2012, Volume 28, Number 1, Page(s) 083-086
Gastric Adenocarcinoma Deposits Presenting as Multiple Cutaneous Nodules: A Case Report with Review of Literature
Aparna NARASIMHA , Harendra KUMAR
Department of Pathology, Sri Devaraj Urs Medical College, Sri Devaraj Urs Academy of Higher Education and Research, Kolar, KARNATAKA, INDIA
Keywords: Skin, Metastasis, Gastric cancer, Fine-needle, Aspiration cytology
Metastases to the skin from internal tumors are uncommon, yet they
may be the first presentation of such malignancies. They usually
arise from the breast, lung and large bowel. Cutaneous metastases
from gastric adenocarcinoma are extremely rare. We report a case of
gastric adenocarcinoma that at presentation had multiple clinically
benign looking skin nodules. Fine needle aspiration cytology of the
cutaneous nodule revealed metastatic deposits. The current literature
on cutaneous metastases of gastric carcinoma is reviewed in this case
Cutaneous metastases may occur as the initial manifestation
of internal malignancy or late in the course of the disease.
Furthermore, they can be the first sign of disseminated
neoplasm or an important presenting feature of recurrence
after successful therapy. The course of cutaneous metastases
may also be used as a reflection of the behavior of the
internal lesions, in particular their response to systemic
chemotherapy. Presence of cutaneous metastases may
progress the stage of an internal malignancy and hence
affect its prognosis. In general, cutaneous metastases are
associated with advanced systemic cancers and the expected
survival is less than one year1,2
This case is reported for its rarity of presentation and to
highlight the importance of cutaneous metastases as a poor
prognostic sign for the patient.
A 66-year-old woman came with a history of fever and
generalized weakness since 1 month. The patient gave a
history of having undergone surgery for gastric ulcers 17
years back. The histopathology report was unavailable.
Examination revealed enlarged cervical and supraclavicular
lymph nodes. Multiple subcutaneous nodules (around
four) were seen over the abdomen largest measuring 2x2
cm, firm in consistency and freely mobile.
A hard mass was palpable in the epigastric region,
measuring about 8x5 cm, fixed to the underlying structures.
The patient also had pleural effusion and ascites.
Computed Tomography (CT) scan of the abdomen
revealed a soft tissue mass lesion in the retropancreatic,
periportal, pre-aortic and bilateral para-iliac regions along
with multiple mesenteric lymphadenopathies, minimal
left sided hydronephrosis, bilateral pleural effusion and moderate ascites. A provisional diagnosis of disseminated
malignancy was given.
Ultrasound guided fine needle aspiration cytology (FNAC)
of the retroperitoneal mass along with FNAC of cervical,
supraclavicular lymph nodes and cutaneous nodules were
Cytology findings: Fine needle aspiration smears
showed pleomorphic round to oval cells arranged in
groups, glandular and papillary patterns (Figure 1) with
vesicular nucleus showing prominent nucleoli and scanty
eosinophilic cytoplasm (Figure 2). A few signet ring cells
were also observed. A possibility of gastric/pancreatic
adenocarcinoma with lymph node and cutaneous
metastases was suggested.
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|Figure 1: Microphotograph of fine needle aspiration smears
showing tumor cells arranged in groups, glandular and papillary
patterns (H&E, x100).
Click Here to Zoom
|Figure 2: Microphotograph of fine needle aspiration smears
showing pleomorphic round to oval cells (MGG, x1000).
Upper Gastrointestinal (GI) endoscopy showed a large
stomal ulcer on the body of stomach. Biopsy sent revealed
fragments of gastric mucosa showing tumor cells arranged
in groups (Figure 3). Cells were pleomorphic with round
to oval nucleus having fine chromatin and moderate
amount of eosinophilic cytoplasm. Signet ring cells were
also seen infiltrating the stroma. Mucin was demonstrated
by mucicarmine stain (Figure 4). The above features were
compatible with mucin secreting gastric adenocarcinoma
with cutaneous metastases. Subsequently the patient died
before the surgery could be performed.
Click Here to Zoom
|Figure 3: Microphotograph of biopsy showing fragments of
gastric mucosa with signet ring cells seen infiltrating the stroma
Click Here to Zoom
|Figure 4: Microphotograph of tumor cells showing mucin
Skin or cutaneous metastases refer to growth of cancer
cells in the skin originating from an internal cancer. In
most cases, cutaneous metastases develop after the initial diagnosis of the primary internal malignancy such as breast
or lung cancer and late in the course of the disease1
in our case the primary presentation of the patient was with
multiple subcutaneous nodules.
