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 Table of Contents 
CASE REPORT
Year : 2019  |  Volume : 8  |  Issue : 10  |  Page : 3443-3446  

Skin metastasis from squamous cell carcinoma of the cervix to the lower extremities: Case report and review of the literature


Department of Dermatology, King Abdulaziz University Hospital, Jeddah, Saudi Arabia

Date of Submission14-Jul-2019
Date of Decision22-Aug-2019
Date of Acceptance11-Sep-2019
Date of Web Publication31-Oct-2019

Correspondence Address:
Dr. Hussein M Alshamrani
Department of Dermatology, King Abdulaziz University Hospital, Jeddah
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jfmpc.jfmpc_541_19

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  Abstract 


Squamous cell carcinoma of cervix commonly metastasizes to the lymph nodes of the pelvis and skin metastasis is a rare presentation even in the late stages of cervical cancer. We report here the first case of cervical cancer with skin metastasis in Saudi Arabia in a 69-year-old female that preceded the diagnosis of cervical carcinoma. Microscopic examination of the skin lesion revealed poorly differentiated squamous cell carcinoma. The patient was in stage IVB based on the International Federation of Gynecology and Obstetrics (FIGO) staging system. Due to her late presentation and advanced stage, the decision was to place the patient on palliative therapy. Later, the patient passed away due to the progression of her disease. The case reported in this paper emphasizes the need for a complete clinical assessment to rule out metastatic disease from cases with known cervical cancer and include skin examination in their follow-up.

Keywords: Carcinoma of the cervix, cervical cancer, cutaneous metastasis, skin metastasis


How to cite this article:
Alrefaie SI, Alshamrani HM, Abduljabbar MH, Hariri JO. Skin metastasis from squamous cell carcinoma of the cervix to the lower extremities: Case report and review of the literature. J Family Med Prim Care 2019;8:3443-6

How to cite this URL:
Alrefaie SI, Alshamrani HM, Abduljabbar MH, Hariri JO. Skin metastasis from squamous cell carcinoma of the cervix to the lower extremities: Case report and review of the literature. J Family Med Prim Care [serial online] 2019 [cited 2019 Nov 19];8:3443-6. Available from: http://www.jfmpc.com/text.asp?2019/8/10/3443/269981




  Introduction Top


According to the latest statistics of the Saudi Cancer Registry, there was 177 cases of cervical cancer with incidence of 1.2 per 100,000 population.[1] The incidence of carcinoma of cervix has dramatically decreased in the developed countries due to the increased awareness and availability of screening using  Pap smear More Detailss test. Yet, the awareness of PAP smear is poor among Saudi women.[2]

Squamous cell carcinoma of cervix commonly metastasizes to the lymph nodes of the pelvis and a distant metastasis is uncommon which frequently detected in liver, lung, and bone.[3],[4] Skin metastasis is a rare presentation even in the late stages of the cervical cancer and the incidence rate of cutaneous metastasis in stage I, stage II, stage III, and stage IV are 0.8%, 1.2%, 1.2%, and 4.8%, respectively.[5],[6] The most frequent sites of skin metastasis of cervical cancer in descending order are the abdominal wall, vulva, and anterior chest wall.[4] Sadly, the prognosis after cutaneous metastasis is poor and usually a terminal presentation as it is often associated with disease recurrence and the treatment is mostly palliative.[5]

As far as author's knowledge, no similar cases have been reported in Saudi Arabia. We report here the first case of cervical cancer with skin metastasis in Saudi Arabia.


  Case Presentation Top


A 69-year-old postmenopausal Yemeni female was diagnosed with cervical cancer after presenting with vaginal bleeding and abdominal heaviness 6 months ago. On August 2018, the patient was referred to Dermatology clinic at King Abdulaziz University Hospital for evaluation of right leg ulceration that was noticed by the patient 4 months back. Ulcers were preceded by appearance of painless and non-pruritic papules that later was increased in size and began to ulcerate. Week later, same papular lesions started to appear on the left leg.

