|Year : 2015 | Volume
| Issue : 3 | Page : 667
Cutaneous metastasis as primary presentation in unsuspected carcinoma esophagus: Report of two cases
Ashutosh Chauhan1, Anuj K Sharma2, BS Sunita3
1 Department of Oncology, Command Hospital (CC), Lucknow, Uttar Pradesh, India
2 Department of GI Surgery, Army Hospital (R and R), New Delhi, India
3 Department of Pathology, Command Hospital (CC), Lucknow, Uttar Pradesh, India
|Date of Web Publication||9-Oct-2015|
Department of Oncology, Command Hospital (CC), Lucknow, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Cutaneous metastasis from carcinoma esophagus is an extremely rare occurrence. It accounts for less than 1% among all cases of metastatic carcinoma esophagus. We present two such unusual cases in which the primary manifestation was cutaneous lesions. Histology from the biopsy of the lesion in one case was reported as adenocarcinoma and while that from the other case was reported as squamous cell carcinoma. A search for primary revealed previously unsuspected carcinoma esophagus in both the cases. The patients subsequently developed metachronous systemic lesions and expired within 5 months of appearance of the index skin lesion.
Keywords: Carcinoma, cutaneous, esophagus, metastasis
|How to cite this article:|
Chauhan A, Sharma AK, Sunita B S. Cutaneous metastasis as primary presentation in unsuspected carcinoma esophagus: Report of two cases. J Can Res Ther 2015;11:667
|How to cite this URL:|
Chauhan A, Sharma AK, Sunita B S. Cutaneous metastasis as primary presentation in unsuspected carcinoma esophagus: Report of two cases. J Can Res Ther [serial online] 2015 [cited 2019 Nov 14];11:667. Available from: http://www.cancerjournal.net/text.asp?2015/11/3/667/143347
| > Introduction|| |
Esophageal cancer is the eighth most common cancer and sixth leading cause of cancer death.  Worldwide, majority of the esophageal cancers are squamous cell carcinomas (90%), but in Western population the incidence of adenocarcinomas has increased over last two decades and now accounts for 45-55%.  Esophagus as the primary site of tumor with metastasis to the skin is a very rare phenomenon with a reported incidence less than 0.5% and it is the esophageal adenocarcinoma, which is more prone to be associated with cutaneous metastases.  We present two cases that had primary clinical presentation in the form of metastasis to the skin. Subsequent search for the primary site revealed the presence of carcinoma esophagus.
| > Case reports|| |
A 60-year-old man presented to our department with a 4-week history of multiple papules over the upper chest [Figure 1]. According to the patient, he had noticed the index lesion in the upper back and thereafter there was rapid proliferation of the same over next 4 weeks. He had been empirically treated with an unspecified, steroid containing ointment by a medical practitioner outside with no discernible benefit. He had a history of smoking 1-2 packs of cigarettes/day for past 30 years. The patient did not offer history of dysphagia, loss of appetite or weight loss at the time of presentation. Biopsy of one of the skin lesions was done. It showed dermal deposits of malignant squamous cell with no dysplasia of overlying squamous stratified epithelium [Figure 2]. The patient underwent upper gastrointestinal endoscopy as part of a protocol for a systemic search, which aimed at detecting the primary tumor site. This showed carcinoma located in the mid-thoracic part of the esophagus [Figure 3]a. Histological evaluation of the endoscopic biopsy of this lesion showed an intermediate grade squamous cell carcinoma of the esophagus according to the criteria of the American Joint Committee of Cancer.  Staging by contrast-enhanced tomography of chest and abdomen scan showed mediastinal lymph nodes without signs of any other tumor manifestation (T1-2, N1, M1, G2; esophageal squamous cell carcinoma Stage IV) [Figure 3]b. The patient was started on palliative chemotherapy with injection cisplatin (80 mg/m 2 ) and injection 5-fluorouracil (CF) (1000 mg/m 2 ) by continuous 24 h infusion day 1-4, given at 3-weekly intervals. This regimen had to be discontinued after four cycles as patient developed systemic metastases to liver and lung and his performance status deteriorated. The patient expired about 5 months from detection of the lesion.
