Cutaneous Metastases from Gastric Carcinoma: An ...

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from gastric carcinoma on his chin and cheek resembling sebaceous cysts. ... Cutaneous metastasis from gastric carcinoma is uncommon with skin rarely ...
Cutaneous Metastases from Gastric Carcinoma: An Unusual Case Presentation.

Abstract We report the case of a 71-year-old gentleman who initially developed cutaneous metastases from gastric carcinoma on his chin and cheek resembling sebaceous cysts.

Introduction Cutaneous metastasis from gastric carcinoma is uncommon with skin rarely involved by metastatic cancers. Gastric carcinoma is known for its propensity for recurrence in the tumour bed. Haematogenous spread includes sites such as the liver. We describe a 71-year-old gentleman who initially developed cutaneous metastases from gastric carcinoma on his chin and cheek resembling sebaceous cysts, and subsequently developed similar lesions on his thorax and abdomen.

Case Report A 71-year-old gentleman was admitted for palliative oesophageal stenting for dysphagia in March 2006. He was diagnosed six months prior with differentiated adenocarcinoma of the proximal stomach with widespread lymphovascular space invasion and extensive serosal involvement; proximal and distal margins were free. A proximal gastrectomy, omentectomy and nodal dissection were performed in October 2005. New liver lesions and pulmonary nodules were subsequently noted on computerized tomography one month prior to stenting in February 2006. At that time, two skin lesions on the left chin and right cheek were thought to be infected sebaceous cysts. These were excised and drained under local anesthetic. Biopsies showed metastatic adenocarcinoma consistent with spread from a gastric primary. During the admission for oesophageal stenting, cutaneous nodules on the thorax resembling infected sebaceous cysts were noted. These were also of recent onset with the patient himself being unaware of them (Figure 1).

INSERT FIGURE 1

Discussion Cutaneous metastasis from a gastric primary is extremely rare; incidence is 1.1% in the Caucasian population1, 2. Visceral neoplasms tend to present with cutaneous metastases in up to 10% of cases3 with carcinomas most commonly metastasizing to the skin in males being melanoma, lung, colorectal and those of the oral cavity1. Skin involvement usually indicates advanced malignancy but has also been reported as the first indicator in up to 7.8% of cases2, 4. This has mainly been in carcinomas of the lung, kidney and ovary5. Regarding cutaneous manifestation specifically being the first sign of gastric adenocarcinoma, we found only three reported cases6, 7, 8. Cutaneous manifestations of visceral malignancies can vary in both location and clinical presentation. Skin lesions can present either locally near the primary or at a distant site with breast and lung cancers tending to produce local lesions on the thoracic wall2. Although these cancers can also lead to distant metastases, cancers like renal cell carcinoma show a strong predilection for distant metastases primarily2. Gastric carcinomas most often metastasize to the liver, peritoneal cavity and regional lymph nodes with cutaneous manifestations being very unusual. Reported cases to date have presented with either local metastases to the abdominal wall or distant metastases to the head, neck, axilla, thorax and extremities1, 5. Ours is unique as the metastases were both local, to the abdomen and distant, to the thorax and face. Many cutaneous metastases resemble benign dermatological conditions. Clinically, they can present as non-ulcerated or ulcerated nodules, plaques, neoplastic alopecia, carcinoma erysipelatoides, herpetiform or zosteriform lesions, and inflammatory cellulitis-like lesions1, 2, 4, 5. Specifically, cutaneous metastases from gastric carcinoma may take the form of subcutaneous nodules, indurated scar-like lesions, carcinoma erysipelatoides9 and cellulitis-like lesions. In our case, nodules on the face and trunk clinically presented as infected sebaceous cysts, while histology confirmed otherwise.

The difficulty in early detection of cutaneous metastases is because they often mimic common dermatological conditions, like sebaceous cysts. Interestingly, cutaneous lesions in association with gastrointestinal neoplasm are also found in Muir Torre syndrome. This is an important differential diagnosis in younger patients with a history of familial occurrence who present with a gastric primary and cutaneous lesions mimicking sebaceous cysts. As with other cutaneous metastases, neoplastic skin lesions of gastric carcinoma usually indicate advanced disease, though there has been a reported case of longterm survival after systemic therapy in a patient with isolated cutaneous metastasis10. Prognosis varies greatly, depending on the pattern and distribution of the metastases but in the majority of cases, cutaneous metastasis indicates a very poor prognosis as seen from our palliative case with our patient surviving only a further three months after his stenting. In order to improve prognosis, it is vital to perform a complete skin examination and educate patients regarding monitoring and reporting any new skin changes to their doctor. Cutaneous metastasis may be the first presentation of an internal malignancy or indicate recurrence of a previous malignancy. In either case, prompt assessment and follow up is critical.

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