Skin examination showed multiple, erythematous, firm, non-tender skin papules, and plaques of variable sizes, along with shallow ulcers on the medial side of her right leg [Figure 1]. Fewer papules and plaques were located on the anterior right thigh, right sole, and medial side of the left leg. Skin punch biopsy was done, and microscopic examination revealed poorly differentiated squamous cell carcinoma [Figure 2]. On immunohistochemistry examination, tumor cells were positive for CK 5/6m p63 and p16. These results supported the diagnosis of skin metastasis from cervical cancer. A previous abdominopelvic CT scan done on February 2018 revealed uterine cervix enlargement with disfigurement, paraaortic lymphadenopathy, liver enlargement, and mild compression fracture D11 vertebral body. On a recent CT scan of the abdomen and pelvic area, imaging showed, an exophytic mass measuring 5 cm and closely related to, and inseparable from the urinary bladder and the rectum. Abdominal lymph nodes were enlarged and involved; right internal iliac, para aortic, and portacaval. There were hydroureters, hydronephrosis, multiple ill-defined and enhancing liver masses, and tiny peripheral nodules in the lower cut of the lung. Head CT scan was unremarkable. The patient was in stage IVB based on the International Federation of Gynecology and Obstetrics (FIGO) staging system. Due to her late presentation and advanced stage, the decision was to place the patient on palliative therapy. One month later, on September 2018, the patient passed away.
Figure 1: Cervical squamous cell carcinoma metastasis to the skin of the right leg

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Figure 2: Skin Biopsy at 10 × magnification showing poorly differentiated squamous cell carcinoma

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  Discussion Top


Cervical cancer is the third commonest malignancy in women worldwide.[7] Distant metastasis from cervical cancer frequently affects bone, lung, and liver in an increasing order.[3],[4] Cutaneous metastasis from carcinoma of the cervix has been rarely reported in literature. We were able to retrieve around 80 cases from 1982 up to 2017.

The incidence of skin metastasis from solid tumors ranges from 0.7 to 9%[8],[9] and breast cancer is the highest propensity to metastasize to the skin.

Incidence of skin metastasis from cervical cancer is rare, and it ranges from 0.1 to 2%.[6],[10],[11] In a large case series, Imachi et al. studied 1,190 patients with cervical cancer. He found the incidence of skin metastasis in these patients to be 1.3%.

Most of the cervical cancer patients present with cutaneous metastasis at the third stage (IIIB) of their disease.[12] This is the fifth case in literature in which the patient was initially diagnosed with cervical cancer and presented with skin metastasis at stage IVB. In four of these five cases, patients have never received any type of treatment before their presentation. One of the five cases received radiotherapy 1 month before appearance of skin metastasis.[6],[13],[14]

Clinical morphology of cutaneous metastasis varies, and the three commonest forms in decreasing order are nodular, plaques, and inflammatory telangiectasia.[12] The first two tend to ulcerate, and the latter might resemble cellulites.[13],[15] Other clinical presentations are maculopapular lesions, scar infiltration, and neoplastic alopecia.[16],[17],[18],[19] Multiple lesions are less commonly seen than a solitary lesion. Lesions in most cases are asymptomatic, but pruritic or painful rash might precede the appearance of skin metastasis.[12] In our case, the lesion started as erythematous papules and later formed ulcerated plaques.

Cutaneous metastasis tends to occur more frequently at proximity to the site of primary malignancy. The commonest sites of skin metastasis are the abdominal wall, followed by anterior chest wall and vulva.[6] Back, extremities, face, and scalp were less commonly reported in the literature. Out of the 80 cases we reviewed, lower extremities were the location of metastasis in 12 patients [Table 1]. Our case is the 13th and first case in which the sole was involved. Unlike of what previously was reported, skin metastasis is more frequent with cervical squamous cell carcinoma than cervical adenocarcinoma.[12] Out of the 80 cases, only 14 were adenocarcinoma, and the majority were squamous cell carcinoma.
Table 1: Reported cases of lower extremities skin metastasis of cervical cancer

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Spread of tumor is usually through lymphatics, especially when the lesion is at proximity with the primary neoplasm.[17],[19] Hematogenous spread is less frequent, and usually the route for distant metastasis.[20]

The interval between initial diagnosis of cervical cancer and skin metastasis range from 0 to 19 years.[13],[21] Treatment includes one or combination of radiotherapy, chemotherapy, and wide local excision.[6],[17],[19],[22],[23],[24] However, up to this date, there is no clear guideline regarding treatment of skin metastasis from cervical cancer, and the treatment remains palliative rather than curative.

