Signet ring cells in carcinomatous lymphangitis due to gastric adenocarcinoma,

AnBrasDermatol.2020;95(4):490---492

Anais

Brasileiros

de

Dermatologia

DERMATOPATHOLOGY

Signet

ring

cells

in

carcinomatous

lymphangitis

due

to

gastric

adenocarcinoma

夽,夽夽

Beatriz

da

Silva

Souza

_,

_Renan

_Rangel

_Bonamigo

_,

_Gabriela

_Lusa

_Viapiana

_,

André

Cartell

a_{DermatologyService,HospitaldeClínicasdePortoAlegre,PortoAlegre,RS,Brazil}

b_{DepartmentofPathology,FaculdadedeMedicina,UniversidadeFederaldoRioGrandedoSul,PortoAlegre,RS,Brazil}

Received5November2019;accepted16December2019 Availableonline5May2020

KEYWORDS

Carcinoma,signet ringcell;

Lymphangitis; Lymphaticmetastasis

Abstract Cutaneousmetastasesarerare.Theyusuallypresentasnodulesortumors.Diagnosis isbasedonhistopathologicalexaminationandprognosisisunfavorable.Thisreportdescribesthe caseofafemalepatient,72yearsold,withsurgicallytreatedgastricantrumadenocarcinoma. Pathologyshowedpoorlydifferentiatedadenocarcinomawithsignetringcells.Itevolvedwith boneinvolvement,lymphnodeenlargementintheinguinalregion,andskininfiltrationinthe lowerlimbs,abdomen,androotoftheupperlimbs.Skinbiopsydemonstratedsignetring carci-nomaembolizingthedermalandhypodermicvesselsandinvasionofadiposetissue,confirming carcinomatouslymphangitis.Carcinomatouslymphangitisisthecutaneousandsubcutaneous lymphaticinvasionbytumorcells.Cutaneousmetastasisisrelativelyuncommonandpresents mainlyascutaneousorsubcutaneousnodules, andmorerarely asinflammatorylesions.The presentcasereportscarcinomatouslymphangitisassociatedwithgastriccancer.

©2020SociedadeBrasileiradeDermatologia.PublishedbyElsevierEspa˜na,S.L.U.Thisisan openaccessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).

Introduction

Lymphedemashouldbeevaluatedfor differentetiologies, includingsolidorgancutaneousmetastases.

夽 _{Howtocitethisarticle:SouzaBS,BonamigoRR,ViapianaGL,}

CartellA. Signetringcellsincarcinomatouslymphangitisdueto

gastricadenocarcinoma.AnBrasDermatol.2020;95:490---2.

夽夽_{StudyconductedattheHospitaldeClínicasdePortoAlegre,}

UniversidadeFederaldoRioGrandedoSul,RS,Brazil.

∗_{Correspondingauthor.}

E-mail:beatrizsouza1987@gmail.com(B.S.Souza).

Cutaneousmetastasesarerelativelyraredermatological malignancies,withareportedincidencerangingfrom0.7% to9.0%amongallcutaneousneoplasms.1_{Theyoftenpresent}

asnodules or tumors,mostlyerythematous,discrete,and solid; inflammatory skin metastases are infrequent.2 _The

diagnosis is basedon histopathological examination.3 _The

prognosisofpatientswithcutaneousmetastasisis unfavor-able,witha meansurvival ofapproximately7.5 months.3

This reportpresentsthecase ofapatientwithsignetring cellsgastricantrumadenocarcinoma,whodeveloped carci-nomatouslymphangitis.

https://doi.org/10.1016/j.abd.2019.12.004

0365-0596/©2020SociedadeBrasileiradeDermatologia.PublishedbyElsevierEspa˜na,S.L.U.ThisisanopenaccessarticleundertheCC

Signetringcellsincarcinomatouslymphangitisduetogastricadenocarcinoma 491

Figure 1 Cutaneous infiltration of the lower limbs, more extensiveontheleftside,andontherightsideaffectingthe rootofthethigh.

