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CORRESPONDENCE
Year : 2018  |  Volume : 14  |  Issue : 3  |  Page : 716-718

Multiple subcutaneous metastases as the solitary presenting site of colorectal cancer


Department of Radiotherapy, Regional Institute of Medical Sciences, Imphal, Manipur, India

Date of Web Publication12-Jun-2018

Correspondence Address:
Dr. Chandran Nallathambi
Department of Radiotherapy, Regional Institute of Medical Sciences, Lamphelpat, Imphal - 795 004, Manipur
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.172586

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 > Abstract 


Skin metastases, as a presenting symptom of gastrointestinal malignancies, are very rare and signify aggressive disease. They usually occur after a long period of diagnosis and along with other visceral metastases. We present the case of an 18-year-old male with diffuse subcutaneous metastases as a presenting feature and as the only site of distant metastases due to rectosigmoid adenocarcinoma. They clinically mimic benign skin lesions and the patient might not present to an oncologist. The diagnosis has to be established by skin biopsy, which will show tumor cell infiltration of the epidermis, dermis, and/or subcutaneous fat. There is no established local treatment for diffuse lesions. Systemic chemotherapy indicated for metastatic colon carcinoma was employed with not much favorable response. Irinotecan based chemotherapy also resulted in posterior reversible encephalopathy syndrome in this patient. Overall, the disease carries a poor prognosis and with no effective treatment available the survival is less than a year.

Keywords: Colorectal cancer, irinotecan, posterior reversible encephalopathy syndrome, skin metastases, unusual presentation


How to cite this article:
Nallathambi C, Singh IY, Patton Z. Multiple subcutaneous metastases as the solitary presenting site of colorectal cancer. J Can Res Ther 2018;14:716-8

How to cite this URL:
Nallathambi C, Singh IY, Patton Z. Multiple subcutaneous metastases as the solitary presenting site of colorectal cancer. J Can Res Ther [serial online] 2018 [cited 2022 Jul 7];14:716-8. Available from: https://www.cancerjournal.net/text.asp?2018/14/3/716/172586




 > Introduction Top


Skin metastases, as a presenting symptom of gastrointestinal malignancies, are very rare and signify advanced disease as well as aggressive behavior.[1] The primary site remains incipient or asymptomatic and sometimes the skin lesions mimic benign conditions such as multiple subcutaneous lipomatosis. Fine needle aspiration cytology may be misleading and further delays the correct diagnosis until tissue biopsy is taken.[2] Skin metastases are found to occur after metastases to other sites and after a long period of diagnosis.[3],[4] We present the case of an 18-year-old male with diffuse subcutaneous metastases as a presenting feature and as the only site of distant metastases apart from asymptomatic peritoneal deposits due to rectosigmoid adenocarcinoma.


 > Case Report Top


An 18-year-old male presented to the dermatologist with multiple painless subcutaneous nodules. In the preceding month, he had several episodes of diarrhea and a colonoscopy was performed, which did not reveal any visible lesions probably due to the infiltrative nature of the lesion. Biopsy of the colonic mucosa showed colitis, and he recovered following a course of antibiotics and antidiarrheal drugs. A month later, skin lesions started appearing suddenly all over his body. The nodules varied in size between 5 mm and 20 mm and involved the skin of the face, trunk, back, and limbs [Figure 1]a, [Figure 1]b, [Figure 1]c. Aspiration cytology of the subcutaneous nodule suggested high grade sarcoma following which he was referred to our department.
Figure 1: Diffuse nodular lesions involving the skin of (a) trunk, (b) back, and (c) face

