Basma Khannoussi

Hanan Elkacemi

Imane Bourhafour

Jihane Khalil

Meryem Benoulaid

Noureddine Benjaafar

Sanaa Elmajjaoui

Tayeb Kebdani

Journal of Medical Case Reports

Springer - Publisher Connector

CASE REPORT Open Access
Skin metastases of cervical cancer: two case
reports and review of the literature
Meryem Benoulaid1*, Hanan Elkacemi1, Imane Bourhafour1, Jihane Khalil1, Sanaa Elmajjaoui1, Basma Khannoussi2,
Tayeb Kebdani1 and Noureddine Benjaafar1
Abstract
Background: Although cervix carcinoma is one of the most common malignancies in women, hematogenous
metastases are relatively not common. Cutaneous metastases, in particular, are unusual even at an advanced stage
of disease. Their presence is a predictor of poor prognosis.
Case presentation: Case 1: A 63-year-old postmenopausal Moroccan woman was diagnosed as having cervical
squamous cell carcinoma. She was treated with radical concurrent chemotherapy and radiation therapy followed by
low-dose brachytherapy. Six months after finishing the therapy, multiple skin nodules appeared on her abdomen
and chest wall. An excision biopsy was performed and showed metastatic squamous cell carcinoma. Her disease
progressed and she died before completing her fourth course of palliative chemotherapy.
Case 2: A 48-year-old Moroccan woman was diagnosed as having cervical squamous cell carcinoma; she was
treated with concurrent chemoradiation. Before a planned high-dose brachytherapy, she noticed many nodular
lesions on her arms, thighs, and chest wall. An excision biopsy was performed and showed metastatic squamous
cell carcinoma. She then underwent a series of imaging examinations, including computed tomography of her
chest, abdomen, and pelvis, and a whole body bone scan that showed disseminated disease involving her
lungs and bones. She died after two courses of palliative chemotherapy, 2 months after the appearance of
the skin lesions.
Conclusion: We report two cases to illustrate a rare localization of metastasis from cervical carcinoma that is highly
aggressive requiring early detection and aggressive management.
Keywords: Case report, Carcinoma of the uterine cervix, Skin metastasis
Background
Carcinoma of the uterine cervix is the most common
gynecological cancer in developing countries. The most
frequently reported metastases sites are lungs, bone, and
liver [1, 2]. Skin metastases are extremely rare even in
the late stages of disease; they have an incidence range
from 0.1 to 2 % [3, 4]. The presence of metastatic disease
in the skin is a strong predictive of poor prognosis, as
skin metastases are usually associated with local or
regional recurrence. The treatment is usually palliative
with very poor outcomes. We report here the cases of
two patients with locally advanced cervical cancer who
developed cutaneous metastasis.
Case presentation
Case 1
Nine years ago a 63-year-old Moroccan woman was re-
ferred to our department with the complaint of postmeno-
pausal bleeding and foul smelling vaginal discharge. A
pelvic examination revealed a 4 cm cervical lesion ex-
tending to her upper vaginal wall with left parametrial
extension. A biopsy indicated squamous cell carcinoma
moderately differentiated and keratinizing of her cervix.
Computed tomography of her chest, abdomen, and pelvis
showed a cervical tumor of approximately 5 cm with
hydroureteronephrosis. There was no evidence of distant
* Correspondence: mery-ben23@hotmail.com
1Department of Radiotherapy, National Institute of Oncology, Mohammed V
University, Rabat, Morocco
Full list of author information is available at the end of the article
© 2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Benoulaid et al. Journal of Medical Case Reports  (2016) 10:265 
DOI 10.1186/s13256-016-1042-0
metastasis. Consequently, she was staged as stage IIIB ac-
cording to the International Federation of Gynecology and
Obstetrics (FIGO) staging system. She received concur-
rent chemoradiation followed by low-dose brachytherapy.
Six months after finishing the treatment, she presented
