A 73-year-old man with a history of hypertension and duodenal ulcer surgery 35 years ago.
The patient came to the emergency room for several weeks of progressive jaundice and diffuse abdominal discomfort.
The patient underwent computed tomography and magnetic resonance cholangiography which reported dilation of the main bile duct up to the middle third of the common bile duct with stenosis at this level, all of which was compatible with cholangiocarcinoma.
Magnetic resonance angiography showed no evidence of unresectability.
These findings led to surgical intervention.
The intervention showed a tumor that affected the middle third of the bile duct, extending to the intrapancreatic bile duct and affecting the portal vein at supraduodenal level.
An implant was also found in the second duodenal portion, which was sent for intraoperative biopsy and reported as metastasis of adenocarcinoma.
Given the findings, it was considered unresectable.
Six months after surgery the patient had two skin lesions one at lumbar level and another at cervical level.
Biopsy of them was performed, being informed as an epidermal and dermis due to adenocarcinoma of biliary origin.
During this admission a CAT scan was performed and reported as liver, muscle and bone metastases.
The patient died a week later.
1.
Cutaneous metastases occur in approximately 2% of tumor processes (1).
Tumors can be spread to the skin by lymphatic route, as is most frequently observed in breast and oral tumors, occupying a superficial location of the skin; or rather, it can spread to the kidney as a subcutaneous lesion.
Most metastases of gastrointestinal tumors extend locally, near the lesion or the area of the surgical incision (4).
Cutaneous metastases may be the first manifestation of a tumor process, appear concomitantly with it or be a late manifestation.
In cases with cutaneous metastases of late onset, they are usually multiple and have an average of 3 months of life (5).
The cholangiocarcinoma constitutes a tumor of bad prognosis with great tendency to metastasize in internal organs.
Few studies have reported cutaneous metastases in cholangiocarcinomas, and in almost all cases metastases occur in drainage areas or in percutaneous procedures (6).
In our case distant metastases of the tumor and the area of incision are presented.
The appearance of distant cutaneous metastases in cholangiocarcinoma constitutes a rare phenomenon within the rarity of cutaneous metastases; however, we believe that it should be taken into account as a differential diagnosis in patients with cutaneous cholangiocarcinoma.
1.
A. Landaluce OLANE, B. Estravi Mateos y S. Sarabia García
General Surgery Department.
Galdacano Hospital.
Osakidetza-Vizcaya
