What's Your Assessment?: Part II
What's Your Assessment?: Part II
A 71-year-old man was referred to the dermatology clinic for an asymptomatic eruption in the genital area that had developed over the preceding 4 months (see Figure 1). He was diagnosed 14 years earlier with prostate cancer, Gleason score of two, which was treated with radical prostectomy and radiation therapy. His past medical history was also significant for multiple myeloma, which was treated with thalidomide and pamidronate at the time of diagnosis, 4 years earlier. Current medications include morphine for pain related to multiple myeloma involving his spine, pamidronate, enoxaparin, atorvastatin, ramipril, and aspirin.
(Enlarge Image)
Papules and nodules, some of which had a depressed center, were found in the left and right medial thighs and inguinal folds.
On physical examination, the patient had over 40, 6 to 10 mm erythematous papules and nodules. These papules and nodules, some of which had a depressed center, were found in the left and right medial thighs and inguinal folds. His prostate-specific antigen score was greater than 150 (reference value: <4.0 ng/ml).
1. Secondary syphilis is a sexually transmitted disease caused by Treponema pallidum infection. Its primary stage is characterized by a painless ulcer, while the secondary stage presents as a macular-papular or papular eruption on the face, shoulders, flanks, palms and soles, and anal or genital region. The most useful test (RPR) should be performed when syphilis is suspected (Odom, James, & Berger, 2000a). A biopsy may also identify a perivascular infiltrate comprised primarily of plasma cells and lymphocytes. A Warthin-Starry stain can identify spirochetes (Crowson, Magro, & Mihm, 1997).
2. Colon cancer is the second most common cancer in men and women. The areas most frequently involved by cutaneous metastasis are the abdomen, perineal regions, and scalp or face (Schwartz, 1995), which are often in close proximity to the primary tumor (Helm & Lee, 2002). Cutaneous metastasis of colon cancer usually present as sessile or pedunculated nodules that are vascular or inflamed (Schwartz, 1995). If this is in the differential diagnosis, a biopsy should be taken and sent for carcinoembryonic antigen staining (Elenitsas, Van Belle, & Elder, 1997; Johnson, 1997).
3. Lichenoid drug eruption can occur with many medications. Gold, hydrochlorothiazide, d-penicillamine, nonsteroidal anti-inflammatory drugs, captopril, and antimalarials are the most common causes of this category of drug eruption, which may be photodistributed or generalized. The typical lesions are plaques, papules, or erythema (Odom et al., 2000b). This patient had not started any new medication, his current medications are not known to cause lichenoid eruptions, and he had no peripheral eosinophilia. A biopsy performed to rule out the diagnosis did not reveal a band-like upper-dermal lichenoid infiltrate (Odom et al., 2000b).
4. Metastatic prostate cancer, the correct answer, commonly metastasizes to the liver, lungs, adrenal glands, and bones (Duran et al., 1996). When cutaneous metastases occur, their sites of predilection are the lower abdomen, genitalia, thighs, and (less frequently) the head (Reingold, 1966; Steinkraus, Lange, Abeck, Mensing, & Ring, 1995). Cancer cells spread to the skin by different pathways: (a) direct extension, (b) lymphatic dissemination (possible perineural lymphatics), (c) hematogenous (via vertebral venous system) (Steinkraus et al., 1995); and (d) rare direct surgical implantation (Bangma, Kirkels, Chadha, & Schröder, 1995). Clinically, the metastases have most often been described as firm papules or nodules in red/brown to violaceous hues (Delima, Mohamed, Yalla, & Burros, 1973; Duran et al., 1996; Fallon & Murphy, 1984; Jones & Rosen, 1992; Kawashita et al., 1985; Pervaiz, Fellner, & Davis, 1978; Powell, Venencie, & Winkelmann, 1984; Schellhammer, Milsten, & Bunts, 1973; Venable, Hastings, & Misra, 1983) and are usually asymptomatic (Steinkraus et al., 1995). Metastases from prostate cancer have also presented clinically as skin-colored nodules (Oka & Nakashima, 1982), plaques (Nebesky, Abangan, & Kauffman, 2001), lesions resembling a cyst (Offidani et al., 1997; Peison & Rahway, 1971), a basal cell carcinoma (Rosetti, Neto, Paschoal, & Burnier, 1991), turban tumors (Ronchese, 1940), nodules in a zosteriform distribution (Bluefarb, Wallk, & Gecht, 1957), Sister Mary Joseph nodules at the umbilicus (Pieslor & Hefter, 1986), and carcinoma erysipeloides (Cox & Kruz, 1995). One should keep these various presentations in mind when forming a differential diagnosis.
