Highly aggressive gastric adenocarcinoma with multiple skin nodule and supraclavicular node in a 19-year-old patient

A rare presentation in such young age

Abstract

 

Although gastric adenocarcinoma is common in middle- and old-aged population, it is rare in young people. Development of cutaneous metastasis during presentation is even rarer in any age group. We report the case of a 19-year young man with gastric adenocarcinoma who had multiple skin nodules over the trunk during presentation. Fine-needle aspiration cytology of the nodule revealed it to be metastasis from gastric adenocarcinoma. Cutaneous metastasis may be the first presentation of internal malignancies even with a short history of disease in young patients. Atypical presentation of a malignancy in atypical age group must be evaluated with prompt assessment, active intervention, and close follow-up.

INTRODUCTION

Gastric adenocarcinoma is one of the common causes of cancer death in the world. Cutaneous metastases are rare and generally seen in advanced stage.[¹] Breast carcinoma is the most common cause of cutaneous metastasis, followed by carcinoma large intestine, lung, and ovaries in women. In men, the primary sites of carcinoma with cutaneous metastasis in decreasing order are carcinoma lung, colon, rectum, oral cavity, kidney, and stomach.[²] It may be the first sign of an unknown malignancy. This case is reported due to the rarity of cutaneous metastasis at multiple sites from a highly aggressive adenocarcinoma in a young patient, to emphasize the importance of cutaneous metastasis as a poor prognostic sign in patients with a history of cancer.

CASE REPORT

A 19-year-old patient presented to the Outpatient Department of Shri Ram Murti Smarak Hospital, Bareilly, with the chief complaint of pain abdomen, intermittent melena, and loss of appetite associated with vomiting which aggravated on taking food, in June 2018. There were no other comorbidities associated with the disease. The patient was investigated with upper gastrointestinal endoscopy (UGIE) which showed an ulcerated polypoidal mass present in the midbody along the lesser curvature [Figure 1], and biopsy was taken from the growth for histopathology. The patient was further referred to Govind Ballabh (GB) Pant Hospital, New Delhi, for further management. UGIE was repeated at GB Pant Hospital, which showed a large ulceroproliferative growth arising from the lesser curvature and the anterior wall of the stomach, causing luminal compromise filling up the fundus and the body of the stomach. Scope was negotiable till antrum easily. Esophagus, fundus, antrum, pylorus, and D1 and D2 mucosa appeared normal. A biopsy was taken which came out to be poorly differentiated adenocarcinoma.

Figure 1: Image from upper endoscopic examination demonstrating a large ulceroproliferative growth in the stomach

Further, contrast-enhanced computed tomography (whole abdomen) was done, which showed the evidence of multilobulated, heterogeneously enhancing, irregular polypoidal mass along the anterior wall of the body of the stomach measuring ~6.9 (cc) cm × 6.6 (anteroposterior) cm × 4.9 (trans) cm with exophytic component into the adjacent omentum [Figure 2]. Cardia, fundus, gastroesophageal junction, and pyloric region were uninvolved. Multiple (>15) conglomerate necrotic lymph nodes were seen in the paracardiac, supra and infra pyloric, supra and infrarenal, paraaortic, aortocaval along the lesser and greater curvature, periportal, hepatoduodenal, splenic hilar, and along aortic branches. Multiple omental deposits were seen in the perigastric region, perihepatic region, and bilateral retroperitoneal fat behind the paracolic gutter (largest measuring 2.9 cm × 1.7 cm) in the perigastric region. Also noted was a bulky pancreas with few hypodense lesions in the tail, which were suspicious for metastasis. In view of the extensive, advanced, inoperable disease, the patient was referred to our department for further management.

Figure 2: Contrast-enhanced computed tomography of the abdomen showing gastric tumors

On examination, the general condition of the patient was poor. Pallor was seen in the bilateral lower palpebral conjunctiva. The abdomen was distended with palpable epigastric mass. Multiple cutaneous nodules were palpated over the bilateral arm, chest wall, anterior abdominal wall and back, and right lower limb. The left supraclavicular node was also palpable which was approximately 4 cm × 3 cm, was firm in consistency, and was nontender [Figure 3]. Fine-needle aspiration cytology was performed from multiple cutaneous nodules and supraclavicular node, which came out to be metastatic adenocarcinoma [Figure 4]. The patient developed 2–3 episodes of melena during investigative workup, for which he was given hemostatic radiotherapy to the stomach at a dose of 4 Gy in single fraction. The patient had some improvement in symptoms. Then, the patient was lost to follow-up.

Figure 3: (a) Metastatic subcutaneous nodule at multiple sites and (b) supraclavicular node

Figure 4: Histology of metastatic cutaneous nodule

DISCUSSION

Cutaneous metastasis is a very rare (<5%) presentation in gastric adenocarcinoma patients. However, metastasis to the liver, peritoneal cavity, and regional lymph nodes is relatively common.[^3,4] Adenocarcinoma is seen to be the most common cause of cutaneous metastasis arising mainly from the lung, breast, and colon.[^5,6] Only 6% of all cutaneous metastases in male and 1% in female are from gastric origin. However, 0.8% of all gastric cancers present cutaneous metastasis.[^5,7] According to the literature, the most common presentation of cutaneous nodule reported was observed over the abdominal wall.[^1,5,8] In our patient, cutaneous nodules were present over the bilateral arm, back, and abdominal wall.

Cutaneous metastasis is a very rare clinical presentation of a malignancy, which can be seen as a nonspecific clinical presentation and can be missed by the physician. Although it is a strong sign of poor prognosis, it is recommended to be aware of such condition, and biopsy must be taken from such cutaneous nodules in cancer patients. However, there are difficulties in the early detection of cutaneous metastasis, especially in young patients with a short history of disease (like in our case), which often mimics common dermatological condition such as sebaceous cyst and Muir–Torre syndrome (cutaneous lesion associated with gastrointestinal neoplasm), which is an important differential diagnosis in young patients. In various studies and majority of case reports, cutaneous metastasis indicates a very poor prognosis.

This case is remarkable for various points: first, it is rare to find gastric adenocarcinoma in such young age with a short duration of disease. Second, the presentation with multiple cutaneous nodules is very rare although the development of supraclavicular node may be seen.

CONCLUSION

Cutaneous metastasis may be the first presentation of an internal malignancy even with a short history of disease in young patients or may indicate recurrence. In either cases, prompt assessment, active intervention, and close follow-up are recommended.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.