Cutaneous Metastases of Pancreatic Carcinoma as a First Clinical Manifestation
A 68-year-old Korean man was seen in the dermatology department because he had a painless subcutaneous right forearm nodule for 3 months. Two firm, 1.0 cm, subcutaneous nodules were noted on the physical examination (). The histology revealed neoplastic gland cords or nests in the desmoplastic stroma, and this was consistent with metastatic adenocarcinoma (). He was referred to the gastroenterology department to further investigate the source of the cutaneous lesion. He was totally asymptomatic except for the multiple subcutaneous nodules on his forearm, but he complained of a 5 kg weight loss during the last six months. His past medical history and family history were non-contributory. Apart from the subcutaneous nodules, the remainder of the exam was normal, including both the rectal and abdominal examinations that showed no masses. No enlarged lymph nodes were present, and the prostate was normal in size and consistency. The routine blood chemistry tests revealed only a slightly elevated alkaline phosphatase of 238 U/L (normal: 30~110 U/L), but there was a remarkable elevation in the tumor markers CA 19-9 to 486.9 U/mL (normal: 0.139 U/mL). The gastroscopy and colonoscopy exams revealed no specific abnormality except for a hyperplastic gastric polyp. The abdominal computed tomography (CT) detected a low-density mass located in the tail of the pancreas along with multiple liver metastases (). The CT and ultrasonography findings of the abdomen were compatible with pancreatic cancer with multiple liver and cutaneous metastases. The immunohistochemical staining of the skin biopsy showed a positive reaction to monoclonal antibodies for CK 7, CK 19 and thyroid transcription factor (TTF), and these markers are normally present in adenocarcinoma of the lung (). The patient declined pancreatic fine needle aspiration biopsy and chemotherapy. Therefore, he was scheduled for follow-up.