Indian Journal of Nuclear Medicine

CASE SERIES
Year
: 2019  |  Volume : 34  |  Issue : 3  |  Page : 205--208

Cutaneous metastasis from visceral organs: 18F-fluorodeoxyglucose positron emission tomography-computed tomography scan aiding in localizing primary site


Nitin Gupta1, Dharmender Malik1, Ritu Verma1, Ethel Shangne Belho1, Anisha Manocha2,  
1 Department of Nuclear Medicine and PET/CT, Centre for Advanced Research in Imaging, Neuroscience and Genomics, Sir Ganga Ram Hospital, New Delhi, India
2 Department of Pathology, Sir Ganga Ram Hospital, New Delhi, India

Correspondence Address:
Dr. Dharmender Malik
Department of Nuclear Medicine and PET/CT, Centre for Advanced Research in Imaging, Neuroscience and Genomics, Sir Ganga Ram Hospital, New Delhi
India

Abstract

Skin metastases are rare from systemic malignancy, and incidence reported is between 0.7% and 9% in various malignancies and usually occur in advanced stage. Here, we report three cases, one each of carcinoma esophagus, carcinoma breast, and carcinoma lung, where patients presented with metastatic cutaneous lesions and positron-emission tomography-computed tomography (PET-CT) scan whole body helped in localizing the primary site. Whole-body fluorodeoxyglucose PET-CT scan helps in scanning whole body at once and detect occult primary and metastatic sites.



How to cite this article:
Gupta N, Malik D, Verma R, Belho ES, Manocha A. Cutaneous metastasis from visceral organs: 18F-fluorodeoxyglucose positron emission tomography-computed tomography scan aiding in localizing primary site.Indian J Nucl Med 2019;34:205-208


How to cite this URL:
Gupta N, Malik D, Verma R, Belho ES, Manocha A. Cutaneous metastasis from visceral organs: 18F-fluorodeoxyglucose positron emission tomography-computed tomography scan aiding in localizing primary site. Indian J Nucl Med [serial online] 2019 [cited 2022 Nov 29 ];34:205-208
Available from: https://www.ijnm.in/text.asp?2019/34/3/205/260764


Full Text



 Introduction



Cutaneous metastases are particularly seen with breast cancer, followed by lung, colorectal, ovarian, renal cell carcinoma, and gastrointestinal tumors. They are a sign of poor prognosis and end-stage disease. It usually results from lymphatic embolization, hematogenous or contiguous spread, and also by iatrogenic implantation of malignant cells following surgical procedures. The presenting complaint in breast cancer patients is usually breast lump; however, in late stages, cutaneous lesions have been seen in few cases. Carcinoma esophagus is the sixth-most common cause of mortality worldwide. Patients usually present with dysphagia as the main symptom. Esophageal carcinoma most commonly spreads to the lymph nodes, lung, liver, and bones. However, in our case, cutaneous lesions were the presenting complaint. Lung carcinoma is the most common cause of cancer death worldwide. The most common sites of metastasis from lung cancer are the bones, adrenal gland, and brain. Skin is rarely affected and is rarely the initial presenting complaint. Whole-body fluorodeoxyglucose positron-emission tomography-computed tomography (FDG PET-CT) offers high lesion to background contrast and helps in scanning the whole body at once, to localize occult primary and detect metastatic lesions.

 Case Examples



Case 1

A 58-year-old male presented with multiple skin lesions and weight loss. The skin lesions were discrete and confluent, erythematous papules, and plaques were distributed over the scalp, neck, abdomen, and pelvic regions. Biopsy from the skin lesion revealed metastatic carcinoma. Whole-body FDG-PET-CT scan performed to localize the primary site shows multiple areas of abnormal increased FDG uptake spread throughout the body [Figure 1]a. The transaxial fused PET-CT and CT images localized increase FDG uptake in mural thickening with mass formation in the lower end of the esophagus [Figure 1]b and [Figure 1]c; arrowhead] causing luminal compromise and cutaneous lesions in the abdomen and pelvis [Figure 1]d, [Figure 1]e, [Figure 1]f, [Figure 1]g; arrowhead]. The PET-CT findings were suggestive of esophageal mural thickening as primary site carcinoma with multiple metastases which were later proved on histopathological examination [Figure 2].{Figure 1}{Figure 2}

