Prostate carcinoma metastatic to the skin as an extrammamary Paget’s disease
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The current paper describes a case of prostatic adenocarcinoma metastatic to the skin presenting as an extrammamary Paget's disease, a very rare and poorly characterised morphological entity. We report a case of prostatic carcinoma metastatic to skin showing a pattern of extramammary Paget's disease which has not been clearly illustrated in the literature Case presentation: A 63 year-old man with prostatic adenocarcinoma developed cutaneous metastases after 16 years. The inguinal metastases were sessile and 'keratotic.' The tumour displayed solid, glandular areas as well as a polypoid region suggestive of extramammary Paget's disease were identified.
Discussion and conclusions
We review the diagnostic criteria that have led to the correct histopathological diagnosis in this case. A differential diagnosis of the pagetoid spread in the skin and various forms of cutaneous metastases determined by a prostatic adenocarcinoma as well as the role of immunohistochemistry in establishing the prostatic origin are presented in the context of this case. Although, morphologically the cells presented in the skin deposits were not characteristic for adenocarcinoma of prostate, immunohistochemistry for PSA and PSAP suggested a prostatic origin.
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Prostate adenocarcinoma is one of the most common cancers in Australia. The Melbourne Collaborative Cohort Study revealed that 8.4% of the subjects enrolled in the study developed over 15 years prostatic adenocarcinoma and more than 10% of these patients died. While some long-term survivors develop an indolent disease without dissemination others develop early or even late metastases. Secondary deposits associated with prostatic adenocarcinoma are located with predilection in the bone system while skin metastasis represents an exceptional event. Evaluation of these skin lesions should always include a thorough clinical examination, past history and histopathological evaluation. In some patients the history of prostatic adenocarcinoma is absent and in others the histology is not characteristic for a prostatic origin or the patients might have had cancers with various origins. In these cases, immunohistochemistry is an invaluable tool, the most commonly used markers being prostate-specific antigen (PSA) and prostate acid phosphatase (PSAP). Skin metastasis determined by a prostate adenocarcinoma may display a variety of patterns including the extrammamary Paget’s disease. However, at the present time, we do not understand the implication of this morphology for the aggressiveness of the primary cancer and the general outlook of the patient.
Pagetoid spread in the epidermis
A. PRIMARY NEOPLASMS
Paget’s Disease (PD)
• Primary PD
• De novo in the areola
• Malignant melanoma
• Spitz’s nevus
• Acral nevus
Epithelial Cutaneous Neoplasms
• Squamous cell carcinoma (Bowen’s disease)
• Merkel cell carcinoma
• Tricholemmal carcinoma
• Basal cell carcinoma
Benign Epidermal Conditions
• Focal acantholytic dyskeratosis
• Cutaneous hamartoma with pagetoid cells
• Pagetoid dyskeratosis of the prepuce
• Benign mucinous metaplasia of the penis (mucosal side of prepuce)
• Cutaneous T-cell lymphoma
• Pagetoid reticulosis
• Localized Woringer-Kolopp disease
• and generalized Ketron-Goodman disease
• Mycosis fungoides, common type
• Leukemia: Monoblastic leukemia
B. METASTATIC NEOPLASMS
Carcinomas and Malignant Melanoma
We present a rare pattern of prostatic adenocarcinoma metastatic to the skin. Immunohistochemistry for PSA and PSAP along with clinical and radiological examination and personal history were corroborated for the final diagnosis. For the histo/dermatopathologist it is important to recognize the plethora of various patterns displayed by cutaneous metastases of a prostatic adenocarcinoma. Last but not least, we should be aware that the PSA/PSAP might not be helpful in confirming the diagnosis if the skin lesion represents the extension of a poorly differentiated prostatic adenocarcinoma and other markers and/or methods need to be employed.
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