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LETTER
Year : 2014  |  Volume : 60  |  Issue : 4  |  Page : 424-426

Facial cutaneous metastases of advanced rectal malignancy masquerading as lip cancer


Department of General Surgery, Seth Gordhandas Sunderdas Medical College and King Edward Memorial Hospital, Mumbai, Maharashtra, India

Date of Web Publication5-Nov-2014

Correspondence Address:
Dr. N S Kantharia
Department of General Surgery, Seth Gordhandas Sunderdas Medical College and King Edward Memorial Hospital, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0022-3859.144002

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How to cite this article:
Kantharia N S, Jathar A H, Surpam S M, Rege S A. Facial cutaneous metastases of advanced rectal malignancy masquerading as lip cancer. J Postgrad Med 2014;60:424-6

How to cite this URL:
Kantharia N S, Jathar A H, Surpam S M, Rege S A. Facial cutaneous metastases of advanced rectal malignancy masquerading as lip cancer. J Postgrad Med [serial online] 2014 [cited 2019 Nov 17];60:424-6. Available from: http://www.jpgmonline.com/text.asp?2014/60/4/424/144002


Sir,

Cutaneous metastases from colorectal cancer (CRC) are rare, seen in 4-6.5% cases. [1],[2],[3] The most common site is abdominal wall skin; especially post-operative scars. [1],[2],[3] They generally occur metachronously, indicating tumor relapse after primary surgery. [2],[3] They also signal disseminated malignancy and these patients often have widespread visceral metastases, including those of the liver and lung. [2],[3],[4] We present in this paper, an unusual case of carcinoma rectum with synchronous facial metastases, in the absence of hepatic and pulmonary metastases.

A 70- year-old male presented with a nodule over the left angle of the mouth [Figure 1] constipation and significant weight loss. There was no rectal bleed. There was mild abdominal distension and per rectal examination revealed a tumor that partially occluded the lumen with its lowermost margin 3 cm from the anal verge. On contrast-enhanced computerized tomography (CECT) scan, the tumor was advanced, involving the lower and mid rectum with loss of fat planes between the tumor and seminal vesicle. It had infiltrated the right ureter leading to hydroureter and hydronephrosis [Figure 2]. Multiple omental nodules were seen but without liver or lung metastases [Figure 3]. A diverting loop transverse colostomy was fashioned to palliate the large bowel obstruction. The right ureter was stented. Subsequently, the patient refused further treatment and died 48 hous later. Histopathology of both rectal and omental nodule biopsy showed a poorly differentiated adenocarcinoma. Fine-needle aspiration (FNA) of the facial lesion revealed metastatic adenocarcinoma [Figure 4]. Immunohistochemistry (IHC) was positive for cytokeratin (CK)20, suggestive of colorectal origin of the metastatic deposit [Figure 5].
Figure 1: Nodule over left angle of mouth

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Figure 2: Venous phase CECT showing advanced rectal growth

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Figure 3: Venous phase CECT with an arrow pointing to the omental nodule

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Figure 4: FNA of a lip lesion showing metastatic adenocarcinoma

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Figure 5: IHC of a lip lesion showing CK 20+

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The most common site of cutaneous CRC metastases is the abdominal wall, especially surgical scars. [1],[2],[3] Other sites of involvement in order of frequency include the extremities, perineum, head and neck and penis. [4]

CRC metastasis to skin are typically multiple firm non-ulcerating nodules. [5] However, they may be solitary and of varied morphology, including ulcers, carcinoma erysipelatoides, alopecia neoplastica, cicatricial and zosteriform. [5] They may invoke a rapid inflammatory response in surrounding skin, mimicking cellulitis. [5] As colonic mucosa expresses cytokeratin CK20 but not CK7, this profile CK20+/CK7- can be used to identify a metastatic deposit as arising from colorectal primary. [3]

There is much speculation regarding the mode of spread of CRC to skin. In the case of metastases to abdominal wall, colostomy sites and surgical incisions, there may be direct extension via surgical tracts or implantation of tumor cells at surgery. [5],[6] In cases with remote cutaneous disease and associated visceral metastases, there may be hematogenous spread of tumor cells which get trapped by capillary beds of the overlying skin. [5],[6] The flaw in this explanation is that it considers purely mechanical factors and is inadequate if there are no liver and lung metastases as in this case. An alternative explanation may be that circulating tumor cells bind specifically to the skin by site-specific adhesion molecules and/or respond preferentially to growth factors found there. [6]

Cutaneous metastases are a sign of disseminated disease with median survival of 3 months, [4] ranging from 2 to 4.5 months. [3] However, if the cutaneous metastasis is isolated without visceral involvement, the removal of the metastatic site and/or radiotherapy may prolong life. [2]



 
 :: References Top

1.
Hashimi Y, Dholakia S. Facial cutaneous metastasis of colorectal adenocarcinoma. BMJ Case Rep 2013;2013:pii: bcr2013009875.  Back to cited text no. 1
    
2.
Fyrmpas G, Barbetakis N, Efstathiou A, Konstantinidis I, Tsilikas C. Cutaneous metastasis to the face from colon adenocarcinoma. Case report. Int Semin Surg Oncol 2006;3:2.   Back to cited text no. 2
    
3.
Saladzinskas Z, Tamelis A, Paskauskas S, Pranys D, Pavalkis D. Facial skin metastasis of colorectal cancer: A case report. Cases J 2010;3:28.  Back to cited text no. 3
    
4.
Attili VS, Rama Chandra C, Dadhich HK, Sahoo TP, Anupama G, Bapsy PP. Unusual metastasis in colorectal cancer. Indian J Cancer 2006;43:93-5.  Back to cited text no. 4
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5.
Rajan D, Shah M, Raghavan P, Mujeeb S, Rashid S, Desouza A, et al. Lower extremity cutaneous lesions as the initial presentation of metastatic adenocarcinoma of the colon. Case Rep Med 2012;2012:989104.  Back to cited text no. 5
    
6.
Civitelli S, Civitelli B, Martellucci J, Tanzini G. Diffuse cutaneous metastases as the only sign of extranodal tumor spread in a patient with adenocarcinoma of the colon. ISRN Surg 2011;2011:902971.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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2004 - Journal of Postgraduate Medicine
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