Unusual initial presentation of intra-abdominal ma-lignancy.
Singh A, Luthra A, and Nakhle A. Unusual initial presentation of intra-abdominal ma-lignancy. J Gen Intern Med 2018; 33(2):656.
J Gen Intern Med
Learning Objective #1: Cutaneous metastases of internal malignancy are not only rare, but they're also unlikely to be the first sign of cancer. Learning Objective #2: The frequency of malignancy in non-healing wounds and ulcers is high enough to consider a biopsy after three months of appropriate wound treatment. CASE: Our patient was a 50-year-old Caucasian female with a past medical history of abdominoplasty who presented to our hospital due to non-healing abdominal wall ulcers. She reported a history of abdominoplasty in six years prior to her presentation where the surgical wound never completely healed and had intermittent fowl smelling discharge requiring antibiotic treatment. Currently, the wound had been worsening over the past one month along with increased pruritus and drainage. Examination of her skin ulceration showed an indurated tender plaque, measuring 4x6 cm which was present near umbilicus with satellite erythematous to violaceous papules coalescing into nodules. Few of those nodules had superficial erosions and yellow crusting. A punch biopsy of the lesion showed features of metastatic adenocarcinoma, and immunohis-tochemical staining was consistent with high-grade serous carcinoma of Mullerian origin. Evaluation for a primary origin included CT of the chest, abdomen, and pelvis which showed mediastinal and axillary lymphadenopa-thy, moderate ascites, and granulomas in spleen. Uterus and adnexa were grossly unremarkable, and no intraabdominal mass was found. Paracentesis was performed and the ascitic fluid was positive for malignant cells consistent with metastatic adenocarcinoma. Tumor marker CA 125 was significantly elevated, while CEA and CA19-9 were normal. In the absence of a pelvic mass, this was thought to be primarily a peritoneal adenocarcinoma. Neoadju-vant chemotherapy was planned, but the patient had a complicated course with sepsis, worsening heart failure, and eventually death. IMPACT: There are multiple known skin manifestations for different types of malignancy. Abdominal wall metastasis after resection of intraabdominal cancer have been described in the past, but it usually occurs in the setting of a known diagnosis of malignancy. There was no evidence in the literature about cutaneous ulcers being the first sign of internal malignancy. This case highlights the importance of main-taining a high level of suspicion for any non-healing skin lesion after appropriate wound care. DISCUSSION: This is a case of an immunocompromised female who had a non-healing wound after undergoing a surgical abdominoplasty. Despite appropriate wound care and antibiotic therapy for suspected soft tissue infection, wound ulcers failed to improve. A skin biopsy six years later showed a possible peritoneal adenocarcinoma, but the patient was not a candidate for treatment due to her multiple comorbidities and advanced disease.