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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