The Diagnostic Approach to Cutaneous Metastases of

Adenocarcinoma of the Prostate: A Case Report

Peppy Fourina

, Riesye Arisanty

, Sri Adi Sularsito

, Lili Legiawati

, Rahadi Rihatmadja

, Shannaz

Nadia Yusharyahya

Department of Dermatology and Venereology, Faculty of Medicine Universitas Indonesia Dr. Cipto Mangunkusumo

National General Hospital, Jakarta, Indonesia

Department of Pathology, Faculty of Medicine Universitas Indonesia Dr. Cipto Mangunkusumo National General

Hospital, Jakarta, Indonesia

Keywords: adenocarcinoma of the prostate, cutaneous metastasis, PSA, AMACR

Abstract: The incidence of prostate cancer has increased all over the world, likely due to better detection methods. It

becomes one of the most common cancers among elderly men. Almost all cases of prostate cancer are

adenocarcinoma. The most common sites for metastases are lymph nodes and bone. We present a case of a

67-year-old man with an ulcer on his lower back for the past 6 months. Three years ago, he was diagnosed

with poorly differentiated adenocarcinoma of the prostate with bone metastases. On physical examination,

there was a solitary, 2x2x1 cm ulcer with elevated border and yellowish slough. The ulcer was painful and

surrounded by erythematous and indurated tissues. There is no inguinal lymphadenopathy. Despite

antibiotics, conventional and modern wound dressing, no significant improvement was noted. Considering

the history of malignancy, skin biopsy was performed. Histopathological examination revealed scattered

atypical cells around the blood vessels that stained positively with prostate-specific antigen (PSA) and

alpha-methylacyl-CoA racemase (AMACR), confirming cutaneous metastases of AP. Metastasis of AP to

the skin is rare, and indicates a poor prognosis. Early recognition of cutaneous spread manifesting as ulcer

that does not respond to proper treatment in the background of malignancy is important.

1 INTRODUCTION

Based on the GLOBOCAN 2012 statistics, prostate

cancer is the third most common cancer in

Indonesian men after lung and colorectal, with an

estimated incidence of 13.663 (WHO, 2012). About

all cases of prostate malignancies are

adenocarcinoma (Crawford, 2009). Adenocarcinoma

of the prostate (AP) favors pelvic lymph nodes and

bone for its metastases, while cutaneous metastases

are distinctly rare (Patne et al., 2015; Tengue et al.,

2017). Cutaneous metastases of AP usually appear

as nodule or papule in the abdominal, inguinal

region, anterior thigh, and near the umbilicus

(Pistone et al., 2013; Alcaraz et al., 2012). Although

uncommon, cutaneous metastases usually occur late

and indicate grave prognosis (Patne et al., 2015;

Wang et al., 2008). Dermatologists have to be aware

of the various clinical lesions of cutaneous

metastases because early diagnosis and prompt

management will result in favorable prognosis. We

report a rare case that illustrated the diagnostic

approach to cutaneous spread of AP, presented as a

chronic ulcer on the lower back.

2 CASE

A 67-year-old male patient was consulted from

Internal Medicine Department with a chronic ulcer of

6-month duration located on his lower back. Initially,

it began as pruritic papules that later became

ulcerated. No previous medications were applied.

Past history was noted for diabetes mellitus,

hypertension, and prostatic cancer.

Three years before, he complained worsened

lower back pain followed with weakness on lower

extremities; physical and imaging examination

concluded spinal cord compression due to metastasis.

Based on a markedly elevated prostate-specific

antigen (PSA) and imaging studies, the primary

cancer is adenocarcinoma of the prostate. Prostate

424

Fourina, P., Arisanty, R., Sularsito, S., Legiawati, L., Rihatmadja, R. and Yusharyahya, S.

The Diagnostic Approach to Cutaneous Metastases of Adenocarcinoma of the Prostate: A Case Report.

DOI: 10.5220/0008158904240427

In Proceedings of the 23rd Regional Conference of Dermatology (RCD 2018), pages 424-427

ISBN: 978-989-758-494-7

 2021 by SCITEPRESS – Science and Technology Publications, Lda. All rights reser ved

biopsy confirmed a Gleason score of 4+5=9,

associated with poorly differentiated prostate

adenocarcinoma. Whole abdomen CT scan showed

no paraaorta, parailliac, and inguinal

lymphadenopathy. After bilateral subcapsular

orchiectomy as an androgen deprivation therapy, his

PSA dropped from 215 ng/ml to 0.03 ng/ml. He also

had 30 radiotherapy session, followed by bone

directed therapy using bisphosphonate injections for

24 months.