5. Molluscum contagiosum is a benign skin disease caused by a poxvirus that commonly affects children, sexually active adults, and immunocompromised individuals. It typically presents as discrete papules or nodules that are pearly to skin-colored with a domed shape, central umbilication and a central white curd-like core that is often easily expressed. The lesions frequently appear in groups of 20 or less (Lowy, 1999). This patient's clinical presentation differed from molluscum contagiosum in the shape, color, and number of lesions and lacked the central white core and umbilication. The diagnosis is often based on the distinctive clinical findings, but a biopsy or staining of the fluids expressed from the central core (via the Shelley method) can be performed to confirm the diagnosis (Odom et al., 2000a).
Cutaneous metastasis is associated with poor prognosis (Steinkraus et al., 1995) and an average survival time of 1 year because the presence of cutaneous metastasis represents widespread metastatic disease (Helm & Lee, 2002). Prognosis is also affected by the primary tumor grade, in addition to the amount of other organ involvement (Hahnfeld & Moon, 1999; Marquis & Benson, 1980). High clinical suspicion is necessary to avoid needless delay in diagnosis or changes in treatment regimen. Whereas other metastatic cancers to the skin are often responsive to systemic therapy, intralesional chemotherapy, or radiation (Schwartz, 1995), metastatic prostate cancer has little response to radiotherapy or chemotherapy (Jones & Rosen, 1992). Lesions may be responsive to hormonal therapy with estrogen (Jones & Rosen, 1992) and anti-androgen hormonal treatment (Kawashita et al., 1985; Powell et al., 1984; Steinkraus et al., 1995). In a case report, one patient who underwent bilateral orchiectomy did not show improvement of skin lesions, but did describe decreased bone pain. Patients with cutaneous metastases from internal malignancies should be referred to an oncologist for treatment options.
Although adenocarcinoma of the prostate is the second most common cause of cancer death in men in the United States (after lung cancer), its cutaneous metastasis is relatively uncommon (Hahnfeld & Moon, 1999; Schwartz et al., 1995). Cutaneous metastases are reported to occur in 2% to 9% of patients with visceral malignancies (Steinkraus et al., 1995), while cutaneous metastases are reported in less than 1% of patients with prostate cancer (Gates, 1937; Held & Johnson, 1972). Rarely are these metastases the first sign of prostate cancer (Azana, de Misa, & Gomez, 1993); more often they are a harbinger of advanced disease (Reingold, 1966).
A 71-year-old man was referred to the dermatology clinic for an asymptomatic eruption in the genital area that had developed over the preceding 4 months (see Figure 1). He was diagnosed 14 years earlier with prostate cancer, Gleason score of two, which was treated with radical prostectomy and radiation therapy. His past medical history was also significant for multiple myeloma, which was treated with thalidomide and pamidronate at the time of diagnosis, 4 years earlier. Current medications include morphine for pain related to multiple myeloma involving his spine, pamidronate, enoxaparin, atorvastatin, ramipril, and aspirin.
(Enlarge Image)
Papules and nodules, some of which had a depressed center, were found in the left and right medial thighs and inguinal folds.
On physical examination, the patient had over 40, 6 to 10 mm erythematous papules and nodules. These papules and nodules, some of which had a depressed center, were found in the left and right medial thighs and inguinal folds. His prostate-specific antigen score was greater than 150 (reference value: <4.0 ng/ml).
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1. Secondary syphilis is a sexually transmitted disease caused by Treponema pallidum infection. Its primary stage is characterized by a painless ulcer, while the secondary stage presents as a macular-papular or papular eruption on the face, shoulders, flanks, palms and soles, and anal or genital region. The most useful test (RPR) should be performed when syphilis is suspected (Odom, James, & Berger, 2000a). A biopsy may also identify a perivascular infiltrate comprised primarily of plasma cells and lymphocytes. A Warthin-Starry stain can identify spirochetes (Crowson, Magro, & Mihm, 1997).
2. Colon cancer is the second most common cancer in men and women. The areas most frequently involved by cutaneous metastasis are the abdomen, perineal regions, and scalp or face (Schwartz, 1995), which are often in close proximity to the primary tumor (Helm & Lee, 2002). Cutaneous metastasis of colon cancer usually present as sessile or pedunculated nodules that are vascular or inflamed (Schwartz, 1995). If this is in the differential diagnosis, a biopsy should be taken and sent for carcinoembryonic antigen staining (Elenitsas, Van Belle, & Elder, 1997; Johnson, 1997).
