Brief Article Open Access
Copyright ©2012 Baishideng. All rights reserved.
World J Gastrointest Oncol. Jul 15, 2012; 4(7): 176-180
Published online Jul 15, 2012. doi: 10.4251/wjgo.v4.i7.176
Cutaneous metastases secondary to pancreatic cancer
Kei Horino, Hiroshi Takamori, Yoshiaki Ikuta, Osamu Nakahara, Akira Chikamoto, Takatoshi Ishiko, Toru Beppu, Hideo Baba, Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Kumamoto 860-8556, Japan
Author contributions: Horino K and Takamori H performed the majority of the study and wrote the manuscript; Ikuta Y, Nakahara O, Chikamoto A, Ishiko T and Beppu T provided analytical tools and the collection of all the human material and were also involved in editing the manuscript; Baba H designed the study.
Correspondence to: Hideo Baba, Professor, Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Kumamoto 860-8556, Japan. horino@tamana-chp.jp
Telephone: +81-96-3735213 Fax: +81-96-3714378
Received: November 30, 2011
Revised: July 10, 2012
Accepted: July 12, 2012
Published online: July 15, 2012

Abstract

AIM: To evaluate prognoses after cutaneous metastases, derived from pancreatic cancer.

METHODS: We treated two patients with cutaneous metastases from pancreatic cancer. We reviewed 40 reported patients in addition to our cases and analyzed clinical features of cutaneous metastases from pancreatic cancer.

RESULTS: The median survival time (MST) was 5 mo after diagnoses of cutaneous metastases. The cumulative 2-year survival rate was 3.5%. The most frequent site of cutaneous metastases was the umbilicus. The MST of patients who were treated with chemotherapy or chemoradiotherapy (CRT) was 6.5 mo, which was statistically longer in comparison to patients without treatment. Prognoses of cutaneous metastases are similar to other metastatic sites from pancreatic cancer. Receiving chemotherapy or CRT was the only prognostic factor of cutaneous metastases from pancreatic cancer.

CONCLUSION: The prognoses of cutaneous metastases are similar to other metastatic pancreatic cancers. Receiving chemotherapy or CRT was the only prognostic factor of cutaneous metastases from pancreatic cancer.

Key Words: Cutaneous; Metastasis; Pancreas; Cancer; Prognosis



INTRODUCTION

Secondary neoplasm involvement of the skin seems to be rare from an anatomical point of view. It is reported that the incidence of cutaneous metastases secondary to pancreatic cancer is 2.0% of all metastases[1] but sometimes it appears as a first symptom of advanced pancreatic cancer. Several cases of this condition have been reported, especially as umbilical metastases, that is, a Sister Mary Joseph’s nodule (SMJN)[2]. The most common metastatic tumors of the skin are derived from breast, lung, stomach, colon, head and neck, renal cancers and melanoma[1,3-5]. We evaluated clinical significance of cutaneous metastases from pancreatic cancer because it has not been clearly described in detail before.

MATERIALS AND METHODS

We treated two patients and found 64 patients with cutaneous metastases from pancreatic cancer in the literature searched using PubMed and Igaku Chuo Zassi (in Japanese) from 1950 to 2011. Of 66 patients, 42 were analyzed to clarify clinical features because these patients were recorded in detail (Table 1)[4-27].

