Cutaneous metastasis of gastric adenocarcinoma: an unusual clinical presentation

ARTICLE

Metastases to the upper extremities are uncommon, usually late findings. There are few reports of metastasis of gastric adenocarcinoma to the upper extremities. We describe a patient who had a gastric adenocarcinoma and developed an erythematous plaque on his left forearm. To the best of our knowledge this is the first description of metastasis from gastric adenocarcinoma with this presentation.

Case report

A 72-year-old man with a history of esophagitis, lung tuberculosis and total gastrectomy due to a poorly differentiated gastric tubular adenocarcinoma staged T3N1M0, developed two years later a tender, erythematous, slightly infiltrative, edematous, and well-circumscribed large plaque on the dorsal aspect of his left forearm (Fig. 1). An incisional biopsy was performed and histological examination revealed diffuse infiltration of the dermis by polygonal or round cells with irregular and conspicuous nuclei and poor cytoplasm, some of them containing periodic acid-Schiff material with the typical morphology of signet-ring cells (Fig. 2). Lymphatic and blood vessels were not dilated and did not contain tumoral cells. Immunohistochemical study revealed expression of epithelial cytokeratins (Fig. 3), CEA, EMA, and were negative for CD45, S-100 and CD68. The tumour was diagnosed as a skin metastasis of the gastric adenocarcinoma. On exploration no lymph nodes were detected by palpation.

Complementary examination including abdominal computerized tomography scan and gastric endoscopy did not reveal abnormal findings. The full blood count and blood biochemistry studies were normal but both alkalin phosphatases (874 mU/ml) and carcinoembryonic antigen (122 ng/ml) were elevated. The patient was treated with only one cycle of a combination chemotherapy (cisplatin, 5-fluouracil and epirubicin). Cutaneous metastasis did not respond to the treatment and kept on growing progressively, neither visceral nor new cutaneous metastasis appeared before the patient died 6 months later. Regrettably, post mortem study was not performed.

Discussion

The incidence of cutaneous metastasis from neoplasms of internal organs has been estimated in autopsy studies, with recorded frequencies varying from 0.6 to 9% of all cases of malignant disease (lymphoma and leukemia excluded) [1, 2].

Cancer metastasis to the skin most commonly occurs as indolent cutaneous nodules that tend to be localised at the head, neck, chest and abdomen [3, 4], and represent a serious prognostic sign particularly in patients with cancers of lung, ovary, upper respiratory tract or upper digestive tract [1].

Primary tumours in men that most commonly metastatize to the skin are carcinomas of the lung, colon and melanomas [5].

The incidence of cutaneous metastasis from carcinomas of the upper digestive tract has been reported to be less than 1 % [2].

Gastric carcinomas usually metastatize to the liver, peritoneal cavity and regional lymph nodes more often than to the skin [6] and when cutaneous metastasis occur they usually arise in the vicinity of the primary tumour (e.g. the abdominal wall) [3, 7].

Cutaneous metastasis from adenocarcinoma of the stomach may be solitary or multiple and has appeared on the head, eyebrow, neck, axillae, chest, lip, fingertips, shoulders, arms and umbilical region [3].

Cutaneous metastases have been reported to follow the diagnosis of gastric carcinoma by 3 to 10 years. Although cutaneous metastases usually appear late in the course of the disease, they may also constitute the presenting sign [8].

Clinically, they occur as nonspecific nodules or, rarely, show a zosteriform pattern or an erysipelas-like pattern [5]. They may appear as an inflammatory metastatic carcinoma or as a scarring alopecia, but most cutaneous metastases arise as nonspecific painless dermal or subcutaneous nodules with an intact overlying epidermis [5].

A distinct variety of cutaneous metastasis, called carcinoma erysipelatoides, consists of an ill-defined area of warm, tender, erythematous-edematous skin, which closely simulates erysipela or cellulitis [9]. This entity has been reported in conjunction with primary tumours of the stomach [10-12]. Histopathology characteristically shows occlusion of the lymphatic vessels by neoplastic cells.

Metastases to the upper extremities are uncommon and usually appear late. The most frequent primary tumour metastatic to the upper extremities is malignant melanoma; less often it is carcinoma of the breast, lung, kidney or large intestine [3, 5].

Several reports of gastric metastasis localised on shoulders, upper arms and hands have been reported [11-15] but we have not found any other case localised on the forearm.

Miyashita et al. reported in 1991 one case of metastatic gastric carcinoma with an erythematous plaque located on the upper back, which closely resembled our case, but they did not perform a biopsy of this lesion [12].

The metastatic pattern we report is very unusual. It has an uncommon location and, although it clinically resembles carcinoma erysipelatoides, histopathologically it is not. Besides, the distance between the original tumour and the metastasis is too great to consider a lymphatic mechanism of spread, which typically belongs to carcinoma erysipelatoides. We believe that, in our case, the neoplastic cells of the metastasis present in the interstitium of the skin, arrived by dissemination via vessels, then extravasated from those vessels and proliferated in the interstitium

Article accepted on 27/6/01

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