Dermatology Online Journal

Neurofibroma like nodules on shoulder: First sign of gastric adenocarcinoma
Yeliz Karakoca, Canan Aslan, Asli Turgut Erdemir, Ummuhan Kiremitci, Mehmet S Gurel, Osman Huten
Dermatology Online Journal 16 (5): 12

Department of Dermatology, Istanbul Education and Research Hospital, Istanbul, Turkey. yelizkarakoca@hotmail.com

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Abstract

Cutaneous metastasis is a relatively uncommon manifestation of visceral malignancies. It most often occurs late in the course of a disease but may also be the first presenting sign of advanced visceral cancer. The average incidence of cutaneous metastasis from a visceral neoplasm is 5.3 percent. The incidence of cutaneous metastases from carcinomas of the upper digestive tract has been reported as less than 1 percent. Cutaneous metastases of gastrointestinal tumors are usually nodular and their typical location is in the abdominal wall. A 68-year-old woman presented with a three-month history of painless nodules on the right side of her neck. Skin examination revealed two joined nodules on the right side of her neck. The nodules were skin colored, well-circumscribed, non-motile, soft, and non-tender. Histopathological examination of the skin growth revealed diffuse infiltration of the dermis and subcutaneous tissue by tumoral cells. A diagnosis of metastatic gastric carcinoma was made. However,various cutaneous metastases have been reported as erysipelas-like, zosteriform, and epidermoid cyst-like. Cutaneous metastases must always be distinguished from primary skin tumors. This report emphasizes the need for appropriate investigation of newly appearing, unusual, or persistent skin lesions such as non-healing ulcers, persistent indurated erythemas, and all skin nodules of undetermined causes.

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Introduction

The skin is uncommonly involved by metastatic tumors. When present, it typically signifies disseminated disease with a poor prognosis. Cutaneous metastasis ordinarily appears late in the course of fatal neoplastic disease, but can be the earliest sign of tumor arising elsewhere. Metastases to the skin usually arise from breast, lung, and large bowel. Metastasis of gastric adenocarcinoma to the skin is extremely rare. We report here a case of metastatic adenocarcinoma of the stomach in which the initial-appearing sign consisted of two adjacent tumors resembling neurofibroma.

Case

Figure 1

A 68-year-old woman presented with a three-month history of painless nodules on the right side of her neck. She was previously healthy except for a three-year history of gastric ulcer. Skin examination revealed 2 skin colored, well-circumscribed, non-movable, soft, non-tender nodules on the right side of her neck (Figure 1). On palpation there were three lymph nodes of the posterior right cervical trigon, approximately 1 cm in diameter. General physical examination revealed normal vital signs. Laboratory studies disclosed the following values: hemoglobin 11.5 gm percent, hematocrit 33.4 percent, leukocyte count 3.700. Serum glucose, BUN, creatinine, aspartate aminotransferase, alanine aminotransferase, serum total protein, albumin and electrolytes were within normal limits. Alkaline phosphatase (525 U/I) and erythrocyte sedimentation rate (51 mm/h) were elevated. Serum tumor marker studies were within normal limitis. The chest Xray was interpreted as showing extensive pulmonary nodular calcifications bilaterally, consistent with metastasis.

Histopathological examination of the skin lesion revealed epidermal acanthosis, but diffuse infiltration of the dermis and subcutaneous tissue by tumor cells. The neoplastic cells showed a signet ring cell appearance, which was characterized by eccentric and hyperchoromatic nuclei and accumulation of intracytoplasmic acidic mucin on alcian-blue staining. (Figure 2). Immunohistochemically, staining for cytokeratin 7 was positive and staining for cytokeratin 20 was negative (Figure 3).

Figure 2	Figure 3

With the information obtained from the biopsy specimens, a diagnosis of metastatic gastric carcinoma was made. An abdominal computed tomography scan showed thickening of the gastric wall and enlarged lymph nodes in the lasser sac region. Upper gastrointestinal endoscopy demonstrated an ulcerated mass on the prepyloric antrum and a hemorrhagic, rough crease surrounding the stomach body. A fiberoptic-assisted biopsy was performed of the ulcerated mass. Hematoxylin-eosin stained sections of the specimen showed adenocarcinoma infiltration. A bone scan showed multiple areas of focal activity on the calvarium, vertebral column, and ribs.

The tumors were determined to be inoperable and the patient was transferred to the department of internal medicine for systemic chemotherapy.

Discussion

Virtually any tumor can metastasize to the skin. Most skin metastases occur after the diagnosis of the primary tumor, some at the same time, and occasionally some occur before diagnosis of the primary tumor (known as precocious) [1]. Cutaneous metastasis is a relatively uncommon manifestation of visceral malignancies. It most often occurs late in the course of a disease but may also be the first presenting sign of advanced visceral cancer (as in our case), or a sign of tumor progression or recurrence. The average incidence of cutaneous metastasis from a visceral neoplasm is 5.3 percent (range, 0.7% to 9%) [2, 3, 4, 5, 6]. However, a more recent review of 92 patients with cutaneous metastases reported that about 10 percent of all visceral malignancies develop cutaneous metastases [7]. More than 60 percent of skin metastases are adenocarcinomas, usually arising in the breast, lung, or large intestine [8]. The incidence of cutaneous metastases from carcinomas of the upper digestive tract has been reported to be less than 1 percent [9].

Cutaneous involvement by gastrointestinal tumors usually occurs as single or multiple non-specific nodules and only 6.4 percent to 7.8 percent of these cutaneous metastases are the first clinical manifestation [3, 6, 10]. Their typical location is in the abdominal wall, particularly in the periumbilical area (known as Sister Mary Joseph nodules) [11, 12]. However, various cutaneous manifestations have been reported. They can appear to be erysipelas-like patterns (carcinoma erysipelatoides), zosteriform, allergic contact dermatitis-like, or cellulitis-like. Metastatic tumors may resemble epidermoid cysts, condyloma acuminatae, erythema annulare cetrifugum, or benign soft tissue tumors [3, 4, 13, 14, 16]. In our case, the skin lesions resembled neurofibroma, which has never been reported before.

Cutaneous metastases must always be distinguished from primary skin tumors. The clinical history will usually be very helpful with regard to making this determination. Cutaneous metastases tend to grow quickly and are more commonly multiple. There will often be a history of a relevant primary tumor. In contrast, the clinical history is much longer for the evolution of primary adnexal tumors. This report emphasizes the need for appropriate investigation of newly appearing, unusual, or persistent skin lesions, such as non-healing ulcers, persistent indurated erythemas, and all skin nodules of undetermined causes.

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