A 49-year-old man with a past medical history of alcoholism and the diagnosis of adenocarcinoma of the distal esophagus was seen at the outpatient dermatology service. He had undergone an initial CAT scan of the chest and abdomen for staging, which showed no evidence of metastases. He then underwent transhiatal esophagectomy and the pathology study reported moderately differentiated adenocarcinoma at stage pT3N1 (1 out of 9 lymph nodes) M0. Following the surgery, adjuvant chemoradiotherapy was begun, utilizing the modified McDonald regimen (5 FU/LV). After the third chemotherapy cycle (6 months after surgery) the patient presented with a permanent lesion on his left cheek that became red, formed a scab, and bled upon removal of the scab, which was why the patient presented at our service. Upon physical examination of the left cheek, a shiny, raised nodule was palpated and its center was covered by a sanguineous crust measuring approximately 1 cm (Fig. 1). The lesion was biopsied and metastatic adenocarcinoma was reported (Fig. 2). After said diagnosis, the patient presented with dorsal pain. A thoracic spine magnetic resonance imaging scan was performed that identified bone metastasis. A new cycle of radiotherapy and second-line chemotherapy with cisplatin and 5FU were begun. We presented his case due to the rareness of esophageal adenocarcinoma relapse manifesting in the skin.

Fig. 1.

Shiny raised nodule with center covered by a sanguineous micro-crust measuring approximately 1 cm.

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Fig. 2.

Histologic section of the skin, showing tumor cell infiltration of the dermis.

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Esophageal cancer is an uncommon neoplasia, with a high mortality rate. The 2012 GLOBOCAN project estimated 455,784 cases of cancer of the esophagus and 400,169 deaths caused by the disease.1 Statistics are similar in Colombia, with the latest registers of 1-year survival reported at 37.2 %, decreasing to 20 % for 5-year survival.1 Currently, 2 types of primary esophageal tumors are identified: squamous cell carcinoma and adenocarcinoma. The majority of esophageal adenocarcinomas develop in or close to the gastroesophageal junction and arise from Barrett’s esophagus, which is a complication of chronic gastroesophageal reflux disease. Regarding metastases from the 2 subtypes, neighboring structures, such as the tracheobronchial tree, aorta, pericardium, and the recurrent laryngeal nerve are compromised. The liver and brain can be sites of distant metastasis, but metastasis to the skin is rare.2 The majority of reports of metastasis to the skin in the literature are case presentations. Quint et al. estimated that the incidence of all cutaneous metastases originated from esophageal carcinomas, and 1 % were from adenocarcinomas and squamous cell carcinomas of the esophagus.3 It is important to keep in mind that the presence of cutaneous metastases in any type of cancer is a poor outcome factor, given that survival rates have been reported at 4.7 months.4 The clinical picture of those patients is often asymptomatic, and therefore requires a high degree of suspicion. The most frequent forms of presentation are papules, neoplastic alopecia, indurated erythematous plaques, or cutaneous nodules.5 In the majority of cases, cutaneous metastases are secondary to primary tumors located in the lower third of the esophagus, and have been identified as both the first finding of disease and disease progression in patients with no previous metastatic involvement.6 The case presented herein is important because the first manifestation of disease progression was in the skin. All patients with lesions that are suspected to be metastatic should undergo a dermatologic evaluation and adequate histopathologic study, given that the differential diagnoses range from benign lesions to primary neoplastic lesions of the skin.