e338
Correspondence
carried out on these patients. Biopsies should be performed in patients with suspected vulvar lesions, especially in postmenopausal women. Yasßam Kemal Akpak, MD Department of Obstetrics and Gynecology Sarıkamıs Military Hospital Kars Turkey
Figure 1 An ulcerated, erythematous lesion at the right of the vulvar region
€ ur Dandin, MD Ozg€ Department of General Surgery Bursa Military Hospital Bursa Turkey E-mail: [email protected] I˙smet G€ un, MD Vedat Atay, MD Department of Obstetrics and Gynecology Gulhane Military Medical Academy Haydarpasa Training Hospital Istanbul Turkey Apdullah Haholu, MD Department of Pathology Gulhane Military Medical Academy Haydarpasa Training Hospital Istanbul Turkey
Figure 2 Microscopic view of vulvar skin (hematoxylin & eosin, 100 9). Adenocarcinoma composed of atypical glandular structures around normal squamous epithelium of vulva (arrow)
We declare there are no conflicts of interest and/or affiliations. References
and radiation oncology services for postoperative chemotherapy and/or radiation therapy. Metastatic spread of adenocarcinoma to the skin could be due to lymphatic and hematogenous spread, direct extension, or implantation during surgery.3 Metastasis to the vulva is a rare condition of internal malignancies. The prognosis with such lesions is generally poor, although early diagnosis can change the treatment and prognosis. The possibility of metastases might be considered for any new vulvar lesion in a woman with a history of visceral malignancy, and detailed physical examinations should be
1 Hoyt BS, Cohen PR. Cutaneous scrotal metastasis: origins and clinical characteristics of visceral malignancies that metastasize to the scrotum. Int J Dermatol 2013; 52: 398–405. 2 Kilickap S, Aksoy S, Dincer M, et al. Cutaneous metastases of signet cell carcinoma of the rectum without accompanying visceral involvement. South Med J 2006; 99: 1137–1139. 3 Kauffman LC, Sina B. Metastatic inflammatory carcinoma of the rectum: tumour spread by three routes. Am J Dermatopathol 1997; 19: 528–532.
More insights into the immunocompromised district
our attention as, in our opinion, they may hinge upon a common pathogenic background. Ghorpade presented a typical example of Wolf’s isotopic response (IR), describing a case of a furuncle at the
Sir, Two recent articles,1,2 both published in the January issue of the International Journal of Dermatology, drew International Journal of Dermatology 2014, 53, e332–e346
ª 2014 The International Society of Dermatology
Correspondence
site of healed herpes zoster,1 while Badri et al.2 reported a case of unilateral skin sarcoid reaction after homolateral mastectomy and lymphadenectomy for breast cancer. Both the articles gave us the opportunity to refer to the innovative concept of cutaneous immunocompromised district (ICD), i.e. a cutaneous site that once has been ‘scarred’ by prior clinical events (including chronic lymphedema, herpetic infection and neurological injuries,3–5 vaccination, thermal, or mechanical injuries, especially amputation), develops the propensity to host a secondary disease, which can appear after a variable time break (days to years).6 As underlined by Ghorpade, Wolf’s IR refers to the occurrence of a new disease at the site of healed herpetic infection.1,7 However, Wolf’s IR represents only a facet of the wider concept of ICD, which includes it, as already asserted by Ruocco et al.6 Badri et al.2 suppose that the cutaneous sarcoid reaction after mastectomy is caused by soluble tumoral antigens leading to a hypersensitivity reaction. Although interesting, this hypothesis seems to be not exhaustive in explaining this singular phenomenon. In fact, we think that lymph stasis following axillary lymphadenectomy for breast cancer might have been responsible for a consequent immune stasis, thus favoring the occurrence of sarcoid reaction strictly confined to that vulnerable area, which features a typical example of ICD. It is worth clarifying that the term immunocompromised generically indicates an alteration of the immune response and not necessarily a reduction of it.8 Depending on which neurotransmitters and immune cells are each time involved in the immune destabilization, this could be either defective and predispose to the outbreak of opportunistic tumors and infections (such as furuncle in the first report), or excessive and favor the occurrence of immunemediated diseases (such as sarcoid reaction in the second report). Through their brilliant observations, the authors of both articles gave us the opportunity to discuss such an intriguing topic. We think that the novel concept of ICD would be a good guidance for further investigations
