|Year : 2014 | Volume
| Issue : 3 | Page : 153-156
Esophageal carcinoma presenting with cutaneous nodules
I Sufyan1, SA Edaigbini1, AA Liman2, MB Aminu1, IZ Delia1
1 Division of Cardiothoracic Surgery, Ahmadu Bello University, Zaria, Nigeria
2 Department of Pathology, Ahmadu Bello University, Zaria, Nigeria
|Date of Submission||06-Feb-2014|
|Date of Acceptance||05-May-2014|
|Date of Web Publication||17-Aug-2014|
S A Edaigbini
Department of Surgery, Division of Cardiothoracic Surgery, Ahmadu Bello University, Zaria
Esophageal cancer accounts for 7% of all gastrointestinal cancers but presentation with metastases in the form of cutaneous nodules is a rare occurrence. Majority of esophageal cancers are mainly those of squamous cell type and so are the reported cases of cutaneous metastasis as our own case. Here we report a 55-year old man with cutaneous metastasis from esophageal squamous cell carcinoma presenting as nodules on the face back and digital pulp with associated skeletal metastasis and pathological fractures. Our case represents the third in the reported series of digital pulp metastasis from esophageal squamous cell carcinoma. The nodule may appear before or after the onset of esophageal symptoms such as dysphagia and weight loss, and is a pointer of tumor aggressiveness.
Keywords: Cutaneous nodules, esophageal carcinoma, squamous cell, metastasis, mechanisms
|How to cite this article:|
Sufyan I, Edaigbini S A, Liman A A, Aminu M B, Delia I Z. Esophageal carcinoma presenting with cutaneous nodules. Sub-Saharan Afr J Med 2014;1:153-6
|How to cite this URL:|
Sufyan I, Edaigbini S A, Liman A A, Aminu M B, Delia I Z. Esophageal carcinoma presenting with cutaneous nodules. Sub-Saharan Afr J Med [serial online] 2014 [cited 2020 Nov 26];1:153-6. Available from: https://www.ssajm.org/text.asp?2014/1/3/153/138949
| Introduction|| |
Esophageal cancers account for 7% of all gastrointestinal cancers and pose a considerable medical and public health challenge resulting from early metastasis, poor prognosis and the economic burden of management.  Metastasis is the most life-threatening event and are responsible for treatment failures in patients with cancer.  The biology of the metastatic cascade is a complex and difficult subject that is dependent on both host and tumor properties, but we must register the occurrence of an unusual kind of its incidence when it happens, especially in our environment where a similar case has not been reported before.  Current understanding of the mechanisms, pathways and cascades involved in tumor metastases, reveals that metastases do not occur randomly but that a combination of tumor biology and tumor-host interaction allows for either tumor progression or regression at particular sites including spread to unusual sites. ,
The cancers most commonly associated with cutaneous metastases are breast, lung and melanoma and esophageal cancer metastasis to the skin is a rare occurrence. ,
Here we report the case of a 55-year old male with cutaneous metastases from esophageal squamous cell carcinoma
| Case report|| |
A 55-year-old male presented with a 2-month history of dysphagia, weight loss, and a 3-week history of hoarseness of voice and multiple skin nodules on the face, back and pulp of the left index finger. He smoked cigarettes for about 60-pack years and drank alcohol heavily for about 40 years. He also developed pathological fractures of the left humerus and femur following a trivial traumatic event. He was found to be wasted, he was not pale and his functional capacity was about 50% (karnofsky). He had multiple nontender nodules measuring 2 cm × 2 cm firm, on the pulp of the left index finger [Figure 1], the left cheek [Figure 2], upper back and lower back. Examination also revealed crepitus and tenderness of the left humeral surgical neck and left upper femur.
A clinical diagnosis of dysphagia secondary to advanced carcinoma of the esophagus was made. He had endoscopy (esophagoscopy) done which revealed an irregular mass, about 30 cm from the mouth gag, that bled on biopsy, with a stricture at the same level preventing distal intubation. The histology showed a necrotic tumor growing in nests and in diffuse sheets, comprising of polygonal cells having enlarged hyperchromatic nuclei and scanty cytoplasm with abundant fibrocollagenous stroma and areas of acantholysis and keratin pearl formation. Morphologic diagnosis of well differentiated squamous cell carcinoma was made.
|Figure 1: Metastasis to the pulp (ulcerated) of left index finger. The feeding tube can be seen plastered to the left hypochondrium|
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Histologic assessment of the biopsied skin nodule also showed an ulcerated epidermis overlying an infiltrative well-differentiated squamous cell tumor that is growing in nests with prominent intercellular bridges; keratin pearl formation and abundant fibrous stroma [Figure 3] and [Figure 4].
|Figure 3: Photomicrograph of a large nest of the esophageal squamous cell carcinoma with prominent intercellular bridges; keratin pearl formation and abundant fibrous stroma (H and E, ×1000)|
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|Figure 4: Histology of skin nodule showing an ulcerated epidermis overlying an infiltrative well differentiated squamous cell tumor that is growing in nests with prominent intercellular bridges; keratin pearl formation and abundant fibrous stroma|
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Patient had a tube feeding gastrostomy. He was commenced on intravenous paclitaxel for palliative chemotherapy with slight regression in the sizes of some of the nodules. His general condition deteriorated over time and he died about 3 months after admission.
| Discussion|| |
The majority of esophageal cancers are mainly squamous cell type with the other major type being adenocarcinoma. Squamous cell carcinoma mainly occurs in the setting of smoking and alcohol consumption. Adenocarcinomas however, occur often in association with Barret's esophagus. 
