Abstract

This is a case of squamous cell carcinoma of esophagus presenting with scalp metastasis, metastatic esophageal cancer is associated with poor outcomes.

Keywords: Esophageal cancer; Scalp lesion.

Citation: Jalota S, Yadav AK, Arya AK, Uttam A, Singh R. Scalp metastasis in esophageal squamous cell carcinoma: A case report. J Clin Images Med Case Rep. 2024; 5(4): 3003.

Introduction

Esophageal cancer is the fifth most common malignancy in India, and is associated with a high mortality rate [1]. It seldom presents with metastases to the skin which accounts for only 1% of the metastatic sites for esophageal cancer [2]. Cutaneous metastases most often present as firm nodules or alopecia neoplastica. We present a unique case of esophageal Squamous Cell Carcinoma (SCC) with metastasis to the scalp.

Case report

CA 60-year-old woman presented with dysphagia and dyspepsia for 2 months and a progressive ulcerative lesion in the scalp for 1 month (Figure 1). An endoscopy was performed and biopsies were obtained from the esophageal lesion, present in the upper esophagus (15 cm from carina, scope not negotiated beyond) The patient was diagnosed with esophageal SCC based upon the histopathologic findings. A dermatology consultation for the ulcerative nodule in the occipital area of the scalp was advised and eventually a biopsy from which revealed SCC. To evaluate the primary origin of the nodule special stains were done, they were suggestive of the same immunohistochemistry profile as the primary. Subsequent Positron Emission Tomography-Computed Tomography (PET-CT) was suggestive of no FDG avid lesion other than the primary and the scalp lesion.

Owing to the poor general condition of the patient, she was managed with a palliative intent, with feeding jejunostomy to facilitate improvement in nutrition status. Once her status showed improvement she was planned for three weekly Paclitaxel and Carboplatin. However, after four cycles she succumbed in hospice care.

Figure 1: Ulcerative lesion in the occipital region of scalp.

Discussion

Adenocarcinoma is the most prevalent histologic type in the western world while SCC is more common in developing nations [3,4]. The most common sites of metastasis seen in both types are liver, lung and bone. Cutaneous metastasis is uncommon and metastasis to the scalp is extremely rare. Two specific anatomical features of the esophagus could predispose to distant metastasis [5]. Firstly, the anastomosis between portal and systemic venous system. Secondly, the absence of a serosa allowing local and distant tumour spread. In esophageal cancer distant metastases can occur via arterial, venous or lymphatic route and potential venous spread from a proximal esophageal cancer could lead to metastasis to a site in the head or neck [5,6]. But isolated metastasis in terminal structures like skin as in this case, is very rare [5]. A handful of cases have been reported with skin lesions in adenocarcinoma esophagus, however to our knowledge this is the first case reported with scalp metastasis in SCC esophagus. Incidence of cutaneous metastases from internal malignancies has been reported in 0.5% to 9%. They usually originate from cancer of the breast, lung, and large bowel [7]. The clinical appearance of cutaneous scalp metastases has been described as ulcerative nodules associated with alopecia which is consistent with our case [8]. Our patient was an elderly woman with a metastatic disease at presentation. The prognosis of esophageal cancer depends on the stage at diagnosis, age and nutritional status which eventually determines the response to therapy. Those presenting with metastasis to distant sites have reported a 5year survival rate of only 5%. [9].

Conclusion

Cutaneous metastasis with esophageal SCC is a rare diagnosis, especially an isolated scalp lesion. A suspicious skin lesion with a malignancy of the esophagus should warrant a biopsy to exclude metastasis. However, like all metastatic esophageal cancers, the prognosis remains dismal.

References

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