Cutaneous metastases from gastric adenocarcinoma.

Sir,

Cutaneous metastases from internal primary tumors are uncommon. Typically, they are associated with an advanced stage of the disease and a poor prognosis. A metastatic adenocarcinoma in the skin is usually secondary to a tumor in the large intestine, lung, breast, or ovary. Here, we describe the case of a 63-year-old man with a nodule on his neck in whom biopsy showed metastatic adenocarcinoma; subsequent endoscopic examination revealed a gastric tumor.

A 63-year-old male patient presented to our dermatology clinic with a nodule on the left side of the neck. The nodule had been present for approximately 2 months. The patient also had dysphagia and weight loss. His past medical history was unremarkable except for hypertension.

There was bilateral inguinal lymhadenopathy. On the left side of his neck and in the left submandibular area there were two solid, erythematous, infiltrated, well-circumscribed nodular lesions [Figure 1]. Two other small nodules were present on the right side. Biopsy from the nodule on his neck showed epidermal acanthosis and diffuse infiltration of the dermis by polygonal/round cells with irregular nuclei and poor cytoplasm. Some of them had the typical morphology of signet-ring cells [Figure 2]. Immunohistochemical study revealed that the dermal infiltration was negative for anti-leukocyte common antigen and positive for cytokeratin.

Figure 1

Two solid, erythematous, infiltrated, well-circumscribed nodular lesions on the left side of the neck

Figure 2

Diffuse infiltration of the dermis by polygonal/round cells with irregular nuclei and poor cytoplasm. Some of them had the typical morphology of signet-ring cells (H and E, ×100)

The blood counts were normal. Blood biochemistry showed blood urea 74 mg/dl, creatinine 1.29 mg/dl, uric acid 11.3 mg/dl, cholesterol 233 mg/dl, triglycerides 215 mg/dl, lactate dehydrogenase 484 U/l levels, and carcinoembryonic antigen 148 mg/ml. Abdominal computerized tomography scan revealed minimal thickening of the stomach wall. Upper gastrointestinal endoscopy demonstrated a tumoral mass extending from the cardia to the esophagus. Biopsy from the tumoral lesion revealed gastric adenocarcinoma. General surgery and oncology consultation was asked for and the patient was evaluated as inoperable and was put on combination chemotherapy.

The skin is an unusual location for metastasis from visceral neoplasms, the incidence ranging from 0.7% to 9%.[1-3] The incidence of cutaneous metastasis from carcinomas of the upper digestive tract has been reported to be less than 1%. Umbilical metastasis, Sister Mary Joseph's nodule, is the typical site for a cutaneous tumor resulting from metastasis of gastric cancer.[134] Apart from the umbilical metastasis, the most common clinical presentation of gastric carcinoma metastatic to the skin is as multiple discrete, slow-growing, hard nodules.[1] Lesions are solitary or multiple and mostly symptom free, as in our patient. However, metastatic skin tumors may appear in a zosteriform pattern, as scarring alopecia, or as epidermoid cyst–like or condyloma acuminatum–like lesions. The appearance of cutaneous metastasis has been reported to follow the diagnosis of gastric carcinoma by 3–10 years.[15] Although cutaneous metastases usually appear late in the course of the disease, they may also rarely be the presenting sign.[12] Internal cancer only uncommonly presents itself with skin metastasis.

In conclusion, we suggest that long-standing firm and nonpainful nodules, nonhealing ulcers, or persistent indurated erythema need to be biopsied to rule out cutaneous metastasis of visceral cancer.