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Generalized Cutaneous Metastases From Carcinoma Stomach
AJG – September 1998 tomatic only since 3 months. Her intermittent dysphagia appears to be caused by the retrograde motility of the esophagus as other investigations were normal. We cannot be certain whether the peristaltic abnormality existed before sclerotherapy. Esophageal motility disorders occurring after sclerotherapy for varices is well documented though the pathogenesis is poorly understood (2– 4). Low-amplitude contractions, simultaneous contractions, and nonprogressive contractions are the most frequently observed. Literature is unclear whether these abnormalities occur or persist several months after sclerotherapy. Similarly, therapeutic interventions are ill defined. Satheesh Nair, M.D. Harish Grover, M.D. C. S. Pitchumoni, M.D., F.A.C.G. Our Lady of Mercy University Medical Center New York Medical College Bronx, New York REFERENCES 1. Fass R, Landau O, Kovacs TO, et al. Esophageal motility abnormalities in cirrhotic patients before and after endoscopic variceal treatment. Am J Gastroenterol 1997;92:941– 6. 2. Grande L, Planas R, Lacima G, et al. Sequential esophageal motility studies after endoscopic injection sclerotherapy: A prospective evaluation. Am J Gastroenterol 1991;86:36 – 40. 3. Reilly JJ, Schade RR, Van Theil DS. Esophageal function after sclerotherapy: Pathogenesis of esophageal stricture. Am J Surg 1984;47:85– 8. 4. Bovero E, Farese A. Manometric evaluation of esophageal motility in patients submitted to prophylactic variceal sclerosis. Surg Endoscopy 1988;2:156 – 8. Reprint requests and correspondence: C. S. Pitchumoni, M.D., F.A.C.G., Chief, Division of Gastroenterology, Our Lady of Mercy University Medical Center, 600 East 233 Street, Bronx, NY 10466. Received June 30, 1997; accepted June 18, 1998.
Generalized Cutaneous Metastases From Carcinoma Stomach To the Editor: Cutaneous metastases from internal malignancy are rare. The commonest tumor to metastasize to the skin in men is lung carcinoma and in women is breast carcinoma (1). We report a case of metastatic adenocarcinoma of the stomach presenting as generalized cutaneous metastasis, a rare entity. A 40-yr-old man had a progressive generalized cutaneous eruption of 2-months duration that started on the scalp and then spread to the face and trunk. He did not seek medical attention until he later developed epigastric discomfort, anorexia, and vomiting of stale food. He had lost 12 kg in weight during this period. Examination revealed small round, solid, tender, nonpruritic nodules measuring 1–3 cm in diameter. They were discrete with welldefined borders and extended into subcutaneous tissue. They were seen over scalp, face, neck, chest, abdomen, and both upper and lower extremities. He was found to be pale but had no icterus, lymphadenopathy, or edema. He had fullness in the epigastrium and a gastric succussion splash. The rest of the systemic examination was unremarkable. Investigations revealed a mild iron deficiency anemia. Upper gastrointestinal endoscopy revealed a large ulcer extending along
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the greater curvature from the antrum to the pylorus. Biopsy of this ulcer revealed adenocarcinoma. However, stomach biopsy was negative for mucin, and leucocyte common antigen (LCA) stain was negative. Biopsy specimens from the skin nodules demonstrated signet ring cell carcinoma. Chest x-ray and computed tomography scan of abdomen did not show any metastatic deposits. He underwent partial gastrectomy and was given palliative chemotherapy. Skin nodules persisted. He developed fever and died of secondary infection. Gastric adenocarcinoma spreads chiefly by direct extension and occasionally by way of lymphatics, blood, and transcoelomic extension. Although metastases from gastric adenocarcinoma can at times have a wide distribution, generalized cutaneous metastases are relatively rare. Cutaneous metastatic growths in these patients occur most commonly on the abdominal wall (2). Skin metastasis may indicate progression of the tumor and early fatal termination (3). It is noteworthy, however, that it may often be the initial manifestation of a primary gastric tumor as in our case (1). Our patient was also unique in that he had cutaneous metastasis for 2 months in the absence of extracutaneous metastasis. This supports the hypothesis of organ-specific metastasis proposed by Paget (4). It suggests the presence of a clonal population of carcinoma cells with a high cutaneous affinity and a low affinity for other organ systems. Ajit Sood, M.D., D.M. Vandana Midha, M.D. Jagdev S. Sekhon, M.D., D.M. Sandeep S. Sidhu, M.D., D.M. Department of Medicine Dayanand Medical College and Hospital Ludhiana, Punjab, India REFERENCES 1. Brownstein M, Helwing E. Patterns of cutaneous metastasis. Arch Dermatol 1972;105:862– 8. 2. Reingold IM. Cutaneous metastasis from internal carcinoma. Cancer 1966;19:162– 8. 3. Bischoff AJ, Fishkin BG. Carcinoma of the urinary bladder: Report of four cases. J Urol 1956;79:701–10. 4. Paget S. The distribution of secondary growths in cancer of the breast. Lancet 1889;1:571–3. Reprint requests and correspondence: Ajit Sood, M.D., D.M., 6-E, Tagore Nagar, Opp. New DMC and Hospital, Ludhiana 141001 Punjab, India. Received Jan. 16, 1998; accepted Apr. 24, 1998.
