Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 
  • Users Online: 268
  • Home
  • Print this page
  • Email this page


 
 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 5  |  Issue : 1  |  Page : 54-56

Cutaneous metastasis of gastric carcinoma: A rare case with unusual presentation site


1 Department of Pathology, Solid Tumor Research Center, Urmia University of Medical Sciences, Urmia, Iran
2 Department of Pathology, Faculty of Medicine, Urmia University of Medical Sciences, Urmia, Iran
3 Department of Surgery, Faculty of Medicine, Urmia University of Medical Sciences, Urmia, Iran

Date of Web Publication22-May-2018

Correspondence Address:
Dr. Ata Abbasi
Department of Pathology, Faculty of Medicine, Urmia University of Medical Sciences, Urmia
Iran
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijdpdd.ijdpdd_38_17

Rights and Permissions
  Abstract 


Skin metastases are relatively rare but are of important clinical significance because they usually indicate a worse prognosis. The most common sources are lung and colorectal cancers in males and breast and colorectal in females. In this report, we presented a chest wall skin metastasis of gastric origin in a 50-year-old male. Tumor metastasis to unusual locations such as chest wall skin and from unusual origins such as stomach is of great clinical importance.

Keywords: Gastric carcinoma, metastasis, skin


How to cite this article:
Abbasi F, Abbasi A, Mahmodlou R, Mehdipour E. Cutaneous metastasis of gastric carcinoma: A rare case with unusual presentation site. Indian J Dermatopathol Diagn Dermatol 2018;5:54-6

How to cite this URL:
Abbasi F, Abbasi A, Mahmodlou R, Mehdipour E. Cutaneous metastasis of gastric carcinoma: A rare case with unusual presentation site. Indian J Dermatopathol Diagn Dermatol [serial online] 2018 [cited 2018 Dec 12];5:54-6. Available from: http://www.ijdpdd.com/text.asp?2018/5/1/54/232957




  Introduction Top


Skin metastasis is not so frequent.[1],[2],[3] About 0.7%–10.4% of different malignancies have skin metastasis at some point of time.[1] Colon is the most common source of primary gastrointestinal carcinoma with cutaneous metastasis.[1],[4] However, skin metastasis from gastric origin is relatively rare and occurs in <5% of gastric cancers.[4],[5]

Here, we reported a rare case of skin metastasis of gastric carcinoma which was clinically presented by multiple skin nodules of neck and chest wall. This case is reported because of rarity of skin metastasis of gastric cancer and occurrence in relatively unusual site with unusual clinical presentation to emphasize the importance of cutaneous metastasis as a possible and also a poor prognostic sign in patients with a history of cancer.


  Case Report Top


A 50-year-old male was admitted with dysphagia. The routine hematology and biochemistry tests were normal. Upper gastrointestinal endoscopy was performed for the patient and revealed an ulcerative mass at gastroesophageal junction (GEJ) and cardia [Figure 1]. Endoscopic biopsy from the lesion was performed. The specimen received in pathology department was composed of multiple fragments of creamy-colored soft tissue measuring 1.2 cm × 0.7 cm × 0.4 cm, totally.
Figure 1: Endoscopic view of the patient stomach showing an ulcerative lesion with elevated periphery

Click here to view


Microscopic examination of prepared slides stained with hematoxylin and eosin method showed proliferation of signet ring tumoral cells in mucosal and submucosal layers [Figure 2]. The diagnosis was signet ring cell carcinoma of stomach.
Figure 2: Gastroesophageal mucosa infiltrated by malignant signet ring cells (arrows), (H and E, ×20)

Click here to view


The patient underwent gastrectomy. Gross examination of gastrectomy specimen showed an infiltrative ulcerated tumoral area at gastric cardia with extension to GEJ measuring 8 cm in greatest diameter. Microscopic evaluation revealed signet ring cell carcinoma of stomach with penetration to gastric serosal surface (PT3). Lymphatic and perineural invasion, involvement of proximal margin, and also lymph nodes' involvement (two involved lymph nodes, PN2) were also seen. As no distant metastasis was identified during metastasis workup, the patient stage was categorized as Stage IIIB. The patient received standard chemoradiotherapy regimen for gastric carcinoma.

Nine months later, the patient admitted with multiple skin nodules on neck and chest wall. Chest radiography, brain magnetic resonance imaging, colonoscopy, and upper gastrointestinal endoscopy were normal and did not reveal any tumoral lesion.

Biopsies were taken from skin lesions, and microscopic examinations showed skin tissue infiltrated by signet ring cell carcinoma [Figure 3]a and [Figure 3]b. Histochemistry staining with periodic acid–Schiff (PAS) method revealed large malignant epithelial cells containing cytoplasmic PAS-positive material (mucin), [Figure 4]. To confirm the diagnosis, immunohistochemistry staining for CK7, CK20, and CDX2 was performed. The tumoral cells were positive for all three markers [Figure 5] and [Figure 6]. These features confirmed the diagnosis of skin involvement by metastatic signet ring cell (adeno) carcinoma of gastric origin. The patient underwent new chemotherapy treatment course but unfortunately died 1 month later.
Figure 3: (a) Low magnitude of skin showing intact epidermis and an infiltrative area in deep dermis (arrows) (H and E, ×4). (b) higher magnitude of Figure 3a showing infiltration of malignant cells within dermis (arrow), with clear cytoplasm and signet ring features (signet ring cell carcinoma) (H and E, ×20)

