Background: Cutaneous metastasis is valuable though with infrequent occurrence in clinical practice. It is of esteem value in diagnosis as well as treatment of cancer due to the ease of accessibility for clinical examination and biopsy. Case Series: This is a presentation of 5 consecutive patients with histologic diagnosis of cutaneous metastatic malignancies at the University of Calabar Teaching Hospital, (UCTH), Calabar, Nigeria from 2010 to 2013. They were studied in an attempt to evaluate the clinical significance of cutaneous metastatic nodules/disease in a tropical setting. This was compared with total cutaneous malignancies and total malignancies seen over the same period. Conclusion: The spectrum in the reported cases ranged from localised and barely noticeable nodules to generalised nodules. Clinicians are urged to show renewed interest in cutaneous nodules in view of the estimable value by subjecting such for histological evaluation.
Cutaneous metastases arising from carcinomas though rare are important findings in clinical practice [
Case 1
H. I, a 65-year-old male presented with recurrent abdominal pain and swelling of 9 months duration. He no- ticed recurrent episodes of right sided abdominal pain and admitted to episodes of alternating history of consti- pation and diarrhea. However, there was no history of passage blood in stool but admitted to history of weight loss and gets tired easily. His attention was drawn to the presence of an umbilical swelling as part of his clinical evaluation 6 months after the onset of his ailment.
Examination revealed a chronic ill-looking patient, anicteric, pale, afebrile with no peripheral lymphadeno- pathy. Pulse was 76 beats per minute and Blood pressure 140/70 mm/Hg. Chest examination was normal. Ab- dominal examination revealed no organomegally except for a mild tenderness on palpation of the right flank in addition to an umbilical nodule that was non tender, firm, measuring 2 × 1.5 cm. Rectal examination was not remarkable. A preoperative diagnosis of colonic cancer was made.
Haemogram showed a packed cell volume (PCV) of 29%, white blood count (WBC) 5.3 × 109/l, (lympho- cytes 27%, neutrophils 70%, monocytes 2%, and eosinophils 1%), Platelets 257 × 109/l, ESR 80 mm/hr. Faecal occult blood was positive. Carcino embryonic antigen (CEA) was 7.0 ng/ml. Chest X-Ray (CXR) was normal. Abdominal computerized tomogram (CT) was reported as revealing features suggestive of malignant mass in the ascending colon. Biopsy of the umbilical nodule revealed metastatic adenocarcinoma.
Patient was commenced on haematinics counseled for surgery which he declined and was lost to follow-up after a month.
Case 2
A. E, was a 75-year-old female, she presented with a mass located at the upper part of the back of 4 months duration. She however did not present with any other symptoms.
Examination revealed a patient in apparent good health, anicteric, not pale, afebrile with no peripheral lymphadenopathy. Chest and abdominal examinations were normal. Rectal and vaginal examinations were not re- markable. Examination of the back revealed a hard irregular non tender, cutaneous mass over the left scapula measuring 3.5 × 2.5 cm.
Haemogram revealed a PCV 34%, WBC 5.8 × 109/l, (Neutrophils 70%, lymphocytes 28%, monocytes 1%, eosinophils 1%), platelets 276 × 109/l. Biopsy of the mass revealed metastatic adenocarcinoma suggestive of colonic site.
Patient however, declined further evaluation on account of cost and was lost to follow-up after one month.
Case 3
J. T, was a 56-year-old female who presented with multiple swellings on the scar of a previous operation of 3 months duration. She was offered a right hemicolectomy 3 months ago for a diagnosis of carcinoma of the cae- cum that presented as an emergency with malignant intestinal obstruction.
Examination revealed a patient in relative good health, anicteric, afebrile, not pale with no peripheral lym- phadenopathy. Chest examination was normal. Abdominal examination was essentially normal but for 3 discrete nodules distributed along the laparotomy scar. They were non tender, hard with measurements that ranged from 1.5 × 1.0 to 1.5 × 2 cm. Rectal examination was normal.
Haemogram showed a PCV of 33%, WBC 5.0 × 109/l (Neutrophils 70%, lymphocytes 26%, monocytes 2%, and eosinophils 2%), platelets 272 × 109/l. CXRay and abdominal ultrasound scan (USS) were reported as normal. CEA was 5.3 ng/ml. Nodules were excised and histology revealed metastatic adenocarcinoma. She was commenced on adjuvant chemotherapy with 5FU but was however lost to follow-up after 2 months.
Case 4
I. S. E, a 37-year-old male barber presented with multiple skin masses located on the fore head, left shoulder, anterior abdominal wall, back, gluteal region and left foot; (
Nine months prior to this he presented to the ENT clinic with a 2 month history of left eye protrusion and left nasal obstruction of 6 months duration. Clinical examination then revealed a chronically ill-looking man with left cervical lymphadenopathy (3 × 4 cm) with supraorbital proptosis of the left eye with a firm mass on the medial canthus. Visions in both eyes were intact. CT of the paranasal sinuses showed left orbital mass involving the nasal cavity, ethmoidal, maxillary and sphenoidal sinuses. Histology and immunohistochemistry of the mass revealed?olfactory neuroblastoma
He was offered 3 courses of 5FU, cisplatin and zofran fortnightly and 2 weeks of radiation which initially resulted in near resolution of the mass and nasal obstruction. However, 6 weeks after commencement of chemo- radiation, multiple skin masses appeared.
