Getting Under Your Skin: A Case of Esophageal Cancer With Subcutaneous Metastases and Spontaneous Tumor Lysis

Abstract

Introduction: Cutaneous metastases of esophageal and gastric cancer are rare but have been reported usually as late findings. We present a case of a stage IV adenosquamous carcinoma with rapidly progressing cutaneous metastases as the presenting finding, leading to the identification of a primary tumor at the gastroesophageal (GE) junction.Figure 1Figure 2Figure 3Case: The patient was a 62 year old male with chronic HCV (Hepatitis C), alcohol and tobacco abuse who presented with 1 month of decreased appetite with acute worsening over the last 4 days and the sensation of regurgitation without dysphagia or odynophagia. Over the previous 3 weeks he had noticed nodules in his skin, first on his scalp, and then on his abdomen, back and right arm. Vital signs were remarkable for tachycardia to 120. On physical exam the patient had multiple firm, mobile, non-tender subcutaneous nodules on his head, neck, back, abdomen and upper extremities with the largest palpable nodule on the left upper back measuring 2 cm in diameter. Labs on admission were remarkable for elevated creatinine, potassium, lactate dehydrogenase, transaminases, total bilirubin, and uric acid, all indicating tumor lysis syndrome. AFP was normal. CT scan of the abdomen and pelvis identified a large heterogeneous mass at the GE junction, a cirrhotic liver with multiple hypodensities, numerous subcutaneous nodules and extensive retroperitoneal lymphadenopathy. Biopsy of a subcutaneous nodule in the right parietal scalp showed metastatic poorly differentiated carcinoma with staining consistent with an adenosquamous carcinoma of upper GI origin. On esophagogastroduodenoscopy a large friable mass at the GE junction was visualized and biopsies showed the same morphology as the right parietal cutaneous lesion, suggesting an esophageal primary. Renal function worsened despite fluid resuscitation and the patient became oliguric and then anuric. On day 5 of hospitalization, he became hypotensive and passed away. Discussion: Regardless of the primary site, cutaneous metastases of gastrointestinal malignancy portend a poor prognosis, with several studies demonstrating median survival of less than six months. Spontaneous tumor lysis of solid tumors is even more rare and there are only 11 other cases described in the literature, 4 of which were gastrointestinal in origin. Spontaneous tumor lysis is seen more often, and should be considered in patients with advanced malignancy and electrolyte abnormalities.