Skin metastasis is a pre-terminal sign. Its occurrence is usually associated with local recurrence and other metastasis to distant organs, and skin biopsy should be always considered in any skin lesion in these patients.[32]

Since skin diseases is the most common reason for the clinic visit, a family physician may encounter patients with skin metastasis, who frequently present with a lesion mimics ulcer, it is crucial to recognize this condition early and make timely referral to dermatology. This will help in making a proper diagnosis and better prognosis. Therefore, primary physicians need to have a high index of suspicion for skin metastasis in patients with cervical cancer to early detection and proper referral.


  Conclusion Top


Skin metastasis from squamous cell carcinoma of the cervix are rare as it is usually a terminal presentation and have a poor prognosis. The case reported in this paper emphasizes the need for a complete clinical assessment to rule out metastatic disease from cases with known cervical cancer and include skin examination in their follow-up.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Registry SC. Cancer Incidence Report Saudi Arabia 2014. 2017;1-82. Availablefrom: https://nhic.gov.sa/eServices/Documents/2014.pdf. [Last accessed on 2019 Jul 14].  Back to cited text no. 1
    
2.
Al Khudairi H, Abu-Zaid A, Alomar O, Salem H. Public awareness and knowledge of pap smear as a screening test for cervical cancer among Saudi population in Riyadh City. Cureus 2017;9:e984.  Back to cited text no. 2
    
3.
Hacker NF. Berek and Hackers Gynecologic Oncology. Philadelphia: In: Lippincott Williams and Wilkin; 2014.  Back to cited text no. 3
    
4.
Carlson V, Delclos L, Fletcher GH. Distant metastases in squamous-cell carcinoma of the uterine cervix. Radiology 1967;88:961-6.  Back to cited text no. 4
    
5.
Bellefqih MI, Khalil J, Diakité A, Khannoussi BE. Skin metastasis of cervical cancer: About an unusual case. J Clin Case Rep 2013;3.  Back to cited text no. 5
    
6.
Imachi M, Tsukamoto N, Kinoshita S, Nakano H. Skin metastasis from carcinoma of the uterine cervix. Gynecologic Oncology 1993;48:349-54.  Back to cited text no. 6
    
7.
Jemal A BF, Center MM, Ferlay J, Ward E, Forman D. Global cancer statistics. CA Cancer J Clin 2011;61:69-90.  Back to cited text no. 7
    
8.
Schwartz RA. Cutaneous metastatic disease. J Am Acad Dermatol 1995;33:161-82; quiz 183-166.  Back to cited text no. 8
    
9.
Brownstein MH, Helwig EB. Patterns of cutaneous metastasis. Arch Dermatol 1972;105:862-8.  Back to cited text no. 9
    
10.
Brady LW, O'Neill EA, Farber SH. Unusual sites of metastases. Semin Oncol 1977;4:59-64.  Back to cited text no. 10
    
11.
Greenlee RM, Chervenak FA, Tovell HM. Incisional recurrence of a cervical carcinoma. Report of a case. JAMA 1981;246:69-70.  Back to cited text no. 11
    
12.
Agrawal A, Yau A, Magliocco A, Chu P. Cutaneous metastatic disease in cervical cancer: A case report. J Obstet Gynaecol Can 2010;32:467-72.  Back to cited text no. 12
    
13.
Vasuki S, Durgalakshmi J, Latha J. Cutaneous metastases presenting as genital ulcer disease. Indian J Sex Transm Dis AIDS 2014;35:43-5.  Back to cited text no. 13
    
14.
Chapman GW, Abreo F, Thompson H. Squamous cell carcinoma of the cervix metastatic to the umbilicus. J Natl Med Assoc 1987;79:1293-7.  Back to cited text no. 14
    
