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Unusually large colon cancer cutaneous and subcutaneous metastases occurring in resection scars

  • Author(s): Alexandrescu, Doru T;
  • Vaillant, Juan;
  • Yahr, Laura J;
  • Kelemen, Pond;
  • Wiernik, Peter H
  • et al.
Main Content

Unusually large colon cancer cutaneous and subcutaneous metastases occurring in resection scars
Doru T Alexandrescu MD1, Juan Vaillant, MD2, Laura J Yahr MD3, Pond Kelemen MD4, and Peter H Wiernik MD1
Dermatology Online Journal 11 (2): 22

Comprehensive Cancer Center1, Department of Dermatology2, Department of Pathology3, and Department of Surgery4 New York Medical College, Our Lady of Mercy Medical Center, Bronx, NY 10466. mddoru@hotmail.com

Abstract

Development of cutaneous metastases from colon cancer is a rare event, usually occurring in the setting of diffusely-disseminated disease and commonly carrying a dismal prognosis. Cutaneous and subcutaneous metastases in surgical scars occur extremely rarely, with only a few cases reported. We describe two cases of cutaneous metastases from colon cancer. A 62-year-old woman developed an 11-cm midline abdominal mass that slowly grew on the skin surface. The mass occurred at the scar site of her previous surgery performed 5 years prior for resection of a colon adenocarcinoma. A 46-year-old male presented with a subcutaneous 4.5-cm nodule in midline-abdominal scar, 3 years after resection of the primary colon cancer. These cases illustrate the pathological features and natural history of cutaneous metastases observed until the tumors have reached a very large size. Particular features of cutaneous scar metastases from colon cancer observed in our cases are a superficial pattern of spread, strong positivity for EGFR, low serum carcinoembrionic antigen, and long survival of the patients, possibly contributed to by the use of chemotherapy.



Clinical synopsis


Case 1


Figure 1a Figure 1b
Fig. 1 A: Patient in Case 1 presented with a large (11x9 cm) ulcerated abdominal mass, originating from the midline scar, secondary to prior resection of a colonic adenocarcinoma. B: Surgical resection specimen demonstrating an exophytic architecture, with the deep margin of the tumor invading the subcutaneous tissue.

A 60-year-old woman presented for evaluation of an abdominal mass that was expanding superficially in the umbilical area. The cutaneous mass started to grow in a midline surgical scar and had been present for 1 year before she sought medical attention. The patient had a history of an infiltrating, moderately differentiated adenocarcinoma of the colon, invading through the entire thickness of the muscularis propria, extending into the surrounding adipose tissue, and involving two regional lymph nodes (T3N1M0). The primary tumor was resected 5 years prior and at that time there was no systemic spread of the disease.


Figure 1c
CT abdomen shows the superficial mass, extending into the subcutaneous fat but not invading the fascia.

Physical exam revealed a large mass, superficially ulcerated, movable along with abdominal superficial planes. The main direction of growth was horizontal, perpendicular to the surgical scar (Fig. 1 A). The tumor was growing into the subcutaneous fat, but no deep invasion was present (Figs. 1B, 1C).

Carcinoembryonic antigen (CEA) was 7.7 ng/mL (normal 0-3), and CA-125 46.3 u/mL (normal, 0-35).


Figure 2
Cutaneous involvement by the tumor in Case 1: Adenocarcinoma invading the underlying dermis, with ulceration of the overlying epidermis. (magnification 40 x).

Resection was performed; the surgical specimen consisted of a lobulated mass measuring 11x9x5 cm. Histology revealed metastatic colonic adenocarcinoma, centered in the dermis, extending to and ulcerating the underlying skin, and invading into the superficial subcutaneous tissue (Fig. 2). Adjacent skin showed dermal scar. Immunohistochemistry for EGFR showed intense positivity (3+). The right ovary showed metastatic adenocarcinoma, but the entire colon appeared to be free of disease. Over the course of 6 months, and to date, the patient received nine cycles of chemotherapy (oxaliplatin/5-florouracil/leucovorin), and has remained disease free.


Case 2

A 46-year-old man presented with a 4.5-cm abdominal nodule. A CT scan and a PET scan showed a 4.5 x 4.5-cm superficial subcutaneous midline hypermetabolic paraumbilical mass, accompanied by a second deeper nodule in the abdominal wall. The patient had a 3-year history of a B2 (T3N0M0) mucinous, colonic adenocarcinoma, treated with primary resection followed by adjuvant 5-florouracil/ leucovorin. He had a local omental recurrence that was surgically resected 2 years prior; he was further treated with chemotherapy (5-florouracil/leucovorin/irinotecan). Currently, the patient presented with periumbilical pain.

