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Metastatic Adenocarcinoma of the Esophagus Presenting as Painless Cutaneous Nodules

Published:December 07, 2020DOI:https://doi.org/10.1016/j.amjmed.2020.10.034
      We report a case of a previously healthy, 57-year-old gentleman who presented with multiple painless, hard skin nodules that appeared sporadically over the past month. On physical examinations, small pinkish nodules of approximately 2 × 2 × 2 cm were present on his lower back, left flank, right shoulder, and breast, which did not resolve with the use of topical ointments (Figure, A). The lesions were subsequently biopsied, and the histopathological findings were consistent with adenocarcinoma. Further immunohistochemical staining revealed the tumor cells stained positive for carcinoembryonic antigen, epithelial membrane antigen, CK5/6, and p63, concerning for metastatic adenocarcinoma of the gastrointestinal tract (Figure, B and C). The cells also stained positive for the Kreyberg mucin stain, suggesting a significant component of mucin-containing cells. A whole-body positron emission tomography scan was then done, which showed a large area of [18F]-fluorodeoxyglucose uptake in the esophagus and diffusely metastatic disease involving the axial skeleton, subcutaneous tissue, and the liver. Based on the histopathology and imaging findings, he was diagnosed with metastatic adenocarcinoma of the esophagus. Before palliative chemotherapy could be initiated, he developed a pathologic left hip fracture requiring surgical repair. His hospitalization course was complicated by massive hemoptysis requiring urgent endoscopy and radiation therapy. He was started on carboplatin and paclitaxel, which was continued as an outpatient.
      Figure
      Figure(A) Nodular lesion on the patient's right arm. Hyperkeratosis with central crust formation can be appreciated. Similar lesions were present on the right breast, lower back, and the left flank. (B) Hematoxylin and eosin staining of the right flank mass showing abundance of mucinous cells with clear cytoplasm with eccentric nuclei. (C) Immunohistochemical staining revealed the tumor cells of the breast mass to stain strongly positive for cytokeratin 7 (CK7), indicating origin from the gastrointestinal tract.
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