Reply to: a rare case of vulvar skin metastasis of rectal cancer after operation
Editor, We appreciate the comments of Akpak et al. with regard to our manuscript on cutaneous scrotal metastasis1 and their interesting clinical observation of a woman who developed metastatic visceral malignancy to the vulva. What is truly fascinating is that the scrotum and the ª 2014 The International Society of Dermatology
aimed at clarifying the opportunistic localization of several cutaneous disorders. Vincenzo Piccolo MD Teresa Russo MD Adone Baroni MD, PhD Department of Dermatology and Venereology Second University of Naples Naples Italy E-mail: [email protected] Conflict of interest: No conflict of interest or financial disclosure is present. All authors had equally contributed. References 1 Ghorpade A. Wolf’s isotopic response manifesting as a furuncle on the forehead of an Indian man. Int J Dermatol 2013; 52: 119–120. 2 Badri T, Kerkeni N, Marrak H, et al. Unilateral upper limb skin sarcoid reaction after homolateral mastectomy for breast cancer. Int J Dermatol 2013; 52: 124–125. 3 Baroni A, Ruocco V, Di Maio R, et al. Papillomatosis cutis arising on an immuno-compromised district due to paraplegia. Br J Dermatol 2010; 163: 646–648. 4 Baroni A, Piccolo V, Russo T, et al. Recurrent blistering of the fingertips as a sign of carpal tunnel syndrome: an effect of nerve compression. Arch Dermatol 2012; 148: 545–546. 5 Piccolo V, Russo T, Baroni A. Unilateral bullous pemphigoid in hemiplegic patients: an instance of immunocompromised district. J Dermatol 2013; 40: 64–65. 6 Ruocco V, Brunetti G, Puca RV, et al. The immunocompromised district: a unifying concept for lymphoedematous, herpes-infected and otherwise damaged sites. J Eur Acad Dermatol Venereol 2009; 23: 1364– 1373. 7 Wolf R, Wolf D, Ruocco E, et al. Wolf’s isotopic response. Clin Dermatol 2011; 29: 237–240. 8 Ruocco V, Ruocco E, Brunetti G, et al. The correct meaning of the term immunocompromised: a necessary explanation. J Eur Acad Dermatol Venereol 2011; 25: 1242.
vulva are embryologically derived from the same origin.2 Between gestational weeks 4 and 7, both male and female embryos develop urogenital and labioscrotal folds. In males, these precursors develop into the urethra and scrotum, whereas in females they subsequently differentiate into the labia minora and labia majora.2 Metastasis of visceral malignancies to the scrotum is uncommon1 and hence, based on the similar embryologic derivation of the International Journal of Dermatology 2014, 53, e332–e346
e339
Correspondence
carried out on these patients. Biopsies should be performed in patients with suspected vulvar lesions, especially in postmenopausal women. Yasßam Kemal Akpak, MD Department of Obstetrics and Gynecology Sarıkamıs Military Hospital Kars Turkey
Figure 1 An ulcerated, erythematous lesion at the right of the vulvar region
€ ur Dandin, MD Ozg€ Department of General Surgery Bursa Military Hospital Bursa Turkey E-mail: [email protected] I˙smet G€ un, MD Vedat Atay, MD Department of Obstetrics and Gynecology Gulhane Military Medical Academy Haydarpasa Training Hospital Istanbul Turkey Apdullah Haholu, MD Department of Pathology Gulhane Military Medical Academy Haydarpasa Training Hospital Istanbul Turkey
Figure 2 Microscopic view of vulvar skin (hematoxylin & eosin, 100 9). Adenocarcinoma composed of atypical glandular structures around normal squamous epithelium of vulva (arrow)
We declare there are no conflicts of interest and/or affiliations. References
and radiation oncology services for postoperative chemotherapy and/or radiation therapy. Metastatic spread of adenocarcinoma to the skin could be due to lymphatic and hematogenous spread, direct extension, or implantation during surgery.3 Metastasis to the vulva is a rare condition of internal malignancies. The prognosis with such lesions is generally poor, although early diagnosis can change the treatment and prognosis. The possibility of metastases might be considered for any new vulvar lesion in a woman with a history of visceral malignancy, and detailed physical examinations should be
1 Hoyt BS, Cohen PR. Cutaneous scrotal metastasis: origins and clinical characteristics of visceral malignancies that metastasize to the scrotum. Int J Dermatol 2013; 52: 398–405. 2 Kilickap S, Aksoy S, Dincer M, et al. Cutaneous metastases of signet cell carcinoma of the rectum without accompanying visceral involvement. South Med J 2006; 99: 1137–1139. 3 Kauffman LC, Sina B. Metastatic inflammatory carcinoma of the rectum: tumour spread by three routes. Am J Dermatopathol 1997; 19: 528–532.
