Generic selectors
Exact matches only
Search in title
Search in content
Search in posts
Search in pages
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Art & Psychiatry
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Conference Oration
Conference Summary
Continuing Medical Education
Cosmetic Dermatology
Current Best Evidence
Current View
Derma Quest
Dermato Surgery
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
Editor Speaks
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
In Memorium
Inaugural Address
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters in Response to Previous Publication
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Medicolegal Window
Miscellaneous Letter
Net Case
Net case report
Net Image
Net Letter
Net Quiz
Net Study
New Preparations
News & Views
Observation Letter
Observation Letters
Original Article
Original Contributions
Pattern of Skin Diseases
Pediatric Dermatology
Pediatric Rounds
Presedential Address
Presidential Address
Presidents Remarks
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Review Article
Review Articles
Revision Corner
Self Assessment Programme
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Special Article
Specialty Interface
Study Letter
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Systematic Reviews and Meta-analysis
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapy Letter
View Point
What’s new in Dermatology
View/Download PDF
Letter to the Editor
doi: 10.4103/0378-6323.79723
PMID: 21508581

Zosteriform cutaneous metastasis of renal cell carcinoma

Didem Dincer1 , Mustafa Tunca1 , Ahmet Akar1 , Bulent Kurt2
1 Department of Dermatology, Gulhane School of Medicine, Ankara, Turkey
2 Department of Pathology, Gulhane School of Medicine, Ankara, Turkey

Correspondence Address:
Mustafa Tunca
GATA Dermatoloji AD. Etlik, Kecioren, Ankara 06018
How to cite this article:
Dincer D, Tunca M, Akar A, Kurt B. Zosteriform cutaneous metastasis of renal cell carcinoma. Indian J Dermatol Venereol Leprol 2011;77:340-342
Copyright: (C)2011 Indian Journal of Dermatology, Venereology, and Leprology


A 45-year-old man presented to our outpatient clinic with numerous, quite firm, hyperpigmented to violaceous, well-defined papules mostly ranging from a pinpoint to a few millimeters, up to 0.5 cm in diameter, located on his anterior left lower chest in a zosteriform distribution which persisted for more than a month [[Figure - 1]a and b]. He had a history of stage IV renal cell carcinoma (RCC) involving the right kidney, diagnosed 7 years ago. His case records showed that he had cytoreductive right radical nephrectomy, right suprarenalectomy and wedge resection; for the primary tumor, metastatic adrenal and metastatic corpus sternum tumors, respectively. Meanwhile, he received three courses of radiotherapy and chemotherapy; he also got medical therapies including interferon and an angiogenesis/multikinase inhibitor, sunitinab. A month before he was admitted to our clinic, he had developed zosteriform papules over the lower part of the anterior chest wall on the left side which erupted suddenly within days, accompanied by mild pain and deep dermal tenderness. He had been diagnosed to have herpes zoster by a dermatologist. Antiviral treatment was initiated but the lesions had not responded.

Figure 1: (a) Zosteriform appearance of metastatic lesions over the lower anterolateral part of the chest on the left side. (b) Close-up view of the firm, hyperpigmented to violaceous, well-defined papules mostly ranging from pinpoint to a few millimeters in diameter. (c) Clinical picture of the patient after radiotherapy, 7 months later

Upon admission to our clinic, one of these lesions was punch biopsied. A light microscopic evaluation of the hematoxylin and eosin (H and E)-stained histopathological slides showed a diffuse, solid, dense dermal infiltrate of atypical epithelial cells. Neoplastic cells had a pleomorphic nucleus, and a large nucleolus with pale cytoplasm [[Figure - 2]a]. These tumor cells were identical with patient′s previous renal cell carcinoma cells [[Figure - 2]b].