|Figure 2: (a) Squamous cell carcinoma cell nests in sub dermal space; (b) With normal overlying epidermia (H and E, ×40)|
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|Figure 3: (a) Endoscopy picture of a stricture middle one-third esophagus in case 1 (b) Contrast enhanced computed tomography scan shows grwoth middle one-third esophagus in case 1|
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A 42-year-old man presented to our department with a 6-week history of solitary subcutaneous nodule on left upper arm [Figure 4]. Biopsy of this skin lesion was done. It showed dermal nests of malignant glandular cells prompting a diagnosis of metastatic adenocarcinoma [Figure 5]. The patient underwent a protocol esophagogastroscopy, which showed carcinoma located in the lower one-third part of the esophagus. Histological evaluation of the biopsied lesion revealed a high grade adenocarcinoma. Staging by contrast-enhanced tomography of chest and abdomen scan showed no other site of metastases. The patient subsequently received palliative chemotherapy with injection cisplatin (80 mg/m 2 ) day 1 and tablet capecitabine (1000 mg/m 2 ) PO BID, day 1-14, cycled every 3 weeks. After three cycles, the chemotherapy was discontinued as there was rapid progression in the disease state. There was appearance of systemic metastases at multiple sites (liver, lung, and bone). The patient died 4 months from detection of the index cutaneous lesion.
|Figure 5: (a) Normal epidermis (b) Malignant cell nests in sub cutis (H and E, ×40), (c) Inset: Malignant glandular cells|
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| > Discussion|| |
In general, skin metastases from malignant tumors of the internal organs are rarely seen, with a frequency of between 0.7% and 9% reported in various series.  The cancer types most commonly associated with cutaneous metastases are breast, lung and melanoma.  Esophageal carcinoma rarely present with clinical features of skin metastasis. There is limited review in recent literature, which is primarily in form of isolated case reports; hence, it is difficult to make an estimate of its actual incidence.  In a large review of 420 cases of cutaneous metastases, metastases from esophagus accounted for just three cases.  Although, liver and lung are most common site for metastases from esophageal cancer, the skin accounts for less than 1% of the metastatic sites for esophageal cancer. 
The two cases reported by us are highly unusual and rare in the fact that the skin was the primary and sole site of metastases deposits at the time of presentation in both the cases reported by us. In most cases of cutaneous metastases from carcinoma esophagus, which have been reported, the skin lesion occur during the course of appearance of metachronous visceral disease and develop 2.9 years later than the index lesion.  Another unusual feature in these cases was that they primarily presented with cutaneous metastases in hitherto unsuspected underlying malignancy of the esophagus. Metastatic cutaneous lesions from internal malignancies present in myriad presentations which include inflammatory papules and patches or erythematous, indurated plaques, or fixed subcutaneous nodules. The skin lesions in our two cases were mistaken for more common benign skin disorders and treated for the same. The definite diagnosis could be established only after the biopsy of cutaneous lesion and subsequent search for the primary.
Esophageal cancer is one of the cancers associated with a high mortality rate. The relative 5 year survival for all stages is reported as 15%. Squamous cell carcinoma is the most common histologic subtype of esophageal cancer. In recent decades, there has been a rapid increase in the incidence of esophageal adenocarcinoma in Western countries. , It has been reported that a high rate of recurrence and its predominance in patients with tumors of the lower third of the esophagus may suggest biological differences between the adenocarcinoma and the squamous cell carcinoma.  However, since cutaneous metastases from esophageal cancer itself is a rare phenomenon, it has not been investigated as to which histologic subtype tends to metastasize to the skin more.
Metastatic esophageal carcinoma has very poor prognosis with median survival of 9 months.  Combination chemotherapy when compared to monochemotherapy is associated with significantly higher response rates, but nevertheless results in similar survival. CF currently represents one of the most effective regimens for advanced esophageal cancer. Prognosis for the majority of patients, however, remains poor as increases in survival were moderate at best.  Survival differences in terms of histology of cutaneous metastatic esophageal carcinoma has not been investigated, again owing to the fact the that number of cases are too few. It may appear from these two cases that the prognosis of patients with cutaneous metastases is even worse than patients who present with visceral metastases (both showed disease progression, while on chemotherapy, and both did not survive beyond 5 months from initial diagnosis). These cases highlight a rare manifestation of metastases from esophageal cancer and that clinicians are well advised to consider an underlying solid organ malignancy when confronted with an apparent primary skin lesion.
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