BERKELEY, CA (UroToday.com) - Metastasis of internal malignancy to the skin is an uncommon phenomenon that represents 2% of all skin tumors. Prostate cancer rarely metastasizes to the skin, and primary urologic malignancy is estimated to represent less than 1% of cutaneous metastasis in men. We previously reported a case of an 81-year-old man with a history of prostate cancer that presented with multiple metastatic nodules of the scalp and face. Herein we review 77 cases of metastatic prostate cancer to the skin in the literature to better understand associated clinical features and prognosis.
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Features of primary malignancy
Adenocarcinoma is the most common histological subtype of prostate cancer, which comprises the vast majority of cutaneous metastasis reported in the reviewed cases (91.0%). Rare subtypes resulting in cutaneous metastasis include small cell carcinoma (3.8%),[4, 5, 6] transitional cell carcinoma (2.6%),[7, 8] and a mucinous adenoma subtype with signet ring cells (1.3%). More than one type of histological subtype was present in 2 cases (2.6%). The Gleason grade was disclosed in 31.0% of reviewed cases, with an average score of 7.8 in patients with cutaneous metastasis.
Skin eruption is often abrupt and progressive with onset of cutaneous metastasis appearing at any point in the disease course. The average age at cutaneous onset was 69.6 years, ranging from 50 to 90 years. On average, cutaneous eruption occurred 54.4 months after initial prostate cancer diagnosis with cases ranging from 3 to 192 months. In 11 cases (14.3%), the cutaneous eruption was the presenting sign alerting the physician to the presence of the primary prostatic cancer.[5, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17]
The clinical features of cutaneous metastasis varied among the different cases, but may be classified into distinct morphological groups. Most cases (N=53, 68.8%) reported a nodular morphology, generally characterized by multiple skin-colored, firm fleshy nodules. The clinical appearance of nodular eruptions often resembled other primary dermatologic conditions. Examples include basal cell carcinoma,[18, 19] epidermoid cyst,[15, 20] pyoderma, trichoepithelioma, extramammary Paget’s disease, and Sweet’s Syndrome. The nodular pattern has also been described to occur in a zosteriform distribution.[11, 25]
A morphological variant of violaceous or erythematous plaques was frequently observed (N=11, 14.1%). This form was reported to clinically resemble angiosarcoma, inflammatory breast cancer, or morphea in select cases. This particular clinical morphology was associated with the histologic finding of malignant cells in dermal lymphatic vasculature, also known as carcinoma erysipeloides.[12, 28, 29] Anatomical locations of the cutaneous eruption varied from local near the primary site to distant involvement of the head and neck. The chest was the most commonly involved site (N=21, 27.3%), followed by the penis (N=17, 22.1%) and scalp (N=13, 16.9%). Cutaneous metastasis was also reported to occur on the neck (N=10, 13.0%) and face (N=9, 11.7%). The genital region was frequently involved, including the suprapubic and inguinal areas, as well as the scrotum (for each anatomical location, N=8, 10.4%). There are several reported cases of nodules located in the umbilicus, also known as Sister Mary Joseph nodules (N=5, 6.4%). More than one anatomical site was involved in 39.0% of cases. The anatomical site increased suspicion for other conditions, including a rare case in the perianal region mistaken for a primary anal cancer. One case reported cutaneous metastasis that arose at the site of a transabdominal laparoscopic surgery, which was believed to implant during the surgical manipulation of metastatic pelvic lymph nodes.
In patients presenting with cutaneous metastasis, metastatic disease was frequently identified in additional sites. Osseous and lymphatic involvement were the most common (50.6% and 27.3% of all cases, respectively). Select cases reported metastasis to unusual organs, including the paraspinal muscle confirmed with biopsy, and cardiac, pericardiac, and pancreatic metastasis on postmortem examination. More than one visceral metastatic site was identified in 32.5% of cases. On average, patients expired 5.9 months after cutaneous onset.
