Cutaneous Metastases in Patients With Rectal Cancer: A Report of Six Cases

Written By: Sam Savage

Published Date: March 19, 2008 Last Edited: March 19, 2008

By Gazoni, Leo M Hedrick, Traci L; Smith, Philip W; Friel, Charles M; Swenson, Brian R; Adams, Joshua D; Lisle, Turner C; Foley, Eugene F; Ledesma, Elihu J

Cutaneous metastases from rectal cancer are rare manifestations of disseminated disease and uniformly represent dismal survival. A retrospective review of six patients with rectal cancer metastatic to the dermis was performed. The diagnosis of rectal cancer was made concurrently with the diagnosis of the dermal metastases in all six patients. A 100 per cent histopathologic concordance existed between the tissue of the dermal metastases and primary rectal tumor. The progression of systemic metastatic disease was the cause of death in 83.3 per cent of patients (5/6). No patient survived more than 7 months from the time of diagnosis. Recognition of suspicious skin lesions as possible harbingers of undiagnosed visceral malignancy is important in managing patients both with and without a history of previous cancer. RECTAL CANCER METASTASES to the skin, although uncommon, represent disseminated disease and portend a poor prognosis. Cutaneous metastases are most commonly small 1- to 2- centimeter nodules that often coalesce and resemble epidermal cysts, keratoacanthomas, or pyogenic granulomas.1-3 This finding is characteristic of most cutaneous metastases regardless of the origin of the primary tumor. Ulceration occurs in approximately 10 per cent of nodules.2 In this study, we present our series of six patients who were diagnosed with rectal cancer concurrently with metastatic lesions to the skin.

Case Series

Patient Information

Of six patients, one patient was female and five patients were male. The mean age at diagnosis was 67.3 years. Patients commonly presented with constipation, bloating, bloody and thin stools, weight loss, and scrotal edema. All patients had a palpable mass on digital rectal examination.

Cutaneous Manifestations

Cutaneous metastases varied in location and number (Figs. 1-3 & Table 1). Some patients had multiple sites of dermal involvement, but the lower abdomen/back was not involved in any patient.

FIG. 1. Arm metastases.

Management

Anoscopy and rigid sigmoidoscopy were performed on all patients. Complete colonoscopy was performed in all but one patient (the scope was unable to pass the lesion). All tumors were found less than 10 centimeters from the anal verge. A 100 per cent histopathologic concordance existed between the tissue of the cutaneous metastases and primary rectal tumor.

At the time of diagnosis, liver metastases were found in two patients. Two patients had radiologic evidence of metastatic disease; one patient with a lung mass and the other with a retroperitoneal mass. Tumor fixation (frozen pelvis) was present in four patients. The operations performed in all six patients were palliative. Diverting loop colostomies were performed on three patients, one of which was emergent as the patient presented with an acute obstruction. Two patients received end colostomies. A stent was successfully placed with good early functional result in one patient; however, no conclusion to its long-term functionality and consequences could be made as the patient soon died secondary to a myocardial infarction. One patient presented with a severe Enterococcus faecalis soft tissue infection at the site of cutaneous metastasis requiring massive resection of the perineum, scrotum, and lower abdomen. The patient survived this insult and was discharged after skin grafting but then died 3 months later of liver and lung metastases.

FIG. 2. Groin metastases.

FIG. 3. Penile metastases.

All patients underwent radiation and chemotherapy. In three patients, radiation was performed before chemotherapy. Two patients underwent concurrent radiation and chemotherapy and one patient had chemotherapy followed by radiation. The radiation dose varied from 4500 Gy to 5000 Gy. All patients received 5-fluorouracil. All patients received leucovorin except for one who did not tolerate therapy. Subjective improvement of the skin lesions was reported in all but one patient. Progression of systemic metastatic disease was the cause of death in five patients and myocardial infarction in one patient. The skin metastases themselves were not the cause of death although they caused a significant morbidity as the lesions were disfiguring, bleeding, suppurative, and foul-smelling. Notably, the lesions were not painful.

TABLE 1. Patient Information

Discussion

Colorectal cancer accounted for approximately 148,610 cases of newly diagnosed cancer and 55,170 deaths in the United States in 2005 according to the American Cancer Society. Approximately four to six per cent of colorectal cancer cases are metastatic to the skin.2,4-6 Although liver, lung, bone, and brain metastases are more common manifestations of disseminated colorectal cancer, cutaneous metastases of colorectal cancer do occur and will potentially affect up to 6,000 of the 148,610 patients with newly diagnosed colorectal cancer in the United States.

Autopsy series have reported an incidence of 0.7 per cent to 10.4 per cent of cutaneous metastases in all patients with cancer of any cause.7-9 Excluding primary skin cancers, gastrointestinal malignancies account for 15 per cent of cutaneous metastases.10, n In one series of 4,020 cancer patients with metastatic disease, cutaneous metastases were found in 10.4 per cent of patients.2 All tumors were adenocarcinomas. Colorectal cancer was the third most common cause of cutaneous metastases in men behind melanoma and lung cancer and the seventh most common cause in women. Breast cancer and melanoma were the top two primary tumors in 70.7 per cent and 12.0 per cent, respectively, of women with cutaneous metastases. In this series, the mean time of death from diagnosis was 18 months.

In most case reports of metastatic colorectal cancer to the skin, the metastatic lesion was found after re section of the primary lesion. Dermal invasion, which is postulated to occur via intravascular and intralymphatic spread,12 usually occurs within 2 years of the primary resection and represents poor prognosis with mean survival ranging between 3 and 20 months.1-9 Whereas our series, the largest nonautopsy series to our knowledge, mirrors the findings of poor patient survival, all of our patients were diagnosed with cutaneous metastases at or before the time of the diagnosis of the primary rectal cancer. One series of 7316 cancer patients found that only one per cent of patients had dermal metastases at the time of the diagnosis of the primary tumor and 0.6 per cent of patients had dermal metastases as the first sign of visceral malignancy.10 The skin of the lower abdomen/trunk and previous abdominal incisions have been reported as the most common site of dermal metastases.13,14 In contrast, no patient in our series had involvement of the lower abdomen/trunk.

Rectal cancer metastatic to the dermis is a welldescribed, although uncommon manifestation of advanced disease. It should be considered in patients with risk factors or symptoms consistent with colorectal cancer who present with suspicious skin lesions including foul-smelling, suppurative skin lesions. Biopsy of concerning lesions in patients with a history of malignancy is also recommended. Our series also demonstrates that cutaneous metastasis may sometimes be the first sign that leads to diagnosis of a primary rectal cancer.

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LEO M. GAZONI, M.D., TRACI L. HEDRICK, M.D., PHILIP W. SMITH, M.D., CHARLES M. FRIEL, M.D., BRIAN R. SWENSON, M.D., IOSHUA D. ADAMS, M.D., TURNER C. LISLE, M.D., EUGENE F. FOLEY, M.D.,

ELIHU J. LEDESMA, M.D.

From the Department of Surgery, University of Virginia, Charlottesville, Virginia

Address correspondence and reprint requests to Leo M. Gazoni, M.D., MR4 Building, Room 3116,409 Lane Road, Charlottesville, VA 22908. E-mail: [email protected].

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