with multiple abdominal and thoracic subcutaneous
nodules. A skin biopsy was performed and a diagnosis of
metastatic squamous cell carcinoma was confirmed. She
was then given palliative chemotherapy using a single
drug protocol with carboplatin. However, the disease
progressed, and she died before completing her fourth
course of chemotherapy.
Case 2
A 48-year-old Moroccan woman presented to our radio-
therapy department, 2 years ago, with a 6-month history
of vaginal bleeding. On examination, a 5 cm cervical
lesion extending to the upper third of her vagina with
bilateral parametrial involvement was identified. A
cervical biopsy confirmed squamous cell carcinoma that
was well differentiated and keratinizing histology. Com-
puted tomography of her chest, abdomen, and pelvis re-
vealed a 5 cm cervical process extending up to the
upper two-thirds of her vagina and the both parameters
with multiple para-aortic and pelvic lymph nodes. There
was no evidence of distant metastasis. She was staged as
stage IIIB according to the FIGO staging system.
She was treated with concurrent chemotherapy and
radiation. She received weekly cisplatin (40 mg/m2) and
46 Gy external beam radiation therapy to her pelvis in
23 fractions. Brachytherapy was planned before she re-
ported the appearance of subcutaneous nodules on her
arms, thighs, and chest wall (Fig. 1). A biopsy confirmed
squamous cell carcinoma histology (Figs. 2 and 3).
Computed tomography of her chest, abdomen, and
pelvis, and a whole body bone scan revealed multiple
lung, liver, and bone metastases. She died after two
courses of palliative chemotherapy, 2 months after the
appearance of the skin lesions.
Discussion
In Morocco, cervical cancer is the second most common
cancer in the country and the third most common cause
of death [5]. Hematogenous spread is uncommon, pre-
senting either in a recurrence setting or initially in ad-
vanced stages; it is often localized in the liver, lung, and
bone, in order of decreasing frequency [1, 2, 6].
The incidence of cutaneous metastasis from solid
tumors ranges from 0.7 to 9 % [1]. The most common
solid tumors metastasizing to the skin in women include
breast (60 to 69 %), gastrointestinal tract (9 %), lung,
and ovary [2]. Cutaneous metastases from carcinoma of
the cervix are exceptional, even in the late stages of
disease, with an incidence not exceeding 2 % [3, 4].
Fig. 1 Cutaneous metastatic nodule in the upper extremity
Fig. 2 Skin biopsy at 10× magnification (hematoxylin and eosin
stain), showing carcinomatosis proliferation with spans and cords
Fig. 3 P63 immunohistochemistry performed on the skin biopsy
which shows diffuse staining in the tumor cells (avidin-biotin at
40× magnification)
Benoulaid et al. Journal of Medical Case Reports  (2016) 10:265 Page 2 of 4
Imachi et al. [7] in a review of 1190 patients with cer-
vical cancer reported that 15 patients developed skin
metastasis. The incidence of skin metastasis varied ac-
cording to the initial tumor stage, it was 0.8 % in stage I,
1.2 % in stage II, 1.2 % in stage III, and 4.8 % in stage IV.
The incidence of skin metastasis seemed to be higher in
patients with adenocarcinoma and undifferentiated car-
cinoma than in patients with squamous cell carcinoma.
On macroscopic examination, three common patterns of
skin metastasis, such as nodules, plaques, and inflamma-
tory telangiectasic lesions, have been reported [2, 7–9].
Lesions may be single or multiple. Our patients had
multiple nodular lesions. The most common differential
diagnoses include benign dermatitis, subcutaneous phyco-
mycosis, plaque-like mycosis fungoides, and Kaposi’s sar-
coma [10]. A pathological study establishes the diagnosis.
The abdominal wall and vulva are the most common
sites for skin lesions, followed by the anterior chest wall
[2, 11, 12]. However, cases presenting at the scalp [13, 14],
extremities [15], umbilicus [16], and face [17] have been
reported. In our cases, it was mainly localized in the chest
