Cutaneous Nodule in a Young Man FREE

A 21-year-old male student presents with a nodule on his chest that has been progressively enlarging over 1 month. He also has a 1-month history of upper abdominal pain associated with diarrhea but without fever or chills. He was diagnosed with acute gastroenteritis and treated with oral omeprazole and ofloxacin without relief. He has lost 5 kg during the past half year. He denies any history of chronic illness or family history of cancer. Physical examination reveals left supraclavicular and cervical lymphadenopathy. A solitary asymptomatic, nontender, and indurated nodule is found on his chest (Figure 1). Gastrointestinal endoscopy shows multiple ulcers on the gastric fundus and gastric corpus.

Cutaneous metastasis of gastric adenocarcinoma

D. Obtain a biopsy of the nodule

The key clinical feature to recognize in this case is the rapidly growing asymptomatic nodule associated with gastrointestinal symptoms. Although cutaneous metastases of gastric adenomas are uncommon especially in younger persons, a rapidly growing asymptomatic skin nodule of undetermined causes should be biopsied. If cutaneous metastasis is diagnosed, the origin of metastases should be found.

Virtually any tumor of the visceral organs can metastasize to the skin. However, cutaneous metastases are uncommon, with a reported frequency of 0.7% to 10.4%.^1- 5 Metastases are usually a late manifestation of widely disseminated disease, but occasionally they may be the first indication of an undiagnosed internal malignancy.^2- 3,6 Cutaneous metastases usually originate from the breast, lungs, colon, rectum, ovary, head and neck, or kidney.^2- 3

Malignant cutaneous lesions indicative of systemic cancer most commonly occur as asymptomatic multiple nodules (46.6%), single nodules (37.7%), plaques or erythematous patches (9.4%), and ulcers (6.5%).⁶ Metastases typically present with relatively sudden onset and rapid growth.^1,6- 7 Skin metastases may be isolated or associated with metastases at multiple sites.^3,8

Gastric carcinoma is usually detected after the fifth decade of life⁹ and is rare in adults younger than 30 years.⁹ The most common metastatic sites from gastric carcinoma are liver, intra-abdominal lymph nodes, ovary, and peritoneal cavity.^3,6- 7 Gastric carcinoma presents as skin metastasis 6.4% to 7.8% of the time.^2,8 The lesions of cutaneous metastases of gastric carcinoma are usually located on the abdominal wall or near the lymph nodes^2,8 and are similar to cutaneous metastases of other malignancies.

Lesions of cutaneous metastases may be clinically indistinguishable from benign lesions, such as hemangiomas, epidermal cysts, pyogenic granulomas, or neurofibromas.^1- 2,7 Diagnosis depends on histological evaluation combined with immunohistochemical staining.⁸ Histologically, cutaneous metastases usually show features consistent with the underlying primary malignancy. However, metastases may exhibit less differentiation and be more anaplastic.^2,7 The survival rate of patients with cutaneous metastases from internal malignancies is usually low.^6- 7 The median duration of survival after cutaneous metastases from gastric carcinoma is not known.

In this patient, a biopsy revealed infiltrating neoplastic cells scattered or clustered in the dermis. Some neoplastic cells appeared as signet ring cells (Figure 2A). Immature lumens of glands consistent with neoplastic cells were found in the deep dermis (Figure 2B). There was a narrow layer beneath the epidermis that is not infiltrated by atypical cells distributed in the deep dermis. Immunohistochemically, the signet ring cells were positive for carcinoembryonic antigen, epithelial membrane antigen, and CK20 and negative for markers of CD3, CD4, CD8, CD30, and gross cystic disease fluid protein 15 (GCDFP-15). Staining with Ki-67 indicated prominent proliferative activity. Mucin stained positively in the metastatic cells with Alcian blue. These pathological studies indicated a diagnosis of secondary signet ring cell adenocarcinoma and suggested digestive tractorigin. Pathology of biopsy specimens from ulcers in the stomach was compatible with a gastric signet ring cell adenocarcinoma. Abdominal computed tomography detected many metastatic nodules in mesentery, hepatic hilar region, and retroperitoneal lymph nodes. In view of the metastases, surgical intervention would be noncurative. The patient received chemotherapy with oxaliplatin (day 1) and S-1 (egafur, gimestat, and oteracil potassium) (days 1 to 7). His symptoms improved and the size of the nodule reduced after 2 weeks of the chemotherapy.