Table 1 Characterization of patients with cutaneous metastases from pancreatic cancer.
Age (yr)SexSymptonAppearanceSkin sitePrimaryPrognosisOther metastasisOther therapyAuthor
76FPresentNoduleUmbilicusTail8 mo, deadPeritoneumTegaful, 5-FU, OK432Hisamoto et al[6]
67FAbsentNoduleAbdomenTail4 wk, deadLiverNo therapyTaniguchi et al[1]
69MPresentNoduleFace, headHead5 mo, deadLiver, lung, LNNo therapyTaniguchi et al[1]
70MPresentNoduleUmbilicusTail8 mo, alivePeritoneumTegaful, lentinanTaniguchi et al[1]
67MPresentInflammatoryChest, abdomenNot detail5 mo, deadLungNo therapyTaniguchi et al[1]
55MPresentNoduleMultiple skin siteTail2 mo, deadLung, liverNo therapyOhashi et al[8]
53MPresentNoduleUmbilicusTail5 mo, deadPeritoneumNo therapyMiyahara et al[4]
76FPresentNoduleUmbilicusTail7 mo, deadPeritoneumNo therapyMiyahara et al[4]
72MAbsentNoduleUmbilicusNot detail14 wk, deadLiver, intestineNo therapyMiyahara et al[4]
61MPresentNoduleUmbilicusBody4 wk, deadPeritoneumNo therapyMiyahara et al[4]
67MAbsentNoduleUmbilicusTail2 mo, deadPeritoneumNo therapyMiyahara et al[4]
73FAbsentNoduleAbdominal wallHead22 mo, deadAbdiminal wallNo therapyMiyahara et al[4]
60MPresentNoduleFace, neckTail2 mo, deadMesenteryNo therapyMiyahara et al[4]
62FPresentInflammatoryUmbilicusTail1 yr, deadLiver, spleen5-FUMiyahara et al[4]
36MPresentNoduleUmbilicusTail5 mo, deadPeritoneum5-FU, RTMiyahara et al[4]
77MPresentInflammatoryUmbilicusTail2 mo, deadLungNo therapyMiyahara et al[4]
80MPresentNoduleMultiple skin siteNot detail5 mo, deadPara-aortic LNNo therapyNakano et al[9]
78MAbsentNoduleUmbilicusTail4 mo, deadPeritoneumNo therapyLesur et al[10]
65FPresentNoduleChest wallHead8 mo, deadLiver5-FU, CDDP, IORHorino et al[5]
60FPresentNoduleUmbilicusTail2 mo, deadPeritoneumChemotherapyYoneda et al[11]
53FAbsentNoduleUmbilicusTail7 mo, deadPeritoneumChemotherapyYoneda et al[11]
64FAbsentNoduleUmbilicusBody8 mo, aliveLungChemotherapyCrescentini et al[12]
75MPresentNoduleUmbilicusBody6 mo, deadLiverGEMOkazaki et al[13]
82MPresentNoduleUmbilicusHead5 mo, deadPeritoneumNo therapyInadomi[14]
60FPresentNoduleUmbilicusBody15 mo, deadPeritoneum, ovaryGEMTokai et al[15]
73FAbsentNoduleUmbilicusBody6 mo, deadPeritoneumChemotherapyNagato et al[16]
79FPresentNoduleUmbilicusTail6 mo, deadPeritoneumNo therapyAsai et al[17]
65MPresentNoduleMultiple skin siteBody1 mo, deadLiver5-FUHorino et al[18]
73FAbsentNoduleUmbilicusTail6 mo, aliveSupraclavicular LNGEMLimmathurotsakul et al[19]
85MPresentNoduleTempleHead3 mo, deadLungGEMTakemura et al[20]
84FPresentNoduleUmbilicusTail4 mo, deadLiverNo therapyHayami et al[21]
75FPresentNoduleUmbilicusBody1 mo, deadLiverNo therapyKamata et al[22]
50MPresentNoduleLateral abdomenBody2 mo, deadLiver, brainGEM, irinotecanKimura et al[23]
68MAbsentNoduleUmbilicusBody4 mo, deadLiver, LNGEM, UFT-E, RTYamashita et al[24]
72FPresentNoduleUmbilicusTail32 mo, deadPeritoneumGEM, S-1Hirahara et al[25]
67FPresentNoduleLower abdomenTail3 mo, deadLiver, LNGEMPontinen et al[26]
70FPresentNoduleUmbilicusTail4 mo, deadLiver, peritoneumGEMOzaki et al[27]
81MPresentNoduleUmbilicusTail7 mo, deadPeritoneumS-1Ozaki et al[27]
59MAbsentNoduleUmbilicusBody11 mo, aliveLiver, peritoneumGEM, 5-FUOzaki et al[27]
66MAbsentNoduleUmbilicusBody18 mo, deadLiverGEM, 5-FUOzaki et al[27]
58FPresentNoduleLower abdomenBody10 mo, deadLiver, lung, peritoneumGEM, 5-FUOur case
65FAbsentNoduleLower abdomenTail4 mo, deadLiver, bone, LNGEM, RTOur case

