Vulvar squamous cell carcinoma metastatic to skin of the forearm.

THE PATIENT was a 77-year-old female who initially underwent radical vulvectomy with bilateral inguinal lymphadenectomy for classification of the International Federation of Gynaecologists and Obstetricians stage III squamous cell carcinoma of the vulva. At the time of the original treatment, there was no evidence of systemic spread of disease. Over the following 6 months, the patient developed a progressively enlarging, firm, rounded tumor on the anterior aspect of the right forearm (Figure 1). Incisional biopsy of the lesion documented poorly differentiated squamous cell carcinoma with infiltration of the adjacent connective tissue and skeletal muscle. The findings were consistent with cutaneous metastasis secondary to vulvar carcinoma. Computerized tomography (CT) of the abdomen and pelvis did not show any sign of distant metastasis, but there was evidence of lymphatic metastasis suggested by right inguinal lymphadenopathy. CT and scout films of the forearm showed a multiloculated intramuscular soft tissue mass invading the subcutaneous tissue and showing hemorrhage within the mass, without adjacent bone involvement. The patient then underwent excision of the forearm mass as palliative treatment. The pathologist’s examination of the tissue found a poorly differentiated high-grade carcinoma extending to the deep resection margin and consistent with metastatic squamous cell carcinoma of the vulva. After a 4-month disease-free interval, right axillary lymphatic metastasis developed, followed by metastasis to the lungs. The patient remained alive, however, for 1 year after excision of the forearm lesion, finally succumbing to her disease shortly thereafter. Cancer of the vulva represents 4% to 5% of all gynecologic malignancies and is the fourth most common. It is a slowly progressive tumor that advances locally and metastasizes via regional lymph nodes first to the inguinal then to the deep pelvic nodes. Hematogenous spread may occur in the late stages. In females, cutaneous metastasis occurs most commonly from breast carcinoma, followed by colorectal carcinoma, melanoma, and ovarian carcinoma. Cutaneous metastasis from vulvar carcinoma is extremely rare, and there are only five previous cases presented in the literature. In all of these cases, the cutaneous metastasis was to the skin of the thigh and the lower abdomen, with close proximity to the genitalia, and represented a preterminal event. All five reported patients expired within the ensuing year. Our report describes the first case of cutaneous metastasis of vulvar carcinoma to the upper extremity, remote from the genital tract, and associated with a survival of more than 1 year after the development of metastasis.