Cutaneous Metastasis from Pancreatic Carcinoma- A Case Report and Review

Copyright: © 2010 Bhat W, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. malignant glandular structures. Immuno-histochemical staining showed a positive reaction to CK 7, CK20, CEA, Mesothelin (Figure 3), which was in keeping with well differentiated pancreatic adenocarcinoma.

She had an uneventful post operative period and when followed up her scalp rotational flap had completely healed.
She was readmitted with a pleural effusion and has since then been receiving palliative chemotherapy with Gemiocitabine.

Discussion
Cutaneous metastases occur in 0.7-9% of all patients with cancer, Breast, lung and colon cancer are the most frequent origins [2]. Cutaneous metastases from pancreatic cancer are very uncommon. Mean age of presentation of cutaneous metastases is 68.4 years and there is a male predominance [1].

Abstract
Carcinomas of the pancreas represent less than 5% of human malignant neoplasms [5], skin involvement is rare, and metastasis generally occurs at the umbilical area. There are few reported cases with cutaneous lesions disclosing a pancreatic carcinoma at sites other than the umbilical area. We report a case of cutaneous metastases of pancreatic carcinoma to the scalp. The literature on pancreatic cutaneous metastasis is reviewed and discussed.   Distant spread shows that a pancreatic carcinoma can reach all cutaneous tissue via blood or lymphatic systems. The most frequent cutaneous metastatic site is the umbilicus, known as the Sister Mary Joseph nodule and the pancreatic tail was the most common site of the primary tumour [1]. Our case is interesting in that the unusual cutaneous metastases of pancreatic cancer was to the scalp in contrast to the umbilicus. To the best of our knowledge there are only 3 other reports of pancreatic cancer with cutaneous metastases to the scalp [2][3][4].
A literature review of the published data, has found 17 cases, with non-umbilical cutaneous metastasis to the face, chest, back, axilla, forearm, buttock and thigh [5]. (Table 1) Miyahara et al [2] reported 5 cases and reviewed 17 cases of cutaneous metastasis originating from the pancreatic cancer. In 20 cases, the cutaneous metastases were present prior to the diagnosis of pancreatic cancer. In 11 of these cases, the metastatic lesions in the skin were the first symptoms of pancreatic cancer, and in the other 9 cases, the lesions were discovered by physical examination. Horino et al. [13] reviewed 49 reported cases of pancreatic metastasis from 1950 to 1999. In the majority of cases, skin metastatic lesions were the first signs of the pancreatic cancer. Moreover, 90.3% of the cases had multiple organ metastases or peritoneal seeding. Cubilla et al. [14] reported that 8 of 50 (16%) of occult pancreatic cancer had metastatic skin lesions as the first manifestation of the malignancy.
Although such cases are rare, it is important to note that metastatic lesions in the skin may be the first sign and one type of distant metastases originating from pancreatic cancer, this may relate to the propensity for tail of pancreas cancers to remain asymptomatic until a later stage when distant metastasis has already occurred.
Grossly the Cutaneous lesions are oval, firm, solid, non painful nodules. Macroscopically they tend to lack uniformity or distinction and are difficult to distinguish from other skin lesions [1]. Most patients die within 7 months from presentation of cutaneous metastases, therefore metastases to skin indicates widespread general dissemination and a poor prognosis [1].
Immunohistochemical staining of the lesion with for CK 7, 19 and 20 is helpful for identification of the cutaneous lesions primary neoplasm [1].

Conclusion
Cutaneous metastases from pancreatic carcinoma are rare clinical findings, can vary considerably and be non-specific. Metastatic lesions can be the initial presenting sign of pancreatic cancer. When surgery for the pancreatic cancer is contemplated the evaluation and presence of not only liver or lung but also cutaneous metastases has important implications for tumour staging and therapy. To the best of our knowledge, very few patients have been reported with cutaneous metastasis to the scalp disclosing a pancreatic carcinoma, making this a case particularly interesting.