Adenocarcinoma of Rectum with Scalp Nodules: A Rare Case Report and Review of Literature

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Asian Journal of Radiation Oncology | January-June 2016 | Volume 5 | Number 1
Original Article
Sanjukta Padhi
Papuji Meher
Linclon Pujari
K C Patro
Department of Radiation Oncology
AHRCC, Cuttack, India
Corresponding author:
Dr Kanhu Charan Patro
HOD, Radiation Oncology
Mahatma Gandhi Cancer Hospital &
Research Institute,
1/7, MVP, Vishakhapatnam, Andhra
Pradesh, India-530017
Email: drkcpatro@gmail.com
Adenocarcinoma of
Rectum with Scalp
Nodules: A Rare
Case Report and
Review of Literature
INTRODUCTION
Colorectal cancers account for 10% of all incident cancers. Liver,
peritoneum, the pelvis, lung and bone are usual sites of secondaries in
case of colorectal cancers. Skin metastases is detected in 10% cases of
metastatic carcinoma (3). Carcinoma breast in females and carcinoma
lungs in males mostly give rise to cutaneous metastases. In case of
carcinoma rectum skin secondaries is very rare and it occurs in <5 %
of cases (1). Skin metastasis of rectal cancer is usually detected around
surgical scars or on the abdominal wall, especially in the periumbilical
region, and it is mostly due to perioperative implantation. It rarely
presents at other sites. Ulceration, nodules, bullae or fibrotic processes
are the most common signs of cutaneous metastases. Scalp is one of the
unusual sites and has been reported in small case series and reports (2).
When presents with such metastases it indicates advanced disease and
carries poor prognosis.
CASE REPORT
A 55 year old female presented to our OPD with scalp nodules and
bleeding per rectum for 2 months. Clinically there were multiple scalp
nodules over scalp of various sizes 0.5cm to 1cm, hard, nontender,
free from underlying bone, not associated with erythema or local
inflammation. Per-rectally a mass was palpable around 8 cm from
anal verge encircling anterior and right lateral wall which bleeds on
touch. Colonoscopy showed a large semi-circumferential growth 10 cm
from anal verge. Rectal biopsy came invasive adenocarcinoma. CECT
abdomen and pelvis demonstrated irregular thickening of anterior,
right lateral and posterior wall of rectum extending upto rectosigmoid
junction with involvement of mesorectum and pararectal node. Serum
CEA was 12ng/ml on initial evaluation. Plain MRI head revealed small
hypointense lesions(sagittal T1 image) seen in scalp over posterior
parietalregion involvingskin and subcutaneous tissue- likely metastasis,
no evidence of bony erosion seen. FNAC of scalp nodule showed poorly
differentiated carcinoma which was later confirmed by biopsy. On
evaluation patient has no any other site of visceral metastases clinically
or radiologically. Patient is posted for chemotherapy with diagnosis of
stage IV rectal cancer. After 5 cycles of chemotherapy (Capecitabine
+ Oxaliplatin) patient is symptomatically better and lesions over scalp
responded very well.

2. 8 Asian Journal of Radiation Oncology | January-June 2016 | Volume 5 | Number 1
Biopsy from Rectum:
At the time of diagnosis
FNAC from Scalp nodule:

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Asian Journal of Radiation Oncology | January-June 2016 | Volume 5 | Number 1
After Chemotherapy DISCUSSION
Skinsecondariesfromainternalmalignancyisanominous
finding which usually denotes advanced disease and
usually carries poor prognosis (1). The overall incidence
of cutaneous metastasis is 5.3%. The most common
tumor to metastasize to the skin is breast cancer. The
chest is the most common site of cutaneous metastasis
(9). In previous studies found that skin secondaries occur
infrequently and can be present initially at the time of
diagnosis of malgnancy. In patients with no evidence of
primaries, cutaneous metastasis is most commonly seen
as first sign in lung, kidney and ovary malignancies (10).
More recently, Rendi and Damian reported that only
0.5% of colorectal patients present cutaneous metastasis
at the time of their initial diagnosis (11). Lookingbill et
al (3) in a retrospective study of 4,020 patients found
that after recognition of skin metastases, mean survival
ranged from 1 to 34 months depending on the primary
tumor. An average survival of 18 months was noted in
patients with skin metastasis from colorectal carcinoma
(3). Schoenlaub et al. (4) retrospectively reviewed 200
cases of patients with evidence of cutaneous metastasis
from a visceral primary and found the median survival
to be 6.5 months. Patients with an underlying colorectal
primary fared even worse with a median survival of 4.4
months (4). Kaufmann et al suggested that metastatic
spread of adenocarcinoma to the skin and subcutaneous
tissue could be by lymphatic and haematogenous spread,
by direct extension or by implantation during surgery
(5). Kilickap et al. (6) have reported a case of cutaneous
metastases of signet cell carcinoma of the rectum without
any visceral meatstases that presented 14 months after
completion of adjuvant treatment (6). Horiuchi et al (7)
have reported a case of cutaneous metastses to scalp and
chestwall from carcinoma sigmoid colon (7). Upfront
presentation of scalp nodule is a rare event, hence persue
us to report such case. On literature review no such case
presented with scalp nodule in primary anorectum.
CONCLUSION
Development of isolated skin metastases without
any other sites of visceral involvement n internal
malignanciesis very rare and occurs n context with
advanced disease. Any case with skin metastases is
diagnosed to be stage IV disease and it has poor survival.
Treatment in this setting is mostly palliative. Thorough
examination and follow up is necessary.

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