Title: Grouped skin metastases from laryngeal squamous cell carcinoma and overview of similar cases
Authors: Sadollah Shamsadini MD[1], Aliakbar Taheri MD[2], Shahriar Dabiri[3], Kerman Farshid Darvish Damavandi[1], and Siamak Salahi[2] 
Affiliations: Departments of Dermatology[1], Otolaryngology[2], and Pathology[3], Kerman University of Medical Sciences, Kerman, Iran. shamsadini@yahoo.com
Citation: Dermatology Online Journal 9(5): 27
Keywords: Zosteriform, metastases, Malignancy, Squamous cell carcinoma.

Abstract:
Cutaneous metastases from internal malignancies or primary skin cancers are uncommon, particularly in a grouped pattern. We report a 58-year-old man with a known case of laryngeal squamous cell carcinoma who underwent radiotherapy after surgical excision of the tumor. Unilateral, grouped, red-brown, vesicle-like nodules appeared on his shoulder 9 months after the laryngeal surgery. The pathologic diagnosis of an excised nodule was metastatic squamous cell carcinoma.     
Body: 
I:Introduction
In a review of 4,020 patients with metastatic squamous-cell carcinoma (SCC), cutaneous lesions occurred in 10.4 percent [1]. The morphology of these metastases include nodules, ulcers, inflammatory areas, sclerotic areas, bullae, and vesicles [2]. Carcinoma encuirasse, metastases presenting as alopecia, and grouped or zosteriform metastases are additional and uncommon presentations. A literature review found eight cases of grouped zosteriform skin metastases from   various primary sites, but none from the larynx [3, 4, 5, 6, 7]. In general, skin metastases of SCC to the head and neck are rare [8]. In a recent description of 2,491 patients with SCC of the upper aerodigestive tract, only 19 (0.763 %) developed skin metastases [8]. As expected, this was a poor prognostic sign; 90 percent of these patients died within a median time of 3 months. We describe a patient with laryngeal SCC who developed grouped vesicle-like metastases on the left shoulder following radiotherapy.  
 
Figures 1 and 1a: 1.jpg, 1a.jpg
Grouped erythematous and vesicle-like nodules 

Figures 1b and 2: 1b.jpg, 2.jpg
Grouped nodules on left shoulder(fig. 1<i>b</i>). Low-power histologic view of metastatic SCC (fig. 2).


Figure 3: 3.jpg
Metastatic squamous cell carcinoma.

I: Clinical summary
A 58-year-old man with squamous cell carcinoma of the larynx is presented. He had a 20-year history of cigarette smoking and a history of heroin and opium addiction. Laryngeal SCC was diagnosed, and the patient underwent total laryngectomy followed by radiotherapy. Shortly after the radiotherapy and 1 year following surgery, a group of red-violet vesicle-like nodules appeared on his left shoulder. An attempt to aspirate fluid from a shiny, translucent lesion disclosed that it was actually a nodule (figs. 1, 2). A representative lesion on the right shoulder was excised, and the histology revealed a solid tumor with infiltration into the  mid-dermis, islands of atypical squamous cells, and a few squamous eddies (fig. 3); these findings were  consistent with the diagnosis of a nodular SCC metastasis. Additional radiotherapy was recommended.

I: Discussion
The clinical appearance of cutaneous metastases varies over a wide morphologic spectrum. Malignant melanoma has a high frequency of  metastasis to the skin; skin metastasis from lung and kidney malignancies are less common [9]. In 1998 Cuq-Viguier et al. reported a case with a similar configuration of grouped  vesicle-like skin metastases originating from SCC   of the stump of an amputated arm [4].  Kato et al. in  2001 reported  a case of zosteriform, epidermotropic metastases from primary skin SCC [3]. The cause of a grouped or dermatomal metastatic distribution in malignant lesions is not known, but  perineural lymphatic invasion and spread has been hypothesized as a possible explanation for this pattern [10, 11, 12]. Tumor invasion of dorsal root ganglia with  peripheral extension may have an important role [13]. Grouped and zosteriform metastases are uncommon but may result from neoplasms of many primary sites. In addition, the upper aerodigestive tract is a rare primary source for cutaneous SCC metastases. Our case demonstrates the unusual combination of grouped cutaneous metastases from a primary laryngeal SCC.  
References: 
1. Lookingbill DP, Spangler N, Helm KF: Cutaneous metastases in patients with metastatic carcinoma: a retrospective study of 4020 patients. J Am Acad Dermatol 1993;29:228-36.
2. Brownstein MH, Helwig EB: Spread of tumors to the skin. Arch Dermatol 107:80-6,1973.
3. Kato N,Aoyagi S,Sugawara H,Mayuzumi M.Zosteriform and epidermotropic  primary cutaneous squamous cell carcinoma.Am J Dermatopathol Jun 23[3]:216-20 2001
4. Cuq-ViguierL, Viraben R. Zosteriform  matastases from squamous cell carcinoma of the stump of an amputated arm. Clin Exp Dermatol. 1998 May;23[3]:116-8.
5. Bauza A, Redonod p,ldoate MA. Cutaneous zosteriform squamous cell carcinoma metastasis arising in an immunocompetent patient. Clin Exp Dermatol. 2002 May;27[3]:199-201.
6. Shafqat A, Viehman GE, Myers SA. Cutaneous squamous cell carcinoma with zosteriform metastasis in a transplant recipient. J Am Acad Dermatol. 1997 Dec;37[6]:1008-9.
7. Manteaux A, Cohen PR, Rapini RP. Zosteriform and epidermotropic metastasis. Report of two cases. J Dermatol Surg Oncol 1992;18:97-100. 
8. Pitman KT, Johnson JT. Skin metastases from head and neck squamous cell carcinoma: incidence and impact. Head Neck 1999;21:560-5.
9. Matarasso SL, Rosen T: Zosteriform metastasis:case presentation and review of the literature. J Dermatol Surg Oncol 14: 77-8, 1988.
10. Bluefarb SM, Wallk S, Gecth M: Carcinoma of the prostate with zosteriform cutaneous lesions. Arch Dermatol 76:402-6,1957.
11. Hodge SJ, Mackle S, Owen LG: Zosteriform inflammatory metastatic carinoma. Int Dermatol 18: 142-5, 1979.
12. Shamsadini S Dabiri S Zosteriform metastases in a man with malignant melanoma: Medical journal of the Islamic republic of Iran vol 16 Num 2 August 2002 pp115-17.   
13. Jaworsky C, Bergfeld WF: Metastatic transition cell carcinoma mimicking zoster sine herpete. Arch Dermatol 122: 1357-8,1986.