|Year : 2010 | Volume
| Issue : 3 | Page : 316-317
Carcinoma colon presenting as cutaneous metastasis to an old operative scar of hysterectomy
Shilpi Singh Gupta, Onkar Singh
Department of Surgery, M.G.M Medical College and M.Y. Hospital, Indore - 452 001, India
|Date of Web Publication||29-Nov-2010|
Shilpi Singh Gupta
VPO- Sangowal, Tehsil- Nakodar, District- Jalandhar - 144 041, Punjab
Cutaneous metastases from asymptomatic colonic carcinoma have been documented rarely in the literature. But cutaneous metastasis to an already present operative scar as the mode of presentation of otherwise asymptomatic colon cancer is an extremely rare phenomenon which has been described only thrice till now. We report such a case of adenocarcinoma of sigmoid colon which presented as a large subcutaneous metastasis to an already existing scar of hysterectomy.
Keywords: Carcinoma colon, cutaneous metastasis
|How to cite this article:|
Gupta SS, Singh O. Carcinoma colon presenting as cutaneous metastasis to an old operative scar of hysterectomy. J Can Res Ther 2010;6:316-7
| > Introduction|| |
Skin metastases from colon cancer are rare and usually develop after the primary tumor has manifested. This usually occurs to the scar of incisions used for resection of the colonic tumor itself. ,, Cutaneous sites other than abdominal scar include skin of extremities, penis, head and neck. ,,,,,, Manifestation of colon carcinoma as cutaneous metastasis to an already existing scar of incision used for unrelated surgery done years back is an extremely rare occurrence with only three cases mentioned in the literature. ,, We report another such case.
| > Case Report|| |
A 72-year-old lady presented with two and half month history of a lump in the skin of her anterior abdominal wall in the region of a lower midline scar of previous hysterectomy done twenty-four years back. Lump was associated with vague pain. She did not complain any other symptoms including alteration in her bowel habit and bleeding per rectum. On examination, a hard mass with overlying skin tethered to it was felt in the scar of previous hysterectomy. After her hysterectomy, she had been enjoying good health. Computerized tomography (CT) scan of the abdomen showed a large subcutaneous mass in lower anterior abdominal wall in the previous scar, along with a growth in the sigmoid colon [Figure 1]. Colonoscopic biopsy taken from this area showed features of moderately differentiated adenocarcinoma. Laparotomy was performed via midline incision making it elliptical around the subcutaneous mass and taking healthy surrounding skin. There was no other site of metastasis or carcinomatous nodules found during the operation. The mass was not contiguous with the tumor in the sigmoid colon. Mass was excised along with resection of the sigmoid colon and end-to-end anastomosis was done. Histopathological examination of the colonic specimen confirmed moderately differentiated adenocarcinoma reaching up to the serosa. None of the eleven lymph nodes removed were found to be positive for tumor cells. Cutaneous specimen showed similar features of adenocarcinoma as that of bowel tumor. She made uneventful recovery and was referred for chemotherapy which she took and tolerated well. After eighteen months, she is well without any evidence of recurrence.
|Figure 1: Abdominal CT scan of a 72-year-old woman (a) axial section- showing a partially obstructing growth in sigmoid colon with a subcutaneous mass in the lower abdominal wall in midline, (b) Sagittal view showing large subcutaneous mass. It measured 11.9 × 7.3 cm|
Click here to view
| > Discussion|| |
Cutaneous metastases from colorectal cancer are infrequent and usually occur when the disease has widely spread. , In colorectal cancers, cutaneous metastases usually develop after the primary tumor has been identified and/or operated. These are extremely rare before the identification of the primary tumor and in the absence of secondaries to the liver; however, few cases have been described which presented with cutaneous metastases only. ,,,,,, The most frequent site of cutaneous metastases from colorectal cancer is the abdomen.  Other sites including extremities, penis, head and neck have been described. ,,,,,, Cutaneous operative-scar metastases usually occur in the scars of incisions used for resection of the colorectal tumor itself, rather than in an already present scar. 
