A rare case of multiple skin metastases from squamous cell carcinoma of the esophagus.

BACKGROUND: Esophageal cancer is an aggressive disease that generally has a poor prognosis. Patients affected by the disease usually present with signs and symptoms related to local growth of the tumor, gastrointestinal bleeding and nutritional impairment. Skin metastases are rare events, associated with advanced stage and poor survival. CASE REPORT: We report the case of a 51-year-old man who presented poor general status, dysphagia, weight loss and skin lesions disseminated throughout the body. Endoscopic examination revealed the presence of esophageal squamous cell carcinoma, and biopsies of skin lesions showed metastasis of this cancer to the esophagus.
CONCLUSIONS: We believe that any suspicious lesion that presents together with a history of gastrointestinal malignancy should be biopsied, since it can change the staging and prognosis of patients.

Background

Squamous cell esophageal cancer is an aggressive disease that generally presents at an advanced stage when diagnosed. The clinical presentation of the majority of patients can be attributed to the local and regional spread of the disease. Symptoms related to distant metastasis can also be found; lymph nodes, lungs and liver are the main affected sites [1]. Cutaneous metastases of abdominal malignancies are uncommon, with frequency ranging from 0.7 to 9% [2]. Skin metastases from esophageal cancer are even rarer, and affect less than 1% of cases [3].

We report the case of a 51-year-old patient who presented with multiple skin lesions due to metastasis of squamous cell cancer of the lower esophagus.

Case Report

A 51-year-old male attended the Santa Casa clinic of Porto Alegre reporting dysphagia for 4 months, associated with weight loss and appearance of painless skin lesions in limbs, abdominal wall, trunk and scalp. Endoscopy revealed the presence of an elevated, ulcerated and stenotic lesion in the lower esophagus, affecting about 60% of the circumference of the organ, 5 cm in length. An elevated and irregular lesion was also identified in the second part of the duodenum. Biopsy revealed squamous cell carcinoma in both sites. Tomography of the thorax and abdomen showed multiple pulmonary and liver nodules suggestive of secondary implants, as well as regional lymph node enlargement. The patient’s skin lesions were painless rocky nodules of various sizes, presenting some bleeding to the touch, with the largest located on the scalp (Figure 1). We decided to perform excisional biopsies of 2 lesions, one in the abdominal wall and another on the right forearm. The result indicated metastatic carcinoma with immunohistochemical panel revealing squamous cell carcinoma of probable esophageal origin (Figure 2). The patient was then considered out of surgical treatment, and was then referred for palliative management with radio- and chemotherapy. He died 5 months after diagnosis.

Figure 1

Multiple skin lesions, with the largest on the scalp.

Figure 2

Histological pattern of skin lesions seen at microscopy.

Discussion

Skin metastases of malignant gastrointestinal tumors are rare and have a poor prognosis. For esophageal carcinoma, authors believe that the incidence is less than 1%, and report survival times from 4 to 20 months after diagnosis [4].

The cancer types most commonly associated with skin dissemination are breast, lung and melanoma [5]. Metastatic spread to the skin occurs either hematologically or via the lymphatic system, and presents in the form of growing papules or nodules of various sizes [4].

Only a small number of cases of squamous cell esophageal cancer with solid skin metastasis have been reported. Presentation with diffuse lesions, as with our patient, most likely indicating highly aggressive disease, was also report by Iwanski et al. [6]. In their report, the lesions appeared after surgery, indicating cutaneous recurrence of the disease.

According to Omranipour et al., the most frequent site of cutaneous metastasis from gastrointestinal cancer is the skin of the abdominal wall. The scalp is also a common site for cutaneous metastatic disease, but the extremities and the face are generally not affected [7]. Our patient’s largest lesion was on the scalp, but they were spread throughout the body.

Conclusions

Although rare, we strongly believe that any suspicious lesion that presents together with a history of gastrointestinal malignancy should be biopsied, since finding a skin metastasis will change the staging of the disease and its prognosis, and hence its treatment.