Cutaneous metastasis from cholangiocarcinoma as the first clinical sign: a report of two cases

Application value of 18F-FDG PET/CT in soft tissue metastasis of intrahepatic cholangiocarcinoma: a case report and literature review

Intrahepatic cholangiocarcinoma (ICC)originates from the epithelial cells of the intrahepatic bile ducts, with insidious onset and strong invasiveness, and most of the cases are found in the advanced stage, with extremely poor prognosis. In advanced stages, distant metastases to the lungs, bones, and brain are common, but distant soft tissue (subcutaneous and skeletal muscle) and breast metastases are rare, and simultaneous metastases to all three rare sites had not been reported. We report a 69-year-old woman with right upper abdominal pain who underwent a plain and enhanced CT scan of the upper abdomen, which revealed an intrahepatic space-occupying lesion, as well as subcutaneous and peritoneal nodules in the abdomen. To further evaluate the presence of other metastases, an 18F-FDG PET/CT scan was performed, which showed abnormal FDG uptake in the liver, peritoneum, left upper femur, right breast, subcutaneous tissues of the thoracic and abdominal regions, and skeletal muscle, while the corresponding CT densities of part of the skeletal muscle and the left upper femur did not show any significant abnormality. Pathologic confirmation of ICC with multiple metastases was obtained by puncture biopsy of the liver and subcutaneous nodes. This case demonstrates the advantages of 18F-FDG PET/CT in comprehensively evaluating systemic metastasis of ICC and detecting occult metastases, which is of great significance in its clinical diagnosis and staging.

Clinical characteristics and survival analysis of cutaneous metastases in a single tertiary centre in Korea

BACKGROUND

Cutaneous metastasis (CM) refers to the spread of malignancy to the skin. CM is perceived as an advanced stage. It might be the first sign of a primary cancer or an indicator of recurrence.

OBJECTIVES

To identify primary cancers associated with CMs and perform a survival analysis according to advanced stage of cutaneous metastasis at a single tertiary centre in Korea.

METHODS

A total of 219 patients from Samsung Medical Center from January 2009 to April 2020 were retrospectively analysed to identify cases with biopsy-proven CMs. According to advanced stage of metastasis, patients were divided into three stages, CM only (CMO), CM with lymph node metastasis (CM/LM) and CM with distant metastasis (CM/DM), to analyse clinical characteristics and survival rate.

RESULTS

The most common CM from primary cancer was breast cancer, followed by lung cancer, stomach cancer, colorectal cancer and others. When all primary cancers were included, the median survival period was 4.82 years for the CMO stage, 2.15 years for the CM/LM stage and 0.80 years for the CM/DM stage, with a tendency to deteriorate with advancing stage. At 1- and 3-year after occurrence of CM, the CM/DM stage showed a significantly poorer survival rate than the other two stages.

CONCLUSIONS

This study showed a median survival period of 22 months for CM patients overall. Breast cancer has greater accessibility to the skin than other cancers. Therefore, breast cancer can metastasize to the skin without involving lymph nodes or other sites.

Alopecia neoplastica as a sign of visceral malignancies: a systematic review

Alopecia neoplastica (AN) from visceral tumours is a rare form of cutaneous metastasis in which internal malignancies spread to the scalp. The diagnosis of AN may be very challenging, especially when its onset precedes the diagnosis of the primary tumour. We aimed to improve the knowledge on AN, highlighting that in case of scarring localized alopecia, a differential diagnosis with metastasis should always be considered. We performed a systematic review to describe the main demographic and clinical features associated with AN from visceral malignancies; a survival analysis was also performed. In 118 reports, accounting for 123 patients, we found that women were more affected by AN than men (53.7% vs. 46.3%). The most frequent site of the primary tumour was the gastrointestinal tract (24.4%), followed by breast (17.9%), kidney (8.1%), lung (7.3%), thyroid (7.3%), uterus (6.5%), central nervous system (6.5%), liver (3.3%) and other anatomic areas for 18.7% of cases. Furthermore, in more than half of the cases (66.1%), AN lesions were single and were mainly diagnosed after the primary visceral tumour (71.5%). Finally, survival analysis highlighted a lower progression-free survival in men; while, no significant differences in overall survival were reported among genders. In conclusion, metastatic skin disease should always be taken into consideration when dealing with patients with localized scarring alopecia.

Scalp recurrence of cholangiocarcinoma after curative hepatectomy: A report of two cases

Cholangiocarcinomas are the second most common primary liver malignancies. The lymphatics are the common route of metastatic spread for cholangiocarcinomas. The most frequent sites of metastasis are the liver, abdominal lymph nodes, peritoneum and lungs. Cutaneous metastasis of cholangiocarcinoma is rare, and most commonly occurs following percutaneous biliary drainage. Brain or skull metastases from this tumor are uncommon. However, these rare metastatic lesions may occasionally be the first disease manifestation, although scalp recurrence following curative treatment is uncommon. We herein present the cases of two patients with cholangiocarcinoma, who were evaluated as resectable based on the criteria for cholangiocarcinoma resectability, and developed scalp recurrence following curative hepatectomy. Therefore, although scalp recurrence is a rare occurrence following curative treatment for cholangiocarcinoma, metastases should be included in the differential diagnosis.