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Skin biopsy was performed showing normal epidermis and dermis, but the subcutaneous fat was diffusely infiltrated by a malignant tumor composing signet ring cells in a mucinous background [Figure 2]a, [Figure 2]b, [Figure 2]c. Provisional diagnosis of metastatic signet ring carcinoma was made and a possible primary from the gastrointestinal tract was suspected. Infiltrative lesion of the rectosigmoid colon was discovered along with peritoneal deposits, and biopsy of the rectal wall showed poorly differentiated adenocarcinoma [Figure 3]. Involvement of other sites were ruled out with computed tomography.
Figure 2: (a) ×2 microscopic image showing signet ring cells arranged in singles around a hair follicle in a background of mucin, (b) ×20 microscopic image showing tumor cells dissecting through bundles of collagen, and (c) ×40 microscopic image showing tumor cells in clusters

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Figure 3: Axial computed tomography scan showing heterogeneously contrast enhancing irregular concentric wall thickening of the distal sigmoid colon causing luminal stenosis

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The patient was started on palliative chemotherapy with FOLFIRI regime. He had a subjective improvement of gastrointestinal symptoms, and there was a marginal reduction in the size of the peritoneal deposits and subcutaneous nodules after 3 months of chemotherapy [Figure 4]. He received ten cycles of FOLFIRI chemotherapy given every 2 weeks following which he abstained from treatment. No grade 3/4 toxicities were noted during treatment.
Figure 4: Computed tomography scan of the abdomen showing a stationary disease after 3 months of chemotherapy

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After a drug-free period of 2 months, he presented again with seizures, loss of consciousness, and raised blood pressure. Magnetic resonance imaging of the brain showed the development of posterior reversible encephalopathy syndrome (PRES) probably due to chemotherapy [Figure 5]. PRES was treated with antihypertensive drugs and no further chemotherapy was contemplated. He regained consciousness and remained seizure-free once his blood pressure normalized. The patient died due to abdominal complications after surviving for 9 months from the initial time of diagnosis and for 3 weeks after the diagnosis of PRES was made. Diffuse skin lesions and peritoneal deposits were the only extra nodal sites of disease during the entire period.
Figure 5: Magnetic resonance flair image showing symmetric cortical and subcortical hyperintensities involving the bilateral parietooccipital and frontal lobes suggestive of posterior reversible encephalopathy syndrome

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 > Discussion Top


Skin metastases are rare during clinical practice but are of great significance because it implies advanced disease. The primary neoplasm could be from breast, lung, or gastrointestinal tract in most cases. Metastases to skin occur more commonly as a relapse following treatment for localized cancer. It may be associated with multiple metastatic sites or may be the only extra nodal disease site. Incisional sites are more commonly involved and a diffuse presentation has not been frequently reported.

In a retrospective analysis, 0.4% (three patients) of colorectal cancers had skin metastases as their initial presentation and 0.1% (one patient) had a diffuse presentation. From their data, it was seen that 0.8% had skin involvement as the first sign of cancer. It should be noted that the authors included local skin involvement of breast cancer also which contributed to the majority of patients presenting with skin involvement.[3]

They usually appear as painless dermal or subcutaneous nodules. In some cases, they may present as macules, infiltrated or indurated plaques, discoid lesions, telangiectasias, bullous, or papulosquamous lesions also.[5] As the first sign of cancer, they present a diagnostic challenge and should be biopsied in order to attain a diagnosis.

The most common site of metastases in a colorectal malignancy is the skin of the abdomen. Solitary lesion could be treated with local excision when the patient is expected to have a good prognosis. Other treatment options such as laser ablation, radiofrequency ablation, cryotherapy, or electro chemotherapy used for melanoma have also been tried with success. Diffuse skin nodules might respond to the systemic therapy directed according to the primary.[2]

In another single hospital retrospective analysis, the mean duration between diagnosis of cancer and onset of skin metastases was 33 months. The average survival following skin metastases was 7.5 months.[4] Schoenlaub et al.[6] described the survival rates systematically with different malignancies. About 7.5 and 4.4 months of median survival were seen for all cancers and colorectal cancers, respectively.