We evaluated clinical parameters, including age, gender, symptoms, cutaneous metastatic site, primary site of pancreatic cancer and the receiving of chemotherapy or chemoradiotherapy (CRT). Survival curves were depicted using the Kaplan-Meier method and levels of significance were tested with the log rank test. Probability values < 0.05 were considered significant. Prognostic factors were assessed by odds ratios with 95% confidence interval using univariate and comparative analysis. Cox’s proportional hazard model was used in a stepwise multivariate analysis for all parameters to identify factors independently associated with the prognosis.

RESULTS

All 42 patients were diagnosed as pancreas cancer due to histological examination from cutaneous and/or primary biopsy sample or imaging, including enhanced computed tomography or magnetic resonance imaging. The patient population comprised of 22 men and 20 women with a median age of 68 years, ranging from 36 to 85 years. Survival time ranged from 1 to 32 mo. The median survival time (MST) of all patients was 5 mo after diagnosis of cutaneous metastases. The cumulative 1- and 2-year survival rate was 17.5% and 3.5%, respectively (Figure 1A).

Figure 1
Figure 1 Kaplan-Meier survival curve. A: Survival of all patients after diagnosis of cutaneous metastasis from pancreatic cancer; B: Relationship between the presence of chemotherapy or chemoradiotherapy (CRT) and survival after diagnosis of cutaneous metastasis from pancreatic cancer.

Twenty-nine patients (69.0%) had some symptoms, including inflammatory changes such as a flare or sore in 3 patients and the painful or non-tender subcutaneous nodule in 26 patients. Cutaneous metastases were discovered by physical examination without symptoms in the remaining 13 patients (Table 1).

Sites of cutaneous metastases were head or neck in 3 patients, abdomen or chest excluding umbilicus in 7 patients, umbilicus (namely SMJN) in 28 patients and multiple sites in 4 patients. The primary pancreatic lesion was located in the head in 6 patients, body in 11 patients, tail in 22 patients and not recorded in 3 patients (Table 2). Umbilical metastases occurred in 28 patients. Primary pancreatic lesions of umbilical metastases were pancreatic body and tail in 26 patients out of 28. Incidence of umbilical metastases from cancers of pancreatic body and tail was significantly more frequent than from pancreatic head cancer (P = 0.0375).

Table 2 The local area of the cutaneous metastasis and the site of primary pancreatic cancer.
Primary site of pancreasHead or neckChest or abdominal wall1UmbilicusMultiple1
Head (n = 6)2310
Body (n = 11)0191
Tail (n = 22)13171
Unknown (n = 3)0012

Twenty-two patients received chemotherapy after diagnoses of cutaneous metastases. Twelve patients were treated with gemcitabine and 6 with 5-flurouracil (5-FU). Two patients received CRT. The other two patients received other chemotherapeutic agents (Table 1). There was no significant difference between treatment with Gemcitabine and 5-FU (data not shown).

Significant prognostic factors after detection of cutaneous metastases from pancreatic cancer were females and receiving of chemotherapy or CRT among six clinical variables using only univariate analysis (Table 3). The MST of the patients with chemotherapy or CRT was 6.5 mo, significantly better than 4 mo in the patients without any treatment (Figure 1B).