Physical exam confirmed a subcutaneous 4.5 cm firm midline nodule, arising in a midline abdominal scar.

Laboratory examination revealed the CEA was rising to 8.3 ng/ml (normal, 0-3 ng/ml) at the time of diagnosis. Other than the abdominal lesions, a metastatic workup showed one pelvic metastasis.


Figure 3a Figure 3b
Subcutaneous superficial mass originating in a surgical scar (open arrows), with another deep mass located in the abdominal wall (dark arrows) in Case 2 (bivalved specimen section). B: PET scan reveals a subcutaneous superficial 4.5 cm, midline nodule (arrow), accompanied by a second deeper and larger mass.

The subcutaneous tumors were resected. The superficial metastasis measured 4.5 cm, and was located in the scar from the previous laparotomy, involving the subcutaneous tissue up to the superficial cutaneous tissue (Figs. 3A, 3B). EGFR receptors in tumoral tissue were intensely positive (3+). Systemic chemotherapy with 5-florouracil/ leucovorin/oxaloplatin was given concomitantly with intraperitoneal mitomycin-C and cisplatin for three months. One year after this cutaneous metastasis, the patient has no active disease.

Diagnoses: Cutaneous and subcutaneous metastases from colon cancer


Comment

Cutaneous metastases from colon cancer are rare [1, 2], and usually occur in the setting of disseminated disease. In a large series of cutaneous metastases, only 6.5 percent of skin metastases originated in the colon. The most common primaries are the lung (28.6 %), melanoma (18.2 %), gastrointestinal (colon, liver, small bowel) (14.2 %), and genitourinary tract (10.4 %) [1]. In the absence of liver involvement, skin metastases from colon cancer are very uncommon, however a few cases have been reported in which cutaneous metastases were found at presentation [3, 4, 5]. Although most reports depict cutaneous metastases from colon cancer as superficial [6, 7, 8, 9, 10, 11], rare instances of tumors located in the subcutaneous tissue have been described [5, 12]. Uncommonly, cutaneous metastases may develop in postsurgical scars (0.6 % of cases) [2], and with even greater rarity, occur in subcutaneous scar tissue [3, 4, 13].

The most common site of cutaneous metastases from colon cancer is the abdomen [3]. Occurrence in previous scars after tumor resection has been described in 0.6 percent of patients experiencing a recurrence, with only 0.2 percent being diagnosed clinically [2]. Among the 77 cutaneous metastases analyzed by Saeed et al, [1], three (3.9 %) occurred in the scars from prior resection of the primary tumor.

The mean interval to development of skin metastasis after diagnosis of colon cancer is 4.9 years, but an extended interval of 15 years was noted in one case [1]. Occurrence of skin metastases is an adverse prognostic factor, as average survival is 3.3 months (range, 2-4.5 months) after diagnosis [1]. A more prolonged survival of over 8 months was recorded in a case of head and neck metastases from a colon cancer, where despite radiotherapy, the tumor continued to grow, and the patient died of pulmonary metastases [6].

To our knowledge, current cases are the first to describe the occurrence of very large cutaneous metastases (particularly case 1), in the presence of resected colon cancer. Furthermore, in both cases, a particular biology of these cutaneous and subcutaneous tumors arising in surgical scars is suggested by the superficial spreading pattern (with lack of deep invasion in the first case, and limited deep extension in the second case), the lack of involvement of other organ systems despite reaching an impressive size, the long interval of occurrence after the primary cancer, and a low serum CEA. Both tumors were found to intensely express EGFR receptors on cell surface, which might explain their location in scar tissue.


Management

The long survival of both patients (22+ and 12+ months, respectively) correlates with other similar colon metastases occurring in cutaneous scars (4.5 months [1], 3 patients alive at 1.8 years [2]). Whether in such cases a special tumor behavior relates to the tumor cell itself, or is modulated by the surrounding scar environment is currently unknown. Although impossible to ascertain precisely, our patients long survival may be due in part due to chemotherapy. Given the long survival of patients with cutaneous metastases from colon cancer, local surgical resection is warranted.


Conclusion

We were able in these cases to observe the evolution of colonic skin metastases that developed in previous surgical scars, with a particularly long course in the patient described in Case 1. The experience gained from these cases suggests that these metastases may grow as superficially expanding lesions without deep invasion despite reaching a very large volume, while the patients may experience a long survival, possibly contributed to by the use of chemotherapy after resection of the lesions.

References

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