Abstract

A 51 year old man presented with multiple painless skin nodules throughout his body for 3 weeks. He complained of cramping pain in his calf muscles and thighs for 3 months, occasional fever with chills for 2 months and lost about 10kgs in these 3 months. Initially he was diagnosed as a case of viral myositis. His CPK and LDH were raised, febrile antigens and widal test were negative, CA 19-9 was very high (5018 u/ml). Biopsy of skin nodules showed features of metastatic adenocarcinoma.

Ibrahim Med. Coll. J. 2010; 4(1): 31-33

Key word: Cutaneous metastasis, adenocarcinoma

Address for Correspondence: Mazharul Huque Khan, Professor, Department of Surgery, Bangladesh Institute of Research and Rehabilitation for Diabetes, Endocrine and Metabolic Disorders (BIRDEM), Dhaka, Bangladesh, E-mail: [email protected]

Introduction

Cutaneous metastasis from underlying carcinoma is relatively uncommon in clinical practice, but is very important to be recognized. Skin involvement has been reported as the first sign in approximately 1% of patients suffering from internal malignancy. Involvement of skin can occur as a result of direct extension of tumor, local or distant metastasis. Early recognition helps in accurate and prompt diagnosis and timely treatment. A high index of suspicion is required because the clinical findings may be subtle. The recognition of cutaneous metastasis often dramatically alters therapeutic plans as it signals to widespread dissemination and poor prognosis.

Case report

A 51 year old male presented with multiple skin nodules throughout his body for 3 weeks. However his complains started 3 months back with cramping pain in his thighs and calf muscles having no relation with walking or exercise. He also developed occasional fever (1020F) with chills in last 2 months and lost about 10kgs in these 3 months. Initially he was diagnosed as a case of viral myositis. Nodules were multiple, located throughout his body, more prominent on thighs. Size was variable, firm, non tender, fixed to skin and mobile. All the parameters on general examination were normal except for poor body built and malnutrition. Abdominal and other systemic examinations were unremarkable. Investigations revealed neutrophilic leukocytosis, and raised ESR (42 mm in 1st hour). Blood biochemistry including liver function test, renal function test, thyroid function test- all were within normal range except for increased CPK (48 U/L), increased LDH (618 I.U.). MT test, widal test, febrile antigens, X-ray chest, USG of whole abdomen all were within normal range. Histopathology of an excised skin nodule reported as metastatic adenocarcinoma with possible primary site in the GIT, lung, or, kidney. Tumor marker CEA was not significant (11.7ng/ml) but CA 19-9 was found to be very high (5018 u/ml). Review USG revealed a linear hypoechoic area in the tail of the pancreas. He was advised CT scan of the whole abdomen. But the patient refused CT scan and went out of our follow up.

MACROSCOPIC appearance of excised nodule:

The excised nodule was about 2cmx3cm in size, oval in shape, firm to hard in consistency, with irregular surface. Cut surface was fleshy at look.

Fig-1. Enlarged right supraclavicular lymph node

Fig-2. Cutaneous nodule on the anterior aspect of right

MICROSCOPIC appearance of excised nodule:

Sections showed a malignant epithelial tumor. The anaplastic cells were arranged in clusters and acinar pattern separated by thin fibrous septae.

Fig-3. Biopsy taken from one of the multiple nodules

Diagnosis: The case was diagnosed as one of adenocarcinoma, metastatic in nature.

                        Histo-pathological slides of cutaneous nodule:

Photograph of Cutaneous nodule (Metastatic):

Discussion

Cutaneous metastases occur in 0.7% to 9.0% of all patients with cancers.1 Skin metastases are the first sign of extranodal disease in 7.6% of cancer patients.2 Incidence of various tumours metastasizing to the skin correlate with the sex-wise frequency of occurrence of various primary malignancies.1 Breast carcinoma (69%) is the commonest cause of cutaneous metastases in women followed by carcinoma of the large intestine (9%), lungs and ovaries (4%).3 The primary sites of carcinoma with cutaneous metastases among men in decreasing order are lungs (24%), large intestine (19%), oral cavity (12%), kidney and stomach (6% each).3 Cutaneous metastases as the first sign of internal malignancy are seen most frequently with carcinoma of the lung, kidney and ovary.4

Cutaneous metastases are commonly early indicators of metastatic disease.5 Diagnosis may be delayed for several months unless the skin lesion grows rapidly or other sites such as the lung or liver are affected by tumour spread.6 In general, skin metastasis is a poor prognostic sign. If the primary tumour is the lung, cervix or the oesophagus most patients die within three months. In the case of colorectal cancer however skin involvement is not a preterminal event.7 Treatment involves radiotherapy or excision and patients may survive up to a year.7,8

This case is reported here to highlight the importance of cutaneous metastases as a presenting sign of internal malignancy. Such metastases offer an easily accessible tissue sample for rapid histopathological diagnosis of the malignancy. They can be an important presenting feature of a recurrence after successful therapy of the internal malignancy. Discovery of cutaneous metastases may alter the staging of an internal malignancy and hence prognosis for a patient. A thorough clinical examination of the skin for any metastasis is mandatory for a patient with any type of cancer.

References

1.  Spencer PS, Helm TN. Skin metastases in cancer patients. Cutis 1987; 39:119-121.

2.  Lookingbill DP, Spangler N, Helm KF. Cutaneous metastases in patients with metastatic carcinoma. A retrospective study of 4020 patients. J Am Acad Dermatol 1993; 29: 228-236.

3.  Johnson WC. Metastatic carcinoma of the skin: incidence and dissemination. In Lever’s Histopathology of the Skin, 8th edn, Edited by Elder D, Elenitsas R, Jaworsky C, Johnson Jr. B, Lippincott-Raven, Philadelphia, 1997; 1011-1018.

4.  Schwartz RA. Cutaneou. ~ Metastatic disease. J Am Acad Dermatol 1995; 33: 161-185.

5.  Lookingbill DP, Spangler N, Helm KF. Cutaneous metastases in patients with metastatic carcinoma: A retrospective study of 4020 patients. J Am Acad Dermatol 1993; 29: 228–236.

6.  Gmitter TL, Dhawan SS, Phillips MG, Wiszniak J. Cutaneous metastases of colonic adenocarcinoma. Cutis 1990; 46: 66–8.

7.  Brady LW, O’Neill EA, Farber SH. Unusual sites of metastases. Semin Oncol 1977; 4: 59–64.

8.  Stavrianos SD, McLean NR, Kelly CG, Fellows S. Cutaneous metastasis to the head and neck from colonic carcinoma. Eur J Surg Oncol 2000; 26: 518–9.