Cutaneous metastasis in esophageal cancer: Case reports of three patients

Poorva Vias; Awadhesh Kumar Pandey; Kislay Dimri; Ashish Saklani

doi:10.4103/oji.oji_39_21

CASE REPORT

Year : 2023 | Volume : 7 | Issue : 1 | Page : 13-16

Cutaneous metastasis in esophageal cancer: Case reports of three patients

Poorva Vias¹, Awadhesh Kumar Pandey¹, Kislay Dimri¹, Ashish Saklani²
¹ Department of Radiation Oncology, GMCH, Chandigarh, India
² Department of Radiology, IGMC, Shimla, Himachal Pradesh, India

Date of Submission	20-Sep-2021
Date of Decision	17-Mar-2023
Date of Acceptance	03-Apr-2023
Date of Web Publication	26-Apr-2023

Correspondence Address:
Poorva Vias
Department of Radiation Oncology, GMCH, Sector 32, Chandigarh
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/oji.oji_39_21

Abstract

Carcinoma of esophagus is one of the cancers with a high mortality rate. Metastasis with esophageal carcinoma in lymph nodes, lung, liver, bones, and adrenal glands is a common pattern. Nowadays, uncommon sites of metastasis are increasingly reported including skin. Cutaneous metastasis in squamous cell carcinoma is more common than in adenocarcinoma. Here, we present three cases of cutaneous metastasis in patients with carcinoma of esophagus, out of which two cases were seen with squamous cell carcinoma and one was with adenocarcinoma. The prognosis in such patients is dismal and they are treated with palliative chemotherapy.

Keywords: Carcinoma esophagus, cutaneous metastasis, nodules

How to cite this article:
Vias P, Pandey AK, Dimri K, Saklani A. Cutaneous metastasis in esophageal cancer: Case reports of three patients. Oncol J India 2023;7:13-6

How to cite this URL:
Vias P, Pandey AK, Dimri K, Saklani A. Cutaneous metastasis in esophageal cancer: Case reports of three patients. Oncol J India [serial online] 2023 [cited 2023 Jun 4];7:13-6. Available from: https://www.ojionline.org/text.asp?2023/7/1/13/374816

Introduction

Carcinoma esophagus is the seventh most common cancer worldwide and ranks sixth in mortality due to cancers. It accounts for 3.2%of all new cases.^[1] Seventy percent of these cases occur in men with 2–3-fold difference in incidence and mortality rates between the sexes.^[1] Most of these patients present with advanced unresectable or metastatic disease. Tobacco use and alcohol are the main risk factors for squamous cell carcinoma of esophagus while long-standing gastroesophageal reflux disease is the major risk factor in causing adenocarcinomas of esophagus. Direct invasion of the adjacent organs occurs early as esophagus has no covering serosa. The presence of satellite nodules is also common in carcinoma of esophagus. Lung, liver, and bone are the most common sites of distant metastasis. However, cutaneous metastasis in esophageal malignancy is rare and accounts for <1% of lesions.^[2]

Breast, lung, oral mucosa, and colorectal cancers are the likely tumors spreading to skin and subcutaneous tissue.^[2] Subcutaneous nodules in esophageal malignancy may be seen in both the histological types such as squamous cell carcinomas and the adenocarcinomas. The location of these nodules is variable. Commonly reported sites include scalp, neck, and face, although metastatic lesions to chest wall, back, and axillary regions have also been reported.^[3],[4],[5]

The prognosis of patients presenting with subcutaneous metastasis is poor and the estimated survival rates are <1 year.^[5] Herein, the present case series describes three patients of carcinoma esophagus with cutaneous metastasis along with the literature review.

Case Reports

We detected three patients of carcinoma of esophagus with cutaneous metastasis whose demographics and tumor characteristics are shown in [Table 1].

Table 1: Synopsis of patient's data including their demographics, primary tumor, and treatment

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Case 1

A 48-year-old male, smoker, and alcoholic for the last 25 years presented to us with complaints of dysphagia for solids for more than 2 months which was gradually increasing. There was a history of regurgitation of food. On contrast-enhanced computed tomography (CECT) scan of the thorax, asymmetrical mural thickening was seen in the midthoracic esophagus for a length of 4.7 cm with angle of contact with aorta >90°. Liver was measuring 16.8 cm, but no lesion was seen. Upper gastrointestinal endoscopy showed proliferative growth from 20 cm to 25 cm from incisors and biopsy showed squamous cell carcinoma, moderately differentiated.