The patient was moderately ill. A solitary, 2x2x1

cm ulcer was found on his lower back corresponding

with lumbar 1-2. It had elevated border and

yellowish slough as its base. The ulcer was painful

and surrounded by erythematous and indurated

tissues (figure 1). No lymphadenopathy was noted.

He was treated as bacterial ulcer with normal saline

dressing and topical fucidic acid 2% cream.

When no significant improvement was achieved

after 2 weeks, the ulcer was treated with cutimed

sorbact gel and cutimed siltech. Still, it has not

healed by two weeks. Cutaneous metastases from PA

was considered along with the differential diagnoses

of bacterial ulcer and squamous cell carcinoma. We

performed bacterial culture and incisional biopsy.

Bacterial culture was positive for Pseudomonas

aeruginosa, sensitive to Levofloxacine.

Figure 1. (a)(b). Solitary ulcer at the lower back

Figure 2. Histopathological and immunohistochemistry examination: (a). scattered atypical cells (H&E 400x), (b). the cells

were positive for AMACR stain

The Diagnostic Approach to Cutaneous Metastases of Adenocarcinoma of the Prostate: A Case Report

425

Table 1. Sensitivity, specificity, positive predictive value, and negative predictive value for PSA and AMACR highly

specific for AP

Prostatic

markers

Sensitivity Specificity Positive predictive

value (PPV)

Negative predictive

value (NPV)

PSA 100% 90,6% 89,5% 100%

AMACR 66,7% 77,3% 86,1% 77,3%

Histopathological examination revealed scattered

atypical cells around the blood vessels, suggesting

metastasis (figure 2a). Immunohistochemistry was

positive for PSA and AMACR (figure 2b). These

finding strongly supported the diagnosis of

cutaneous spread of AP.

3 DISCUSSION

Cutaneous metastasis is defined as a spread of

malignant cells from a primary cancer to the skin.

The exact mechanism of metastasis remains unclear.

Malignant cells may spread beyond the prostate

through some hypotheses, such as direct infiltration,

lymphatic, hematogenous, or combination of these

routes (Rattanasirivilai et al., 2011; Rodriguez-Lojo

et al., 2016). A meta-analysis study by Krathen et al.

(2003) found the overall incidence of cutaneous

metastasis in 2003 was 5.3% from 20,380 cases. The

most common tumor which spread to the skin was

breast cancer, with an incidence of 24%. Skin

metastates from AP are rare, with an incidence of

0.7% (Crawford, 2009; Stanko et al., 2007).

AP favors bones and lymph nodes for its

metastases (Tengue et al., 2017; Brown et al., 2014).

The result of whole spine MRI and bone scan

revealed osteoblastic lesions as metastases to spine,

cranium, costae, sacroiliac, and ischium. For this

bone metastases, the patient had 30 radiotherapy

session and followed by bone directed therapy with

bisphosphonate injections once in a month for 24

months. Whole abdomen CT scan showed no para

aorta, para iliac, and inguinal lymphadenopathy.

Cutaneous metastases of PA have more than one

of clinical morphology, they most frequently appear

as nodules or papules in the abdominal wall,

inguinal region, anterior thigh, and near the

umbilicus as Sister Mary Joseph nodules (Mak et al.,

2014; Wang et al., 2008). They usually

asymptomatic and rarely ulcerated (AbAziz et al.,

2013).

Immunohistochemistry might aid to confirm the

origin tumor of cutaneous metastases (Rodriquez et

al., 2016). In our patient, the specimen was positive

for PSA and AMACR, strongly supported the

diagnosis of skin metastases from the patient’s AP.

PSA and AMACR staining is widely used to identify

metastasis of AP. PSA is a serine protease member

of the human glandular kallikrein family which is

highly specific for AP, because it is synthesized in

the prostate ductal and acinar epithelium. AMACR

is a peroxisomal and mitochondrial enzyme that

plays a key role in beta oxidation of fatty acid. It is

identified as being overexpressed in AP cells (Oh et

al., 2016).

4 CONCLUSION

Cutaneous spread of AP is rare, but it happens in

0.7% of all skin metastases cases. Patient’s complain

and physical appearance can vary from one patient

to another. Malignancy should always be kept in

mind when working up on diagnosis of unhealed

skin lesion after adequate local and systemic

treatment done. The combination of clinical history,

physical examination, laboratory tests, routine

pathology, and immunohistochemistry assay can

provide enough information for a diagnosis of

metastatic adenocarcinoma of the prostate.

REFERENCES

AbAziz, A., Mahaletchumy, T., & Chung, J. K., 2013.