Case

report

Female, 72 years old, diagnosed with stage IIIA gastric antrum adenocarcinoma. She underwent partial gastrec-tomywithenlargedlymphadenectomy,with histopathologi-calevidenceshowingpoorlydifferentiatedadenocarcinoma, mixed type in Laurén’s classification, with signet ring cells,ulcero-infiltrativelinitisplastica-type,compromising the gastric antrum and pylorus. Adjuvant chemotherapy withcapecitabine+oxaliplatinwasstarted, but therewas intolerance and therapy was discontinued. A computed tomography(CT)scanperformedtenmonthsaftersurgery showedosteolyticlesiononT2andlymphnodeenlargement intheleftinguinalregion.Palliativeradiotherapywas per-formed for bone lesions, with significant improvement in localpain.Aftertwomonths,therewasvolumeincreasein theleftlowerlimb,whichprogressedwithbilateral involve-ment; in five months, she washospitalized due to lower limblymphedema.Onphysicalexamination,shepresented cutaneousinfiltrationinthelowerlimbs,morepronounced on the left side (Fig. 1), withextension tothe abdomen androot of the upperlimbs. The histopathological exam-inationof theskin of themedialsurface of theleftthigh showedsignet ring carcinoma embolizing vessels through-outthedermisandhypodermis,withneoplasticinvasionof adiposetissue(Figs.2and3),confirmingcarcinomatous

lym-Figure2 Presenceofdiffuselymphaticembolization associ-atedwithdermaledema(Hematoxylin&eosin,×50).

Figure 3 Greater detail showing lymphatic embolus with signetringcells(indicatedbythearrow)(Hematoxylin&eosin, ×200).

phangitis.Palliativechemotherapystarted,butthepatient progressedtorespiratoryfailureandeventuallydeath.

Discussion

Lymphedema is a clinical condition marked by increased volume of subcutaneous soft tissues due to impairment of the lymphatic system.2 _{Lower limb edema is a very}

common symptom; the mechanisms most often involved initscauseincludevenousandlymphatic disease,volume overload,increased capillarypermeability, and decreased oncoticpressure.Themostcommonassociateddiseasesare deepveinthrombosisandchronicvenousinsufficiency,heart failure,hepaticorrenalfailurehypoproteinemia,idiopathic cyclicedema,anddrug-inducededema.4

Incancer patients, themain etiologies oflymphedema arecomplications after lymphadenectomy or after radio-therapy. Carcinomatous lymphangitis exhibits extensive cutaneous andsubcutaneous lymphatic invasion by tumor cells, caused by lymphogenic dissemination.2 _When

lym-phoedema is diagnosed in patients previously treated for malignancy,itisimportanttoconsiderwhetherthe symp-tom corresponds to disease progression or recurrence, or a complication of the initial cancer treatment, and histopathologyis veryimportantfor etiological differenti-ation.Lymphedemaduetomalignantinfiltrationshouldbe considered,particularlywhenitdevelopsrapidly;itis

con-492 SouzaBSetal. stantlypresent,withvisibledilatedveinsandisassociated

withseverepain.2

The signet ring pattern defines a specific cell shape change, during which the cell nucleus is pushed to the peripherydue tocytoplasmic accumulationofmucin, vac-uoles, or inclusion bodies.1 _{Metastatic skin biopsy of this}

type of cancer usually demonstrates infiltration of the affectedsite,inthepresentcaseofthedermisand hypoder-mis,byinflammatorycellsandsmallroundedmononuclear cellswithlargecytoplasm,occasionallywiththeappearance ofasignetring.5,6

The histological typemost prone todistant metastasis issignetringcelladenocarcinoma.7_{Perisseetal.reported}

a case of poorly differentiated antrum adenocarcinoma withsignetring cells withcutaneous metastasis, present-ingasasymptomaticnodulesontheface,neck,chest,and scrotum.7

In general, cutaneous metastases occur in the final courseofthedisease,butmayalsobethepresentingsign of underlying cancer, related both to poor prognosis and decreased survival.8,9 _{These lesions are often cutaneous}

or subcutaneous,normochromic or erythematousnodules, oftenasymptomatic,2,10 _{rarely presenting asinflammatory}

metastases,2 _{as in the present case, in which cutaneous}

metastasismanifestedasacarcinomatouslymphangitis.

Financial

support

Nonedeclared.

Authors’

contributions

Beatriz da Silva Souza: Drafting and editing of the manuscript;intellectual participation in thepropaedeutic and/ortherapeuticconductofthestudiedcases.

RenanRangelBonamigo:Intellectualparticipationinthe propaedeutic and/or therapeutic conduct of the studied cases.

GabrielaLusaViapiana:Intellectualparticipationinthe propaedeutic and/or therapeutic conduct of the studied cases.

André Cartell: Intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases.

Conflicts

of

interest

Nonedeclared.

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