15.
Yang HI, Lee MC, Kuo TT, Hong HS. Cellulitis-like cutaneous metastasis of uterine cervical carcinoma. J Am Acad Dermatol 2007;56 (2 Suppl):S26-8.  Back to cited text no. 15
    
16.
Chung JJ, Namiki T, Johnson DW. Cervical cancer metastasis to the scalp presenting as alopecia neoplastica. Int J Dermatol 2007;46:188-9.  Back to cited text no. 16
    
17.
Freeman CR, Rozenfeld M, Schopflocher P. Cutaneous metastases from carcinoma of the cervix. Arch Dermatol 1982;118:40-1.  Back to cited text no. 17
    
18.
Pradhan S, Asthana AK, Sharan GK, Kumar M, Sharma OP. Recurrence of carcinoma cervix in the scar of previous cesarean section: A case report. Int J Gynecol Cancer 2006;16:900-4.  Back to cited text no. 18
    
19.
Tharakaram S, Rajendran SS, Premalatha S, Yesudian P, Zahara A. Cutaneous metastasis from carcinoma cervix. Int J Dermatol 1985;24:598-9.  Back to cited text no. 19
    
20.
Pertzborn S, Buekers TE, Sood AK. Hematogenous skin metastases from cervical cancer at primary presentation. Gynecol Oncol 2000;76:416-7.  Back to cited text no. 20
    
21.
Chen YY, Wang CH, Tsai WC, Yu MH, Lee SC, Chang H, et al. An isolated chest wall metastasis from cervical squamous cell carcinoma after 19 years of disease-free survival and no local recurrence: A case report and review of literature. J Med Sci 2014;34:272-6.  Back to cited text no. 21
  [Full text]  
22.
Franciolini G, Momoli G, Minelli L, Mutolo F, Franchini MA, Chiodini S, et al. Cutaneous metastases from carcinoma of the cervix. Tumori Journal 1990;76:410-2.  Back to cited text no. 22
    
23.
Bachaud JM, Mazabrey D, Berrebi A, Maisongrosse V. Cutaneous metastatic lymphangitis from squamous cell carcinoma of the cervix. Dermatology (Basel, Switzerland) 1990;180:163-5.  Back to cited text no. 23
    
24.
Bordin GM, Weitzner S. Cutaneous metastases as a manifestation of internal carcinoma: Diagnostic and prognostic significance. Am Surg 1972;38:629-34.  Back to cited text no. 24
    
25.
Reingold IM. Cutaneous metastases from internal carcinoma. Cancer 1966;19:162-8.  Back to cited text no. 25
    
26.
Yamamoto T, Ohkubo H, Nishioka K. Cutaneous metastases from carcinoma of the cervix resemble acquired lymphangioma. J Am Acad Dermatol 1994;30:1031-2.  Back to cited text no. 26
    
27.
Kagen MH, Ruhl KK, Aghajanian C, Myskowski PL. Squamous cell carcinoma of the cervix metastatic to the skin. J Am Acad Dermatol 2001;45:133-5.  Back to cited text no. 27
    
28.
Palaia I, Angioli R, Cutillo G, Manci N, Panici PB. Skin relapse from cervical cancer. Gynecol Oncol 2002;87:155-6.  Back to cited text no. 28
    
29.
Chen CH, Chao KC, Wang PH. Advanced cervical squamous cell carcinoma with skin metastasis. Taiwan J Obstet Gynecol 2007;46:264-6.  Back to cited text no. 29
    
30.
Singh S. Isolated cutaneous metastasis to thigh from cancer cervix- fourteen years after curative radiotherapy. 2009:11.  Back to cited text no. 30
    
31.
McCarthy WA, Laucirica R. Cutaneous metastases from cervical squamous cell carcinoma in a 55 year-old woman: A rarely reported manifestation. Case Rep Clin Pathol 2014;1:27.  Back to cited text no. 31
    
32.
Katiyar V, Araujo T, Majeed N, Ree N, Gupta S. Multiple recurrences from cervical cancer presenting as skin metastasis of different morphologies. Gynecol Oncol Rep 2019;28:61-4.  Back to cited text no. 32
    


    Figures

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