and abdominal areas. The mechanism behind this type of
metastases is not well established, the possible reason
could be attributable to a retrograde spread of tumor sec-
ondary to lymphatic obstruction [18].
To date, no effective treatment has been identified.
Treatment is nearly always palliative, and consists of
using radiation, chemotherapy, or surgery, either alone
or in combination [16, 19]. Electrochemotherapy (ECT)
can provide immediate clinical benefit in patients with
advanced cutaneous and subcutaneous metastases [20].
ECT combines the administration of a poorly permeant
cytotoxic agent, such as bleomycin or cisplatin regard-
less of histological type, with the local application of
electric pulses that induce reversible electroporation,
thus improving drug diffusion into cells [21, 22]. ECT
was introduced in 2006, demonstrating a high rate of ef-
ficacy and favorable toxicity profile in a European multi-
center study on skin metastases from different tumor
histotypes [23]. In this study, the objective response rate
on treated tumor nodules was 89.0 % with complete
regression in 73.3 % of cases. For our patients who had
multiple metastases, we opted for palliative chemotherapy.
Skin metastasis from cervical carcinoma occurs pre-
dominantly in cases of tumor recurrences, with metasta-
sis developing up to 10 years after initial diagnosis and
averaging less than 1 year [24, 25]. In the largest series
[7], the mean interval between the diagnosis of the
primary tumor and skin metastasis was 16.9 months.
Only two cases of cutaneous metastasis at initial presen-
tation have been reported in the literature [12, 26]. In
our report, both of the patients presented skin metasta-
sis during the treatment or in the first months following
treatment completion.
Prognosis in such cases is poor and is considered a
sign for preterminal disease. The mean survival being
3 months and survival for more than 1 year seen in only
20 % of patients [7, 8, 16]. The cases that we have re-
ported are consistent with these findings.
Conclusions
Skin metastasis of cervical cancer remains extremely
rare. Physicians should pay more attention to cutaneous
lesions in patients with cervical cancer that can be the
first sign of the disease, and should perform a biopsy
whenever they are doubtful.
Abbreviations
ECT: Electrochemotherapy; FIGO: International Federation of Gynecology
and Obstetrics
Acknowledgements
Not applicable.
Funding
Not applicable.
Availability of data and materials
Not applicable.
Authors’ contributions
All the individuals listed as co-authors in this manuscript have participated in the
research work and manuscript write-up in ways that conform to International
Committee of Medical Journal Editors (ICMJE) authorship criteria. All authors read
and approved the final manuscript.
Competing interests
The authors declare that they have no competing interests.
Consent for publication
Written informed consent was obtained from the patients' next-of-kin for
publication of this case report and any accompanying images. A copy of the
written consent is available for review by the Editor-in-Chief of this journal.
Author details
1Department of Radiotherapy, National Institute of Oncology, Mohammed V
University, Rabat, Morocco. 2Department of Pathology, National Institute of
Oncology, Mohammed V University, Rabat, Morocco.
Received: 21 April 2016 Accepted: 26 August 2016
References
1. Schwartz RA. Cutaneous metastatic disease. J Am Acad Dermatol.
1995;33:161–82.
2. Brownstein MH, Helwig EB. Metastatic tumors of the skin. Cancer.
1972;29:1298–307.
3. Brady LW, O’Neill EA, Farber SH. Unusual sites of metastases. Semin Oncol.
1977;4:59–64.
4. Rosen T. Cutaneous metastases. Med Clin North Am. 1980;64:885–900.
5. Tazi M, Benjaafar N, Er-Raki A. Incidence des Cancers a Rabat-Annee 2005.
Registre des Cancers de Rabat 2009.
6. Carlson V, Delclos L, Fletcher GH. Distant metastases in squamous-cell
carcinoma of the uterine cervix. Radiology. 1967;88:961–6.
7. Imachi M, Tsukamoto N, Kinoshita S, Nakano H. Skin metastasis from
