Cutaneous metastasis from visceral malignancy: A rare presentation.

Cutaneous metastasis is an uncommon manifestation of visceral malignancy and a grave prognostic indicator. In extremely rare cases it may be the presenting sign of underlying malignancy. Here we report two cases of carcinoma gall bladder that presented with skin nodule. Fine needle aspiration cytology of these nodules revealed metastatic deposits of adenocarcinoma and was instrumental in establishing the primaries.

Introduction

Cutaneous metastasis is an uncommon manifestation of visceral malignancy and in extremely rare cases it may be the presenting sign of underlying malignancy. The presence of cutaneous metastasis is a grave prognostic indicator with an average survival time of 7.5 months.[1] The incidence of metastasis of adenocarcinoma of gall bladder to the skin is rare, with only a few reported cases.[2-6] The skin lesions are easily accessible to fine needle aspiration cytology (FNAC) and may help in the diagnosis of the primary. We report two cases where FNAC of the cutaneous deposits helped in diagnosing the primaries in the gall bladder.

Case Reports

Case 1

A 42-year-old female underwent cholecystectomy for cholecystitis with cholelithiasis in 2006. Grossly the gall bladder was benign-looking and therefore not submitted for histopathology. A few months later, she presented with a painless nodule at the site of the cholecystectomy incision, along with a painless lump in the subcutaneous area over the right breast and enlarged left axillary lymph nodes.

Ultrasonography (USG) of abdomen revealed a 3 × 4 cm mass in gall bladder fossa with metastatic deposits in the liver. FNAC was done from all sites. Smears revealed sheets of pleomorphic cells with high Inucleo-cytoplasmic ratio and prominent nucleoli forming glandular pattern [Figure 1]. Diagnosis of adenocarcinoma with possibility of malignancy arising in gall bladder fossa and metastasizing to skin and axillary lymph nodes was rendered. Patient was advised biopsy of nodule in hypochondrium which confirmed the diagnosis.

Figure 1

Neoplastic cells forming acini and glands (H and E, × 500)

Case 2

A 51-year-old male presented with a small nodule in the umbilical region. Nodule increased in size despite local and systemic antibiotic treatment. FNAC yielded mucoid material with few atypical cells. Histology of the lesion showed adenocarcinoma with evidence of mucin secretion [Figure 2] periodic acid Schiff (PAS) stain showed positive staining for mucin.

Figure 2

Section showing malignant glands lying in pool of mucin and invading muscle (H and E, × 100)

Patient was evaluated further with the aim of localizing primary malignancy. USG abdomen showed small shrunken gall bladder. Computed tomography (CT) of the abdomen showed the presence of a growth in the gall bladder. FNAC from gall bladder growth was performed under ultrasound guidance. The smears were positive for adenocarcinoma.

Discussion

Cutaneous metastases from visceral carcinoma are relatively rare. An estimated 0.7-9% of these tumors metastasize to the skin. The most frequent primary tumor to metastasize to the skin is breast carcinoma forming 24% of all cutaneous metastasis, followed by carcinoma of the lung, colorectal carcinoma, renal carcinoma, ovarian carcinoma and bladder carcinoma with rates of 3.4-4% each.[78]

In men, carcinoma of the lung is the most common primary tumor, followed by carcinoma of large intestine and oral cavity.[9] In women, the primary tumor is mostly carcinoma of the breast, followed by carcinomas of the large intestine and ovary.[9] The incidence of metastasis of adenocarcinoma of gall bladder to the skin is even rarer, with only a few cases reported.[2-6]

The primary neoplasm is usually identified before the cutaneous metastasis but in approximately 8% of cases, cutaneous metastasis is the presenting feature as was seen in both our cases.[1] Fine needle aspiration cytology was instrumental in pointing to the diagnosis.

There is a need for microscopic examination of each and every excised gall bladder as 70% of gall bladder carcinomas present as diffusely growing lesion and gross distinction from chronic cholecystitis may be difficult.[10] This was the reason why the malignancy was not detected after cholecystectomy in case 1.

Conclusion

Here, we emphasize the need for microscopic examination of each and every excised gall bladder as 70% of gall bladder carcinomas present as diffusely growing lesion and gross distinction from chronic cholecystitis may be difficult.[10]