Esophageal squamous cell carcinoma presenting with extensive skin lesions: a case report
© Iwanski et al; licensee BioMed Central Ltd. 2008
Received: 26 September 2007
Accepted: 21 April 2008
Published: 21 April 2008
Esophageal squamous cell carcinoma (ESCC) is the most common histological subtype of cancer in the upper and middle esophagus and is characterized by a high rate of mortality. The incidence of esophageal cancer varies greatly among regions of the world and occurs at a high frequency in Asia and South America.
In our department, a 51-year-old man was diagnosed with ESCC after presenting with extensive disseminated skin nodules. Biopsy of the nodules showed metastatic ESCC. Cutaneous manifestations of esophageal neoplasia are very rare and are mainly described for esophageal adenocarcinoma (EADC). Here we report a very uncommon case of extensive skin metastases of ESCC.
Early biopsies of suspicious skin lesions are important and should be performed in patients with unclear symptoms such as weight loss or dysphagia and especially in patients with a history of cancer, since they can reveal the existence of a distant malignant disease leading to diagnosis and prompt therapy.
Cancer of the esophagus is the ninth most common malignancy and ranks as the sixth most frequent cause of cancer death in the world, constituting 7% of all gastrointestinal cancers . Patients with esophageal cancer usually present with disease that is locally advanced and which has already metastasized stage at the time of initial diagnosis. Cancer of the esophagus exists in two main forms with different etiological and pathological characteristics: esophageal squamous cell carcinoma (ESCC) and esophageal adenocarcinoma (EADC). ESCC is the predominant histological subtype, comprising about 70% of cases .
In general, skin metastases from malignant tumors of the internal organs are rarely seen, with a frequency of between 0.7 and 9% [3–5]. The overall survival rate varies from 4.3 to 4.7 months . The cancer types most commonly associated with cutaneous metastases are breast, lung and melanoma [4, 7, 8]. Metastatic spread to the skin occurs either hematogenously or via the lymphatic system and presents in the form of rapidly growing papules or nodules [9, 10]. On histopathology, clusters of atypical cells infiltrating the dermis without connection to the adjacent epidermis can be seen . Here we report an uncommon case of massive cutaneous metastases of ESCC in a 51-year-old man.
Due to the extreme rarity of cutaneous metastases from ESCC, there are only limited data in the literature regarding their incidence. Fereidooni and colleagues reported a solid facial skin metastasis of EACC . Two additional cases have been published discussing solitary metastases on a digit from an unusual variant of ESCC, the basaloid squamous cell carcinoma [12, 13]. Schoenlaub and colleagues reviewed the clinical findings and overall survival of 200 patients with cutaneous metastases of various cancers. The incidence of cutaneous metastases from EACC was 2 out of the 200 cases studied . The cancers most frequently causing cutaneous metastases were breast cancers (n = 64), pulmonary cancers (n = 36) and melanomas (n = 31) . Reingold reported clinical and necropsy findings of 32 cases out of 2,300 internal carcinomas. The most common primary site was the lungs (50%). The esophagus was the primary tumor site in just one case and this was an adenocarcinoma. The most common sites of skin metastases were on the chest and abdomen . Lookingbill et al reviewed 420 patients with cutaneous metastases from melanoma and carcinoma . In this study, tumor registry data from 7,608 patients was evaluated; 4,020 of these patients had metastatic disease and 420 (10.4%) had cutaneous metastases. The most common primary tumors causing cutaneous metastases were melanoma (n = 77) and breast cancer (n = 212). The esophagus was the primary site in only three cases, spreading mainly to the chest and abdomen . Tharakaram described five cases of skin metastases from ESCC in male patients .
Skin manifestations of ESCC are extremely rare and only a small number of cases with solid skin metastases have been reported. A case of ESCC with such diffuse and massive skin metastases, most likely indicating highly aggressive disease, has not been described previously. Our patient complained about these unusual cutaneous metastases before any of the more usual symptoms such as dysphagia or weight loss were manifested.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
We thank A Niendorf MD and K Hamper MD for providing histopathological figures, T Göttsche MD for radiological diagnosis and HANSERAD for providing the CT scan pictures.
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