More insights into the immunocompromised district
our attention as, in our opinion, they may hinge upon a common pathogenic background. Ghorpade presented a typical example of Wolf’s isotopic response (IR), describing a case of a furuncle at the
Sir, Two recent articles,1,2 both published in the January issue of the International Journal of Dermatology, drew International Journal of Dermatology 2014, 53, e332–e346
ª 2014 The International Society of Dermatology
Correspondence
site of healed herpes zoster,1 while Badri et al.2 reported a case of unilateral skin sarcoid reaction after homolateral mastectomy and lymphadenectomy for breast cancer. Both the articles gave us the opportunity to refer to the innovative concept of cutaneous immunocompromised district (ICD), i.e. a cutaneous site that once has been ‘scarred’ by prior clinical events (including chronic lymphedema, herpetic infection and neurological injuries,3–5 vaccination, thermal, or mechanical injuries, especially amputation), develops the propensity to host a secondary disease, which can appear after a variable time break (days to years).6 As underlined by Ghorpade, Wolf’s IR refers to the occurrence of a new disease at the site of healed herpetic infection.1,7 However, Wolf’s IR represents only a facet of the wider concept of ICD, which includes it, as already asserted by Ruocco et al.6 Badri et al.2 suppose that the cutaneous sarcoid reaction after mastectomy is caused by soluble tumoral antigens leading to a hypersensitivity reaction. Although interesting, this hypothesis seems to be not exhaustive in explaining this singular phenomenon. In fact, we think that lymph stasis following axillary lymphadenectomy for breast cancer might have been responsible for a consequent immune stasis, thus favoring the occurrence of sarcoid reaction strictly confined to that vulnerable area, which features a typical example of ICD. It is worth clarifying that the term immunocompromised generically indicates an alteration of the immune response and not necessarily a reduction of it.8 Depending on which neurotransmitters and immune cells are each time involved in the immune destabilization, this could be either defective and predispose to the outbreak of opportunistic tumors and infections (such as furuncle in the first report), or excessive and favor the occurrence of immunemediated diseases (such as sarcoid reaction in the second report). Through their brilliant observations, the authors of both articles gave us the opportunity to discuss such an intriguing topic. We think that the novel concept of ICD would be a good guidance for further investigations
Reply to: a rare case of vulvar skin metastasis of rectal cancer after operation
Editor, We appreciate the comments of Akpak et al. with regard to our manuscript on cutaneous scrotal metastasis1 and their interesting clinical observation of a woman who developed metastatic visceral malignancy to the vulva. What is truly fascinating is that the scrotum and the ª 2014 The International Society of Dermatology
aimed at clarifying the opportunistic localization of several cutaneous disorders. Vincenzo Piccolo MD Teresa Russo MD Adone Baroni MD, PhD Department of Dermatology and Venereology Second University of Naples Naples Italy E-mail: [email protected] Conflict of interest: No conflict of interest or financial disclosure is present. All authors had equally contributed. References 1 Ghorpade A. Wolf’s isotopic response manifesting as a furuncle on the forehead of an Indian man. Int J Dermatol 2013; 52: 119–120. 2 Badri T, Kerkeni N, Marrak H, et al. Unilateral upper limb skin sarcoid reaction after homolateral mastectomy for breast cancer. Int J Dermatol 2013; 52: 124–125. 3 Baroni A, Ruocco V, Di Maio R, et al. Papillomatosis cutis arising on an immuno-compromised district due to paraplegia. Br J Dermatol 2010; 163: 646–648. 4 Baroni A, Piccolo V, Russo T, et al. Recurrent blistering of the fingertips as a sign of carpal tunnel syndrome: an effect of nerve compression. Arch Dermatol 2012; 148: 545–546. 5 Piccolo V, Russo T, Baroni A. Unilateral bullous pemphigoid in hemiplegic patients: an instance of immunocompromised district. J Dermatol 2013; 40: 64–65. 6 Ruocco V, Brunetti G, Puca RV, et al. The immunocompromised district: a unifying concept for lymphoedematous, herpes-infected and otherwise damaged sites. J Eur Acad Dermatol Venereol 2009; 23: 1364– 1373. 7 Wolf R, Wolf D, Ruocco E, et al. Wolf’s isotopic response. Clin Dermatol 2011; 29: 237–240. 8 Ruocco V, Ruocco E, Brunetti G, et al. The correct meaning of the term immunocompromised: a necessary explanation. J Eur Acad Dermatol Venereol 2011; 25: 1242.
vulva are embryologically derived from the same origin.2 Between gestational weeks 4 and 7, both male and female embryos develop urogenital and labioscrotal folds. In males, these precursors develop into the urethra and scrotum, whereas in females they subsequently differentiate into the labia minora and labia majora.2 Metastasis of visceral malignancies to the scrotum is uncommon1 and hence, based on the similar embryologic derivation of the International Journal of Dermatology 2014, 53, e332–e346
e339
