factory worker, smoker until 5 years before, presented with infiltrated erythematous plaques on his right supraclavicular and infraclavicular regions (Fig. 1). Skin lesions had irregular margins without clear borders and a slight swelling was present on his right breast.

Five years before, the patient had undergone a laryngectomy for an epidermoid carcinoma of the larynx. After surgery he was treated with radiotherapy using Cobalt 60 for a total dose of 3,000 cGy.

After two years a right laterocervical lymphadenectomy was performed: 12 out of 13 lymph nodes resulted positive for the presence of metastases from epidermoid carcinoma. Afterwards a further course of radiotherapy (3,000 cGy) was administrated.

The patient was disease free until two months before our examination when small erythematous spots appeared on his right supraclavicular region, slightly enlarging. Two different dermatologists were consulted and they gave respectively the diagnosis of insect bites and herpes zoster: however, the treatments they suggested were ineffective.

At admission in our Institute of Dermatology, all the laboratory tests were normal. A biopsy of skin lesion was taken confirming the diagnosis of inflammatory cutaneous metastasis from laryngeal epidermoid carcinoma. Histological examination showed the presence of large cells inside dilated lymphatic vessels in papillary and reticular dermis (Fig. 2). These cells had eosinophylic cytoplasm with central nucleus and distinct nucleoli. Atypical cells and mitosis were also observed. Immunohistochemical markers showed only positive staining of atypical cells with monoclonal anti-cytokeratin antibodies (cytokeratin B-ORTHO=34betaE12) (Fig. 3) confirming the epithelial origin of metastastic cells [21].

Discussion

Inflammatory metastasis generally arises near the primary tumour and the clinical picture is characterised by marked inflammatory signs like intense erythema and swelling which can mime an erysipelas; however lack of fever, shiver and leucocytosis may help to differentiate skin metastasis from erysipelas. According to these features some authors had defined it as erysipeloid [20], erysipelatoides [16], or erysipelatodes [12]. This was the word that Rasch used [12], the first author to describe inflammatory skin metastasis. Inflammatory metastasis is the clinical expression of rapid spreading of tumour cells along sub-epidermal lymphatic vessels, which appear in many of them. As a consequence of lymphatic block, oedema, erythema and vesicles can appear.

Inflammatory cutaneous metastases are frequently observed in patients with breast carcinoma [11, 12], and their preferential localisation is on the anterior wall of the thorax. Occasionally it has been observed during the course of other malignant tumours [13-20]. However, until now, no inflammatory metastasis from laryngeal epidermoid carcinoma has been reported in the literature.

Malignant tumour of the larynx generally spreads to regional lymph nodes or, through blood, to the pulmonary system. Skin metastasis have rarely been described, always as multiple or solitary nodules [7, 22, 23]. Another skin lesion frequently observed in patients after laryngectomy is "stomal recurrence" or "peristomal recurrence" [24-29]. It has been defined as a diffuse infiltrate of neoplastic tissue at the junction of the amputated trachea and the skin [25]. The lesion usually presents as a nodule, plaque or exuberant granulation tissue [24-29]. The incidence of stomal recurrences varies from 3.4% [27] to 10% [29] and it is more frequent in patients who had undergone an "emergency tracheotomy". However, in our patient, no stomal recurrence had been seen during the five years follow up after the first surgical operation for laryngeal carcinoma. Moreover, the erythematous plaques of inflammatory metastasis were sited on the right upper trunk of the patient and they were not contiguous to the primary neoplasm or to the stoma of laryngectomy.

Sometimes inflammatory metastasis must be differentiated from lymphangiosarcoma, arising in swelling regions subjected to radiotherapy (Stewart-Treves' syndrome). As a matter of fact, our patient had undergone two cycles of radiotherapy, but immunohistochemical markers showed only positive staining of atypical cells with monoclonal anti-cytokeratin antibodies (cytokeratin B-ORTHO=34betaE12) confirming the epithelial origin of metastastic cells.

CONCLUSION

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