carcinoma of the uterine cervix. Gynecol Oncol. 1993;48:349–54.
8. Malfetano JH. Skin metastasis from cervical carcinoma: A fatal event.
Gynecol Oncol. 1986;24:177–82.
9. Freeman CR, Rozenfeld M, Schopflacher P. Cutaneous metastases from
carcinoma of the cervix. Arch Dermatol. 1982;118:40–1.
10. Tharakaram S, Rajendran SS, Premalatha S, Yesudian P, Zahara A.
Cutaneous metastasis from carcinoma cervix. Int J Dermatol. 1985;24:598–9.
Benoulaid et al. Journal of Medical Case Reports  (2016) 10:265 Page 3 of 4
11. Hayes AG, Berry AD. Cutaneous metastasis from squamous cell carcinoma
of the cervix. J Am Acad Dermatol. 1992;26:846–50.
12. Franciolini G, Momoli G, Minelli L, Mutolo F, Franchini MA, Chiodini S, et al.
Cutaneous metastases from carcinoma of the cervix. Tumori. 1990;76:410–2.
13. Shimizu I, Hayashi S, Uehara M, Nakayama S. Cutaneous metastases to the
scalp from carcinoma of the uterine cervix. Arch Dermatol. 1983;119:275–6.
14. Park JY, Lee HS, Cho KH. Cutaneous metastasis to the scalp from squamous
cell carcinoma of the cervix. Clin Exp Dermatol. 2003;28:28–30.
15. Chen CH, Chao KC, Wang PH. Advanced cervical squamous cell carcinoma
with skin metastasis. Taiwan J Obstet Gynecol. 2007;46:264–6.
16. Behtash N, Mehrdad N, Shamshirsaz A, Hashemi R, Amouzegar HF.
Umbilical metastasis in cervical cancer. Arch Gynecol Obstet. 2008;278:489–91.
17. Hsin-I Yang MD. Cellulitis-like cutaneous metastasis of uterine cervical
carcinoma. J Am Acad Dermatol. 2007;56:S26–8.
18. Srivastava K, Singh S, Srivastava M, Srivastava AN. Incisional skin metastasis
of a squamous cell cervical carcinoma 3.5 years after radical treatment.
Int J Gynecol Cancer. 2005;15(6):1183–6.
19. Diehl LF, Hurwitz MA, Johnson SA, Butler WM, Taylor HG. Skin metastases
confined to a field of previous irradiation; report of two cases and review of
the literature. Cancer. 1984;53:1864–8.
20. Campana LG, Clover AJP, Valpione S, et al. Recommendations for improving
the quality of reporting clinical electrochemotherapy studies based on
qualitative systematic review. Radiol Oncol. 2016;50(1):1–13.
21. Mir LM, Orlowski S. Mechanisms of electrochemotherapy. Adv Drug Deliv
Rev. 1999;35:107–18.
22. Cabula C, Campana LG, Grilz G, et al. Electrochemotherapy in the Treatment
of Cutaneous Metastases from Breast Cancer: A Multicenter Cohort Analysis.
Ann Surg Oncol. 2015;22 Suppl 3:S442–50.
23. Marty M, Sersa G, Garbay JR, Gehl J, Collins CG, Snoj M, et al.
Electrochemotherapy – An easy, highly effective and safe treatment of
cutaneous and subcutaneous metastases: Results of ESOPE (European
Standard Operating Procedures of Electrochemotherapy) study.
Eur J Cancer – Suppl. 2006;4:3–13.
24. Daw E, Riley S. Umbilical metastasis from squamous carcinoma of the cervix.
Case report. Br J Obstet Gynecol. 1982;89:1666.
25. Copas RR, Spann CO, Thoms WW, Horwitz IR. Squamous cell carcinoma of
the cervix metastatic to a drain. Gynecol Oncol. 1995;56(1):102–4.
26. Pertzborn S. Hematogenous skin metastases from cervical cancer at primary
presentation. Gynecol Oncol. 2000;76:416–7.
•  We accept pre-submission inquiries 
•  Our selector tool helps you to find the most relevant journal
•  We provide round the clock customer support 
•  Convenient online submission
•  Thorough peer review
•  Inclusion in PubMed and all major indexing services 
•  Maximum visibility for your research
Submit your manuscript at
www.biomedcentral.com/submit
Submit your next manuscript to BioMed Central 
and we will help you at every step:
Benoulaid et al. Journal of Medical Case Reports  (2016) 10:265 Page 4 of 4


Skin metastases of cervical cancer: two case reports and review of the literature

file:///data/core-remote/dit/data/Springer-OA/pdf/5ff/aHR0cDovL2xpbmsuc3ByaW5nZXIuY29tLzEwLjExODYvczEzMjU2LTAxNi0xMDQyLTAucGRm.pdf

Skin metastases of cervical cancer: two case reports and review of the literature

Abstract

Similar works

Full text

Available Versions

Springer - Publisher Connector

Springer - Publisher Connector