Case 2

A 42-year-old female presented with multiple skin lesions, weight loss, and generalized body pain. She had erythematous papules over the scalp and abdomen. Whole-body FDG-PET CT scan was performed for further evaluation. The maximum intensity projection (MIP) image shows multiple areas of abnormal increased FDG uptake spread throughout the body [Figure 3]a. The PET-CT and CT images localized increase FDG uptake in coalescent ulcerative soft-tissue mass lesion in the left breast [Figure 3]b and [Figure 3]c; arrowhead] and cutaneous lesions in the abdomen and scalp [Figure 3]d, [Figure 3]e, [Figure 3]f, [Figure 3]g; arrowhead]. The PET-CT findings were suggestive of soft-tissue mass in the left breast, as a primary site with multiple metastases. On retrospective analysis, the patient was found to have lump in the left breast. Biopsy from the left breast and cutaneous lesions confirmed carcinoma left breast with cutaneous metastasis.{Figure 3}

Case 3

A 70-year-old male presented with a history of the scalp and nasal swelling and plaque skin lesions. Biopsy done from nasal swelling was suggestive of metastatic squamous cell carcinoma. Thus, the patient was referred for whole-body FDG PET-CT scan for staging and to detect occult primary. The MIP image shows multiple areas of abnormal increased FDG uptake [Figure 4]a. The PET-CT and CT images localized increase FDG uptake in heterogeneously enhancing soft-tissue mass lesion in the upper lobe of the left lung [Figure 4]b and [Figure 4]c; arrowhead] and cutaneous lesions in the nose and pelvis [Figure 4]d, [Figure 4]e, [Figure 4]f, [Figure 4]g; arrowhead]. The PET-CT findings were suggestive of the left lung lesion (primary site) with multiple metastases.{Figure 4}

 Discussion



Skin metastases are an uncommon phenomenon accounting for frequency ranging from 0.7% to 9% in all abdominal malignancies and usually present after the sixth decade of life.[1] Excluding melanoma, breast cancer is the most common cancer to metastasize to the skin, in women, with the incidence of approximately 23.9%.[2] The percentage of patients with lung cancer who develop cutaneous metastases ranges from 1% to 12%.[3] The scalp is a favorite site of cutaneous metastasis of lung cancer, representing 54% of all cutaneous metastases of this cancer. The reason for higher scalp metastasis may be rich blood flow.[4] It was also found that cancer of the upper lobes of the lungs has a greater tendency to metastasizing in the skin, as seen in our patient.[5] Cutaneous metastasis from esophageal malignancy is rare, affect <1% of cases, and usually occurs in the advanced stage of the disease.[6] The majority of cutaneous metastasis is diagnosed only after primary cancer; it is rarely the tell-tale sign of an unknown malignancy.[7] In same rare cases, cutaneous metastasis can occur even before the symptom of the primary site,[8] as seen in our patients. Cutaneous metastasis can be seen in both variants squamous cell carcinoma and adenocarcinoma, although the frequency is relatively more with squamous cell carcinoma in case of carcinoma esophagus.[9]

Several studies have conferred the importance of PET-CT scan in detecting sites of unexpected metastasis.[10],[11] FDG-PET has been shown to have a higher sensitivity for the detection of metastatic disease compared to CT in combination with endoscopic ultrasonography (EUS). Flamen et al. reported both higher accuracy (82% vs. 64%) and sensitivity (74% vs. 47%) for FDG-PET when compared to CT and EUS for the detection of distant disease.[12],[13] Patients with skin metastatic disease usually have significantly poorer prognosis with reported survival rates of <1 year after the identification of metastatic lesions. The treatment is usually aimed to palliation through possible resection with chemotherapy and radiotherapy.[14]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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