Herpetiform cutaneous metastases from transitional cell carcinoma of the urinary bladder: immunohistochemical analysis

Abstract

The case of an 83-year-old woman with an uncommon presentation of cutaneous metastases from muscle-invasive transitional cell carcinoma of the urinary bladder is reported. The band-like eruption of the metastatic lesion can often be misdiagnosed and treated initially as herpes zoster. A detailed immunohistochemical analysis is also described to differentiate metastatic lesions from other sources. C utaneous metastasis from bladder carcinoma is rare. Of the cutaneous metastasis from genitourinary organs, transitional cell carcinoma (TCC) of the bladder accounts for 17% of cases.1 Clinical diagnosis can often be difficult owing to non-specific appearances of these lesions, which can vary from nodular to sclerodermoid skin lesions. With the availability of antibodies to different cytokeratins (CKs), it is possible to define the tissue-specific profiles of cytokeratins staining by immunohistochemistry.2 The differential expression of cytokeratins by different epithelial tissues can be used to subclassify epithelial tumours from different organs. We describe an immunohistochemical profile of a herpetiform metastatic lesion from muscleinvasive TCC of the urinary bladder. CASE REPORTAn 83-year-old woman presented with a 3-week history of gross haematuria. She underwent a transurethral resection of a solid-looking bladder tumour. The radiological investigation, which included a computed tomography scan of the abdomen, showed a large bladder tumour with perivesicle extension. The upper urinary tract was normal. Chest x ray was normal and the histopathological examination showed a poorly differentiated (pT2 G3) muscle-invasive TCC of the bladder associated with carcinoma in situ. Six weeks later, she presented with multiple reddish nodules on the left side of her neck and chest (fig 1). Biopsy of the lesion showed metastatic carcinoma, with appearance similar to TCC of the urinary bladder (fig 2, 3). Immunocytochemical analysis indicated that these cells were positive for CK7 (fig 4) and CK20 ( fig 5). An algorithm (table 1) was used to exclude metastases from most common sites in female subjects. She underwent four fractions of palliative radiotherapy to her pelvis, owing to problems with persistent bleeding and pain, and a single fraction of radiotherapy to the metastasis on her left chest wall owing to ulceration after biopsy. We found no clinical evidence of healing of the ulcer. She died at a followup of 6 months. DISCUSSIONCutaneous metastasis from primary bladder carcinoma is a rare event and carries a poor prognosis.1 The primary sites for metastatic bladder cancer are the liver, lung and bone. Our patient presented with haematuria and was diagnosed as having TCC of the bladder. Six weeks later, she developed a herpetiform rash on her neck and chest wall. Owing to the diagnostic dilemma and a suspicion of skin metastasis, a punch biopsy of the lesion was carried out, which showed a metastatic, poorly differentiated carcinoma in the dermis. Immunohistochemical analysis showed that the tumour cells were negative for...

Metastatic bladder transitional cell carcinoma presenting as a vascularised cutaneous right arm lesion

“…Cutaneous metastases most commonly manifest on the chest and abdomen, being in relatively close proximity to the bladder. They are often initially misdiagnosed, commonly mimicking a number of different benign conditions such as furuncles, sebaceous cysts [6], erysipeloid [7], herpes zoster [8] or, as would appear to have happened in this case, a pseudoaneurysm. Whereas such vascular-type lesions have been reported previously in the case of renal TCC [10], no previous account exists for bladder TCC.…”

“…Those which are not iatrogenic normally present after widespread disseminated disease is already evident [1,5]. Such metastatic lesions are often initially misdiagnosed [6][7][8]. Here we present a very rare but interesting case in which a solitary symptomatic cutaneous lesion, not of iatrogenic cause, highly vascularised, and anatomically distant from the primary tumour was the first clinical indication of widespread metastatic disease.…”

Cutaneous Metastases: A Review and Diagnostic Approach to Tumors of Unknown Origin

“…57,58 Bladder, urothelial, and prostate lesions are often described as rubbery papules or nodules, and, like lung lesions, can have a viral-like or zosteriform pattern, or can have a Sister Mary Joseph nodule. [59][60][61] Cases of prostatic adenocarcinoma presenting as ''lipoma,'' large inflammatory plaques, or morpheaform-like lesions have been reported. 62,63 Clear cell carcinoma (the most common type of RCC) comprises the majority of cutaneous kidney metastases, and can show papillary, nested, trabecular, or cystic arrangements.…”

Exanthematous cutaneous spread of metastatic urothelial carcinoma in a 69‐year‐old man

“…Clinically, cutaneous metastases of urothelial carcinoma have most frequently been described as solitary or multiple erythematous nodules or plaques [ 2 ] . There have also been reports of herpetiform nodules and vesicles, which sometimes initially led to the incorrect diagnosis of herpes zoster [ 3 ] . Other possible manifestations include infl ammatory sclerodermatous or erysipelas-like skin lesions [ 4,5 ] .…”