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On-line version ISSN 1806-4841
An. Bras. Dermatol. vol.86 no.5 Rio de Janeiro Sept./Oct. 2011
WHAT IS YOUR DIAGNOSIS?
Case for diagnosis*
Mariane de Castro PerisseI; Camila FerronI; Ricardo Barbosa LimaII; Márcio Soares SerraIII; Carlos José MartinsIV
IPostgraduate student in the Department of Dermatology, Gaffrée e Guinle University Hospital, Federal University of the State of Rio de Janeiro (HUGG - UNIRIO), Rio de Janeiro (RJ), Brazil
IIPostgraduate degree in Dermatology, Assistant Professor in the Department of Dermatology, Federal University of the State of Rio de Janeiro (HUGG - UNIRIO), Rio de Janeiro (RJ), Brazil
IIIMaster in Dermatology, Volunteer Professor in the Department of Dermatology, Federal University of the State of Rio de Janeiro (HUGG - UNIRIO), Rio de Janeiro (RJ), Brazil
IVMaster in Dermatology, Associate Professor and Head of the Department of Dermatology, Federal University of the State of Rio de Janeiro (HUGG - UNIRIO), Rio de Janeiro (RJ), Brazil
Cutaneous metastases of visceral cancers are relatively rare, with an incidence of 0.7 to 10%. The most frequent primary sites are breast, lung and colon tumors. They generally occur after the primary cancer is diagnosed and signify a poor prognosis. They may occur as the first manifestation in 20% of cancers in general. The most common manifestations are single or multiple asymptomatic nodules, most often located on the chest, abdomen, head and neck, sometimes with unusual clinical features which present a challenge to clinical diagnosis.
Keywords: Adenocarcinoma; Gastrointestinal neoplasms; Skin neoplasms
60 year-old male patient with asymptomatic nodules on the face, neck, chest and scrotum noted 3 months previously. Reported smoking, drinking and illicit drug use and complained of fatigue, heartburn and weight loss of 15kg over the 3-month period. Physical examination revealed erythematous-violaceous nodules on the scalp, face, neck, chest, upper limbs and scrotum. The nodules, some of them exulcerated, were of firm consistency, with smooth surfaces, measuring between 0.5 and 2.0 cm in diameter, asymptomatic. Palpable lymph nodes in the occipital and posterior cervical regions. Increased abdominal size was noted, with ill-defined mass (Figures 1 and 2).
A biopsy of a lesion was performed and the histopathological examination revealed diffuse infiltrate in the dermis, with the presence of cells with clear cytoplasm with nuclei compressed to the periphery, characterizing signet-ring cells (Figure 3). Digestive endoscopy showed nodular and ulcerated lesions in the antrum (also biopsied). A CT scan of the abdomen revealed an infiltrating lesion, with swelling in the antrum and gastric body. The chest scan was normal.
Given the patient's clinical symptoms, diagnostic hypotheses were formulated for cutaneous lymphoma, cutaneous metastases and immunosuppression-related cryptococcosis.
The histopathological examination of the skin lesion revealed metastatic adenocarcinoma, while that of the antrum lesion showed a poorly differentiated adenocarcinoma with signet-ring cells, leading to a final diagnosis of Stage IV gastric cancer with skin metastasis. The patient underwent chemotherapy but died five months following the diagnosis of neoplasia.