Figure 2: (a) Histopathologic view of the metastatic renal cell carcinoma: diffuse, solid, dense dermal infiltrate of neoplastic epithelial cells with a pleomorphic nucleus and a large nucleolus with pale cytoplasm. (b)- These cells were identical with the tumor cells of renal cell carcinoma resected from kidney 7 years ago (both slides H and E stained, ×100)

With a higher magnification, a high mitotic activity was noted. We also noted a peripheral nerve branch near the tumor mass [Figure - 3]. To verify diagnosis, both original and metastatic tumors were stained immunohistochemically with CD10. Both of them were positive and the patient was diagnosed as having metastatic RCC. In computed tomographic evaluation, findings of metastasis to left adrenal gland, mass formation at the right suprarenal region, and another mass formation with irregular borders in the anterior mediastinal region, adjacent to ascending aorta, were detected.

Figure 3: With higher magnification, high mitotic activity can be seen. This figure also shows a nerve branch near the tumor mass (H and E, ×400), ↑ : Mitotic cells, ±: Nerve branch

The skin is a relatively uncommon site for metastasis of internal malignancies and most common primary sites are breast, lung, gastrointestinal system, and oral mucosa. [1] The most common clinical presentation of cutaneous metastasis is nodule(s) or mass(es). In our case, both the primary tumor (RCC) and clinical presentation (zosteriform pattern) are rare features. [2],[3] When we searched PubMed for zosteriform cutaneous metastatic RCC, we only detected an abstract of a case which was presented as a poster in 2004. [4]

The exact mechanism of zosteriform metastases is not known. Several possible explanations have been proposed. One possible mechanism is increased susceptibility at the site of previous herpes zoster. Perineural lymphatic spread, and spread via fenestrated vessels of the dorsal root ganglion are other theories and in some cases accidental surgical implantation was blamed. [3],[4] Our patient did not have a history of previous herpes zoster or surgery in the metastatic tumor site. The most likely mechanism responsible for zosteriform distribution in our patient may be perineural lymphatic spread. In histopathological examination, we noted a nerve branch near the tumor mass. At one point, the distance from the tumor mass to a nerve branch was measured to be 150 ΅m [Figure - 3]. This may be a clue for perineural lymphatic spread and may also explain mild pain in our patient.

It has been shown that in most patients with cutaneous metastasis of internal malignancies, there is other organ or lymph node involvement at the time of diagnosis of cutaneous metastasis. [5] Therefore, cutaneous metastasis is a sign that the disease is already widespread and the prognosis is poor. In our case, we have searched for possible metastases and found evidence of metastatic lesions in both adrenal regions and in the anterior mediastinal region.

The management of RCC is dependent on the status of the patient and the number of metastatic lesions. The treatment for localized cutaneous metastatic lesions is usually surgical. Radiotherapy and/or chemotherapy have much of a role in extensively disseminated cases. Cutaneous lesions in our case resolved with radiotherapy [[Figure - 1]c]. However, several new lesions began developing on the right lateral chest wall 7 months later, and these lesions were also treated with radiotherapy.

In conclusion, this case shows that the clinical presentation of skin metastasis of RCC is variable, and although very rare, lesions may occur in a zosteriform pattern. Dermatologists should also remember that in most cases, cutaneous metastasis is a sign of widespread metastatic disease and warrants intensive search for other possible metastatic tumors elsewhere in the body.

Hu SC, Chen GS, Wu CS, Chai CY, Chen WT, Lan CC. Rates of cutaneous metastases from different internal malignancies: Experience from a Taiwanese medical center. J Am Acad Dermatol 2009;60:379-87.
[Google Scholar]
LeSueur BW, Abraham RJ, DiCaudo DJ, O'Connor WJ. Zosteriform skin metastases. Int J Dermatol 2004;43:126-8.
[Google Scholar]
Rao R, Balachandran C, Rao L. Zosteriform cutaneous metastases: A case report and brief review of literature. Indian J Dermatol Venereol Leprol 2010;76:447.
[Google Scholar]
Davidson KA, Wong H. Zosteriform metastatic renal cell carcinoma. (Poster Abstract) J Am Acad Dermatol 2004;50:P113.
[Google Scholar]
Saeed S, Keehn CA, Morgan MB. Cutaneous metastasis: A clinical, pathological, and immunohistochemical appraisal. J Cutan Pathol 2004;31:419-30.
[Google Scholar]

Fulltext Views

PDF downloads
Show Sections