Skin meta stases (SM) are infrequent secondary locations of deepneoplasia that can sometimes be indicative of primary cancer. They represent 0.2 to 10% of metastases from solid tumors . The most frequent primary tumors in men were carcinoma of the lung (24%), carcinoma of the large intestine (19%), melanoma (13%), and squamous cellcarcinoma of the oral cavity (12%). The most common primary tumors in women were carcinoma of the breast (69%), carcinoma of the large intestine (9%), melanoma (5%), and carcinoma of the ovary (4%) . The incidence of cutaneous involvement by all urolo gicalm alignanciesis 1.1% to 2.5% . The kidneyis the most common organ to serve as a source of meta stasis to the skin . Bladder cancers are lesslikely to metastasize to the skin We report a new case of skin metastases presenting as a large tumor in the thoraciclevel in a patient followed for a urothelial carcinoma of the bladder.
We report the case of a 66-year-old patient, followed for a high-grade urothelial carcinoma for 2 years, initially mesastatic at the level of the prostate. The patient wasthen put on neoadjuvant chemotherapy, but hew as lost to follow-up and presented him self after 5 months, with extension of the tumor to the gall bladder, and the urethral masses, the internal obturator muscle and bilateral externaliliac lymphadenopathy, as well as adrenal metastasis, with an examination of oncologists the presence of a skin tumor in the right thoracic level, hence a dermatological opinion was requested. A dermatological examination on an objectified presence of a pigmented tumor of 5/6 cm of large, anulcerated and bleeding surface, sitting at the level of the anterior surface of the thorax, on the right side (Figure 1). At the dermoscopy we had pigmented areas without structures, with the presence of a polymorphic vascularization made of arborising vessels as well as tortuous vessels (Figure 2), in front of this aspect associated with the clinical context we first thoughtto a skin metastasis bladder tumor, and a skin biopsy was performed confirming this diagnosis. The patient was then kept on palliative chemotherapy based on cisplatin + gemcitabine, and died 2 monthslater.
Only 5.3% of all malignancies lead to cutaneous metastasis. Out of these, 1.34% are linked to underlying genitourinary malignancy; bladder cancer accounts for 0.84% of these  with a limited number of published cases, It usually metastasizes to regional lymphnodes, liver, lungs and bones  Large 20-year retrospective Taiwanese study found only 2 cases of skin meta stases among 911 patients with bladder and ureter cancer  and Kishi et al.  reported that 66.7% of patients with T3 and T4 tumors had metastatic disease Cutaneous involvement from bladder cancer is achieved by direct tumor invasion, hematogenous routes, lymphatic spread, and direct seeding due to iatrogenic implantation . Iatro genic implantation is the most common cause of seeding outside of the urinary tract  anditsdue to surgical treatment of these tumors, includingcy stectomy, partial cystectomy, TURBT, and other procedures . The clinical appearance of these lesions varies and maymimicother dermatologic diseases. The lesionscanbesolitary or multiple, and can have anodular, fibrotic, and inflammatory appearance .
In urological cancer withcutaneousmetastasis, several aspects have been described in the literature, like , A cutaneousery sipelas-likelesion  Zosteri form cutaneous metastases  or Herpetiform cutaneous metastases , butthe most common clinical picture is aninfiltrated plaque or nodule  Ul cerated swelling, subcutaneous nodules, violaceous papules, and ulcerated plaques have been reported  in our patient the appearance was that of a large tumor withulcerated surface Dermoscopy of skin metastases has been recently reported in the literature , the mostreported sign was a polymorphic vascularization made of arborising vessels, as well as serpiginous, but these aspects were not retained as specific, sincethey canbe found even in front of a primary skin tumor, such as melanoma or squamous cell carcinoma. Local excision, radiotherapy, chemotherapy, immunological and combination therapy have been reported in previous studies . Due to the poorout comes of these patients, the treatment options are limited and primarily supportive in nature. The prognosis of any cancer with cut aneous metastasisis poor; with regard to bladder cancer with cutaneous metastasis, median survival time is< 12 months .
We report a new case of skin metastasis of a bladder tumor, in the form of a pigmented tumor in a patient with multiple visceral metasases. Although cutaneous metastasisis a rare dermatological condition, cutaneous metastasis should be included in the differential diagnosis of tumo allesion. Skin biopsy should be performed to preventmis diagnosis. For the patients with urologic malignancies, we suggest that all urologists should increase attention to the physical examination of the skin because skin lesion scanbe the first sign of silent or recurrent urologic malignancies.
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