Cutaneous metastases (CM) of visceral cancers are fairly rare, with an incidence of 0.7 to 10%. 1 The most commonly encountered primary sites are tumors in the breast, lung and colon. They usually occur after the primary cancer is diagnosed and signify a poor prognosis. 2 The metastases may appear as a first manifestation in 20% of cancers in general. Although gastric cancer is common it accounts for only 6% of all CM in men and 1% in women. 2 Fernandez et al., in a study of 11 cases of CM of gastric adenocarcinoma, found that CM were the initial manifestation of the disease in 64% of patients, as in our reported case. 3
The CM can be due to lymphatic or hematogenous spread, contiguity or iatrogenic implantation.1
The histological type most prone to distant metastasis is signet-ring cell adenocarcinoma.4
The most common manifestations are hemispheric single or multiple nodules with moderate to firm consistency and with smooth shiny surfaces. The manifestations can also appear as macules, hard infiltrated plaques, discoid lesions, and tumor nodules with telangiectasia or ulcerations. Herpetiform, zosteriform or erysipelas-like formations are frequently mentioned as patterns of cutaneous dissemination. Some typical features are erysipeloid carcinoma, cuirass cancer and neoplastic alopecia. Most of the CM are asymptomatic, but sometimes they can be itchy and, at the advanced stage, painful. 5
Located anywhere in the body, the manifestations most frequently appear on the chest (33%), abdomen (22%), head and neck (10%). 6 In the umbilical region they are known as Sister Mary Joseph's nodule 5. In gastric adenocarcinoma, single or multiple nodules generally affect the abdominal wall, while generalized CM is uncommon. 7
Treatment is usually palliative. Surgical excision and radiotherapy are the first options for treating small numbers of lesions. 6
The literature shows an increased incidence of cutaneous metastases in recent decades, related to increased rates of cancer and post-treatment survival. In the event of encountering single or multiple cutaneous nodules with a nonspecific appearance and of a firm consistency, the dermatologist should always include the possibility of CM in his diagnostic hypotheses given that their presence can alter the prognosis of the disease.
1. Hu SC, Chen GS, Lu YW, Wu CS, Lan CC. Cutaneous metastases from different internal malignancies: a clinical and prognostic appraisal . J Eur Acad Dermatol Venereol. 2008;22:735-40. [ Links ]
2. Xavier MH, Vergueiro T de R, Vilar EG, Pinto JM, Issa MC, Pereira GB, et al. Cutaneous metastasis of gastric adenocarcinoma: An exuberant and unusual clinical presentation. Dermatol Online J. 2008;14:8. [ Links ]
3. Aneiros-Fernandez J, Husein-ElAhmed H, Arias-Santiago S, Escobar Gómez-Villalva F, Nicolae A, O'Valle Ravassa F, et al. Cutaneous metastasis as first clinical manifestation of signet ring cell gastric carcinoma. Dermatol Online J. 2010;16:9. [ Links ]
4. Ahn SJ, Oh SH, Chang SE, Jeung YI, Lee MW, Choi JH. Cutaneous metastases of gastric signet ring cell carcinoma masqueradingas allergic contact dermattitis. J Eur Acad Dermatol venereol. 2007;21:123-4. [ Links ]
5. Nashan D, Müller ML, Braun-Falco M, Reichenberger S, Szeimies RM, Bruckner-Tuderman L. Cutaneous metastases of visceral tumors: a review. J cancer res clin oncol. 2009;135:1-14 [ Links ]
6. Segura Huerta A, Perez-Fidalgo JA, Lopez-Tendero P, Ginores R, Sarrio, Aparício UJ. Supervivência de trace años en una paciente com metástasis cutáneas aisladas de adenocarcinoma gástrico. An Med Interna. 2003;20:251-3. [ Links ]
7. Lookingbill DP, Spangler N, Helm KF. Cutaneous metastases in patients with metastatic carcinoma: a retrospective study of 4020 patients. J Am Acad Dermatol. 1993;29:228-36 [ Links ]
Mariane de Castro Perisse
Rua Rita Ludolf 16/402 Leblon
22440-060 Rio de Janeiro - RJ, Brazil
Received on 17.10.2010
Approved by the Advisory Board and accepted for publication on 29.11.2010.
Conflict of interest: None
Financial funding: None
* Work undertaken at the Department of Dermatology, Federal University of the State of Rio de Janeiro (HUGG - UNIRIO), Rio de Janeiro (RJ), Brazil