Gastric adenocarcinoma cutaneous metastasis arising at a previous surgical drain site: a case report
© Morelli et al; licensee BioMed Central Ltd. 2009
Received: 14 February 2008
Accepted: 16 February 2009
Published: 16 February 2009
Skin metastasis from internal carcinoma rarely occurs. It has an incidence of 0.7 to 9% and it may be the first sign of an unknown malignancy. However, it can also occur during follow-up.
A 90-year-old female patient was admitted to our surgical division with a diagnosis of anemia from a bleeding gastric adenocarcinoma. She underwent a gastric resection and Billroth II retrocolic Hofmeister/Finsterer reconstruction. She developed an enteric fistula, which needed a permanent abdominal drain until the 60th postoperative day. After 12 months she was readmitted to our division with subacute small bowel obstruction and an erythematous swelling on the right side of the abdomen. Biopsies characterized it as a cutaneous metastasis from the gastric adenocarcinoma. No surgical therapy was performed given her poor clinical condition.
Skin metastasis from carcinomas of the upper gastrointestinal tract is very rare. Persisting erythematous nodules must be biopsied in order to diagnose cutaneous metastases and to recognize them early and start prompt therapy with anti-tumour agents before the occurrence of massive visceral metastases.
Metastasis to the skin from internal carcinoma rarely occurs and it has an incidence of 0.7 to 9% [1, 2]. Skin metastases may be the first sign of an unknown malignancy. However, it can also occur during follow-up [3, 4]. The most common origin of cutaneous metastases is breast cancer in women and lung cancer in men. Skin metastases from gastric adenocarcinoma are rare [3, 5]. Surgical drain site metastasis is rare, but possible . It usually occurs after palliative resection in which the tumour mass remains. We describe here a patient who developed a skin metastasis from a gastric adenocarcinoma in the location of a previous surgical drain.
Metastatic carcinoma of the skin is an uncommon occurrence, with incidence rates of 5% or less [1, 2, 7]. Skin metastases from gastric adenocarcinoma are very rare [3, 5]. Cutaneous metastases may occur late in the course of the disease, but they can also occur at the beginning, showing a severe underlying disease. Breast cancer is one of the most common tumours to metastasize to the skin, but also lung cancer, colorectal cancer, renal cancer, ovarian cancer and bladder cancer have similar rates for cutaneous metastases of between 3.4 and 4% . Also, metastases from carcinomas of the upper digestive tract have an incidence less than 1% . Gastric cancer, specifically, causes only 6% of all skin metastasis. Metastasis from gastric adenocarcinoma can also have a wide distribution, presenting with wide generalized cutaneous metastases. The main feature is the histological appearance as it is similar to the primary tumour. In our case, the main component was signet ring cells with mucin and laterally displaced nuclei mixed with malignant cells; however, the undifferentiated component was almost absent. Globally, the histological features of the lesion can be similar to those of the primary tumour. Another element is the widely known possibility for tumour cells seeding in drain or trocar locations in patients operated on by laparoscopy [6, 9, 10]. The long permanence of abdominal drains can be an additional risk in developing cutaneous metastasis, but this incident is still rare [6–9]. Otherwise, given the poor general condition and the age of the patient, medical management of the enteric fistula was almost mandatory . Because of advances in cancer therapy, patients who are diagnosed with cutaneous metastasis may live longer than before. Nevertheless, skin metastases are still a sign of poor prognosis, particularly in patients affected by lung cancer, ovarian cancer or cancers of the upper respiratory tract or upper digestive tract . The prognostic value of this clinical sign is important in the management of the manifestation of the disease: the average survival is 11.4 weeks (range from 2 to 34 weeks) . The treatment is palliative in most cases, although chemotherapy and radiotherapy are often used to treat these patients but in many cases the treatment presents moderate or no results. The widespread dissemination of the tumour often means an early fatality.
We have described a patient with cutaneous metastasis from gastric adenocarcinoma surgically treated with no macroscopic and microscopic evidence of residual disease who developed an enteric fistula from the duodenal stump which was medically treated. The age and the immunological competence of the patient can be a fertile field for uncontrolled malignant cell proliferation. However, skin metastases from carcinomas of the upper gastrointestinal tract are very rare, especially those from gastric cancer. Persisting erythematous nodules must be biopsied in order to diagnose cutaneous metastases and early recognition of them enables prompt therapy with antitumour agents before the occurrence of massive visceral metastasis.
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
The authors wish to thank Ms Carolina Santoro Blengini and Mr Ettore Morelli for their help and support.
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