Cutaneous Metastasis from Cholangiocarcinoma Presenting as Thigh Mass

Skin is an uncommon site for metastasis with only 0.7-9% of all patients with cancer being affected when compared to other organs. Generally, the time lag between the diagnosis of primary malignancy and the recognition of the skin metastases is long, but sometimes these metastases may be the first indication of otherwise clinically silent visceral malignancies as seen in our case. In cholangiocarcinomas, the occurrence of cutaneous metastases is extremely rare. Their most common sites of metastasis are visceral organs i.e., lungs, bones, adrenal glands and brain. The present case is unique and describes a patient with metastatic cutaneous thigh nodule as the first sign of cholangiocarcinoma. The early recognition of skin metastasis of previously undiagnosed cancers is critical for timely intervention as it indicates poor prognosis with overall survival after cutaneous metastasis of only few months. Very few reports of cutaneous metastases from cholangiocarcinomas have been published. Also, most of these were derived from direct tumour seeding by percutaneous procedures whereas our case showed distant metastasis to thigh. Extensive literature search showed ours to be the first case of cholangiocarcinoma presenting as thigh nodule where Fine Needle Aspiration Cytology (FNAC), histopathology and immunohistochemistry helped in clinching an early diagnosis and judicious management of a patient with unsuspecting thigh nodule.

Colon Mass as a Secondary Metastasis from Cholangiocarcinoma: A Diagnostic and Therapeutic Dilemma

Cholangiocarcinoma (bile ducts cancer) is a rare and aggressive form of cancer. It metastasizes frequently to liver, peritoneum, and lungs. Colon metastasis is extremely uncommon. We report here a 70-year-old male who was diagnosed with cholangiocarcinoma for which he underwent a Whipple procedure. Fifteen months later, a CT scan revealed mural thickening in the colon; this was supplemented with a PET scan, which confirmed this mass. Histological diagnosis of metastatic cholangiocarcinoma to the colon was made and the patient was treated with chemotherapy. Although rare, cholangiocarcinoma metastasis can be found in the colon. A high index of suspicion is required to diagnose and treat early. More cases need to be reported to find out further about the prognosis of the disease.

Cutaneous metastasis of cholangiocarcinoma

AIM: To investigate the clinical characteristics and prognostic factors of cutaneous metastasis of cholangiocarcinoma by a retrospective analysis of published cases.

METHODS: An extensive search was conducted in the English literature within the PubMed database using the following keywords: cutaneous metastasis or skin metastasis and cholangiocarcinoma or bile duct. The data of 30 patients from 21 articles from 1978 to 2014 were analyzed. Patient data retrieved from the articles included the following: age, gender, time cutaneous metastasis occurred, number of cutaneous metastases throughout life, sites of initial cutaneous metastasis, anatomic site, pathology and differentiation of cholangiocarcinoma, and immunohistochemical results of the cutaneous metastasis. The assessment of overall survival after cutaneous metastasis (OSCM) was the primary endpoint.

RESULTS: The median age at diagnosis of cutaneous metastasis of cholangiocarcinoma was 60.0 years (range: 35-77). This metastasis showed a predilection towards males, with a male to female ratio of 3.29. In 8 cases (27.6%), skin metastasis was the first sign of cholangiocarcinoma. Additionally, 18 cases (60.0%) manifested single cutaneous metastasis, while 12 cases (40.0%) demonstrated multiple skin metastases. In 50.0% of patients, the metastasis occurred in the drainage region, while 50.0% of patients had distant cutaneous metastases. The scalp was the most frequently involved region of distant skin metastasis, occurring in 36.7% of patients. The median OSCM of cholangiocarcinoma was 4.0 mo. Patient age and cutaneous metastatic sites showed no significant relation with OSCM, while male gender and single metastasis of the skin were associated with a poorer OSCM (hazard ratio: 0.168; P = 0.005, and hazard ratio: 0.296; P = 0.011, respectively).

CONCLUSION: The prognosis of cutaneous metastasis of cholangiocarcinoma is dismal. Both male gender and single skin metastasis are associated with a poorer OSCM.

Cutaneous metastasis of cholangiocarcinoma: report of two cases

Cutaneous metastasis of cholangiocarcinoma is extremely rare. It can be seen at distant locations or at the site of biliary drainage. To the best of our knowledge less than 30 cases have so far been reported in the English literature. This event should be considered in every skin lesion in a patient with cholangiocarcinoma and be treated promptly by resection and chemotherapy to increase the patient's survival. Herein, we report our experience with two patients with cholangiocarcinoma and cutaneous metastasis at the site of biliary drainage.