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Diagnosis and Discussion


Esophageal adenocarcinoma, initially presenting as a cutaneous metastasis.


Esophageal cancer is the eighth most common cancer worldwide and the sixth most common cause of cancer-related death. The two most common types of esophageal cancer are adenocarcinoma (EAC) and squamous cell carcinoma (ESCC). ESCC is more common worldwide; however, EAC is more common in the United States and has increased 7-fold since the 1970s. ESCC most commonly occurs in the mid to upper esophagus and is most commonly associated with tobacco and alcohol use, yet may be seen with increased nitrosamine or hot beverage consumption, Plummer-Vinson syndrome, and achalasia. In contrast, EAC risk factors include obesity, male gender, gastroesophageal reflux disease (GERD), and tobacco use.

Most often, patients with GERD develop intestinal metaplasia (Barrett esophagus), which develops into dysplasia and ultimately EAC. The majority of patients with esophageal cancer, whether ESCC or EAC, present with dysphagia between 65-70 years old. Unfortunately, approximately 50 percent of patients with esophageal cancer present with lymph node or distant organ metastasis with a 5-year survival rate around 25-30 percent. The most common sites of metastasis for esophageal cancer include the liver, lungs, and brain. Metastasis to the skin is rare; however, cases from both EAC and ESCC have been documented.

Involvement of the skin from extracutaneous malignancies can result from direct extension or via metastasis. Less than 1 percent of all cancers metastasize to the skin. Skin metastasis is most commonly seen with lung, breast, and colorectal carcinomas. Breast cancer is the most common cancer metastasizing to the skin in females, while lung cancer is the most common in males. The presence of skin metastasis usually indicates advanced disease and poor prognosis. Most patients with skin metastasis present with painless lesions, which may vary in appearance from skin papules or nodules to plaques, rashes, or ulcers. As is demonstrated by our case of metastatic EAC to skin on the upper abdomen, it is important for clinicians to recognize and biopsy new/atypical skin lesions, as these may be the first sign of an underlying visceral malignancy. 


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