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CASE REPORT  
Year : 2011  |  Volume : 54  |  Issue : 2  |  Page : 394-395
Cutaneous metastasis of prostate carcinoma to neck and upper chest


Department of Urology and Pathology, All India Institute of Medical Sciences, New Delhi, India

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Date of Web Publication27-May-2011
 

   Abstract 

Prostate adenocarcinoma is the most common urologic malignant neoplasm in men. Metastasis to skin is rarely reported and usually occurs late. The incidence and appearance of cutaneous metastasis are not well established in patients with prostate adenocarcinoma and their recognition remains poor among practicing urologists. Their clinical appearance may mimic other common dermatologic disorders. Definitive diagnosis requires a high index of suspicion. Immunohistochemical staining helps in establishing the diagnosis. We report a case of prostate adenocarcinoma presenting with widespread metastasis, including those to dermis and subcutaneous tissue of neck and upper chest.

Keywords: Prostate adenocarcinoma, immunohistochemical stain, skin metastasis

How to cite this article:
Abrol N, Seth A, Chattergee P. Cutaneous metastasis of prostate carcinoma to neck and upper chest. Indian J Pathol Microbiol 2011;54:394-5

How to cite this URL:
Abrol N, Seth A, Chattergee P. Cutaneous metastasis of prostate carcinoma to neck and upper chest. Indian J Pathol Microbiol [serial online] 2011 [cited 2014 Oct 23];54:394-5. Available from: http://www.ijpmonline.org/text.asp?2011/54/2/394/81644



   Introduction Top


Prostate is the most common site of malignant neoplasm among genitourinary organs. [1] Adenocarcinoma is the most common malignant neoplasm of the prostate. Skin metastasis occurs very rarely and late in the natural history of disease. [2] Mueller et al[3] reviewed the literature and observed the incidence of cutaneous metastasis from prostate cancer as 0.36%. Metastatic deposits usually appear as nodular lesions involving the suprapubic area and anterior aspect of the thighs. [4] Immunohistochemical (IHC) staining with prostatespecific antigen (PSA) is specific for metastasis from prostate.


   Case Report Top


A 51-year-old man had backache, left supraclavicular swelling, pitting edema over lower limbs, and lesions on the skin of neck and upper chest. He did not have lower urinary tract symptoms, hematuria, jaundice, chronic cough, or weight loss. Skin lesions were erythematous to skin-colored, indurated, infiltrative papules and plaques tethered to the skin [Figure 1]. Computed tomography revealed enlarged retroperitoneal lymph nodes and inferior vena cava (IVC) thrombus. Fine-needle aspiration cytology was taken from enlarged supraclavicular node. Features were suggestive of Non-Hodgkin's lymphoma (NHL). A provisional diagnosis of NHL with IVC thrombus was made and he was referred to medical oncology department of our institute for further management. Evaluation at our center did not show evidence of NHL. Bone marrow biopsy showed normal hematopoietic cells of all the series. Excision biopsy of left supraclavicular lymph node showed mainly coagulative necrosis. Viable areas showed several subcapsular and sinusoidal islands of highly atypical cells, which stained positive for cytokeratin (CK) and negative for leukocyte common antigen (LCA), suggesting metastatic carcinoma. Tumor markers pointed toward prostate as primary site [Carcinoembryonic Antigen: 2.5 ng/mL (<10 ng/mL), Carbohydrate Antigen 19-9: 1.74 U/mL (<35 U/mL), PSA: 58 ng/mL (0-4 ng/mL)]. On digital rectal examination (DRE), prostate was enlarged, hard, nodular, and rectal mucosa was not freely mobile. Needle biopsy (12 cores) of prostate revealed a high-grade (Gleason grade 4+5) adenocarcinoma. In one core, from right middle peripheral zone, tumor cells were seen infiltrating into the periprostatic tissue. Perineural invasion was absent. Subsequent evaluation revealed diffuse skeletal and pulmonary metastasis. Biopsy of the skin lesion showed normal appearing epidermis and diffusely infiltrating tumor cells, both in the superficial and deep dermis [Figure 2]a. On higher magnification, tumor cells were seen to be infiltrating along the collagen fibers. These cells were small with scant cytoplasm and hyperchromatic nucleus [Figure 2]b. IHC staining was done for CK (AE1/AE3, Dako, Denmark), PSA (28/A4, Novocastra, UK), and LCA (RP2/18, Novocastra, UK). Tumor cells were positive for CK [Figure 2]c and PSA [Figure 2]d and negative for LCA, confirming prostate as the primary site.
Figure 1: (a) Papules and plaques on the side of neck (b) and front of chest

