Zosteriform skin metastases

Abstract

A 66‐year‐old woman was referred for evaluation of a rash on the leg. She had a 1‐year history of stage IV bronchogenic adenocarcinoma with previous metastases to the right first metatarsal‐phalangeal (MTP) joint and a left supraclavicular lymph node. She underwent six cycles of chemotherapy with paclitaxel (Taxol; Bristol‐Myers Squibb Company, Princeton, NJ, USA) and carboplatin (Paraplatin; Bristol‐Myers Squibb Company, Princeton, NJ, USA) as well as palliative radiation therapy to the metastasis sites. One month after completing radiation therapy, the patient developed a nonpainful rash on the right thigh. This eruption was treated as a herpes zoster infection by her internist with 3 weeks of valcyclovir (Valtrex; Catalytica Pharmaceuticals, Greenville, NC, USA), but without improvement. One month later the leg became painful and swollen and the rash spread up the thigh to involve the groin and vulva. The patient was referred to the dermatology department. Physical examination revealed multiple red, indurated, crusted papules and nodules involving the medial, anterior, and lateral right thigh, labia majora, and suprapubic area. The lesions were grouped and arranged in a dermatomal zosteriform distribution (Fig. 1). There was a visible peau d’orange appearance of the right leg with pitting edema. A punch biopsy showed irregular islands of atypical glandular epithelial cells infiltrating the superficial and deep dermis, consistent with metastatic adenocarcinoma (Fig. 2a). Immunohistochemistry showed positive staining to thyroid transcription factor (TTF) and cytokeratin 7 (Fig. 2b and c). The tissue did not stain with progesterone receptor, estrogen receptor, or gross cystic disease fluid protein (BRST‐2). This immunostaining pattern was identical to previous biopsies of the right first MTP joint and left supraclavicular lymph node metastases and is consistent with adenocarcinoma of the lung. 1 Eruption on the right thigh with grouped papules and nodules arranged in a zosteriform pattern 2 (a) Punch biopsy showing irregular islands of atypical glandular epithelial cells within the dermis (hematoxylin and eosin; original magnification × 100). (b) Positive staining with thyroid transcription factor (original magnification × 40). (c) Positive staining with cytokeratin 7 (original magnification × 40)

A Rare Case of Zosteriform Cutaneous Metastasis from Breast Cancer

“…They reported that the lesions were localized at the anterior thoracic wall in 75 patients. Spontaneous pain was observed in many patients with zosteriform cutaneous metastases just like in our case and most of the cases were given antiviral treatment (2,10).…”

“…There are many theories about the occurrence of zosteriform cutaneous metastasis which include occurrence due to koebnerization at the region which previously had herpes zoster infection, perineural spread, lymphatic spread, spread in dorsal root ganglion veins through fenestral route, or coincidentally during surgery (2,10,12).…”

“…Cutaneous metastases from internal malignancies are rather rare, seen in only 0.7-10% of cases (1,2). Breast cancer is the most common cancer in women and causes metastasis to the skin at the highest rate (1).…”

Zosteriform Cutaneous Metastasis of Lung Adenocarcinoma

“…The mechanism by which cancer cells spread in zosteriform skin metastasis remains unknown but proposed theories include lymphatic or haematogenous spread, neural spread, surgical implantation of tumor cells, and koebnerization [1].…”

“…Although rare, there were 19 published cases of cutaneous metastatic adenocarcinoma arising as a zosteriform eruption [1][2][3][4][5].…”