Consistent with previous reports, our review of 77 cases revealed that adenocarcinoma is the most common primary prostatic malignancy with metastatic potential to the skin. As would be expected with advanced disease, the histological findings of the primary malignancy according to Gleason score were relatively high grade. However, Gleason scoring is a newer construct and many of the earlier case reports did not include such information. Although the cutaneous eruption was the first sign of visceral malignancy in several cases, the onset of cutaneous metastasis occurred, on average, over 4 years after the original diagnosis of prostate cancer. Cutaneous metastasis comprises a wide morphologic spectrum that may resemble common primary dermatologic conditions. Previous reports emphasized cutaneous metastasis of prostate cancer to urogenital structures, however we found that involvement of distant anatomical sites, such as the chest, face, and neck, are commonly reported. Consistent with previous observations, cutaneous metastasis is associated with a poor prognosis with average survival 5.9 months after the onset of the cutaneous eruption. Given the poor prognosis, it is important for providers to consider the possibility of cutaneous metastasis in a patient with a known history of prostate cancer with a new onset skin eruption.
|Author||Year||Age||Type of malignancy||Gleason grade||Time to CO after prostate cancer diagnosis||Clinical morphology||Additional description||Location||Other metastases||Outcome|
|Ali||2002||65||A||NR||NR||Pedunculated||Scalp, face, upper extremity||ND||Death 4 months after CO|
|Arita||2002||88||A||9||2 years||Nodular||Suprapubic region||Lymphatic||NR|
|Azana||1993||70||A||NR||Prostate CA diagnosed at CO||Nodular||Neck||NR||NR|
|Bailey||2007||69||A||9||12 months||Nodular||Penis, scrotum||ND||Death 9 months after CO|
|Bangma||1995||66||A||NR||39 months||Nodular||Abdomen (operative site)||Lymphatic, osseous||Death 2 months after CO|
|Bluefarb||1957||67||A||NR||Prostate CA diagnosed at CO||Nodular||Zosteriform distribution||Lower extremity||Hepatic, lymphatic, pulmonary, osseous||Death 2 months after CO|
|Boswell ||2005||62||A||NR||7 years||Violaceous plaque||Resembled angiosarcoma||Scalp||Osseous||Death 6 weeks after CO|
|Brown & Kurtzman ||2014||81||A||NR||4 years||Nodular||Scalp, face||Osseous||Modest regression of cutaneous metastasis with hormonal treatment|
|Brown ||2014||73||A||7||2 years||Violaceous plaque||Chest||Lymphatic, osseous||Death 1 year after CO|
|Cabria||1999||81||A||NR||11 years||Nodular||Penis||Osseous||Death 5 months after CO|
|Cai||2007||72||A||6||5 years||Nodular||Penis||Lymphatic, osseous||Death 20 months after CO|
|Cecen||2014||80||A, SCCP||4||6 years||Subcutaneous mass||Back||Hepatic||Death from MI|
|Collina ||2011||78||A||NR||NR||Nodular||Resembled BCC||Neck||NR||NR|
|Colovic||2009||65||A||NR||7 months||Nodular||Scrotum||NR||Death 2 months after CO|
|Cox ||1994||56||A||NR||Prostate CA diagnosed at CO||Violaceous plaques||Carcinoma erysipeloides||Inguinal region, lower extremity||NR||Death 1 year after CO|
|Delima ||1973||61||A||NR||15 months||Nodular||Suprapubic region, lower extremities||Genitourinary||Death within 12 weeks of CO|
|65||A||NR||Prostate CA diagnosed at CO||Nodular||Back, suprapubic region||Osseous||Death within 12 weeks of CO|
|Devender ||2009||50||A||7||NR||Nodular||Scalp, face||Osseous, neurologic||NR|
|Fiorelli ||1989||73||A||NR||5.5 months||Edema||Penis, scrotum||NR||NR|