3. Lichenoid drug eruption can occur with many medications. Gold, hydrochlorothiazide, d-penicillamine, nonsteroidal anti-inflammatory drugs, captopril, and antimalarials are the most common causes of this category of drug eruption, which may be photodistributed or generalized. The typical lesions are plaques, papules, or erythema (Odom et al., 2000b). This patient had not started any new medication, his current medications are not known to cause lichenoid eruptions, and he had no peripheral eosinophilia. A biopsy performed to rule out the diagnosis did not reveal a band-like upper-dermal lichenoid infiltrate (Odom et al., 2000b).
4. Metastatic prostate cancer, the correct answer, commonly metastasizes to the liver, lungs, adrenal glands, and bones (Duran et al., 1996). When cutaneous metastases occur, their sites of predilection are the lower abdomen, genitalia, thighs, and (less frequently) the head (Reingold, 1966; Steinkraus, Lange, Abeck, Mensing, & Ring, 1995). Cancer cells spread to the skin by different pathways: (a) direct extension, (b) lymphatic dissemination (possible perineural lymphatics), (c) hematogenous (via vertebral venous system) (Steinkraus et al., 1995); and (d) rare direct surgical implantation (Bangma, Kirkels, Chadha, & Schröder, 1995). Clinically, the metastases have most often been described as firm papules or nodules in red/brown to violaceous hues (Delima, Mohamed, Yalla, & Burros, 1973; Duran et al., 1996; Fallon & Murphy, 1984; Jones & Rosen, 1992; Kawashita et al., 1985; Pervaiz, Fellner, & Davis, 1978; Powell, Venencie, & Winkelmann, 1984; Schellhammer, Milsten, & Bunts, 1973; Venable, Hastings, & Misra, 1983) and are usually asymptomatic (Steinkraus et al., 1995). Metastases from prostate cancer have also presented clinically as skin-colored nodules (Oka & Nakashima, 1982), plaques (Nebesky, Abangan, & Kauffman, 2001), lesions resembling a cyst (Offidani et al., 1997; Peison & Rahway, 1971), a basal cell carcinoma (Rosetti, Neto, Paschoal, & Burnier, 1991), turban tumors (Ronchese, 1940), nodules in a zosteriform distribution (Bluefarb, Wallk, & Gecht, 1957), Sister Mary Joseph nodules at the umbilicus (Pieslor & Hefter, 1986), and carcinoma erysipeloides (Cox & Kruz, 1995). One should keep these various presentations in mind when forming a differential diagnosis.
5. Molluscum contagiosum is a benign skin disease caused by a poxvirus that commonly affects children, sexually active adults, and immunocompromised individuals. It typically presents as discrete papules or nodules that are pearly to skin-colored with a domed shape, central umbilication and a central white curd-like core that is often easily expressed. The lesions frequently appear in groups of 20 or less (Lowy, 1999). This patient's clinical presentation differed from molluscum contagiosum in the shape, color, and number of lesions and lacked the central white core and umbilication. The diagnosis is often based on the distinctive clinical findings, but a biopsy or staining of the fluids expressed from the central core (via the Shelley method) can be performed to confirm the diagnosis (Odom et al., 2000a).
Cutaneous metastasis is associated with poor prognosis (Steinkraus et al., 1995) and an average survival time of 1 year because the presence of cutaneous metastasis represents widespread metastatic disease (Helm & Lee, 2002). Prognosis is also affected by the primary tumor grade, in addition to the amount of other organ involvement (Hahnfeld & Moon, 1999; Marquis & Benson, 1980). High clinical suspicion is necessary to avoid needless delay in diagnosis or changes in treatment regimen. Whereas other metastatic cancers to the skin are often responsive to systemic therapy, intralesional chemotherapy, or radiation (Schwartz, 1995), metastatic prostate cancer has little response to radiotherapy or chemotherapy (Jones & Rosen, 1992). Lesions may be responsive to hormonal therapy with estrogen (Jones & Rosen, 1992) and anti-androgen hormonal treatment (Kawashita et al., 1985; Powell et al., 1984; Steinkraus et al., 1995). In a case report, one patient who underwent bilateral orchiectomy did not show improvement of skin lesions, but did describe decreased bone pain. Patients with cutaneous metastases from internal malignancies should be referred to an oncologist for treatment options.
Although adenocarcinoma of the prostate is the second most common cause of cancer death in men in the United States (after lung cancer), its cutaneous metastasis is relatively uncommon (Hahnfeld & Moon, 1999; Schwartz et al., 1995). Cutaneous metastases are reported to occur in 2% to 9% of patients with visceral malignancies (Steinkraus et al., 1995), while cutaneous metastases are reported in less than 1% of patients with prostate cancer (Gates, 1937; Held & Johnson, 1972). Rarely are these metastases the first sign of prostate cancer (Azana, de Misa, & Gomez, 1993); more often they are a harbinger of advanced disease (Reingold, 1966).