Neoadjuvant chemotherapy based on injection paclitaxel and carboplatin (PC) combination regimen was started. After receiving 3 cycles of chemotherapy, the patient defaulted for two and a half years and reported with dysphagia. On CECT, there was thickening in the mid and lower esophagus for a length of 8.6 cm with loss of fat planes with aorta and precordium of the left atrium. Few subcentimetric lymph nodes were seen in pretracheal, AP window, precarinal, subcarinal, and bilateral axilla. The patient was again treated with 3 cycles of the same chemotherapy. The disease was inoperable, so the patient was taken up for chemoradiotherapy 45 Gy in 25 fractions in 5 weeks with concurrent cisplatin-based chemotherapy which was completed in May 2018.

Subsequently, after a period of 6 months, subcutaneous nodules (1.5 cm × 1.5 cm, hard, nontender) were seen in the anterior abdominal wall [Figure 1] and thigh without any other evidence of malignancy. Cytology from the abdominal wall nodule showed metastatic carcinomatous deposits [Figure 1]. Now, the patient is started on palliative chemotherapy as cisplatin and 5-fluorouracil.

Figure 1: (a) Abdominal wall cutaneous nodule and 1 (b) Cytology under MGG stain (×400) showing large polygonal cells with abundant cytoplasm and pyknotic nuclei suggestive of squamous cell carcinoma. MGG: May–Grunwald–Giemsa

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Case 2

Another 48-year-old male, smoker, and alcoholic for 30 years presented with dysphagia for the last 1 year. On endoscopy, growth was seen at 35 cm from incisors. CECT scan of the thorax showing thickening involving distal esophagus extending to gastroesophageal junction with aspiration pneumonitis. Ultrasonogram abdomen showed multiple hypoechoic lesions in both the lobes of the liver largest measuring 6.9 cm × 5.1 cm suggestive of metastasis. Esophageal growth biopsy features were suggestive of squamous cell carcinoma and moderately differentiated with ulceration. Nodular lesions were seen over the chest wall (hard, round, 2 cm × 2 cm in size, nontender with ulceration), lip, and forearm [Figure 2]. Fine-needle aspiration cytology from nodule over the chest wall showed metastatic squamous cell carcinoma. In order to relieve dysphagia, the patient was given palliative radiotherapy with a dose of 30 Gy in 10 fractions to esophagus by 2 parallel opposed fields. In view of poor general condition of the patient, no further treatment was given and the patient expired after 4 months of treatment.

Figure 2: Cutaneous nodules seen over (a) chest wall and (b) lower lip

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Case 3

A 47-year-old male, chronic smoker, presented in the department of surgery with dysphagia where esophagogastrectomy was done. Detailed histopathological examination revealed ulceroproliferative growth of size 3.9 cm × 3.5 cm × 1.8 cm in lower one-third of esophagus. Microscopic features are suggestive of adenocarcinoma, moderately differentiated [Figure 3]. Tumor was reaching up to serosa; however, surgical margins were free from tumor. Sections from lymph nodes showed metastatic deposits in one out of four lymph nodes.

Figure 3: Histological examination of esophageal growth on H and E stain (a: ×40, b: ×100) showing neoplastic glands lined by atypical epithelial cells on a sclerotic stroma suggestive of adenocarcinoma. (c) Clinical image showing cutaneous nodule over the right lateral chest wall

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Postoperative CECT scan of the thorax showed no abnormal mural thickening, irregularity, or postcontrast mural enhancement. However, few subcentimetric lymph nodes were seen in paratracheal, precarinal, and subcarinal regions. Adjuvant concurrent chemoradiotherapy was started at a radiation dose of 45 Gy in 25 fractions over 5 weeks along with concurrent injection PC weekly over a period of 5 weeks. Followed by that, the patient was treated with adjuvant chemotherapy on injection paclitaxel and carboplatin regimen for six cycles. The patient then defaulted on follow-up for 9 months and presented with skin nodules. A nodule of size 4 cm × 3 cm was seen over the chest wall at the site of intercostal chest tube drainage during surgery [Figure 3]. Other nodules were seen over the abdomen, which showed metastatic adenocarcinoma on cytology. CECT scan of the thorax revealed circumferential irregular asymmetrical mass-like thickening involving gastroesophageal anastomotic site with multiple subpleural nodules in both the lungs. The patient was then started on palliative chemotherapy with the cisplatin and 5-fluorouracil regimen.

