Cutaneous metastasis as first clinical manifestation of signet ring cell gastric carcinoma
Published Web Locationhttps://doi.org/10.5070/D38h84j3d2
Cutaneous metastasis as first clinical manifestation of signet ring cell gastric carcinoma1. Department of Pathology, University Hospital, Granada. Spain. email@example.com
Aneiros-Fernandez J MD1, Husein-ElAhmed H MD2, Arias-Santiago S MD2, Escobar Gómez-Villalva F MD3, Alina Nicolae MD PhD1, O’Valle Ravassa F MD PhD1, Aneiros-Cachaza J MD PhD1
Dermatology Online Journal 16 (3): 9
2. Department of Dermatology, University Hospital, Granada. Spain
3. Department of Internal Medicine, University Hospital, Granada. Spain
Cutaneous metastases from signet ring cell gastric carcinoma are uncommon. A 69-year-old man presented with a 15-day history of an asymptomatic indurated scar-like lesion. The biopsy revealed an infiltrating signet ring cell carcinoma consistent with gastric metastasis. Gastroscopy and biopsy showed gastric carcinoma with signet ring cells; subsequent computed tomography revealed metastatic nodules in the liver, mesentery, and retroperitoneal and peripancreatic lymph nodes. A review of the 10 cases of cutaneous metastasis from signet ring cell carcinoma in the literature revealed that cutaneous metastases of gastric origin usually appear at earlier ages than in our patient and that the primary tumor is unknown at the time of skin biopsy in 64 percent of cases. The present report describes the unusual clinical-diagnostic sequence of a patient diagnosed with cutaneous metastasis before detection of his gastric carcinoma.
About 10 percent of all visceral malignant tumors develop cutaneous metastases, which represent 2 percent of all skin tumors. Cutaneous metastases most frequently derive from carcinomas of breast, lung, colon, rectum, ovary, head, neck, kidney, and the gastrointestinal tract .
Metastatic dissemination is largely via lymphatic vessels and less frequently via the blood stream (to liver, peritoneal cavity, lung, adrenal gland, and skin). The clinical presentation of cutaneous metastases from gastric adenocarcinoma is usually as single or multiple nodules; only 6.4 percent to 7.8 percent of these cutaneous metastases are the first clinical manifestation [2, 3].
We describe a patient diagnosed with gastric carcinoma after detection of cutaneous metastasis.
|Figure 1. Superficial scar-like lesion and a deep palpable nodule|
A 69-year-old man presented with a 15-day history of an asymptomatic indurated scar-like lesion on the chest that clinically resembled basal cell carcinoma (Figure 1). Histopathological study reported infiltrating neoplastic cells dispersed in the dermis with no ulcerations of the epidermis. The tumor comprised cell nests and cords and scattered cells, mostly appearing as signet ring cells surrounded by dense fibrous stroma with a predominantly eosinophilic inflammatory infiltrate (Figure 2). The signet ring cells exhibited positive mucicarmine staining in the cytoplasmatic areas (Figure 3A). Immunohistochemical studies showed positivity for AE1-AE3, CK20 (Figure 3B), and CK18 antibodies and negativity for GCDFP-15, CK7, S-100, HMB-45, MELAN A, and CD45 antibodies. The diagnosis was metastasis of signet ring cell adenocarcinoma of probable gastric origin. We therefore searched for a primary tumor in the gastrointestinal system using gastroscopy and biopsies,; a gastric signet-ring cell adenocarcinoma was detected. Computed tomography then revealed the presence of six metastatic nodules in liver, mesentery, and retroperitoneal and peripancreatic lymph nodes. Because of the advanced stage of the disease, no surgery was undertaken.
The patient showed deterioration in health status and the appearance of new lesions despite seven courses of systemic chemotherapy with CDDP, Taxotere, and Xeloda. He died at 10 months after the diagnosis.
Ring-cell carcinoma in the skin may correspond to a primary or secondary tumor. In men, primary tumors generally appear on the eyelid or axilla . Secondary tumors can derive from tumors in breast, stomach, colon, rectum, cecal appendix, lung, bladder, prostate, endometrium, and esophagus. The immunohistochemical characteristics of signet ring-cell carcinoma can assist the differential diagnosis between primary and secondary tumors. For this purpose, we consider that CK 7, CK 20, GCDFP-15, PSA, TTF-1, and estrogen and progesterone receptors should be studied. The differential diagnosis should also consider malignant tumors that can also have a signet ring cell pattern, such as melanoma and lymphoma .
It has been reported that cutaneous metastases tend to be close to the site of the primary tumor, e.g., abdominal wall in gastrointestinal tumor, chest in lung carcinoma, and back in renal cell carcinoma . However, our group previously reported a cutaneous metastasis of renal origin in the finger  and the localization in the present case was the thorax. Hence, the correlation between the sites of primary and secondary tumors appears to be controversial.
Gastric adenocarcinomas represent approximately 95 percent of gastric tumors and are histopathologically classified as papillary adenocarcinomas, tubular adenocarcinomas, mucinous adenocarcinomas, or signet ring cell carcinomas. Signet ring cell carcinomas comprise only 8.7 percent of all gastric cancers .
Clinically, cutaneous metastases from gastric carcinoma can be red or violet; they may present as a single or multiple hyperpigmented nodules, showing zosteriform, erysipela-like, allergic contact dermatitis-like, or cellulitis-like patterns. They have been reported to appear on the neck, head, eyebrow, axilla, chest, and fingertip .
