Cutaneous metastasis from adenocarcinoma of cervix: a rare case report

INTRODUCTION

Cervical cancer is the commonest cause of death in developing countries.¹ It is the second most common malignancy in women aged 15-44 years in India. Every year around 67,477 women die of cervical cancer in India.² Majority of cervical cancers are squamous cell carcinomas and only 14% are adenocarcinomas.³ However, over the past decade the incidence of adenocarcinoma has increased because of its difficult diagnosis in pre-invasive stage.⁴ Quite often patients present in late stage of the disease portending a poor prognosis. Metastasis of cervical carcinoma to lung, bone and liver are common but to that of skin is rare. Here we report a woman of cervical adenocarcinoma presenting with cutaneous metastasis and vulval lymphedema.

CASE REPORT

A 40 years old woman presented to the dermatology outpatient department with complaints of progressively increasing asymptomatic swelling of vulva for the past 6 months. She also complained of post coital bleeding and dull aching lower abdominal pain since 6 months and recurrent episodes of retention of urine for the last 1 week. Her past medical history including menstrual history was normal. She had four children and the last childbirth was 10 years back. There was no history of sudden weight loss or loss of appetite, foul smelling vaginal discharge, increased frequency of micturition, hematuria, bleeding per rectum or tenesmus. On examination, there was diffuse swelling and induration of both labia majora and labia minora. The surface of labia minora appeared corrugated and there were multiple skin colored vesicles over labia majora, which exuded clear fluid when punctured (Figure 1). Few skin colored papules were present in the left crural fold and over mons pubis. Skin biopsies were taken from labia majora and one of the crural papules. Gynecology consultation was sought for post-coital bleed and catheterization was done to relieve the urinary retention. No abnormality was detected on her per-vaginal and per-speculum examination. Abdominal sonography was reported as normal except for a bulky cervix. Her hemoglobin was 11 g percentage and other biochemical investigations and blood profile were within normal limits. MRI pelvis showed subtle thickening in the urinary bladder neck and vaginal wall. Histopathology of crural papule revealed a well-differentiated adenocarcinoma (Figure 2) and that from labia majora showed multiple dilated angiolymphatic channels with few lymphovascular tumor emboli (Figure 3).

On follow-up gynecological visit colposcopy was done and cervix was found to be eroded with white areas on aceto-white test. Lower lip of cervix bled to touch. Anterior vaginal wall appeared indurated. A biopsy was taken from anterior and posterior vaginal wall. Histopathology of cervix revealed a well-differentiated adenocarcinoma (Figure 4). Thus the patient was diagnosed to have a well-differentiated adenocarcinoma with cutaneous metastasis and vulval lymphedema. She was referred to oncology department for further management but was lost to follow up subsequently.

DISCUSSION

Cutaneous metastases from solid malignancies are rare and the reported incidence is 5.3%.⁵ In women breast cancer, melanoma and ovarian carcinomas are mainly responsible for cutaneous metastasis.⁶ Cutaneous metastasis of carcinoma of cervix is extremely rare. The incidence however is higher for adenocarcinoma of cervix as compared to squamous cell carcinoma. There is a mean interval of 16.9 months between detection of cervical cancer and cutaneous metastasis.⁷ The major sites of secondaries are abdominal wall, vulva and chest. Most of the case reports of vulval metastasis in the literature are of recurrent cervical adenocarcinomas. The present case reports a patient who was diagnosed to have carcinoma of cervix only after she developed cutaneous metastasis.

Morphologically cutaneous metastatic lesions may present as nodules, plaques or maculopapular lesions and are often firm and nontender. Another unusual finding in our patient was that even though she had cutaneous metastasis, her internal malignancy was occult and only after histopathological confirmation of adenocarcinoma was made in skin biopsy she was thoroughly investigated and was found to have cervical adenocarcinoma. On her first gynecological visit she was treated as a case of pelvic inflammatory disease as there was no abnormality detected on per vaginal and per speculum examination. On follow up visit colposcopy and aceto-white test were done and showed abnormal areas which on histopathological examination were confirmed to be adenocarcinoma of cervix. Skin involvement in a patient of cervical cancer indicates widespread disease and a poor prognosis. The average survival time in a patient of cervical cancer with cutaneous metastasis has been reported to be 8.5 months.⁷ In developing countries because of lack of regular screening patients present late in advanced stage of the disease and thus resulting in a poor prognosis. In India though screening of women above 30 years for cervical cancer is promoted under national programme for prevention & control of cancer, diabetes, cardiovascular diseases and stroke; yet most of the cases (85%) present in advanced stages of the disease.²

CONCLUSION

This case is being reported because of its rarity and to emphasize the fact that cutaneous metastases are of diagnostic importance because they may be the first manifestation of an undiscovered internal malignancy or the first indication of a supposedly adequately treated malignancy.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

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