Intravascular Squamous Cell Carcinoma Metastases Presenting Solely as Retiform Purpura: A Case Report

Herein, we report the case of a woman in her mid-forties with stage IIB cervical squamous cancer status post-chemoradiation and brachytherapy with curative intent one year prior, who subsequently presented with lacy red to violaceous patches on the forehead, abdomen, back, and legs, as well as mildly tender, ill-defined, purpuric dermal nodules on the right upper back and right inner thigh. Hypercoagulability work-up was negative, and biopsy was consistent with metastatic, intravascular squamous cell carcinoma of cervical origin. This prompted repeat imaging, which was suspicious for metastatic disease to lymph nodes, lungs, and pericardium with multiple bilateral acute/subacute embolic brain infarcts and left ventricular thrombus, and the patient was subsequently started on pembrolizumab, carboplatin, and paclitaxel. Dermatology recommended warming the skin during infusions to promote vasodilation and improve intravascular medication distribution. Despite almost complete resolution of purpuric skin findings and initial improvement in metastatic bone and lymph node disease, the patient had disease progression with worsening bone and new leptomeningeal metastases, as well as subcutaneous metastatic nodules, and was switched to second-line immunotherapy, tisotumab and bevacizumab. Unfortunately, the patient continued to have progressive metastatic disease, leading to multiple complications and hospitalizations, and was ultimately transitioned to hospice care. She passed eleven months post-presentation. Our case highlights the importance of considering retiform purpura as a rare manifestation of intravascular metastases in patients with cervical squamous cell carcinoma, the value of cutaneous metastases in the management of oncologic patients, and the need to further assess the prognostic utility of cutaneous metastases in the era of immunotherapy, which, based on our case, appears to remain a poor prognostic sign.