Ampullary Carcinoid To the Editor: Mergener et al. (1) reported a 30-yr-old woman who presented with isolated pancreatitis caused by an ampullary carcinoid tumor. They noted that 80 –90% of all carcinoids secrete serotonin or its precursor 5-hydroxytryptophan (2), and commented that four of seven patients with ampullary carcinoid tumors tested at their institution had evidence of serotonin overproduction (3). However, the authors did not include in their discussion the fact that many duodenal carcinoid tumors, occurring in the ampullary and periampullary area, are associated with neurofibromatosis (4, 5). In-
Generalized Cutaneous Metastases From Carcinoma Stomach To the Editor: Cutaneous metastases from internal malignancy are rare. The commonest tumor to metastasize to the skin in men is lung carcinoma and in women is breast carcinoma (1). We report a case of metastatic adenocarcinoma of the stomach presenting as generalized cutaneous metastasis, a rare entity. A 40-yr-old man had a progressive generalized cutaneous eruption of 2-months duration that started on the scalp and then spread to the face and trunk. He did not seek medical attention until he later developed epigastric discomfort, anorexia, and vomiting of stale food. He had lost 12 kg in weight during this period. Examination revealed small round, solid, tender, nonpruritic nodules measuring 1–3 cm in diameter. They were discrete with welldefined borders and extended into subcutaneous tissue. They were seen over scalp, face, neck, chest, abdomen, and both upper and lower extremities. He was found to be pale but had no icterus, lymphadenopathy, or edema. He had fullness in the epigastrium and a gastric succussion splash. The rest of the systemic examination was unremarkable. Investigations revealed a mild iron deficiency anemia. Upper gastrointestinal endoscopy revealed a large ulcer extending along
LETTERS TO THE EDITOR
1601
the greater curvature from the antrum to the pylorus. Biopsy of this ulcer revealed adenocarcinoma. However, stomach biopsy was negative for mucin, and leucocyte common antigen (LCA) stain was negative. Biopsy specimens from the skin nodules demonstrated signet ring cell carcinoma. Chest x-ray and computed tomography scan of abdomen did not show any metastatic deposits. He underwent partial gastrectomy and was given palliative chemotherapy. Skin nodules persisted. He developed fever and died of secondary infection. Gastric adenocarcinoma spreads chiefly by direct extension and occasionally by way of lymphatics, blood, and transcoelomic extension. Although metastases from gastric adenocarcinoma can at times have a wide distribution, generalized cutaneous metastases are relatively rare. Cutaneous metastatic growths in these patients occur most commonly on the abdominal wall (2). Skin metastasis may indicate progression of the tumor and early fatal termination (3). It is noteworthy, however, that it may often be the initial manifestation of a primary gastric tumor as in our case (1). Our patient was also unique in that he had cutaneous metastasis for 2 months in the absence of extracutaneous metastasis. This supports the hypothesis of organ-specific metastasis proposed by Paget (4). It suggests the presence of a clonal population of carcinoma cells with a high cutaneous affinity and a low affinity for other organ systems. Ajit Sood, M.D., D.M. Vandana Midha, M.D. Jagdev S. Sekhon, M.D., D.M. Sandeep S. Sidhu, M.D., D.M. Department of Medicine Dayanand Medical College and Hospital Ludhiana, Punjab, India REFERENCES 1. Brownstein M, Helwing E. Patterns of cutaneous metastasis. Arch Dermatol 1972;105:862– 8. 2. Reingold IM. Cutaneous metastasis from internal carcinoma. Cancer 1966;19:162– 8. 3. Bischoff AJ, Fishkin BG. Carcinoma of the urinary bladder: Report of four cases. J Urol 1956;79:701–10. 4. Paget S. The distribution of secondary growths in cancer of the breast. Lancet 1889;1:571–3. Reprint requests and correspondence: Ajit Sood, M.D., D.M., 6-E, Tagore Nagar, Opp. New DMC and Hospital, Ludhiana 141001 Punjab, India. Received Jan. 16, 1998; accepted Apr. 24, 1998.
Ampullary Carcinoid To the Editor: Mergener et al. (1) reported a 30-yr-old woman who presented with isolated pancreatitis caused by an ampullary carcinoid tumor. They noted that 80 –90% of all carcinoids secrete serotonin or its precursor 5-hydroxytryptophan (2), and commented that four of seven patients with ampullary carcinoid tumors tested at their institution had evidence of serotonin overproduction (3). However, the authors did not include in their discussion the fact that many duodenal carcinoid tumors, occurring in the ampullary and periampullary area, are associated with neurofibromatosis (4, 5). In-