Click here to view
Figure 4: Periodic acid–Schiff stain showing positive reaction in signet ring cells (pinkish-purple stain) showing cytoplasmic periodic acid–Schiff positive material in signet ring cell, (periodic acid–Schiff, ×40)

Click here to view
Figure 5: Positive staining for CK7 in immunohistochemistry staining in signet ring cells (immunohistochemistry, ×20)

Click here to view
Figure 6: Positive nuclear staining for CDX2 in immunohistochemistry staining in signet ring cells (immunohistochemistry, ×20)

Click here to view



  Discussion Top


Skin is an uncommon site for distant metastasis.[1],[2],[3],[6] According to the literature, up to 10.4% of various malignancies may have cutaneous metastasis in their clinical course.[1],[2],[4],[7]

The most common form of skin metastasis is adenocarcinoma, originated from lung, breast, or colon.[1],[7] In males, the most common solid tumors with skin metastasis are lung cancer, colorectal cancer, and malignant melanoma and in women are breast carcinoma, colorectal cancer, and malignant melanoma.[6],[7],[8] Only 6% of all skin metastases in males and 1% in females are from gastric origin.[1] On the other hand, skin metastasis occurs in only 0.8% of gastric cancers.[5] Signet ring cell carcinoma is the most common form of gastric carcinoma with distant metastasis.[3] Similarly, in our patient, skin metastasis resulted from signet ring cell carcinoma of the stomach. Secondary malignant skin tumors usually occur through the direct extension of the nearby tumor such as skin involvement in breast cancer which is usually the overlying skin tissue of the involved breast.[1] Metastatic dissemination to skin may occur through the lymphatic channels or hematogenous spread.[1],[2] According to the literature, most of the reported cases of gastric skin metastases were observed in skin tissue of abdominal wall.[1],[4],[9] In our patient, skin metastasis appeared in neck and chest wall. Skin metastasis of gastric cancer can show different clinical manifestations. Usually, as in our case, they present as skin nodules but can also be seen as erysipelas-like pattern, scirrhous carcinoma, zosteriform pattern, lesions resembling an epidermoid cyst, or even as nonspecific contact dermatitis.[3] In general, cutaneous metastasis indicates a poor prognosis.[1],[2],[4] The overall survival after diagnosis of skin metastasis is only a few weeks.[1],[5] Similarly, our patient died 1 month after diagnosis.

Skin metastasis is a very rare clinical presentation of cancers which can be seen as various nonspecific clinical presentations and so can be missed by physicians. As it is a strong sign of poor prognosis, it is recommended to be aware of this condition and take biopsies from any suspicious skin lesion in patients with a history of cancer.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgments

We are grateful to Mr. Ali Jafari, technician of pathology, for his assistance in processing and staining the samples.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Xavier MH, Vergueiro Tde R, Vilar EG, Pinto JM, Issa MC, Pereira GB, et al. Cutaneous metastasis of gastric adenocarcinoma: An exuberant and unusual clinical presentation. Dermatol Online J 2008;14:8.  Back to cited text no. 1
    
2.
Prabhash K, Talwar V, Vaid AK, Doval DC. Gastric carcinoma presenting as cutaneous metastases. Indian J Dermatol Venereol Leprol 2005;71:208-9.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Ahn SJ, Oh SH, Chang SE, Jeung YI, Lee MW, Choi JH, et al. Cutaneous metastasis of gastric signet ring cell carcinoma masquerading as allergic contact dermatitis. J Eur Acad Dermatol Venereol 2007;21:123-4.  Back to cited text no. 3
[PUBMED]    
4.
Avgerinou G, Flessas I, Hatziolou E, Zografos G, Nitsios I, Zagouri F, et al. Cutaneous metastasis of signet-ring gastric adenocarcinoma to the breast with unusual clinicopathological features. Anticancer Res 2011;31:2373-8.  Back to cited text no. 4
[PUBMED]    
5.
Kairouani M, Perrin J, Dietemann-Barabinot A, Diab R, Ruck S. Cutaneous metastasis revealing a relapse of gastric linitis: Another case. Int J Surg Case Rep 2013;4:185-7.  Back to cited text no. 5
[PUBMED]    
6.
Sittart JA, Senise M. Cutaneous metastasis from internal carcinomas: A review of 45 years. An Bras Dermatol 2013;88:541-4.  Back to cited text no. 6
[PUBMED]    
7.
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. 7
[PUBMED]    
8.
Narasimha A, Kumar H. Gastric adenocarcinoma deposits presenting as multiple cutaneous nodules: A case report with review of literature. Turk Patoloji Derg 2012;28:83-6.  Back to cited text no. 8
[PUBMED]    
9.
Liu F, Yan WL, Liu H, Zhang M, Sang H. Cutaneous metastases from gastric adenocarcinoma 15 years after curative gastrectomy. An Bras Dermatol 2015;90:46-50.  Back to cited text no. 9
[PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Case Report
Discussion
References
Article Figures

 Article Access Statistics
    Viewed484    
    Printed12    
    Emailed0    
    PDF Downloaded47    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]