# Interesting Case of Skin Metastasis in Colorectal Cancer and Review of Literature

Authors: J. M. V. Amarjothi; R. Villalan; J. Jeyasudhahar; O. L. NaganathBabu
Journal: Case Reports in Surgery
 (2018)

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## Abstract

Skin metastasis is a complication rarely seen after curative resection for colorectal cancer and chemotherapy. The article describes a metachronous case of skin metastasis after curative resection. This article is presented to illustrate that genetic and molecular profiling of carcinoma is a must for diagnosis of aggressive biological behavior and that skin metastasis is usually a harbinger of adverse outcome.


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## Body

## 1. Introduction

Cutaneous metastases though rare may be the earliest manifestation of metastatic colorectal cancer. Such metastasis often indicates a poor prognosis, with the situation being further complicated by suboptimal treatment and aggressive biological behavior of such tumors.A 25-year-old male patient presented with a history of bleeding per rectum, mucus discharge, and features of intestinal obstruction for 3 months. He was positive for Hepatitis B surface antigen (HBsAg); the exact etiology of which was unknown. On physical examination, rectal examination revealed semicircumferential growth involving 6 cm from anal verge 9-3 o’clock position. HPE was suggestive of poorly differentiated carcinoma. Colonoscopy was not passible due to stenosis. Carcinoembryonic antigen (CEA) levels were 1.3 ng% (<5 ng%). Contrast-enhanced computerised tomography (CECT) (Figure1) showed irregular circumferential thickening of the wall of the rectosigmoid junction narrowing lumen, 15 cm in length from 6–19 cm with pericolonic and perirectal fat stranding. Hence, a diversion colostomy was done and the patient was subjected to long course chemoradiation with cisplatin and 5-fluorouracil and after 8-week interval, restaging was done. Per rectal, examination did not reveal palpable tumor. Imaging (Figure 2) done showed only wall thickening at the lower rectum without evidence of enlarged lymph nodes. Serum CEA was 1.7 ng% (n<5ng%); low anterior resection was done using CDH31 stapler and diversion ileostomy was done. HPE revealed complete regression of tumour in the tissue studied. The patient was put on adjuvant chemotherapy. Two months later, he developed multiple cutaneous nodules on the chest and back (Figure 3). FNAC was suggestive of adenocarcinoma. Two months later, he developed multiple peritoneal metastases and succumbed to the disease a month later.Figure 1
CECT showing the circumferential rectal thickening extending for 15 cm.Figure 2
MRI pelvis of the same patient showing circumferential thickening of the rectum.Figure 3
Metastatic nodules on the forearm (red arrow), chest (yellow arrow), and back (blue arrow).
(a)
(b)
(c)Skin involvement is seen in about 5% of patients with colorectal cancer [1] where it appears as subcutaneous or intradermal small nodules, and it can be confused with cysts, lipomas, neurofibromas, or alopecia due to these characteristics [2, 3].Two meta-analysis [3, 4] reported a 5–5.3% incidence of skin involvement in cancer patients. In other studies, Kauffman and Sina [5] and Lookingbill et al. [2] reported an incidence of 0.7–9% and 10%, respectively, for skin metastasis.In an autopsy series of review of cutaneous metastasis from internal carcinoma [6, 7], the most common primary site is the breast followed by the lung. The rectum is a very rare site and the most common site of metastasis was the previous