Skin Manifestation of Unsuspecting Prostate Cancer

Detected by 18F-FDG PET/CT Performed To Assess

Underlying Multiple Myeloma. Nuclear medicine and

molecular imaging, 47(4), pp.285-288.

Alcaraz, I., Cerroni, L., Ruetten, A., Kutzner, H., &

Requena, L., 2012. Cutaneous metastases from

internal malignancies: a clinicopathologic and

immunohistochemical review. The American journal

of dermatopathology, 34(4), pp. 347-393.

Brown, G. T., Patel, V., & Lee, C. C. R., 2014. Cutaneous

metastasis of prostate cancer: a case report and review

of the literature with bioinformatics analysis of

multiple healthcare delivery networks. Journal of

cutaneous pathology, 41(6),pp. 524-528.

Crawford, E. D., 2009.. Understanding the epidemiology,

natural history, and key pathways involved in prostate

cancer. Urology, 73(5), S4-S10, . Available from:

http://dx.doi.org/10.1016/j.urology.2009.03.001.

RCD 2018 - The 23rd Regional Conference of Dermatology 2018

426

Krathen, R. A., Orengo, I. F., & Rosen, T., 2003.

Cutaneous metastasis: a meta-analysis of

data. Southern medical journal, 96(2), 164-168.

Mak, G., Chin, M., Nahar, N., & De Souza, P., 2014.

Cutaneous metastasis of prostate carcinoma treated

with radiotherapy: a case presentation. BMC research

notes, 7(1), pp. 505.

Oh, W. J., Chung, A. M., Kim, J. S., Han, J. H., Hong, S.

H., Lee, J. Y., & Choi, Y. J., 2016. Differential

immunohistochemical profiles for distinguishing

prostate carcinoma and urothelial carcinoma. Journal

of pathology and translational medicine, 50(5), pp.

345–354, Available from:

https://doi.org/10.4132/jptm.2016.06.14.

Patne, S. C., Naik, B., Patnaik, P., & Trivedi, S., 2015.

Cutaneous metastases of prostatic

adenocarcinoma. Journal of Cytology/Indian Academy

of Cytologists, 32(2), 121-123, Available from:

http://www.pubmedcentral.nih.gov/articlerender.fcgi?

artid=4520044&tool=pmcentrez&rendertype=abstract

Pistone, G., Pistone, A., Aricò, M., & Bongiorno, M. R.,

2013. Multiple cutaneous metastases in the chest from

prostatic carcinoma. Case reports in

dermatology, 5(1), 27-30, Available from:

http://www.pubmedcentral.nih.gov/articlerender.fcgi?

artid=3719122&tool=pmcentrez&rendertype=abstract.

Rattanasirivilai, A., Kurban, A., Lenzy, Y. M., & Yaar, R.,

2011. Cutaneous metastasis of prostatic

adenocarcinoma: a cautionary tale. Journal of

cutaneous pathology, 38(6), 521-524.

Rodríguez-Lojo, R., Castiñeiras, I., Rey-Sanjurjo, J. L., &

Fernández-Díaz, M. L., 2016. Distant Cutaneous

Metastases of Prostate Cancer: A Report of 2

Cases. Actas Dermo-Sifiliográficas (English

Edition), 107(7), pp. 52-56, Available from:

http://www.sciencedirect.com/science/article/pii/S000

1731016000697.

Stanko, C., Grandinetti, L., Baldassano, M., Mahmoodi,

M., & Kantor, G. R., 2007. Epidermotropic metastatic

prostate carcinoma presenting as an umbilical nodule-

Sister Mary Joseph nodule. The American journal of

dermatopathology, 29(3), pp. 290-292.

Tengue, K., Kpatcha, T., Sewa, E., Sikpa, K., Botcho, G.,

Leloua, E., ... & Dosseh, E., 2017. Prostate cancer

revealed by skin metastasis: A case report in black

African man. African Journal of Urology, 23(4), pp.

204-207, Available from:

http://dx.doi.org/10.1016/j.afju.2016.10.003..

Wang, S. Q., Mecca, P. S., Myskowski, P. L., & Slovin, S.

F., 2008. Scrotal and penile papules and plaques as the

initial manifestation of a cutaneous metastasis of

adenocarcinoma of the prostate: case report and

review of the literature. Journal of cutaneous

pathology, 35(7), 681-684.

World Health Organization., 2012. GLOBOCAN 2012:

estimated cancer incidence, mortality and prevalence

worldwide in 2012 [Internet]. [cited 2018 Feb 12].

Available from:

http://globocan.iarc.fr/Pages/fact_sheets_population.as

The Diagnostic Approach to Cutaneous Metastases of Adenocarcinoma of the Prostate: A Case Report

427