Cutaneous Metastasis of Pancreatic Adenocarcinoma as a First Clinical Manifestation: A Case Report and Review of the Literature

CASE REPORT

In November 2011, a 70-year-old Caucasian woman consulted a dermatologist for a painful lesion in the posterior aspect of her scalp. A biopsy was obtained, and she was discharged from the ambulatory clinic with analgesic treatment. Pathology reported a moderately differentiated adenocarcinoma of unknown primary site. She was referred to the oncology service. At presentation, she admitted having vague gastrointestinal symptoms for months before the appearance of her skin lesion and recent, unquantified weight loss, fatigue, and failure to thrive. On admission, her scalp lesion had also progressed and was very painful. Her work-up comprised a contrast-enhanced computed tomographic (CT) scan of the chest, abdomen, and pelvis that revealed a mass in the tail of the pancreas with carcinomatosis and extensive liver involvement by metastatic disease.

A surgical resection of the scalp lesion was performed with wide margins, which healed well, and with complete resolution of its related symptoms.

Supportive care and pain management were initiated. Pathology reported adenocarcinoma of pancreatic origin, and immunohistochemistry confirmed the diagnosis (Figure 1).

Figure 1.

Excision biopsy from scalp lesion shows metastatic adenocarcinoma of the dermis. (A) Hematoxylin and eosin staining; X10. Neoplastic glands show a positive reaction to immunohistochemical staining of cancer cells for CEA (B), CK7 (C), and CK20 (D). All X20.

Tumor markers were sent (Institut National de Pathologie, Lebanon), and Ca 19-9 was >100,000 U/mL after dilution (0–37 U/mL), Ca 125 was >2,000 U/mL (0–35 U/mL), and CEA was in the 100-U/mL range (< 2.5 U/mL).

On January 17, 2012, she was started on GEMOX FDR and received 4 cycles with an excellent chemical response. Ca 19-9 decreased to 17,565 U/mL, Ca 125 to 761 U/mL, and CEA to only 10.86 U/mL. She initially improved clinically as well, but died of massive pulmonary embolism in April 2012, despite being on deep venous thrombosis (DVT) prophylaxis since diagnosis.

DISCUSSION

The incidence of pancreatic cancer has increased over the past few decades and is presently the fourth leading cause of cancer-related deaths in the United States and the Western world. In 2012, 33,000 new cases were predicted for the United States, with 29,700 associated deaths.¹

The majority of pancreatic cancers are locally advanced or metastatic at presentation, and the only treatment is palliative and a difficult challenge. Despite the many advances in solid-tumor therapy over the past decade, pancreatic cancer continues to have median survival times of 3 to 6 months.² Treatment relies on a multidisciplinary approach for the best palliation of the patient's symptoms, with particular attention to nutritional and functional status, pain control, and psychosocial needs.² Morbidity and mortality are conspicuously associated with metastasis, most frequently to the lymph nodes, lungs, liver, adrenal glands, kidneys, and bones.³ Cutaneous metastases are rare in pancreatic cancer.^4–5 Indeed, the majority of cutaneous metastases, which are found in 0.7% to 9% of all patients with cancer, occur in breast, lung, and colon cancer. Cutaneous involvement is explained by 3 different mechanisms⁶: direct invasion, local metastatic disease, and distant metastasis, the latter mechanism being the least common.

Lookingbill et al⁷ reported a frequency of only 0.48% of pancreatic origin in one of the largest reviews of cutaneous metastases (2/420 cases). When they occur, cutaneous metastases in pancreatic cancer are generally multiple, with a predilection for the periumbilical region,⁸ known as Sister Mary Joseph nodules. Isolated nonumbilical metastases are rare.

Yendluri et al⁹ conducted a PubMed search in 2007 and reviewed the published English and Japanese literature for the past 90 years. They identified 57 cases of Sister Mary Joseph nodules originating from the pancreas and 16 cases of nonumbilical cutaneous metastases, of which only 3 were located in the scalp.

Hafez et al¹⁰ confirmed these data in 2008 and reported a new case of a 55-year-old woman with a cutaneous metastasis on the neck. In 2010, yet another case of scalp lesion was described in a 59-year-old woman.¹¹

Thus, to the best of our knowledge, there are only 4 reports of pancreatic cancer with cutaneous metastasis to the scalp, making our case particularly interesting (Table 1).

Table 1.

Nonumbilical cutaneous metastasis from pancreatic adenocarcinoma

Study	Age	Sex	Metastatic site	Pancreatic tumor site
Sakai et al.12	47	M	Herpes zoster-like	Head
Taniguchi et al.13	69	M	Face, head	Head
Taniguchi et al.13	67	M	Chest, abdomen	No details
Ohashi et al.14	79	M	Neck, chest, abdomen	No details
Ohashi et al.14	65	M	Back	No details
Sironi et al.15	72	M	Right thigh	Head
Fukui et al.16	49	M	Face, chest	No details
Nakano et al.17	80	M	Occipital scalp, arm, chest	Tail
Miyahara et al.18	60	M	Face, neck	Tail
Miyahara et al.18	43	M	Scalp	Uncus?
Miyahara et al.18	65	M	Mentum	Uncus
Horino et al.19	65	F	Chest wall	Head
Ambro et al.20	65	M	Scalp	Ductal?
Florez et al.8	84	M	Buttock	Head
Takeuchi et al.21	77	M	Left axilla	Tail
Jun et al.22	68	M	Right forearm, chest	Tail
Hafez et al.10	55	F	Neck	Head
Bhat W et al.11	59	F	Scalp	Tail
Present case	70	F	Scalp	Tail

Only four cases of scalp metastasis (in bold) have been described in the literature including the present case.

CONCLUSIONS

Pancreatic cancer is a disease of swift progression and dismal prognosis, with a median survival time of only 3 to 6 months after diagnosis. It is known to metastasize rapidly. The liver and peritoneum are the most common sites of metastasis in pancreatic cancer, followed by the lungs, bones, and brain. Cutaneous metastases have very rarely been reported and mostly occur around the umbilicus. Metastasis to other sites is extremely rare. Our patient had a metastatic scalp lesion, a very rare presentation of pancreatic adenocarcinoma that led to her diagnosis.