surgical scar followed by the pelvis, back, chest, upper extremities, head, and neck [5]. Most of the cutaneous metastases are well-differentiated and mucin-secreting [7]. Several mechanisms of cutaneous metastasis have been postulated including lymphatic or hematogenous spread, direct extension, or implantation during surgery [2].Skin metastases from colorectal adenocarcinoma commonly occur metachronously within the first two years after resection of the primary tumor and are often present simultaneously with metastases to other organs like the liver [7]. The most common primary sites of cutaneous colorectal metastasis have been reported as follows: rectum (55%), sigmoid colon (17%), transverse colon (9%), rectosigmoid (7%), cecum (4%), and ascending colon (4%) [8, 9].Skin involvement that can be seen at the time of diagnosis or during the course of treatment is a sign of advanced stage (Table1). The prognosis is generally poor with survival of about 18 months [2] with a general range of about 1–34 months [10]. Surgical biopsy may not be logical for these patients due to poor survival and FNA cytology may be accurate for diagnosis of skin metastasis in a patient with known malignancy [11]. Wide local excision of the cutaneous metastatic lesion is the preferred treatment option in isolated lesions which is quite rare. Multiple cutaneous metastases are only palliated due to dismal prognosis [7].Table 1
Cases of rectal cancer with cutaneous metastasis.
Author, year
Age (years)
Sex
Histology
Stage
Primary cancer treatment
Interval (months)
Skin metastasis location
Skin metastasis morphology
Skin metastasis treatment
Survival (follow-up time in months)
Gottlieb and Schermer, 1970 [12]
72
F
Adenocarcinoma-sigmoid
NA
Sigmoidectomy
57
Palms
Nodules
—
NA
Gottlieb and Schermer, 1970 [12]
67
M
Adenocarcinoma-descending colon
NA
Left hemicolectomy
4
Face
Nodules/ulcers
NA
6 months
Gray and Das, 1989 [13]
79
F
Adenocarcinoma
—
Radiation
0
Leg
Nodules
None
No (18)
Reed and Stoddard, 1992 [14]
68
F
Adenocarcinoma, poorly differentiated
—
LAR
4
Perineum
Nodules
APR
—
De Friend et al., 1992 [15]
49
F
Adenocarcinoma
III
LAR
7
Perineum
Nodules
WLE
—
Kauffman and Sina, 1997 [5]
50
M
Adenocarcinoma, signet ring
IV
LAR+ACR
36
Multiple
Plaques
None
No (3)
Stavrianos et al., 2000 [16]
78
M
Adenocarcinoma-well differentiated
III
Transverse colon resection
3
Cheek oral commissure
Ulcers
RT followed by full thickness excision
11
Sukumar and Qureshi, 2001 [17]
75
M
Adenocarcinoma, poorly differentiated
APR+RT
3
Penile skin
Nodule, ulcers
NA
2
Adani et al., 2001 [18]
70
F
Adenocarcinoma
III
APR+AC
36
Leg
Nodules
CR
Yes (14)
Tsai et al., 2002 [19]
47
M
Adenocarcinoma, signet ring
III
APR+AC
11
Multiple
Nodules
C
No (4)
Melis et al., 2002 [20]
41
M
Adenocarcinoma
IV
NCR
1
Perineum
Plaques
None
—
Damin et al., 2003 [21]
44
M
Adenocarcinoma
II
LAR
6
Groin
Zosteriform
R
No (5)
Hayashi et al., 2003 [22]
50
M
Adenocarcinoma, mucinous
—
LAR
4
Perineum
Nodules
None
—
Wright et al., 2003 [23]
81
F
IV
Cholecystectomy scar
NA
Sarid et al., 2004 [24]
60
F
Adenocarcinoma, mucinous
III
NR+LAR+ACR
16
Chest, abdomen
Ulcers
WLE
No (56)
Alexandrescu et al., 2005 [25]
62
F
Adenocarcinoma
—
NA
60
Scar site
Masses
—
—
Alexandrescu et al., 2005 [25]
46
M
Adenocarcinoma
—
NA
36
Scar site
Masses
—
—
Reuter et al., 2007 [26]
69
M
Adenocarcinoma
II
APR+ACR
5
Perineum
Plaques
None
No (6)
Tan et al., 2006 [27]
70
M
Adenocarcinoma, mucinous
IIIB
LAR+AC
20
Back
Nodules
WLE, C
—
Tan et al., 2006 [27]
51
F
Adenocarcinoma
IIIB
APR
10
Perineum
Nodules
WLE, CR
9 months
Kilickap et al., 2006 [28]
29
M
Adenocarcinoma, signet ring
