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Pancreatic cancer skin lesions

Ito H.a · Tajiri T.b · Hiraiwa S.b · Sugiyama T.b · Ito A.a · Shinma Y.a · Kaneko M.a · Anzai K.a · Tsuda S.a · Ichikawa H.a · Nagata J.a · Kojima S.a · Watanabe N.a

Author affiliations
aDepartment of Gastroenterology, Tokai College Hachioji Hospital, Tokyo, JapanbDepartment of Pathology, Tokai College Hachioji Hospital, Tokyo, Japan
Dr. Hiroyuki Ito

Department of Gastroenterology

Tokai University Hachioji Hospital, Ishikawa 1838

Hachioji, Tokyo 243-0122 (Japan)

E-Mail hito

Abstract

A 71-year-old woguy presented to a nearby hospital with an occipital scalp ulcer with exuday. Thoracoabdominal magnified computed tomography (CT) was perdeveloped because of suspected cancer. The imaging results verified tumors in the pancreatic tail and at multiple sites in the lung, whereupon she was referred to our hospital for even more examination. Histological analysis of the occipital scalp ulcer and the pancreatic tumor led to the diagnosis of pancreatic adenocarcinoma through cutaneous metastasis and also multiple lung metastases. Combicountry chemotherapy (gemcitabine and also nab-paclitaxel) was began, and about 4 months later the patient knowledgeable best lower earlier pain. Abdominal muscle CT verified partial sclerosis of the ideal iliac bone and multiple spinal lesions, which were diagnosed as multiple bone metastases. Narcotic analgesia was started for the ideal reduced ago pain. Due to the fact that then, FOLFIRINOX has actually been introduced as second-line chemotreatment against tumor expansion, and also therapy has been continuous for 10 months because the initial chemotreatment. Pancreatic cancer is a rapidly flourishing cancer and also have the right to display beforehand metastasis to various other organs, lymph node metastasis, and also peritoneal dissemination; therefore, the prognosis of pancreatic cancer is incredibly negative. Cutaneous metastasis from pancreatic cancer is rare, and just a few situations have actually been reported. Here, we report an inexplicable situation of pancreatic adenocarcinoma through cutaneous metastasis and also multiple lung and also bone metastases.

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Case Report

A 71-year-old womale presented to a nearby hospital with an occipital scalp ulcer with exuday. Thoracoabdominal amplified computed tomography (CT) was percreated due to suspected cancer. The imaging outcomes showed tumors in the pancreatic tail and at multiple sites in the lung, whereupon she was described our hospital for even more investigation.

A fragile occipital scalp ulcer lesion measuring 2.5 cm in diameter was provided (Fig. 1a), however no various other skin lesion was observed upon examicountry. Her consciousness was clear; no jaundice or anemia was oboffered, and both lungs were clear on auscultation. The abdomales was flat and also soft, and also the mass was not palpable.


a A delicate ulcer lesion measuring 2.5 cm in diameter in the occipital area. b Ab computed tomography (CT) image mirroring a tumor measuring 30 mm in diameter via an unclear margin and also negative comparison result in the pancreatic tail; intrusion of the bordering adipose tworry was suspected. c Chest CT photo revealing little nodular lesions sized 1 cm or less in both lungs, indicative of multiple lung metastases. d Head CT image revealing a bulging mass through contrast enhancement in the occipital ulcerated area without skull infiltration.


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The blood test results for program parameters were within the normal range: white blood cells, 8,000 cells/μL; hemoglobin, 14.2 g/dL; plateallows, 23.1 cells/μL; glutamic oxaloacetic transaminase, 19 U/L; glutamic pyruvic transaminase, 16 U/L; lactate dehydrogenase, 190 U/L; alkaline phosphatase, 190 U/L; γ-glutamyltranspeptidase, 21 U/L; amylase, 54 U/L; lipase, 45 U/L; elastase-1, 263 U/L; BS, 117 mg/dL; HbA1c, 5.8%; full bilirubin, 0.9 mg/dL; international normalized proportion, 1.00; and C-reactive protein, 0.01 mg/dL. However before, tumor markers were elevated: carcinoembryonic antigen, 3.0 ng/mL; carbohydprice antigen 19-9, 1,720.9 U/mL; DUPAN-2, 1,400 U/mL; and SPAN-1, 880 U/mL.

Abdominal CT proved a tumor measuring 30 mm in diameter via an unclear margin and bad comparison impact in the pancreatic tail, which had probably attacked the bordering adipose tconcern (Fig. 1b). Chest CT revealed small nodules sized 1 cm or less in both lungs, perhaps indicating multiple lung metastases (Fig. 1c). Head CT revealed a bulging mass through contrast enhancement in the occipital region which had actually not infiltrated the skull (Fig. 1d).

Next off, endoscopic ultrasound-guided fine needle aspiration was performed for histological diagnosis. An irconsistent and also heterogeneous mass measuring 33 × 35 mm was oboffered in the pancreatic tail. Infiltration of the splenic artery and vein was likewise observed (Fig. 2a). Histochemical staining verified proliferation of small atypical gland ducts, and also immuno­staining revealed that the tumor was p53 negative and also IMP3 positive (Fig. 2b, c). These findings indicate that the main cancer was pancreatic ductal adenocarcinoma via a clear cytoplasm. Tworry acquired from the occipital ulcer showed almost the exact same morphology as the primary tumor (Fig. 2d), and also therefore, we diagnosed a metastatic cutaneous tumor acquired from the pancreatic cancer (Fig. 2d).


a An irconsistent and heterogeneous mass measuring 33 × 35 mm in the pancreatic tail, and infiltration right into the splenic artery and also vein are oboffered. b Histologically, the tumor tconcern confirmed proliferation of little atypical gland also ducts with a clear cytoplasm, indicating adenocarcinoma. c Immunohistochemically, the tumor tproblem expressed IMP3. d Histological tconcern built up from the occipital ulcer proved nearly the very same morphology as that from the pancreatic tail.


