Case Reports in Surgery

Case Reports in Surgery / 2018 / Article

Case Report | Open Access

Volume 2018 |Article ID 7102845 | https://doi.org/10.1155/2018/7102845

J. M. V. Amarjothi, R. Villalan, J. Jeyasudhahar, O. L. NaganathBabu, "Interesting Case of Skin Metastasis in Colorectal Cancer and Review of Literature", Case Reports in Surgery, vol. 2018, Article ID 7102845, 7 pages, 2018. https://doi.org/10.1155/2018/7102845

Interesting Case of Skin Metastasis in Colorectal Cancer and Review of Literature

Academic Editor: Christophoros Foroulis
Received17 Aug 2018
Accepted23 Oct 2018
Published30 Dec 2018

Abstract

Skin metastasis is a complication rarely seen after curative resection for colorectal cancer and chemotherapy. The article describes a metachronous case of skin metastasis after curative resection. This article is presented to illustrate that genetic and molecular profiling of carcinoma is a must for diagnosis of aggressive biological behavior and that skin metastasis is usually a harbinger of adverse outcome.

1. Introduction

Cutaneous metastases though rare may be the earliest manifestation of metastatic colorectal cancer. Such metastasis often indicates a poor prognosis, with the situation being further complicated by suboptimal treatment and aggressive biological behavior of such tumors.

A 25-year-old male patient presented with a history of bleeding per rectum, mucus discharge, and features of intestinal obstruction for 3 months. He was positive for Hepatitis B surface antigen (HBsAg); the exact etiology of which was unknown. On physical examination, rectal examination revealed semicircumferential growth involving 6 cm from anal verge 9-3 o’clock position. HPE was suggestive of poorly differentiated carcinoma. Colonoscopy was not passible due to stenosis. Carcinoembryonic antigen (CEA) levels were 1.3 ng% (<5 ng%). Contrast-enhanced computerised tomography (CECT) (Figure 1) showed irregular circumferential thickening of the wall of the rectosigmoid junction narrowing lumen, 15 cm in length from 6–19 cm with pericolonic and perirectal fat stranding. Hence, a diversion colostomy was done and the patient was subjected to long course chemoradiation with cisplatin and 5-fluorouracil and after 8-week interval, restaging was done. Per rectal, examination did not reveal palpable tumor. Imaging (Figure 2) done showed only wall thickening at the lower rectum without evidence of enlarged lymph nodes. Serum CEA was 1.7 ng% (); low anterior resection was done using CDH31 stapler and diversion ileostomy was done. HPE revealed complete regression of tumour in the tissue studied. The patient was put on adjuvant chemotherapy. Two months later, he developed multiple cutaneous nodules on the chest and back (Figure 3). FNAC was suggestive of adenocarcinoma. Two months later, he developed multiple peritoneal metastases and succumbed to the disease a month later.

Skin involvement is seen in about 5% of patients with colorectal cancer [1] where it appears as subcutaneous or intradermal small nodules, and it can be confused with cysts, lipomas, neurofibromas, or alopecia due to these characteristics [2, 3].

Two meta-analysis [3, 4] reported a 5–5.3% incidence of skin involvement in cancer patients. In other studies, Kauffman and Sina [5] and Lookingbill et al. [2] reported an incidence of 0.7–9% and 10%, respectively, for skin metastasis.

In an autopsy series of review of cutaneous metastasis from internal carcinoma [6, 7], the most common primary site is the breast followed by the lung. The rectum is a very rare site and the most common site of metastasis was the previous surgical scar followed by the pelvis, back, chest, upper extremities, head, and neck [5]. Most of the cutaneous metastases are well-differentiated and mucin-secreting [7]. Several mechanisms of cutaneous metastasis have been postulated including lymphatic or hematogenous spread, direct extension, or implantation during surgery [2].

Skin metastases from colorectal adenocarcinoma commonly occur metachronously within the first two years after resection of the primary tumor and are often present simultaneously with metastases to other organs like the liver [7]. The most common primary sites of cutaneous colorectal metastasis have been reported as follows: rectum (55%), sigmoid colon (17%), transverse colon (9%), rectosigmoid (7%), cecum (4%), and ascending colon (4%) [8, 9].