IIIA
LAR+APR+ACR
14
Chest wall, axilla
Nodules
WLE+C
Yes (4)
Fyrmpas et al., 2006 [29]
62
M
Adenocarcinoma-moderately differentiated
NA
Right hemicolectomy
36
Chin
Nodules
Excision biopsy
8 months
Nasti et al., 2007 [30]
76
F
Adeno carcinoma
III
Preop CRT
0
Face with parotid gland involvement
NA
NA
15
Gazoni et al., 2008 [31]
55
F
Adenocarcinoma, poorly differentiated
IV
Colostomy+CR
0
Perineum
—
CR
No (3)
Gazoni et al., 2008 [31]
66
M
Adenocarcinoma, poorly differentiated
IV
Colostomy+CR
0
Perineum
—
CR
No (4)
Gazoni et al., 2008 [31]
68
M
Adenocarcinoma, poorly differentiated
IV
Colostomy+CR
0
Thigh, axilla
—
CR
No (3)
Gazoni et al., 2008 [31]
72
M
Adenocarcinoma
IV
Colostomy+CR
0
Perineum
—
CR
No (5)
Gazoni et al., 2008 [31]
65
M
Adenocarcinoma
IV
Colostomy+CR
0
Perineum
—
CR
No (7)
Gazoni et al., 2008 [31]
78
M
Adenocarcinoma
IV
Stent+CR
0
Perineum
—
CR
No (1)
McWeeney et al., 2009 [32]
72
M
Adenocarcinoma
III
Ileostomy+NCR
6
Perineum
Nodules
WLE
—
Kurihara and Watanabe, 2009 [33]
66
M
III
Right thigh
7 months
Ayadi, 2009 [34]
63
M
Small cell carcinoma-rectum
III
CT
5
Scalp
Ulceroproliferative mass
Palliative CT
16 months
Saladzinskas et al., 2010 [35]
64
M
Adenocarcinoma, mucinous
IIA
NR+LAR
42
Face
Ulcers
WLE
Yes (7)
Ismaili et al., 2011 [36]
50
F
Adenocarcinoma, signet ring
IV
None
0
Multiple
Zosteriform
None
No (1)
Horiuchi et al., 2011 [37]
53
M
Adenocarcinoma
II
36
Scalp
6 months
Civitelli et al., 2011 [38]
73
F
Adenocarcinoma
III
Few days
Abdominal wall, chest, back
6 months
Balta et al., 2012 [39]
46
M
Adenocarcinoma, mucinous
IIIB
Colostomy
12
Perineum
Ulcers
None
—
Wang et al., 2012 [40]
63
M
Adenocarcinoma
III
6
Chest, neck, upper limb
2 weeks
Nasrolahi, 2013 [10]
33
M
Adenocarcinoma
IV
CT
3
Chest, back, neck
Plaque
CT
Few weeks
Rajan et al., 2012 [41]
36
M
Adenocarcinoma
IV
24
Lower extremities
3 months
Hamid and Hanbala, 2012 [42]
70
NA
Adenocarcinoma
II
86
Scalp, upper trunk
NA
Russo et al., 2012 [43]
72
M
Adenocarcinoma-signet cells
II
Right hemicolectomy
33
Back
Nodules
WLE
Yes
Rashid et al., 2012 [44]
65
M
Adenocarcinoma
III
Right hemicolectomy
0
Forearm
Nodules
—
17 months
de Miguel Valencia et al., 2013 [45]
55
M
Adenocarcinoma, mucinous
IIIB
NCR+APR+AC
18
Multiple
Nodules
None
No (—)
Ozgen et al., 2013 [46]
65
M
Adenocarcinoma
IIA
NCR+LAR+ACR
18
Perineum
Nodules
CR
Yes (12)
Akpak et al., 2014 [47]
47
F
Adenocarcinoma
IV
APR
36
Perineum
Ulcers
WLE+CR
—
Nesseris et al., 2013 [7]
80
M
Adenocarcinoma
III
Right hemicolectomy
12 m
Lower abdomen
Ulceroproliferative growth
2 cycles of CT
Yes
Kushwaha et al., 2013 [48]
40
M
Adenocarcinoma-signet cells
IV
CT
0
Chest, neck
Nodules
CT
4 months
Kushwaha et al., 2013 [48]
56
M
Adenocarcinoma
II
APR+CT
10
Chest, neck
Nodules
NA
8 months
Kushwaha et al., 2013 [48]
43
F
Adenocarcinoma
II
LAR+CT
8
Chest
Nodules
NA
7 months
Rogers et al., 2014 [49]
50
M
Adenocarcinoma, mucinous
IV
72
Scalp
Nodules
WLE
NA
Rogers et al., 2014 [49]
45
F
Adenocarcinoma
NCR+SX+ACR
Scalp
Nodules
WLE
Yes
Dehal et al., 2016 [50]
47
M
Adenocarcinoma, mucinous
IV
CR
1
Perineum
Nodules
R
Yes (12)
Fragulidis et al., 2015 [51]
62
M
Adenocarcinoma
IV
Endoscopic stent
4 m
Scalp
Nodules
WLE
No (2 weeks)
Varma et al., 2015 [52]
40
F
Adenocarcinoma
—
Colostomy
2 m
Pubic area, thigh
Nodules
NA
NA
Our case, 2018
NCR: neoadjuvant chemoradiation; CR: chemoradiation; SX: surgery; CT: chemotherapy; WLE: wide local excision; NR: neoadjuvant radiation; ACR: adjuvant chemoradiation; APR: abdominoperineal resection; LAR: low anterior resection; NA: not available.



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*Source: 7102845-2018-12-30.xml*