The intent of treatment in unresectable metastatic colorectal cancer is palliative. The commonly used chemotherapeutic agents include 5-FU or capecitabine used singly or in combination with irinotecan and/or oxaliplatin.[7] Combination chemotherapy is indicated when the patient is symptomatic.

PRES characterized by systemic hypertension and related vasogenic brain edema is a rare but dreaded complication of chemotherapy for colorectal cancer. Irinotecan has been reported to cause PRES, and it is due to the endothelial damage caused by the chemotherapeutic agent.[8] The condition is usually reversible with removal of the causative agent and control of hypertension. Among chemotherapeutic agents used for colorectal cancer, FOLFOX regime, and bevacizumab are also associated with PRES more commonly than Irinotecan, which leaves antineoplastic therapy post-PRES in a more precarious situation.[9]

We report this case not only for its rarity but also to show the aggressive nature of the neoplasm. Diffuse cutaneous nodules could be a sign of internal malignancy and diagnosis at an early stage could lead to an improved survival. Colorectal malignancies arising in a young age are very aggressive with a poorly differentiated histology and can have a disseminated spread even before the manifestations of primary appear.[10] We also need to understand the pathogenesis that is responsible for widespread dissemination to the skin in the absence of metastases in other sites. Overall, the disease carries a poor prognosis and with no effective treatment available the survival is less than a year.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 > References Top

1.
Sariya D, Ruth K, Adams-McDonnell R, Cusack C, Xu X, Elenitsas R, et al. Clinicopathologic correlation of cutaneous metastases: Experience from a cancer center. Arch Dermatol 2007;143:613-20.  Back to cited text no. 1
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2.
Wong CY, Helm MA, Kalb RE, Helm TN, Zeitouni NC. The presentation, pathology, and current management strategies of cutaneous metastasis. N Am J Med Sci 2013;5:499-504.  Back to cited text no. 2
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3.
Lookingbill DP, Spangler N, Sexton FM. Skin involvement as the presenting sign of internal carcinoma. A retrospective study of 7316 cancer patients. J Am Acad Dermatol 1990;22:19-26.  Back to cited text no. 3
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4.
Saeed S, Keehn CA, Morgan MB. Cutaneous metastasis: A clinical, pathological, and immunohistochemical appraisal. J Cutan Pathol 2004;31:419-30.  Back to cited text no. 4
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5.
Nashan D, Müller ML, Braun-Falco M, Reichenberger S, Szeimies RM, Bruckner-Tuderman L. Cutaneous metastases of visceral tumours: A review. J Cancer Res Clin Oncol 2009;135:1-14.  Back to cited text no. 5
    
6.
Schoenlaub P, Sarraux A, Grosshans E, Heid E, Cribier B. Survival after cutaneous metastasis: A study of 200 cases. Ann Dermatol Venereol 2001;128:1310-5.  Back to cited text no. 6
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7.
Chemotherapy of metastatic colorectal cancer. Prescrire Int 2010;19:219-24.  Back to cited text no. 7
    
8.
Dedic Plavetic N, Rakušic Z, Ozretic D, Simetic L, Krpan AM, Bišof V. Fatal outcome of posterior “reversible” encephalopathy syndrome in metastatic colorectal carcinoma after irinotecan and fluoropyrimidine chemotherapy regimen. World J Surg Oncol 2014;12:264.  Back to cited text no. 8
    
9.
Femia G, Hardy TA, Spies JM, Horvath LG. Posterior reversible encephalopathy syndrome following chemotherapy with oxaliplatin and a fluoropyrimidine: A case report and literature review. Asia Pac J Clin Oncol 2012;8:115-22.  Back to cited text no. 9
    
10.
Hill DA, Furman WL, Billups CA, Riedley SE, Cain AM, Rao BN, et al. Colorectal carcinoma in childhood and adolescence: A clinicopathologic review. J Clin Oncol 2007;25:5808-14.  Back to cited text no. 10
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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