Previous reports described cutaneous metastasis as the first manifestation of a carcinoma in 6.4 percent to 7.4 percent [2, 3] of cases. However, a more recent review of 92 patients with cutaneous metastases reported that there had been no clinical manifestation of the primary tumor in 22 percent of cases; this review only included two cases of signet ring-cell gastric carcinoma . We examined published reports on 10 cases of cutaneous metastasis from signet ring-cell gastric carcinoma in conjunction with the present data (total of 11 cases) [9-18] and found that cutaneous metastases appeared between 33 and 71 years of age (mean of 55 years), occurred preferentially in males (7:3), and presented as a single lesion in only 18 percent of cases. Multiple lesions are usually found on chest and face and single lesions on chest or abdomen. The mean interval between detection of gastric cancer and diagnosis of cutaneous metastasis was 7.3 months. However, the primary tumor was unknown at the time of diagnosis of the cutaneous metastasis in 64 percent of cases. Survival time (with or without manifestation of primary tumor) was < 1 yr.
The above data differ in some respects from reports on cutaneous metastases in general [2, 3]. Thus, the age of patients ranged from 38 to 83 years (mean of 62 years) and the interval between diagnosis of metastasis and diagnosis of the primary tumor was 3 months. Metastases were preferentially localized on the trunk, head, neck and limbs. The mean survival after the diagnosis of cutaneous metastasis was 7.5 to 34 months [2, 3]. The majority of cutaneous metastases appeared as multiple nodules; a single metastasis was infrequent and usually from lung carcinoma .
References1. 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 Jan;135(1):1-14. [PubMed]
2. Saeed S, Keehn CA, Morgan MB. Cutaneous metastasis: a clinical, pathological, and immunohistochemical appraisal. J Cutan Pathol. 2004; 31:419-430. [PubMed]
3. Lookingbill DP, Spangler N, Helm KF. Cutaneous metastases in patients with metastatic carcinoma: retrospective study of 4020 patients. J Am Acad Dermatol 1993; 29:228-229. [PubMed]
4. González-Lois C, Rodríguez-Peralto JL, Serrano-Pardo R, Martínez-González MA, López-Ríos F. Cutaneous signet ring cell carcinoma: a report of a case and review of the literature. Am J Dermatopathol. 2001 Aug;23(4):325-8. [PubMed]
5. Rütten A, Huschka U, Requena C, Rodríguez-Peralto JL, Requena L. Primary cutaneous signet-ring cell melanoma: a clinico-pathologic and immunohistochemical study of two cases. Am J Dermatopathol. 2003 Oct;25(5):418-22. [PubMed]
6. Brownstein MH, Helwig EB. Patterns of cutaneous metastasis. Arch Dermatol. 1972 Jun;105(6):862-8. [PubMed]
7. Arrabal-Polo MA, Arias-Santiago SA, Aneiros-Fernandez J, Burkhardt-Perez P, Arrabal-Martin M, Naranjo-Sintes R. Cutaneous metastases in renal cell carcinoma: a case report. Cases J. 2009 Aug 25;2:7948. [PubMed]
8. Kim DY, Park YK, Joo JK, Ryu SY, Kim YJ, Kim SK, Lee JH. Clinicopathological characteristics of signet ring cell carcinoma of the stomach. ANZ J Surg. 2004 Dec;74(12):1060-4. [PubMed]
9. Acikalin MF, Vardareli E, Tel N, Saricam T, Urer S. Erysipelas-like cutaneous metastasis from gastric signet ring cell carcinoma. J Eur Acad Dermatol Venereol. 2005 Sep;19(5):642-3. [PubMed]
10. Charfeddine A, Tahri N, Ben Ali H, Njeh M, Boudawara T, Bouassida S, Krichen MS. [Cutaneous metastases revealing gastric linitis]. Ann Dermatol Venereol. 2001 Feb;128(2):141-3. [PubMed]
11. Lifshitz OH, Berlin JM, Taylor JS, Bergfeld WF. Metastatic gastric adenocarcinoma presenting as an enlarging plaque on the scalp. Cutis. 2005 Sep;76(3):194-6. [PubMed]
12. Michiwa Y, Earashi M, Kobayashi H, Matsuki N. Cutaneous metastases from gastric adenocarcinoma treated with combination chemotherapy producing complete response with long survival. J Exp Clin Cancer Res. 2001 Jun;20(2):297-9. [PubMed]
13. Hashiro M, Fujio Y, Tanimoto T, Okumura M. Disseminated cutaneous nodules revealing gastric carcinoma. Dermatology. 1994;189(2):207-8. [PubMed]
14. Kostandy G, Katapadi M, Pullarkat V, Manzi G, Salama S, Sosler B, Hussain KM. Skin metastases: an unusual presenting sign of gastric carcinoma. J Clin Gastroenterol. 1996 Oct;23(3):236-8. [PubMed]
15. Müller CS, Pföhler C, Reichrath J, Tilgen W. Gastric signet ring cell carcinoma presenting. An erysipelas-like cutaneous metastasis of the abdominal skin. Hautarzt. 2008 Dec;59(12):992-4. [PubMed]
16. Essa K, Pervez S, Shah LM, Soomro IN. Signet cell gastric carcinoma presenting as multiple large skin nodules. Australas J Dermatol. 2001 Aug;42(3):219-20. [PubMed]
17. Xavier MH, Vergueiro Tde R, Vilar EG, Pinto JM, Issa MC, Pereira GB, Carocha AP. Cutaneous metastasis of gastric adenocarcinoma: an exuberant and unusual clinical presentation. Dermatol Online J. 2008 Nov 15;14(11):8. [PubMed]
18. Ahn SJ, Oh SH, Chang SE, Jeung YI, Lee MW, Choi JH, Moon KC, Koh JK. Cutaneous metastasis of gastric signet ring cell carcinoma masquerading as allergic contact dermatitis. J Eur Acad Dermatol Venereol. 2007 Jan;21(1):123-4. [PubMed]
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