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Esophageal Squamous Cell Carcinoma Involving the Lip, Back and Hip

  • Shugeng Gao
    Affiliations
    Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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  • Yalong Wang
    Affiliations
    Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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  • Qi Xue
    Affiliations
    Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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  • Juwei Mu
    Affiliations
    Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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  • Yushun Gao
    Affiliations
    Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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  • Fengwei Tan
    Affiliations
    Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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  • Yousheng Mao
    Affiliations
    Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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  • Dali Wang
    Affiliations
    Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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  • Jun Zhao
    Affiliations
    Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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  • Yin Li
    Affiliations
    Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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  • Jie He
    Correspondence
    Corresponding author. Address for correspondence: Jie He, MD, PhD, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 17 Panjiayuan Nanli, Beijing 100021, China.
    Affiliations
    Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Open ArchivePublished:June 13, 2019DOI:https://doi.org/10.1016/j.jtho.2019.06.005
      A 65-year-old male patient visited the Cancer Hospital Chinese Academy of Medical Sciences (Beijing, China) on January 22, 2019. Nine months previously, he was diagnosed with esophageal squamous cell carcinoma with suspected lung metastasis; he initially received concurrent chemoradiotherapy (radiation dose: 45 Gy; chemotherapy regimen: nedaplatin) and subsequent systemic chemotherapy (oxaliplatin + calcium folinate + fluorouracil). The esophageal lesions responded to chemoradiotherapy; however, the pulmonary lesions enlarged (Fig. 1). After chemotherapy, small nodules formed in his lower lip, right hip, and right back, but the patient did not acknowledge them. The subcutaneous nodules gradually grew into masses (Fig. 2), and the patient visited a doctor. The patient was able to ingest liquid and semiliquid food without difficulty at the time of the doctor visit. Examination revealed a 3.9 × 4.1–cm mass on his lower lip, a 2.2 × 2.0–cm mass on his right back, and a 4.8 × 4.3–cm mass on his right hip. The lip skin was ulcerated, whereas the skin over the other two tumors was not. Ultrasound-guided biopsies were performed on the three lesions (Fig. 3) and they were diagnosed as metastatic esophageal squamous cell carcinomas by two pathologists. The patient then underwent computed tomography examinations of the brain, chest, and abdomen, and no new metastasis except lung metastasis was found. Because of the patient's advanced status, isotope bone scanning was not performed to evaluate bone metastasis. Further chemotherapy was recommended, but he and his family refused treatment and returned home because of the patient’s weakness. During the recent follow-up, a family member of the patient told us that the patient had died of cachexia on April 15, 2019 (the timeline of treatment and follow-up is shown in Fig. 4).
      Figure thumbnail gr1
      Figure 1Computed tomography images of esophageal cancer and lung metastasis before and after concurrent chemoradiotherapy. The left two images: the esophageal lesions responded to chemoradiotherapy after treatment (arrows). The middle two images: the pulmonary metastatic lesion enlarged after chemoradiotherapy (arrows). The right two images: the pulmonary metastatic lesion enlarged after chemoradiotherapy (arrows).
      Figure thumbnail gr2
      Figure 2Clinical presentation of the (A) lower lip, (B) right back, and (C) right hip metastasis.
      Figure thumbnail gr3
      Figure 3Histology of ultrasound-guided biopsy of the lesions of the (A) lower lip, (B) right back, and (C) right hip.
      Figure thumbnail gr4
      Figure 4Timeline of the patient’s treatment and follow-up.
      In the current case, pulmonary metastasis of esophageal cancer was suspected at the time of initial diagnosis. Pulmonary metastasis is usually considered to be the result of tumor metastasis through hematogenous routes, and the presence of pulmonary metastasis means that tumor cells have been hematogenously disseminated.
      • Lambert A.W.
      • Pattabiraman D.R.
      • Weinberg R.A.
      Emerging biological principles of metastasis.
      Although the patient received systemic chemotherapy, the pulmonary lesions continued to increase. Therefore, the tumor cells seemed insensitive to chemotherapy, and they continued to grow and form subcutaneous metastases. The patient survived only half a year from the onset of subcutaneous nodules to death. We hypothesize that the presence of subcutaneous metastasis represents the widespread presence of tumor cells in the blood, which lead to a very short survival period of the patient.
      Cutaneous metastases from the esophagus are rarely reported, as skin metastasis affects only 0% to 1.3% of all patients with esophageal cancer who experience metastasis.
      • Liu M.
      • Wang C.
      • Gao L.
      • Lv C.
      • Cai X.
      A nomogram to predict long-time survival for patients with M1 diseases of esophageal cancer.
      • Quint L.E.
      • Hepburn L.M.
      • Francis I.R.
      • Whyte R.I.
      • Orringer M.B.
      Incidence and distribution of distant metastases from newly diagnosed esophageal carcinoma.
      In a review of 4020 cases of cutaneous metastases, primary metastases were present in the esophagus in only 3 cases, accounting for only 0.07% of all patients with cutaneous metastases.
      • Lookingbill D.P.
      • Spangler N.
      • Helm K.F.
      Cutaneous metastases in patients with metastatic carcinoma: a retrospective study of 4020 patients.
      Subcutaneous lip metastasis is an even rarer malignant tumor event.
      • Yan B.
      • Wu F.
      • Yang N.
      • Zhang Y.
      Lung squamous carcinoma involving the lip and cheek.
      To our knowledge, this is the first reported case of esophageal squamous cell carcinoma involving multiple subcutaneous metastases, including lip metastasis. When skin nodules occur in these patients, doctors should be aware of the possibility of metastasis. A pathologic examination is crucial for diagnosis and is necessary to provide appropriate and timely treatment for patients.

      Acknowledgments

      This work was supported by the National Key R&D Program of China (Grant Nos. 2017YFC0907903 , 2016YFC1303200 ) and the CAMS Initiative for Innovative Medicine (Grant Nos. 2016-I2M-1-001 , 2017-I2M-1-005 ).

      References

        • Lambert A.W.
        • Pattabiraman D.R.
        • Weinberg R.A.
        Emerging biological principles of metastasis.
        Cell. 2017; 168: 670-691
        • Liu M.
        • Wang C.
        • Gao L.
        • Lv C.
        • Cai X.
        A nomogram to predict long-time survival for patients with M1 diseases of esophageal cancer.
        J Cancer. 2018; 9: 3986-3990
        • Quint L.E.
        • Hepburn L.M.
        • Francis I.R.
        • Whyte R.I.
        • Orringer M.B.
        Incidence and distribution of distant metastases from newly diagnosed esophageal carcinoma.
        Cancer. 1995; 76: 1120-1125
        • Lookingbill D.P.
        • Spangler N.
        • Helm K.F.
        Cutaneous metastases in patients with metastatic carcinoma: a retrospective study of 4020 patients.
        J Am Acad Dermatol. 1993; 29: 228-236
        • Yan B.
        • Wu F.
        • Yang N.
        • Zhang Y.
        Lung squamous carcinoma involving the lip and cheek.
        Lancet Oncol. 2018; 19: e726