A Rare Case of Zosteriform Cutaneous Metastases from Squamous Cell Carcinoma of Hard Palate
A 70-year-old woman presented with nodules on the left side of her neck since 1 month. The patient gave history of reverse smoking since 50-years-and did not have any complaints in her oral cavity. The lesions over the neck were not painful and they did not itch. Skin-colored solid papules, nodules, and papulovesicles were scattered and confluent and few crusted plaques were seen on the left side of the neck with typical zosteriform distribution consistent with the left C3 dermatome []. On further examination, the patient had a superficial ulcer of 2 × 2 cm over the hard palate in her oral cavity and the patient was unaware of the lesion with no symptoms. The ulcer had an eroded surface with irregular margins and had pseudomembrane formation []. The ulcer did not bleed on touch and the pseudomembrane was not easily detachable. The rest of the physical examination was normal.\nRoutine blood investigations were within normal limits, except erythrocyte sedimentation rate (ESR) which was 130 mm in the 1st hour, and peripheral blood smear showed normocytic, hypochromic blood picture with eosinophilia. Ultrasound of neck and chest showed single nodule of right lobe of thyroid. Chest X-ray PA view showed moderate cardiomegaly. Computed tomography (CT) scan of the chest, direct laryngoscopy, upper gastrointestinal (GI) endoscopy, and ultrasound abdomen revealed normal study. HIV 1 and 2 was negative and venereal disease research laboratory (VDRL) test was non-reactive. Initially, fine needle aspiration cytology (FNAC) of the nodule was performed, which showed metastatic squamous cell carcinoma deposits. A skin biopsy was performed from the neck lesion and an oral biopsy was done for confirming the diagnosis. Histopathology of the oral biopsy sections showed hyperplasia of epithelium with central ulceration, necrosis, and inflammatory cells. In one area, there was a malignant change seen in the epithelium with few malignant cells breaking into the basement membrane, suggestive of infiltrating squamous cell carcinoma []. Biopsy of nodular lesion from the neck sections showed large sheets of malignant squamous cells with hyperchromatic nuclei and mitoses. Central area showed necrosis with overlying squamous epithelium showing hyperplasia in a few areas. No malignant change was noted in epidermis. Subcutaneous lymphatics were distended with tumor cells, which was suggestive of squamous cell carcinoma secondaries []. Patient was started on external cobalt radiation. A total dose of 5000 cGy radiation was given in 25 fractions (200 cGy for 25 days). Complete clearance of both the oral cavity ulcer and zosteriform lesions over neck was noted after the radiation therapy [Figures and ]. The patient was advised to stop smoking and she is under close follow-up since 6 months after discharge from treatment, with no recurrence.