|Fukuda ||2006||80||A||NR||9 years||Nodular||SMJ||Umbilicus||Osseous||Death 2 months after CO|
|Gupta ||2013||70||A||6||“few months later”||Nodular||Suprapubic region, inguinal region, penis, scrotum||Genitourinary||Lost to follow-up|
|Hunek ||2005||70||A||NR||NR||Nodular||Zosteriform distribution||Chest||Osseous||NR|
|Katske||1982||64||A||NR||NR||Nodular||Abdomen||ND||Patient committed suicide soon after CO|
|Keen||2013||70||A||9||1 year||Nodular||Lower extremity, suprapubic region, inguinal region||Osseous||NR|
|Kim||2010||71||A||NR||5 years||Nodular||Sweet’s panniculitis||Upper extremity, chest||Osseous||Cutaneous metastases resolved with systemic steroids|
|Kobashi||2009||64||A||NR||6 years||Erythematous plaque||Penis||Neurologic, pulmonary||Death 4 months after CO|
|Kotake||2001||58||A||9||29 months||Nodular||Penis||Lymphatic, osseous||No PSA elevation following partial penectomy at 3 months|
|Kraft||2013||60||SCCP||NR||Prostate CA diagnosed at CO||Violaceous ulcerated mass||Scalp||Hepatic, osseous, pulmonary||Death 4 months after CO|
|Kremer||2012||71||A||9||7 months||Nodular||Perianal||NR||Death 2 months after CO|
|Landow||1980||57||A||NR||4 months||Nodular||Scalp, face||Osseous, pulmonary||Death 1 month after CO|
|56||A||NR||4 years||Nodular||Resembled Virchow’s node||Neck (supraclavicular fossa)||Osseous||Death 7 months after CO|
|Leonard||2003||74||A||7||NR||Erythematous plaque||Chest||Lymphatic, osseous||Death 2 months after CO|
|Lopez-Navarro (see table in paper)||2009||62||A (mucinous with signet ring cells)||8||Prostate CA diagnosed at CO||Nodular||Face, chest, axilla||Genitourinary, lymphatic, osseous||Progressive reduction in cutaneous lesions with hormonal therapy|
|Marcoval||1998||69||A||NR||3 years||Nodular||Chest, nipple||Osseous||Death 3 months after CO|
|Mishra||2001||68||TCCP||NR||NR||Nodular||SMJ||Umbilicus||NR||Death 1 month after CO|
|Mueller||2004||77||A||7||3 years||Violaceous plaque||Chest||Osseous||Death 9 months after CO|
|Nason||2012||90||A||10||11 months||Papular||Penis||NR||Cutaneous lesions did not respond to hormonal therapy at 3 months|
|Ng||2000||72||A||NR||7 years||Erythematous plaques||Carcinoma erysipeloides||Lower extremity||Lymphatic, muscular||Progression of cutaneous lesions 18 months later|
|Njiaju||2010||78||A||NR||Prostate CA diagnosed at CO||Erythema and edema||Resembled inflammatory breast cancer||Chest||Osseous||Cutaneous eruption improved following hormonal therapy, but went on hospice|
|Offidani||1997||66||A||NR||Prostate CA diagnosed at CO||Nodular||Resembled epidermoid cyst||Scalp, chest||Pulmonary||NR|
|Ogunmola||2013||62||A||6||Prostate CA diagnosed at CO||Nodular||Neck, chest, abdomen, suprapubic||NR||Lost to follow-up|
|Oka ||1982||77||A||NR||16 months||Nodular||Chest, penis||Lymphatic, osseous, pulmonary, hepatic||Death 6 months after CO|
|Osther ||1991||76||A||NR||3 months||Edema||Penis||Hepatic, pleural, pulmonary||Death 6.5 months after CO|
|78||A||NR||4 years||Edema||Penis||Osseous||Hormonal therapy prevented metastatic progression at 4 months after CO|
|Owen ||2009||67||NR||9||8 years||Nodular||Scalp, face, neck, upper extremity, flank||Lymphatic, osseous, pulmonary||Patient on hospice 9 months after CO|
|Paz-Ares ||2001||67||NR||NR||NR||Nodular||Scalp, neck, chest, inguinal region||Lymphatic, osseous||Death 2 months after CO|
|Peison ||1971||60||A||NR||3 years||Nodular||Resembled epidermoid cyst||Scalp||ND||Death 3 months after CO|