Discussion

Skin metastasis is an uncommon manifestation of visceral malignancy at a frequency of between 0.7% and 9%.^[6],[7],[8] Nowadays, cutaneous metastasis has been increasingly reported. The most common primary neoplasm metastasizing to the skin is breast cancer, followed by lung cancer and colorectal cancers.^[9] Cutaneous metastasis in esophageal cancer is very uncommon and it accounts for <1% of metastasis in patients of carcinoma esophagus.^[2] A retrospective study on rates of cutaneous metastases from various internal malignancies in a Taiwanese medical center population over a 20-year experience reported only 3 out of 403 esophageal cancer cases with cutaneous metastases.^[2] A study by Quint et al. reported incidence of cutaneous metastasis in esophageal malignancies to be 1%.^[10]

The clinical presentation and time of presentation with skin metastasis is highly variable and nonspecific. Skin metastasis as the presenting sign of underlying malignancy is extremely rare.^[4] One of our 3 cases with squamous cell carcinoma histology have diagnosed with cutaneous metastasis at presentation. The clinical manifestations of metastatic cutaneous lesions are often asymptomatic and include inflammatory papules and patches, erythematous, indurated plaques, alopecia neoplastica, or subcutaneous nodules.^[11] Subcutaneous nodules are the most common manifestation and were seen in our all the three patients.

The primary neoplasm is usually identified before skin metastasis, but in some cases, cutaneous metastasis may be the presenting feature which may give a clue to diagnosis of primary. Recently, immunohistochemical stains using specific antibodies have been used to detect tumor antigens to identify primary malignancy.^[9],[12] Cutaneous metastases are seen more in squamous cell carcinoma of esophagus than that of adenocarcinoma histology, but can be associated with adenocarcinoma also.^{[10],[13],[14]} Our 2 out of 3 cutaneous metastases in esophageal malignancy are of squamous histology and rest 1 case of adenocarcinoma histology. Tharakaram in an Indian study reported that all the five cases of primary esophageal malignancy with cutaneous metastases are of squamous cell histology.^[14] However, Quint et al. in a study on distant metastatic patterns in newly diagnosed esophageal carcinoma detected cutaneous metastases in 2 out of 147 metastatic disease and these 2 cases are of adenocarcinoma histology.^[10]

Nevertheless, skin metastases still represent a grave prognostic sign, particularly in patients with cancers of lung, ovary, upper respiratory tract, or upper digestive tract. In carcinoma esophagus, the presence of cutaneous metastasis represents advanced disease and a dismal prognosis.^[2] Skin nodule may be the leading sign of systemic spread of carcinoma esophagus. In most cases, cutaneous metastases occur during the course of metachronous metastases as seen in our first and third case and develop 2.9 years later on average.^[12] In our series of three cases, the first case was diagnosed with cutaneous metastasis after 39 months of primary diagnosis, the second case presented with upfront cutaneous metastasis, whereas the third case was detected with cutaneous metastasis after 15 months of primary diagnosis. The median survival of patients with carcinoma of esophagus has been reported to be 4.7 months after development of cutaneous metastasis.^[15] Patients with cutaneous metastasis are treated as malignant disease using chemotherapy with intent of palliation. Best supportive care should be given to these patients to relieve dysphagia and pain. Metastatectomy of solitary lesions from esophageal malignancy is only considered on an exceptional basis in individuals with a long disease-free interval and no other site of metastasis.^[16] Despite the rare presentation of cutaneous metastasis, it immediately determines worst prognosis and fatality.^[17]

Conclusion

The presence of cutaneous lesion in a patient with history of malignancy should be investigated thoroughly and presence of cutaneous metastasis should be ruled out. The presence of cutaneous metastasis changes the stage and thus the line of treatment.

Declaration of patient consent

The authors declare that they have obtained consent from patients. Patients have given their consent for their images and other clinical information to be reported in the journal. Patients understand that their names 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.

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