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Paper text:
cutaneous metastases are of diagnostic importance as they may be the first manifestation of an undiscovered internal malignancy or the first indication of metastasis from a supposedly adequately treated malignancy . as a rule ,
most regional metastases probably occur through the lymphatic system , while distant metastases are more likely to occur via the hematogenous route . in - transit metastases
are cutaneous metastatic foci located between the tumor and the closest regional lymph nodes . a case of squamous cell carcinoma ( scc ) of the penis with numerous in - transit metastases in the pubic region and scrotum
in may 2010 , a 65-year - old male patient presented at our hospital with complaints of numerous papules and nodules in the pubic and suprapubic region and the scrotum . according to him the lesions had been present for the last 4 months . in october 2009 , he had undergone partial amputation of the penis at a tertiary care hospital for an ulceroproliferative growth involving the glans penis , which was histologically proven to be a moderately differentiated scc .
a fine needle aspiration cytology ( fnac ) of the left inguinal nodes at the same teritiary care hospital where patient underwent surgery , revealed well - differentiated metastatic scc on the left side and reactive lymphoid hyperplasia on the right side . bilateral block resection of inguinal lymph nodes , wth skin grafting from a donor site from the thigh , was performed . however , 4 months later he developed edema of both lower limbs , scrotum , and the suprapubic region .
he also developed multiple painless papules and nodules in the above areas , with some of the lesions discharging a clear fluid .
a diagnosis of post - lymphadenectomy lymphangiectasia , was entertained at that time at the tertiary care hospital and the patient was treated conservatively and reassured .
he presented at our hospital in may , 2010 , with multiple papules and nodules ( some of them ulcerated ) on the scrotum and the pubic and suprapubic regions .
local examination revealed edema of the scrotal skin and suprapubic region , a short stump of the amputated penis , postsurgical scars in both inguinal regions , and postinflammatory pigmentary changes  both hypo- and hyperpigmentation  at the donor site on the thigh [ figure 1 ] .
there were multiple firm papules and nodules of about 23 mm in size , some of them ulcerated and discharging serous fluid , in the pubis , suprapubic region , and scrotum .
[ figure 2 ] roentgenogram of the chest and ultrasonogram of the abdomen did not reveal any metastatic deposits .
other than anemia ( with hemoglobin of 8.1 gm% ) , the routine hematologic and biochemical investigations did not reveal any abnormality .
edema of the scrotal skin and suprapubic region , the short stump of the amputated penis , and postsurgical scars in both inguinal regions .
islands of metastatic squamous cell carcinoma with a clear zone between the deposit and the epidermis .
overlying stratified squamous epithelium is normal ( h and e ; a 200 , b 400 ) a diagnosis of scc with in- transit cutaneous metastasis was made and the patient was referred back to the tertiary hospital for further management .
carcinomas arising from modified skin such as the glans penis and the vulva and from the oral mucosa have a rather high rate of metastasis unless they are recognized and adequately treated at an early stage .
carcinomas arising in sun - damaged skin have a very low propensity to metastasize , the incidence being only about 0.5% . the rate of metastases is higher in adenoid and mucin - producing scc of the skin than in the common type .
however , in our patient , details about the histological type of the primary lesion were unavailable .
dissemination may take place via the lymphatics or the blood stream . in - transit metastases are cutaneous metastatic foci located between the tumor and the closest lymph node region .
analogous to in - transit metastasis found in melanoma , these represent metastatic spread along lymphatic vessels and/or nerves and their presence is an indicator of poor prognosis . in the present case , in view of the innumerable papulonodules and the previous history of regional ( i.e. , inguinal ) lymph node involvement
as proved by fnac study , lymphatic spread was probably the reason for these in transit metastases .
a case of penile cancer has been reported earlier where the patient presented with primary high - grade penile squamous carcinoma and secondary skin metastases , in addition to metastases to liver , lungs , and other organs . however , in our patient there was no clinical or radiological evidence of involvement of other organs .
overall , in - transit metastases occur most frequently from scc risk stratified as high - risk lesions ; however , all scc that occur in immunosuppressed patients have the potential for distant spread . ninety percent of metastatic scc occurs within 3 years of diagnosis of the primary tumor . in our patient , however , the metastasis occurred within a much shorter period of 4 months .
it is possible that the tumor emboli were already lodged in the lymphatic channels at the time the inguinal node resection was undertaken and hence this early recurrence .
clinically , in - transit metastasis are nondescript , subtle , waxy , gray - white or flesh - colored papules of about 26 mm diameter and are not contiguous with the primary lesion .
such a diagnosis was entertained in the present case also at the tertiary care hospital 3 months prior to his visit to our hospital . in a review of 21 cases with in - transit metastases ,
carucci et al . reported that patients presented most commonly with discrete dermal papules distinct from , but in the vicinity of , the primary tumor site . in their series ,
local control of in - transit metastasis should be achieved with mohs surgical technique or some other surgical method , where the surgical margins are rigorously evaluated for residual tumor , perineural extension , or intravascular invasion ( e.g. , excision with intraoperative frozen section control or excision with postoperative margin assessment ) .
the radiation field often involves the primary tumor site , the in - transit metastatic site , and the draining lymph node basin .
our patient was referred for further treatment to the same tertiary care hospital where he had earlier undergone surgery for his scc penis , but he was lost to follow - up .
this case is presented because of the uncommon presentation of  in - transit metastases after the primary tumor and the regional lymph nodes were resected .
an in - transit metastasis is one that is located between the primary tumor and the closest lymph node region and results from tumor emboli getting trapped in the lymphatic channels . 
 a 65-year - old male patient who had undergone partial amputation of the penis and bilateral inguinal lymph node resection for squamous cell carcinoma of the penis 4 months earlier developed multiple cutaneous metastatic lesions in the pubic region and scrotum . 
 the case is reported for the uncommon presentation of in - transit metastases .