Cutaneous metastases are most often rapidly progressing late events with a poor prognosis. Our patient, however, had metastatic carcinoma of the skin manifesting as a clinically benign, small, solitary nodule with no other symptoms. The follow-up computed tomography scan revealed thickening of the gastric wall in the cardia, and the patient had no epigastric pain, epigastric discomfort, dyspepsia or regurgitation, and no weight loss. A barium swallow revealed esophageal mucosal irregularities, despite an absence of reflux or difficulties in swallowing. Esophageal biopsy revealed an immunohistochem-ically CK7+/CK20- invasive adenocarcinoma. To determine the primary site, immunostaining for keratins can provide important information. Although exceptions exist, CK7+/CK20+ is apparent in one-third of gastric adenocarcinomas and CK7-/CK20+ in another one-third of gastric adenocarcinomas , while CK7+/CK20- is reported in esophageal adenocarcinomas. buy ampicillin
Squamous cell carcinomas accounted for 90% of esophageal cancers before 1970; currently, adenocarcinomas are assumed to be increased in number . It was concluded that nearly all cases of esophageal adenocarcinomas arise from a premalignant lesion of esophagus, known as Barrett’s esophagus. In our patient, however, no features of Barrett’s esophagus were detected in the esophageal sample. Although Barrett’s esophagus is recognized as a precursor lesion, its etiology and prevalence remain unclear . Strong association among Barrett’s esophagus, esophageal adenocarcinoma and gastroesophageal reflux has been reported. Our patient was, however, symp-tomless.
Our case emphasizes that, in staging of esophagogastric carcinoma, skin lesions should be looked for and biopsied because the findings can determine further management. Newly appearing skin lesions may be the first presentation of an advanced visceral cancer and should be appropriately explored. Although cancers of internal organs rarely present with skin metastases, nonhealing dermal ulcers, persistent indurated erythema and skin nodules of undetermined cause need to be biopsied so as not to miss cutaneous metastases of an unknown primary cancer.