Table 3 Univariate and multivariate analyses of prognostic factors for survival after discovery of cutaneous metastases from pancreatic cancer.
Variable Univariate analysis
Multivariate analysis
P-valueOdds ratio95% CIP-valueRisk ratio95% CI
Age (≥ 68 yr/< 68 yr)0.75521.47730.4325-5.04630.75271.27000.2872-5.6145
Sex (female/male)0.0142a6.31431.6272-24.50230.90900.92800.2575-3.3436
Sympton (-/+)0.53111.90910.5082-7.17180.94291.05160.2657-4.1619
Skin site (umbilicus/others)0.09824.23080.9660-18.52900.55711.80490.2514-12.9568
Primary site (head, body/tail)0.67191.62500.4353-5.82400.97461.02820.1859-5.6854
Chemotherapy or CRT (+/-)0.0079a8.33331.8784-36.96950.81860.79440.1111-5.6778
DISCUSSION

Pancreatic cancer is the 5th leading cause of cancer related death in both men and women in Japan[28]. The majority of pancreatic cancer is advanced at diagnosis (50.5% metastatic vs 8% localized, 25.9% regional spread)[29]. One of the reasons is that pancreatic cancer presents with various incomprehensive symptoms. Cutaneous metastases as the first signs of pancreatic cancer were reported in several cases[1,4,14,26,27,30]. The target of spread of pancreatic cancer substantially includes the regional lymph nodes, liver, lungs, celiac plexus, superior mesenteric vessels, ligament of Treitz, portal vein and skin[26]. The most common metastatic site of cutaneous is the umbilicus (SMJN)[4,26]. Incidence of umbilical metastases from cancers of pancreatic body and tail was significantly more frequent than from pancreatic head cancer. Our study revealed that the primary site of SMJN was pancreatic body and tail in 92.9% of patients. Yendluri demonstrated that this might relate to the propensity for tail of pancreas cancers to remain asymptomatic until an advanced stage when distant metastasis has been found[30]. Because of potential intercommunications, the umbilicus may gather a variety of tumors. The metastatic cancer cells may travel by retrograde flow from the peritoneal cavity to the umbilicus via the lymphatics of the falciform ligament, the median umbilical ligament of the urachus, the vitello intestinal duct remnant and the obliterated vitelline artery[30,31]. Eventually, tumor micro-embolization through the artery or the portal vein provides a channel for hematogenous implantation and seeding of umbilical tissue[2,30]. Non-umbilical cutaneous metastases are rare but distant spread shows that pancreatic carcinoma can reach all cutaneous tissues via blood or the lymphatic system[26]. There is no significant difference of prognosis between umbilical and non-umbilical metastases in this article (Table 3). Average survival of advanced pancreatic cancer in general is less than 4 mo[30]. Prognoses after detection of cutaneous metastases from pancreatic cancer were similar to those with metastatic pancreatic cancer.

This study demonstrated significant improvement in median overall survival from 6.5 mo vs 4 mo when some treatment, including chemotherapy alone and CRT, for patients with umbilical metastases from pancreatic cancer compared to no therapy. Several treatments might be performed for patients who had a good enough performance status to receive some treatment, although there is a significant difference in background between these two groups.

In conclusion, prognoses of cutaneous metastases are similar to other metastatic pancreatic cancer. Receiving chemotherapy or CRT was the only prognostic factor of cutaneous metastases from pancreatic cancer.

COMMENTS
Background

Cutaneous metastases from pancreatic cancer are uncommon. Prognoses after cutaneous metastases have not been described in detail.

Research frontiers

The authors evaluated clinical significance of cutaneous metastases from pancreatic cancer because it has not been clearly described in detail before.

Innovations and breakthroughs

The median survival time (MST) was 5 mo after diagnoses of cutaneous metastases. The cumulative 2-year survival rate was 3.5%. The most frequent site of cutaneous metastases was the umbilicus. The MST of patients treated with chemotherapy or chemoradiotherapy (CRT) was 6.5 mo, which was statistically longer in comparison to patients without treatment.

Applications

Average survival of advanced pancreatic cancer in general is less than 4 mo. Prognoses after detection of cutaneous metastases from pancreatic cancer were similar to those with metastatic pancreatic cancer.

Peer review

The prognoses of cutaneous metastases are similar to other metastatic pancreatic cancer. Receiving chemotherapy or CRT was the only prognostic factor of cutaneous metastases from pancreatic cancer.

Footnotes

Peer reviewer: Imtiaz Ahmed Wani, MD, Amira Kadal, Srinagar, Kashmir 190009, India

S- Editor Wang JL L- Editor Roemmele A E- Editor Zheng XM

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