Excision of the masses at the shoulder and anterior abdominal wall revealed metastatic olfactory neuroblas- toma (
Case 5
H. E, a 60-year-old retired female civil servant who presented to the surgical outpatient department (SOPD) as a referral from the General Hospital in Calabar with a 5 month history of abdominal pain and progressive abdominal distension of 4 months duration following umbilical herniorrhaphy. She reported to have had a painless reducible umbilical swelling since childhood that became painful and irreducible and was offered herniorrhaphy,
She was not a known peptic ulcer disease patient, known hypertensive and non diabetic but admitted to loss of weight. She was commenced on anti Kock’s therapy to no avail prior to referral. The onset of increasing dyspnoea, abdominal swelling and pedal oedema necessitated her referral.
Examination revealed acute-on-chronic ill looking patient in respiratory distress, anicteric, pale, afebrile with bilateral pitting oedema and no peripheral lymphadenopathy. Respiratory rate was 30 cycles/min. Pulse rate was 92 beats/min, BP 160/90 mm/Hg. Abdominal examination revealed a grossly distended abdomen that moved with respiration. There was a transverse scar across the umbilicus with 2 Sister Mary Joseph’s nodules,
Full blood count showed, PCV 32%, WBC 4.5 × 109/l (lymphocytes 24%, neutrophils 72%, monocytes 4%), platelets 252 × 109/l, ESR 90 mm/hr. CXRay revealed features of hypertensive heart disease. Abdominal CT showed features in keeping with advanced transverse colonic tumour. Histology of umbilical nodule was reported as metastatic poorly differentiated adenocarcinoma, (
She was commenced on antihypertensive drugs, iron dextran and had 2 courses of 5FU. Dyspnoea persisted despite 2 episodes of abdominal paracentesis an succumbed to metastatic disease 5 months post appearance of the umbilical nodule.
Cutaneous metastasis from primary internal malignancies is uncommon. The total number of cutaneous malignancy that presented in the authors setting (2010-2013) was 60 [55(92%) primary, while 5(8%) were metastatic], and total cutaneous malignancy accounted 10% of total malignancies during the same study period,
S/N | Age | Sex | Clinical presentation (Diagnosis) | Site of cutaneous nodule | Histology | Remarks |
---|---|---|---|---|---|---|
1. | 68 | M | Recurrent large bowel adenocarcinoma (ascending colon) | Umbilicus | Metastatic adenocarcinoma | Refused surgery. Lost to follow up |
2. | 75 | F | Irregular hard cutaneous mass | Left scapula region | Metastatic adenocarcinoma | Lost to follow up |
3. | 56 | F | Multiple nodules scar of previous laparotomy | Anterior abdominal wall (midline scar) | Metastatic adenocarcinoma | Adjuvant chemotherapy 5FU. Lost to follow up |
4. | 37 | M | Multiple cutaneous masses | Fore head, abdomen back gluteal, left foot | Metastatic olfactory neuroblastoma | Mortality. 2 months (post cutaneous nodules) |
5. | 60 | F | Abdominal distension umbilical nodules | Umbilicus | Metastatic adenocarcinoma | Hospital mortality 5 months (post cutaneous nodules) |
Total cutaneous malignancy 60 (55 (92%)―primary, 5 (8%)―Metastatic). Total cutaneous malignant 10% of total malignancy. Total cutaneous metastatic malignant―0.8% of total malignancy.
primary site for cutaneous metastasis in these series in our setting. Cutaneous metastases from abdominal cancers are uncommon occurring in less than 5% of patients [
Cutaneous metastases are detached extensions of primary tumours to the skin. Four metastatic pathways namely regional spread (through body cavities), transplantation (via surgery or other invasive procedures), lymphatic (common for carcinomas), and haematogenous (common for sarcomas) have been documented [
Majority of cases present with painless nodules after diagnosis [
Cutaneous metastasis may occur at any time in the course of the malignancy and spread may follow, direct extension, lymphogenous, intravascular dissemination or surgical implantation as noted in a patient [
Diagnosis is by histology and comprehensive evaluation includes assay for markers, imaging, and immunohistochemistry especially when in search for the primary site as in CUPS [
Treatment is palliative aimed at improving the quality of life especially when indicated by disfigurement or pain. Wide local excision of the cutaneous lesion is recommended. Other modalities include cryotherapy, photodynamic therapy, radiation, intralesional, or topical chemotherapy [
The outcomes were generally poor, 2 (40%) patients were recorded mortalities (5 months and 2 months after diagnosis cutaneous metastases), while others were lost to follow up with advance primary disease. Mortality rate is high; however, some improvement has been recorded with chemotherapy. Overall survival has been reported between 3 - 9 months in keeping with this report [
Following the increasing incidence of malignancies, dermatologists including dermatopathologists and generally clinicians are likely to encounter cutaneous metastases hitherto regarded as insignificant and are of esteemed value in directing search for the associated primary malignancy [
Cutaneous metastasis though not a frequent event shows a pattern of clinical significance hence the request for renewed interest by clinicians. Recognition may be a pointer to an undiagnosed disease and when detected warrant a thorough metastatic work up that may result in accurate staging of the disease. Meticulous surgical techniques can prevent skin metastasis from implantation while wide spread metastases may be an indicator of poor prognosis.
MauriceE. Asuquo,AniefonN. Umana,Victor I. C.Nwagbara,MartinNnoli,TheophilusUgbem, (2016) Cutaneous Metastatic Disease: Case Series in a Tropical Setting. Case Reports in Clinical Medicine,05,25-31. doi: 10.4236/crcm.2016.51005