The most common sites of hematogenous metastases from esophageal carcinoma are the lungs and liver whereas the less frequently affected sites are the bones adrenal glands and brain. ,, The few reported cases of cutaneous metastasis from esophageal cancers are of squamous cell type, as is our own case. There are limited data in the literature regarding the incidence of esophageal squamous cell carcinoma presenting with cutaneous metastasis. Iwanski et al. reported a 51-year old man with extensive disseminated skin nodules which turned out to be metastatic squamous cell carcinoma from the esophagus. However, the patient developed these unusual lesions of the skin even before symptoms such as dysphagia or weight loss became apparent.  This is in contrast to our patient who presented with primary esophageal symptoms prior to onset of cutaneous nodules precisely 4-months after the onset of dysphagia.
Paulo Roberto Ott Fontes reported another 51-year old male with multiple skin metastases from squamous cell carcinoma of the esophagus.  In their own case, metastatic nodules were mainly on the scalp, limbs, abdominal wall and trunk. Silfen et al. in their study have reported esophageal squamous cell carcinoma metastasizing to the digital pulp. These authors maintained that, that was the second case described in the literature of a metastatic carcinoma of the esophagus presenting as a lesion of the digital pulp.  Our patient also had digital pulp metastasis in addition to other nodules. This therefore, makes him the third in the series as further search did not reveal any additional reported digital pulp metastasis from esophageal carcinoma. Of particular interest is the similarity in the age range (early fifties) and the sex of these patients.
The occurrence of cutaneous metastasis from esophageal cancer and most gastrointestinal cancers is a sign of the aggressive nature of the disease and an advanced stage and generally have a poor prognosis and several authors have reported a survival time of 4-20 months after diagnosis.  This was also the case in our patient as the tumor not only metastasized to the skin, but also to the skeleton with pathological fracture; another uncommon presentation.
Characteristically, the aggressive presentation of this tumor resulted in the demise of this patient within 5 months of the onset of symptoms. Some authors have reported that the most frequent sites of cutaneous metastasis in gastrointestinal cancers are the skin of the abdominal wall, and that the scalp, and that the face and extremities are generally not affected.  This is in contrast to what we observed in our patient who had both facial and digital pulp metastasis. There remains a question that begs an answer; and that is, what is, or if there is a predisposition to cutaneous metastases?
Metastases generally follow a series of mechanisms, pathways and cascades which depend on both host and tumor factors. 
Metastases do not occur randomly, but the metastatic mechanisms are the end result of a complicated series of events, which begin with invasion of extracellular matrix, angiogenesis (growth of new blood vessels, which feed the tumor), intravasation into vessels embolization and arrest at distal circulation. Following arrest, the cells are extravasated through the endothelium of capillaries into the surrounding tissues where they develop new blood vessels again and then tumor growth occurs at the new site. Therefore, angiogenesis is necessary at the beginning and at the end of metastatic cascade if the new growth must enlarge beyond 0.5 mm in diameter. Multiple host and tumor factors interact to either promote or inhibit tumor progression. These factors include autocrine (tumor derived) and paracrine (organ-derived growth and inhibitory) factors. ,,,
The metastatic pathways may be through tissue spaces or planes, lymphatics, blood vessels, coelomic cavities (transperitoneal and transpleural spread), cerebrospinal spaces, and epithelial cavities and surfaces. One or more of these pathways may be followed by a particular cancer either due to proximity or the abundance of organ with these tissues, e.g., blood vessels or lymphatics. Esophageal metastases spread mainly via blood vessels to the liver and the lung and via lymphatics to the mediastinal, cervical and coeliac lymph nodes. ,
Cancers do not spread solely from the primary site but requires a regular sequence of steps referred to as the cascade process. This requires the spread first to a 'generalizing site' which serve as the filter for blood-borne or lymph born metastases from where spread then extends to several other sites. ,
These processes (mechanisms, pathways and cascades) however do not explain why a tumor would deviate from the convention and spread to sites it does not routinely spread to as in our case report.
| Conclusion|| |
Cutaneous metastasis from esophageal squamous cell carcinoma is a rare occurrence and our case represents the third in reported series of metastasis to the digital pulp. Metastatic nodules may occur prior to the onset of esophageal symptoms such as dysphagia and weight loss or after, and is a pointer to the aggressiveness of the tumor. Though the mechanisms, pathways and cascades by which cancers spread to particular sites they are known for are well-elucidated in the literature, applying these processes to unusual sites would require further research.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]