Skin involvement that can be seen at the time of diagnosis or during the course of treatment is a sign of advanced stage (Table 1). The prognosis is generally poor with survival of about 18 months [2] with a general range of about 1–34 months [10]. Surgical biopsy may not be logical for these patients due to poor survival and FNA cytology may be accurate for diagnosis of skin metastasis in a patient with known malignancy [11]. Wide local excision of the cutaneous metastatic lesion is the preferred treatment option in isolated lesions which is quite rare. Multiple cutaneous metastases are only palliated due to dismal prognosis [7].


Author, yearAge (years)SexHistologyStagePrimary cancer treatmentInterval (months)Skin metastasis locationSkin metastasis morphologySkin metastasis treatmentSurvival (follow-up time in months)

Gottlieb and Schermer, 1970 [12]72FAdenocarcinoma-sigmoidNASigmoidectomy57PalmsNodulesNA
Gottlieb and Schermer, 1970 [12]67MAdenocarcinoma-descending colonNALeft hemicolectomy4FaceNodules/ulcersNA6 months
Gray and Das, 1989 [13]79FAdenocarcinomaRadiation0LegNodulesNoneNo (18)
Reed and Stoddard, 1992 [14]68FAdenocarcinoma, poorly differentiatedLAR4PerineumNodulesAPR
De Friend et al., 1992 [15]49FAdenocarcinomaIIILAR7PerineumNodulesWLE
Kauffman and Sina, 1997 [5]50MAdenocarcinoma, signet ringIVLAR+ACR36MultiplePlaquesNoneNo (3)
Stavrianos et al., 2000 [16]78MAdenocarcinoma-well differentiatedIIITransverse colon resection3Cheek oral commissureUlcersRT followed by full thickness excision11
Sukumar and Qureshi, 2001 [17]75MAdenocarcinoma, poorly differentiatedAPR+RT3Penile skinNodule, ulcersNA2
Adani et al., 2001 [18]70FAdenocarcinomaIIIAPR+AC36LegNodulesCRYes (14)
Tsai et al., 2002 [19]47MAdenocarcinoma, signet ringIIIAPR+AC11MultipleNodulesCNo (4)
Melis et al., 2002 [20]41MAdenocarcinomaIVNCR1PerineumPlaquesNone
Damin et al., 2003 [21]44MAdenocarcinomaIILAR6GroinZosteriformRNo (5)
Hayashi et al., 2003 [22]50MAdenocarcinoma, mucinousLAR4PerineumNodulesNone
Wright et al., 2003 [23]81FIVCholecystectomy scarNA
Sarid et al., 2004 [24]60FAdenocarcinoma, mucinousIIINR+LAR+ACR16Chest, abdomenUlcersWLENo (56)
Alexandrescu et al., 2005 [25]62FAdenocarcinomaNA60Scar siteMasses
Alexandrescu et al., 2005 [25]46MAdenocarcinomaNA36Scar siteMasses
Reuter et al., 2007 [26]69MAdenocarcinomaIIAPR+ACR5PerineumPlaquesNoneNo (6)
Tan et al., 2006 [27]70MAdenocarcinoma, mucinousIIIBLAR+AC20BackNodulesWLE, C
Tan et al., 2006 [27]51FAdenocarcinomaIIIBAPR10PerineumNodulesWLE, CR9 months
Kilickap et al., 2006 [28]29MAdenocarcinoma, signet ringIIIALAR+APR+ACR14Chest wall, axillaNodulesWLE+CYes (4)
Fyrmpas et al., 2006 [29]62MAdenocarcinoma-moderately differentiatedNARight hemicolectomy36ChinNodulesExcision biopsy8 months
Nasti et al., 2007 [30]76FAdeno carcinomaIIIPreop CRT0Face with parotid gland involvementNANA15
Gazoni et al., 2008 [31]55FAdenocarcinoma, poorly differentiatedIVColostomy+CR0PerineumCRNo (3)
Gazoni et al., 2008 [31]66MAdenocarcinoma, poorly differentiatedIVColostomy+CR0PerineumCRNo (4)
Gazoni et al., 2008 [31]68MAdenocarcinoma, poorly differentiatedIVColostomy+CR0Thigh, axillaCRNo (3)
Gazoni et al., 2008 [31]72MAdenocarcinomaIVColostomy+CR0PerineumCRNo (5)