Although there are many cases reported of colorectal cancer spreading to the operative scars after resection of the tumor; , presentation with cutaneous metastasis to an already present operative scar has been reported only thrice in the world literature, till now. ,, Iwase et al. in 1993 described a patient with a solitary subcutaneous metastasis to the scar of open prostatectomy, as the first manifestation the colonic cancer.  Later in 2003, Wright et al. reported second such case which presented with metastasis to the scar of open cholecystectomy done eighteen years back.  Recently, in 2008, Uchendu et al. reported another similar case presenting with metastasis to appendicectomy scar done fifty years back. 
The mechanism of cutaneous metastasis is not fully known although several possible theories have been put forward including direct extension, hematogenous or lymphatic spread, spread along the ligaments of embryonic origin and implantation of tumor cells.  Latter might be the most likely mechanism involved in metastasis to the scars of incisions used for tumor resection.  However, in case of metastasis to already existing operative scar of an unrelated surgery done years back, direct extension of the tumor along the previous adhesions or alteration in lymphatic drainage in the local area of the scar may be the more likely mechanisms. , These could be the possible mechanism responsible for implantation of the tumor cells in our case.
Thus, in view of the fact that the exact pathogenesis of scar metastasis is not clear, we support the opinion of Wright et al. that scar tissue may have a predilection for metastatic deposits, either because of disturbed microscopic anatomy around the scar, probably that of the lymphatic channels, or the local environments of the scar may be receptive to metastatic tumor cells, possibly due to alteration in adhesion molecule profile or altered local immuno-surveillance mechanisms. [ 10] The exact pathogenesis and underlying mechanisms of scar metastasis remain unclear at present, and need to be investigated further. Our case along with three previously reported cases will definitely provide insight to these.
| > References|| |
|1.||Reilly WT, Nelson H, Schroeder G, Wieand HS, Bolton J, O'Connell J. Wound recurrence following conventional treatment for colorectal cancer: A rare but perhaps underestimated problem. Dis Colon Rectum 1996;39:200-7. |
|2.||Camci C, Turk HM, Buyukberber S, Karakok M, Koruk M, Beyazity Y, et al. Colon carcinoma with synchronous subcutaneous and osseous metastasis: A case report. J Dermatol 2002;29:362-5. |
|3.||Luh JY, Han ES, Simmons JR, Whitehead RP. Poorly differentiated colon carcinoma with neuroendocrine features presenting with hypercalcemia and cutaneous metastases: Case report and review of the literature. Am J Clin Oncol 2002;25:160-3. |
|4.||Gray M, Das S. An unusual presentation of colorectal carcinoma. Br J Clin Pract 1989;43:344-5. |
|5.||Davis TP, Knollmann-Ritschel B, DeNobile JW. An unusual cutaneous presentation of metastatic colon carcinoma. Dis Colon Rectum 1995;38:670. |
|6.||Proffer LH, Czarnik KL, Sartori CR. Colon carcinoma cutis: A case report. Cutis 1999;63:301-2. |
|7.||Stavrianos SD, McLean NR, Kelly CG, Fellows S. Cutaneous metastasis to the head and neck from colonic carcinoma. Eur J Surg Oncol 2000;26:518-9. |
|8.||Banerjee GK, Lim KP, Cohen NP. Penile metastasis: An unusual presentation of metastatic colonic cancer. J R Coll Surg Edinb 2002;47:763-4. |
|9.||Iwase K, Takenaka H, Oshima S, Kurozumi K, Nishimura Y, Yoshidome K, et al. The solitary cutaneous metastasis of asymptomatic colon cancer to an operative scar. Surg Today 1993;23:164-6. |
|10.||Wright PK, Jha MK, Barrett PD, Bain IM. Colonic Adenocarcinoma Presenting as a Cutaneous Metastasis in an Old Operative Scar. J Postgrad Med 2003;49:157-8. |
|11.||Uchendu I, Hotouras I, Jonalagadda S, Osman K, Mandal A, Mathur D. Colonic cancer invading appendicectomy incision: A case report and literature review. Grand Rounds 2008;8:35-7. |
|12.||Saeed S, Keehn CA, Morgan MB. Cutaneous metastasis: A clinical, pathological, and immunohistochemical appraisal. J Cutan Pathol 2004;31:419-30. |
|13.||Morton BA, Scholes J, Kral JG. An unusual presentation of colon cancer. J Surg Oncol 1986;33:92-4. |
|14.||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. |