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Combination chemotherapy (gemcitabine and nab-paclitaxel) was started for progressed pancreatic cancer via remote metastasis. About 4 months later, the patient arisen ideal lower ago pain. Conditional abdominal CT imaging showed partial sclerosis of the right iliac bone and multiple spinal lesions, indicating multiple bone metastases (Fig. 3a, b). Narcotic analgesics were began. Imaging likewise revealed even more expansion of the pancreatic tumor and the multiple lung tumors. As such, second-line combination chemotherapy (FOLFIRINOX, i.e., leucovorin, fluorouracil, irinotedeserve to, and oxaliplatin) was began. Chemotherapy is recurring, as tright here have been no special adverse occasions or worsening of the patient’s general problem given that the diagnosis was made 10 months back.


a Computed tomography image showing partial sclerosis of the right iliac bone. b Computed tomography photo reflecting multiple spinal sclerotic lesions and other bone metastases.

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Discussion

Pancreatic cancer has actually a high malignant potential and is taken into consideration to have actually among the worst prognoses. Due to the fact that the pancreas is located in the retroperitoneum and also is a long, slender body organ via a thin film, neighborhood symptoms are not well identified <1>. Tumors flourish on the outer surface of the pancreas, and also therefore can easily reason peritoneal circulation and lymph node metastasis as soon as their diameter exceeds 2 cm <2>. Pancreatic cancer cells are extremely proliferative and also have low adhesiveness, thereby contributing to the highly metastatic nature of the cancer. Cancer cells metastasize initially to major organs, such as the liver and also lung, and then to relatively slow-growing tconcerns such as skin, muscle, and bone <3>. It is assumed that, initially, far-off dissemination and major organ metastases happen and also the general condition of the patient becomes negative, adhered to by metastases to the skin, muscle, and also bone <4>. In current years, renovations in treatment have extfinished survival, probably boosting the detection rate of atypical symptoms as a result of far-off organ metastasis as watched in this instance.

Regarding the incidence of cutaneous metastasis among patients via pancreatic cancer, Lookingbill et al. <5> reported that cutaneous metastasis was listed in only 2 of 420 autopsies of pancreatic cancer patients (0.5%), while Cubilla and Fitzgerald <6> oboffered this finding in 7.6% of their autopsies of pancreatic cancer patients (9 out of 119). The frequency of cutaneous metastasis varies in between reports. Macroscopically, major cutaneous adenocarcinomas regularly present as a wart, erosion, or ulcer. They usually aclimb either from the sebaceous or the sweat gland system. Brownstein and also Helwig <7> classified metastatic cutaneous tumors into 3 types: nodular, inflammatory, and sclerodermoid; the the majority of widespread is the nodular type. Additionally, cutaneous tumors deriving from hematogenous metastatic pancreatic cancer and also those originating from lymphatic metastatic pancreatic cancer are macroscopically various. While hematogenous metastatic cutaneous tumors have actually papule induration through fusion of nodules, lymphatic metastatic cutaneous tumors are thought about to be painful lesions via redness and swelling <8>. Metastatic cutaneous tumors acquired from pancreatic cancer are typically considered to be hematogenous and painless, consistent through the findings of the present case <9>.

Although the abdomales is the a lot of widespread website for cutaneous metastasis from pancreatic cancer, head, chest, and also scalp metastases have been reported. Abdominal cutaneous metastases are common because the tumor cells disseminated in the peritoneum metastasize to the umbilicus, cshed to the epidermis, and form a nodule, called Sister Mary Joseph nodule <10>. About 44% of the cutaneous metastases from pancreatic cancer are Sister Mary Joseph nodules.

Bone metastases in the conmessage of pancreatic cancer aincrease once the tumor is primarily positioned in the organ’s tail area. The many widespread site for bone metastasis is the spine. Metastases to the ribs, scapulae, and cheekbones have actually also been reported <3>. The blood flow from the pancreatic body and also tail passes through the vertebral venous plexus using the portal vein, and therefore a transvenous route for metastasis is feasible. According to Garcia <11>, bone metastasis is normally osteolytic, and also osteogenic metastasis, as detailed in this situation, is rare.

Bone metastasis is treated utilizing pharmacotreatment and radiation therapy, to relieve pain and also reduce neurological symptoms. As pharmacotreatment, in addition to an analgesic agent, a bone resorption inhibitor (having an osteoclast-inhibitory effect) is offered for the osteolytic kind <12>. In this instance, bone resorption inhibitor treatment was not shown bereason the metastases were osteogenic. Furthermore, radiotherapy was not suggested because it was hard to recognize the specific site responsible for the pain, as tbelow were multiple pelvic and spinal metastases.

Recently, the as a whole survival rate of pancreatic cancer patients has actually enhanced because of advancements in treatment such as chemotreatment, but remote metastases, which are taken into consideration rare, are supposed to come to be a new problem <13, 14>. Thus, as soon as dealing with patients with pancreatic cancer, it is important to take into consideration the possibility of distant metastases, such as cutaneous and bone metastases.

Statement of Ethics

This paper does not contain any studies with huguy participants performed by any of the authors. Written informed consent out was acquired from the patient using the hospital default informed consent form.

Disclosure Statement

The authors have no conflicts of interest to declare.

Funding Sources

The authors obtained no financial support for the research or for the writing and/or publication of this post.

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Author Contributions

All the authors contributed to the paper, including composing and also revising it. All authors review and apconfirmed the final manumanuscript.


Chuyên mục: Cancer