The incidence of cutaneous metastases from neoplasms
of internal organs as estimated from autopsy studies
varies from 0.6 to 9% of all cases of malignant disease3. Cutaneous metastases occur most frequently among
women with breast cancer (18.6%-50%) and men with
bronchogenic carcinoma (3%-7.5%)1.
Carcinoma of the stomach presenting as multiple cutaneous
metastases is rare4. It can present as a nodule, cellulitislike
skin lesion or as an erysipelas-like picture5. It is even
more uncommon and unusual to have a patient with gastric
carcinoma whose mode of presentation is that of ‘skin
Common sources of cutaneous metastases in women are
the breast (69%), the colon (9%), melanoma (5%), the
ovaries (4%), and the lungs (4%). In men, they are the lungs
(24%), the colon (19%), melanoma (13%), and the oral
Vachhani et al8 have reported a rare case of adenocarcinoma
of lung presenting as malignant pericardial effusion and
cutaneous metastasis as an initial presentation8. A rare
case of penile metastasis of urothelial carcinoma diagnosed
by fine needle aspiration cytology has been reported by
Santos et al9.
The most common presentation of cutaneous metastases is
nodules. The nodules are often non-painful, round or oval,
firm, mobile and rubbery in consistency. The nodules are
usually flesh colored to brown or blue-black7.
FNAC followed by skin biopsy helps in confirming a
diagnosis of tumor. Immunohistochemical marker studies
and ultrastructural examination may help to delineate the
tissue of origin. Imaging studies like Magnetic Resonance
Imaging, CT and ultrasonography may be employed in
select cases if the biopsy sample is impartial or if performing
a biopsy is dangerous because of proximity to vital organs7.
The skin metastases may be isolated or associated with
metastasis at multiple sites. Cancer metastasis to the skin
most commonly occurs as indolent cutaneous nodules that
tend to be localized at the head, neck, chest and abdomen
and represent a serious prognostic sign particularly in
patients with cancers of lung, ovary, upper respiratory tract
or upper digestive tract3,4.
Gastric carcinomas usually metastasize to the liver,
peritoneal cavity and regional lymph nodes more often
than to the skin and when cutaneous metastases occur they usually arise in the vicinity of the primary tumor
(e.g the abdominal wall). Cutaneous metastases from
adenocarcinomas of the stomach may be solitary or multiple
and has appeared on the head, eyebrow, neck, axillae,
chest, lip, fingertips, shoulders, arms, umbilical region4.
GI cancers (usually colon and gastric carcinomas) often
metastasize to the abdomen and the pelvis. GI cancers
may spread along the urachus and produce nodules at
umbilicus. The presentation of nodules at the umbilicus has
been referred to as a “sister Mary Joseph nodule”7.
Tumor cells metastasize to the skin through several
routes, namely direct invasion from underlying structures,
extension and embolization through lymphatics and
blood vessels, spread along ligaments of embryonic origin
and accidental implantation during surgery. Generally
cutaneous metastases are associated with advanced
systemic disease and expected survival is less than one year1,2. Nodular carcinoma, inflammatory or erysipeloides
carcinoma, telangiectatic and “en cuirasse” are the typical
clinical manifestations of the lymphatic dissemination of
breast cancers to skin10.
In most cases, cutaneous metastases develop after the initial
diagnosis of primary malignancy. In a very small percentage
of patients, metastases may be discovered at the same time
or prior to the diagnosis of a primary tumor (e.g., lung and
renal cell carcinoma)7. A study by Hori et al showed that
the average interval between the detection of the primary
cancer and the appearance of the skin lesion was 20 months11. Prognosis is usually poor owing to the presence of
Our case was also unique in that the patient presented with
subcutaneous nodules, had a rapid downhill course before
the actual treatment plan could be executed, and the patient
expired within a very short duration.
Cutaneous metastases are infrequent manifestations of solid
tumors. Though they usually appear late in the course of the
disease, they may constitute the presenting sign which was
observed in our case.
Hence it is important to recognize them since they may
be the first evidence of a neoplasm or a sign of tumor
progression or recurrence.
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