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Figure 2: Histopathology of skin lesion. (a) Normal epidermis and malignant cell infiltration into dermis (H and E, ×200). (b) Small cells with scant cytoplasm and hyperchromatic nucleus along collagen bundles (H and E, ×400). (c) Malignant cells staining positive for CK (IHC, ×200). (d) Malignant cells staining positive for PSA (IHC, ×200).

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   Discussion Top


Prostate cancer is rarely diagnosed in men younger than 50 years, accounting for less than 0.1% of all patients. [5] PSA and DRE are the main screening tools. PSA is a specific marker of prostate epithelial cells. Wang et al purified it from prostatic tissue in 1979.

Natural history of prostate cancer is highly variable and depends on many factors, such as grade, stage, and PSA levels. It is estimated that only about 16% of men diagnosed with prostate cancer ultimately die of it and prostate cancer is the cause of death in about 3% of the male population. [6] Metastasis occurs late and is associated with poor prognosis. [1],[2],[3],[7] Pelvic lymph nodes and bone are the most common sites of spread. Spread to skin is uncommon and is a manifestation of advanced disease. [1],[2],[7] Skin metastases from prostate cancer most commonly involve genitalia and suprapubic region. The possible routes of spread are hematogenous, through lymphatics, and spread via perineural lymphatics. [1],[7] Metastatic deposits have been reported to resemble angiosarcoma, cellulitis, mammary Paget's disease, sebaceous cyst, Sister Joseph's nodule, basal cell carcinoma, pyoderma, morphea, and trichoepitheliomas. [1]

Among patients with urologic malignancies, the incidence and appearance of cutaneous metastases are not well established and recognition is poor. Their clinical appearance may mimic other common dermatologic disorders affecting patients with advanced malignancies. Definitive diagnosis requires a high index of suspicion and skin biopsy. Staining the malignant cells with PSA confirms the diagnosis. In atypical cases, IHC using a panel of markers helps in establishing the diagnosis. PSA is a specific marker of prostate cells. These cells also stain positive for CK.

 
   References Top

1.Reddy S, Bang RH, Contreras ME. Telangiectatic cutaneous metastasis from carcinoma of the prostate. Br J Dermatol 2007;156:598-600.  Back to cited text no. 1
    
2.Krathen RA, Orengo IF, Rosen T. Cutaneous metastasis: A meta-analysis of data. South Med J 2003;96:164-7.  Back to cited text no. 2
    
3.Mueller TJ, Wu H, Greenberg RE, Hudes G, Topham N, Lessin SR, et al. Cutaneous metastases from genitourinary malignancies. Urology 2004;63:1021-6.   Back to cited text no. 3
    
4.Piqué Duran E, Paradela A, Fariña MC, Escalonilla P, Soriano ML, Olivares M, et al. Cutaneous metastases from prostatic carcinoma. J Surg Oncol 1996;62:144-7.  Back to cited text no. 4
    
5.Ries LAG, Eisner MP, Kosary CL, Hankey BF, Miller BA, Clegg LX, et al. SEER Cancer Statistics Review, 1975-2001, Bethesda, MD: National Cancer Institute; 2004. Available from: http://seer.cancer.gov/csr/1975_2001.   Back to cited text no. 5
    
6.Jemal A, Siegel R, Ward E, Murray T, Xu J, Smigal C, et al. Cancer statistics, 2006. CA Cancer J Clin 2006;56:106-30.  Back to cited text no. 6
    
7.Pal D, Talwar V, Doval DC, Yalpota YP, Kumar N. Cutaneous metastasis in prostatic carcinoma. Indian J Dermatol Venereol Leprol 2009;75:311-2.  Back to cited text no. 7
[PUBMED]  Medknow Journal  

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Correspondence Address:
Amlesh Seth
Department of Urology, All India Institute of Medical Sciences, New Delhi
India
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DOI: 10.4103/0377-4929.81644

PMID: 21623102

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    Figures

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    Abstract
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