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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 5  |  Issue : 1  |  Page : 92-94

Ulcerated subcutaneous nodules: The first presenting sign of gastric adenocarcinoma


Department of Dermatology and Venereology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India

Date of Submission20-Sep-2019
Date of Acceptance16-Feb-2020
Date of Web Publication19-Feb-2021

Correspondence Address:
Sermili Rini Singnarpi
Department of Dermatology and Venereology, Institute of Medical Sciences, Banaras Hindu University, Varanasi - 221 005, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/CDR.CDR_35_19

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  Abstract 


Cutaneous metastasis from internal malignancies is rare and represents about 2% of all skin tumors. Cutaneous metastasis occur in about 0.2%–0.4% of gastric carcinoma cases, most commonly affecting the abdomen with neck, head, eyebrow, axilla, chest, and fingertips being the other sites. Here, we present a case in which cutaneous metastases presenting as multiple crateriform nodules were the first presenting signs of gastric adenocarcinoma.

Keywords: Gastric adenocarcinoma, metastasis, ulcerated nodules


How to cite this article:
Rai T, Singnarpi SR, Kumar V, Singh S. Ulcerated subcutaneous nodules: The first presenting sign of gastric adenocarcinoma. Clin Dermatol Rev 2021;5:92-4

How to cite this URL:
Rai T, Singnarpi SR, Kumar V, Singh S. Ulcerated subcutaneous nodules: The first presenting sign of gastric adenocarcinoma. Clin Dermatol Rev [serial online] 2021 [cited 2021 Jun 13];5:92-4. Available from: https://www.cdriadvlkn.org/text.asp?2021/5/1/92/309754




  Introduction Top


Cutaneous metastasis from internal malignancies represents about 2% of all skin tumors and occurs in about 0.6%–10.4% of patients.[1] The metastases may be the presenting symptom of a malignancy or may herald recurrence of a treated malignancy.[2] Here, we report a case presenting with multiple ulcerated nodules with crateriform appearance in the head and neck, which was subsequently found out to be cutaneous metastases of gastric adenocarcinoma.


  Case Report Top


A 65-year-old, nonsmoker male presented to the outpatient department of a tertiary hospital with complaints of initially asymptomatic, multiple skin-colored solid raised nodules for 3 months over head and neck [Figure 1]. Few of the larger nodules developed ulceration [Figure 2]. History of malaise and weight loss in the past 5 months was present. There was no history of dysphagia, hematemesis, or melena or any other systemic complaints. On examination, a total of eight nodules were present in the forehead, scalp, and neck of size ranging from 0.5 cm × 0.5 cm to 3 cm × 2 cm. Ulceration was present in six of the nodules. The nodules were well-defined, nontender, hard on palpation and fixed to the underlying structures. Bilateral cervical and left supraclavicular lymph nodes were palpable which were firm to hard. There was no organomegaly. Pallor was found to be present, and on investigation, the patient had hemoglobin of 7 g/dl. Enzyme-linked immunosorbent assay was nonreactive for HIV1 and 2. Stool for occult blood was positive. All other biochemical and hematological investigations were within normal limit. Chest X-ray and ultrasonography of the abdomen were not contributory. Differential diagnosis of basal cell carcinoma, histoplasmosis, molluscum contagiosum, and keratoacanthoma was kept. Histopathological examination revealed diffuse dense infiltrate of large neoplastic cells within the reticular dermis, showing moderate variation in their nuclear size, color, and shape. The cells had moderate amount of bluish staining cytoplasm. The neoplastic cells showed acinar arrangement at some places and were arranged in solid islands of varying sizes at other places. Several dilated lymphatics were seen in the upper and mid dermis with the overlying epidermis unaffected. The impression was of metastasis of adenocarcinoma [Figure 3]. Further investigations for finding the primary including computed tomography scan of the abdomen and pelvis showed circumferential heterogeneously enhancing mural thickening at the antropyloric region of the stomach causing luminal narrowing. Endoscopic biopsy and histopathological examination of the stomach growth came out to be gastric adenocarcinoma [Figure 4], consistent with the cutaneous lesions proving them to be secondaries. The patient was referred to the oncology department following which he was lost to follow-up.
Figure 1: Subcutaneous nodules on the forehead and scalp

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Figure 2: Single ulcerated nodule on the back of the scalp showing crateriform appearance and rolled out borders

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Figure 3: Histopathology of the subcutaneous nodule showing diffuse dense infiltrate of large neoplastic cells within the reticular dermis with moderate variation in their nuclear size, color, and shape (H and E, ×20)

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Figure 4: Histopathology of the gastric growth suggestive of adenocarcinoma (H and E, ×40)

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  Discussion Top


Cutaneous metastasis from internal malignancies is rare, represents about 2% of all skin tumors, and occurs in about 0.6%–10.4% of patients.[1] The most common sources of cutaneous metastasis in women are from the breast, colorectum, melanoma, and ovary, while in men, lung cancer, melanoma, colorectal and squamous cell carcinoma of the oral cavity, and renal cell carcinoma are the most common sources. 0.2%–0.4% of gastric carcinoma cases metastasize to the skin, most commonly affecting the abdomen with neck, head, eyebrow, axilla, chest, and fingertips being the other sites.[3] Clinically, they present as solitary or multiple nodules and rarely as carcinoma erysipeloides, carcinoma en cuirasse, zosteriform metastasis, and neoplastic alopecia.[3] Cutaneous metastasis usually occurs late after an internal malignancy; however, rarely, they may be the initial presenting symptom in about 0.5%–1% of cases.[4] This sort or rarity can lead to a misdiagnosis of skin lesions, especially when they the diagnosis of an underlying malignancy is not made. The metastasis may occur through lymphatic spread hematogenous spread, direct contiguity, or iatrogenic implantation. Because they usually represent widespread terminal disease, prognosis is generally poor and the treatment is mainly palliative. For widespread cutaneous metastases, palliative therapy including radiotherapy, systemic chemotherapy, polychemotherapy, isolated limb perfusion, interferon alpha injections, cryotherapy, laser ablation, or radiofrequency ablation may be helpful.[5] Owing to the poor prognosis, early diagnosis of cutaneous metastases has a profound effect on patient management and survival, and the dermatologist plays a key role in it, especially when the cutaneous metastases predated the diagnosis of internal malignancy.


  Conclusion Top


The idea of reporting this case is to be on the lookout for internal malignancies whenever a patient, especially an elderly, presents with asymptomatic ulcerated nodules even in the absence of any systemic signs and symptoms.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Alcaraz I, Cerroni L, Rütten A, Kutzner H, Requena L. Cutaneous metastases from internal malignancies: A clinicopathologic and immunohistochemical review. Am J Dermatopathol 2012;34:347-93.  Back to cited text no. 1
    
2.
Nibhoria S, Tiwana KK, Kaur M, Kumar S. A clinicopathological and immunohistochemical correlation in cutaneous metastases from internal malignancies: Afive-year study. J Skin Cancer 2014;2014:793937.  Back to cited text no. 2
    
3.
Choi WJ, Jue MS, Ko JY, Ro YS. An unusual case of carcinoma erysipelatoides originating from gastric adenocarcinoma. Ann Dermatol 2011;23:375-8.  Back to cited text no. 3
    
4.
Schwartz RA. Cutaneous metastatic disease. J Am Acad Dermatol 1995;33:161-86.  Back to cited text no. 4
    
5.
Wong CY, Helm MA, Kalb RE, Helm TN, Zeitouni NC. The presentation, pathology, and current management strategies of cutaneous metastasis. N Am J Med Sci 2013;5:499-504.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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Discussion
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