|Petcu 23||2012||63||A||6||16 years||Nodular||Extramammary Paget’s disease||Scalp, abdomen, inguinal region||Lymphatic||Death 3 weeks after CO|
|Pieslor ||1986||80||A||NR||NR||Nodular||SMJ||Umbilicus||Osseous||Death 1 month after CO|
|Pique ||1996||64||A||NR||NR||Erythematous plaque||Resembled morphea||Chest||Osseous||Death 6 weeks after CO|
|Pistone ||2013||78||A||NR||8 years||Nodular||Chest||NR||NR|
|Powell ||1984||70||A||NR||NR||Induration||Penis||Genitourinary||Death 2 years after CO|
|72||A||NR||NR||Nodular||Penis||Osseous, pulmonary, hepatic, genitourinary||Death 2 years after CO|
|65||A||NR||7 months||Nodular||Penis||Osseous, pulmonary, hepatic||Cutaneous metastasis cleared following chemotherapy|
|Rattanasirivilai ||2011||78||A||7||5 years||Hemorrhagic nodules||Resembled vascular proliferation||Suprapubic region, inguinal region, scrotum, penis||Osseous||Resolution of cutaneous lesions 9 months after hormonal therapy|
|Ray ||1978||73||A||NR||5 years||Nodular||Penis, scrotum||Lymphatic, osseous||Death 1 year after CO|
|Razvi ||1975||73||TCCP||NR||Prostate CA diagnosed at CO||Nodular||Face, abdomen||NR||NR|
|Reddy ||2007||83||A||NR||12 years||Violaceous plaque||Chest||NR||Death 6 months after CO|
|Rossetti ||1991||63||A||NR||3 years||Nodular||Resembled BCC||Chest||NR||NR|
|Schellhammer ||1973||66||A||NR||2 years||Nodular||Abdomen, lower extremities||Osseous||Death 6 months after CO|
|59||A||NR||6 months||Nodular||Scalp||Cardiac, lymphatic,Osseous, pancreatic, pericardiac, pleural||Death 4 months after CO|
|Senkul ||2002||76||A||7||10 years||Nodular||Penis||Osseous||Improvement in cutaneous lesions with chemotherapy|
|Sharma ||2010||64||A||NR||5 years||Nodular||Resembled trichoepithelioma||Face, neck, chest||NR||Lost to follow-up|
|Sina ||2007||65||A||10||3 years||Nodular||SMJ||Umbilicus||NR||Death 4 months after CO|
|Slovin ||2006||81||A||NR||16 years||Violaceous plaque||Carcinoma erysipeloides||Lower extremities||ND||NR|
|Stahl ||1980||86||NR||NR||7 years||Nodular||Resembled pyoderma||Upper extremities||Osseous||Death 1 year after CO|
|Steinkraus ||1995||79||A||NR||1 year||Nodular||Inguinal region||NR||Death 4 months after CO|
|Van Meter ||2010||67||A||9||8 years||Nodular||Scalp, face, neck, flank, upper extremity||Osseous, pulmonary||Death 1 year after CO|
|Wang ||2008||56||A||9||31 months||Xanthomatous papules with edema||Suprapubic region, scrotum||Lymphatic, osseous||NR|
|Wu ||2006||75||A||NR||13 years||Nodular||Chest||NR||Stable lesions with conservative treatment at 6 months|
|Venable ||1983||81||A||NR||Prostate CA diagnosed at CO||Subcutaneous mass||Neck||Lymphatic, pleural, pulmonary||Death 3 months after CO|
|78||A||NR||1 year||Violaceous plaque||Abdomen, inguinal region||Lymphatic||Death 3 weeks after CO|
|Yildirim ||2008||60||A, SCCP||9||11 months||Papular||Scrotum||Lymphatic||Death shortly after CO|
A – adenocarcinoma
SCCP – small cell carcinoma of the prostate
TCC – transitional cell carcinoma
BCC – basal cell carcinoma
SMJ – Sister Mary Joseph
CO – cutaneous onset
NR – not reported
ND – none detected
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Gabrielle E. Brown, MS;a Drew Kurtzman, MD;b Elizabeth A. Tourville, MD;c James Sligh, MD, PhDb as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.
aCollege of Medicine, University of Arizona, Tucson, AZ USA
bDivision of Dermatology, University of Arizona, Tucson, AZ USA
cDepartment of Urology, University of Tennessee Health Sciences Center, Memphis, TN USA
1515 N. Campbell, #1909
Tucson, AZ USA 85719