Asian Cardiovasc Thorac Ann 2006;14:520-521
© 2006 Asia Publishing EXchange Ltd
Subcutaneous Metastasis from Esophageal Cancer
Mohir H Hedeshian, MD,
Xiaofei Wang, MD1,
Bo Xu, MD1,
Jacques P Fontaine, MD,
Francis J Podbielski, MD
Division of Thoracic Surgery
1 Division of Pathology, University of Massachusetts Medical Center Worcester, USA
For reprint information contact: Francis J Podbielski, MD, Tel: 1 413 748 9628, Fax: 1 413 748 9662, Email: Francis.Podbielski{at}sphs.com, University of Massachusetts Medical Center, Division of Thoracic Surgery, 271 Carew Street, Springfield, Massachusetts 01104, USA.
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ABSTRACT
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Cutaneous metastases from esophageal adenocarcinoma are exceedingly rare. With the institution of multimodality treatments and surgical resection for esophageal adenocarcinoma, loco-regional disease recurrence has been dramatically reduced. In this report, we present a 59-year-old white male with adenocarcinoma of the distal esophagus that was treated with neoadjuvant chemotherapy and radiation therapy, followed by surgical excision. After a disease free interval of two years the patient presented with cutaneous metastatic disease.
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CASE STUDY
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A 59-year-old man presented with a history of four months of dysphagia and upper abdominal discomfort. Barium swallow study demonstrated a short segment narrowing of the distal esophagus, and upper endoscopy showed the presence of a mass at the gastroesophageal junction. Biopsies confirmed the presence of infiltrating adenocarcinoma. Further staging workup with computed tomography (CT) scans showed no evidence of distant metastases, and endoscopic ultrasound showed the tumor to be T3N3 stage. The patient was treated with neoadjuvant chemotherapy (5 cycles of cisplatin and taxol) and radiation therapy (5000 Gy) followed by transhiatal esophagogastrectomy. All resection margins as well as lymph nodes were free of tumor. He did not receive additional chemotherapy, and restaging CT scans after surgery showed no evidence of recurrent or metastatic disease. He was then followed conservatively with physical exams, tumor markers, and periodic CT scans.
Two years after the esophagectomy, the patient presented with significant weight loss, shortness of breath, and loss of appetite. Bilateral thoracentesis yielded effusion fluid that was cytologically negative for malignancy. Despite previous radiographic and endoscopic work-ups that showed no evidence of disease, he was noted to have a palpable subcutaneous nodule on his back above his left scapula (Figure 1
). Subsequent chest films and CT scans showed bilateral pleural effusions and a small peripheral nodule in the upper lobe of the right lung. Bilateral thoracostomy tubes were placed to treat the pleural effusions, and the subcutaneous nodule was excised and submitted for histologic review. Light microscopy revealed adenocarcinoma consistent with metastasis from the esophageal primary (Figure 2). After chest tube placement, the patient was extremely weak and debilitated. Given his limited life expectancy a talc pleurodesis was not performed. It was suspected that hypoalbuminemia and cachexia resulted in the development of cytologically negative pleural effusions. The patient was discharged home with hospice care and died soon after. It is suspected that the ultimate cause of death was most likely due to chronic malnutrition.
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Figure 2. (A) Biopsy of skin and subcutaneous tissue demonstrating invasive adenocarcinoma (Hematoxylin-eosin x 200); (B) Primary infiltrating adenocarcinoma of the esophagus showing mucin-secreting glandular tissue with intestinal features (Hematoxylin-eosin x 200).
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DISCUSSION
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Esophageal cancer is one of the deadliest cancers worldwide. It is the seventh leading cause of death from cancer among American men, particularly black men, who have a higher incidence of this disease (13 cases per 100,000 persons) than do men in other racial or ethnic groups.1 Squamous cell carcinoma accounted for 90% of esophageal cancers prior to 1978; currently adenocarcinoma of the esophagus and gastroesophageal junction region exceeds that of squamous cell carcinoma of the esophagus and represents at least 30% of all malignant esophageal tumors.2
Cutaneous metastasis from esophageal adenocarcinoma is exceedingly rare. In a study by Lookingbill et al of 7316 cancer patients with metastases to the skin, none of the patients had metastases from primary esophageal carcinoma.3 Another study of 4020 cancer patients found only 3 patients with cutaneous metastases from esophageal cancer. The primary tumor in all 3 cases was of squamous cell origin.4 Historically patients with adenocarcinoma of the esophagus die from regional recurrence and tumor progression. However, as newer combined-modality treatments, such as neoadjuvant chemoradiation followed by surgical resection, and newer cytotoxic agents became available, loco-regional disease recurrence has been dramatically reduced. Today, in most patients who have undergone combined-modality treatments for advanced esophageal adenocarcinoma, recurrences have mainly been from hematogenous metastatic spread, as in our patient.5
We believe that excellent local control of this patient’s tumor was achieved with pre-operative radiation therapy, as even at the time of his death there was no evidence of gastrointestinal, mediastinal, or nodal disease. While he remained disease-free for a prolonged interval after his surgical resection, the presence of metastatic disease in his lymph nodes at the time of surgery suggests that hematogenous/lymphangitic spread had already occurred. It is postulated that a subpopulation of slowly growing chemotherapy-refractory cells remained viable after his treatment; these malignant cells appear to have been deposited in the dermal lymphatic channels of his integument and remained quiescent for an extended period of time until their gross clinical presentation as skin nodules.
As new forms of neoadjuvant cytotoxic therapy become available, one would expect to see higher incidences of metastatic disease recurrence after esophagectomy in patients with locally advanced disease. A complete health history, careful physical examination, and adjunctive radiographic studies (CT scans, bone scans, positron-emission tomography) are essential in diagnosis.
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REFERENCES
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- Ries LAG, Eisner MP, Kosary C, et al., eds. SEER cancer statistics review, 1973–1999. Bethesda, Md.: National Cancer Institute, 2002.
- Pera M. Trends in incidence and prevalence of specialized intestinal metaplasia, barrett’s esophagus, and adenocarcinoma of the gastroesophageal junction. World J Surg 2003;27:999–1008.[Medline]
- Lookingbill DP, Spangler N, Sexton FM. Skin involvement as the presenting sign of internal carcinoma. A retrospective study of 7316 cancer patients. J Am Acad Dermatol 1990;22:19–26.[Medline]
- Lookingbill DP, Spangler N, Helm KF. Cutaneous metastases in patients with metastatic carcinoma: a retrospective study of 4020 patients. J Am Acad Dermatol 1993;29:228–36.[Medline]
- Rice TW, Adelstein DJ, Zuccaro G, Flak GW, Goldblum JR. Advances in the treatment of esophageal carcinoma. Gastroenterologist 1997;5:278–94.[Medline]
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