Gazoni et al., 2008 [31]65MAdenocarcinomaIVColostomy+CR0PerineumCRNo (7)
Gazoni et al., 2008 [31]78MAdenocarcinomaIVStent+CR0PerineumCRNo (1)
McWeeney et al., 2009 [32]72MAdenocarcinomaIIIIleostomy+NCR6PerineumNodulesWLE
Kurihara and Watanabe, 2009 [33]66MIIIRight thigh7 months
Ayadi, 2009 [34]63MSmall cell carcinoma-rectumIIICT5ScalpUlceroproliferative massPalliative CT16 months
Saladzinskas et al., 2010 [35]64MAdenocarcinoma, mucinousIIANR+LAR42FaceUlcersWLEYes (7)
Ismaili et al., 2011 [36]50FAdenocarcinoma, signet ringIVNone0MultipleZosteriformNoneNo (1)
Horiuchi et al., 2011 [37]53MAdenocarcinomaII36Scalp6 months
Civitelli et al., 2011 [38]73FAdenocarcinomaIIIFew daysAbdominal wall, chest, back6 months
Balta et al., 2012 [39]46MAdenocarcinoma, mucinousIIIBColostomy12PerineumUlcersNone
Wang et al., 2012 [40]63MAdenocarcinomaIII6Chest, neck, upper limb2 weeks
Nasrolahi, 2013 [10]33MAdenocarcinomaIVCT3Chest, back, neckPlaqueCTFew weeks
Rajan et al., 2012 [41]36MAdenocarcinomaIV24Lower extremities3 months
Hamid and Hanbala, 2012 [42]70NAAdenocarcinomaII86Scalp, upper trunkNA
Russo et al., 2012 [43]72MAdenocarcinoma-signet cellsIIRight hemicolectomy33BackNodulesWLEYes
Rashid et al., 2012 [44]65MAdenocarcinomaIIIRight hemicolectomy0ForearmNodules17 months
de Miguel Valencia et al., 2013 [45]55MAdenocarcinoma, mucinousIIIBNCR+APR+AC18MultipleNodulesNoneNo (—)
Ozgen et al., 2013 [46]65MAdenocarcinomaIIANCR+LAR+ACR18PerineumNodulesCRYes (12)
Akpak et al., 2014 [47]47FAdenocarcinomaIVAPR36PerineumUlcersWLE+CR
Nesseris et al., 2013 [7]80MAdenocarcinomaIIIRight hemicolectomy12 mLower abdomenUlceroproliferative growth2 cycles of CTYes
Kushwaha et al., 2013 [48]40MAdenocarcinoma-signet cellsIVCT0Chest, neckNodulesCT4 months
Kushwaha et al., 2013 [48]56MAdenocarcinomaIIAPR+CT10Chest, neckNodulesNA8 months
Kushwaha et al., 2013 [48]43FAdenocarcinomaIILAR+CT8ChestNodulesNA7 months
Rogers et al., 2014 [49]50MAdenocarcinoma, mucinousIV72ScalpNodulesWLENA
Rogers et al., 2014 [49]45FAdenocarcinomaNCR+SX+ACRScalpNodulesWLEYes
Dehal et al., 2016 [50]47MAdenocarcinoma, mucinousIVCR1PerineumNodulesRYes (12)
Fragulidis et al., 2015 [51]62MAdenocarcinomaIVEndoscopic stent4 mScalpNodulesWLENo (2 weeks)
Varma et al., 2015 [52]40FAdenocarcinomaColostomy2 mPubic area, thighNodulesNANA
Our case, 2018

NCR: neoadjuvant chemoradiation; CR: chemoradiation; SX: surgery; CT: chemotherapy; WLE: wide local excision; NR: neoadjuvant radiation; ACR: adjuvant chemoradiation; APR: abdominoperineal resection; LAR: low anterior resection; NA: not available.

Consent of the next of kin was obtained prior to the preparation of manuscript.

Conflicts of Interest

The authors declare that they have no conflicts of interest.

Authors’ Contributions

Amarjothi JMV and Villalan R were responsible for the conceptualization, data curation, and formal analysis. Jeyasudhahar J and OL NaganathBabu were responsible for investigation, supervision, validation, and visualization and for the writing of the original draft, review, and editing.

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Copyright © 2018 J. M. V. Amarjothi et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


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