Copyright

J Cutan Pathol 2009: 36: 6466

doi: 10.1111/j.1600-0560.2008.01007.x
Blackwell Munksgaard. Printed in Singapore

2008 John Wiley & Sons A/S

Journal of

Cutaneous Pathology

Metastatic colorectal carcinoma:

an unusual presentation
Cutaneous metastases from colorectal carcinomas occur infrequently,
usually in the setting of disseminated disease. They most commonly
appear on the abdominal wall or perineal area; metastases to other
locations of the skin are rare. We describe a case of colorectal signet
ring carcinoma with metastasis to the upper lip. To the authors
knowledge, this is the second reported case of colorectal carcinoma
with metastasis to the lip and first with signet ring features. Because of
the rarity of cutaneous metastases, the primary physician or pathologist
may overlook this diagnosis. However, this entity should be considered
in the differential diagnosis of adnexal tumors as it may be the initial
presentation of the colon carcinoma.
Moonda A, Fatteh S. Metastatic colorectal carcinoma: an unusual
presentation.
J Cutan Pathol 2009; 36: 6466. # 2008 John Wiley & Sons A/S.

Case report
The patient is a 71-year-old male who presented to his
oncologist after being hospitalized for cholecystitis.
He had a history of dilated cardiomyopathy, atrial
fibrillation and hypertension. Additionally, one year
prior to this presentation, the patient had undergone
low anterior resection for a signet ring adenocarcinoma of the rectum with metastases to 21 out of
23 regional lymph nodes (Fig. 1). At this time, the
oncologist found an upper lip nodule adjacent to the
left nasal ala, clinically suggestive of a squamous cell
carcinoma. The patient decided to undergo excision
of the lip lesion at the same time as his elective
cholecystectomy and diverting colostomy. The patient
was lost to follow up.
Materials and methods
Surgical margins of the oriented lip lesion were
inked; specimen sections were fixed in formalin and
embedded into paraffin. The resulting slides were
routinely stained with hematoxylin-eosin. Immunohistochemical stains for p63, CK7, CK20, mucicarmine and synaptophysin were performed on sections
of the lip lesion.

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Afreen Moonda and Shokat

Fatteh
Department of Pathology, Forum Health
Northside Medical Center, Youngstown,
OH, USA

Dr Afreen Moonda, Department of Pathology, Forum

Health Northside Medical Center, 500 Gypsy Lane,
Youngstown, OH 44501, USA
Tel: (330)884-3781
Fax: (330)884-3790
e-mail: ahusai1@neoucom.edu
Accepted date for publication February 4, 2008

Pathologic finding
Grossly, the lip lesion measured 1.5 cm in greatest
dimension. The skin surface revealed a central area
of ulceration, measuring 0.2 cm, with surrounding
pearly induration. Microscopically, sections of the lip
showed a diffusely infiltrating glandular lesion consisting of sheets of signet cells and pools of mucin with
free-floating signet cells. There was focal involvement
of the squamous epithelium and lateral margins of
resection. These findings are consistent with a metastatic epidermotropic signet ring adenocarcinoma
that has pagetoid features (Fig. 2). A strongly positive
mucicarmine stain confirmed the intracellular mucin.
Immunohistochemistry showed a pattern of staining
identical to the selected section of the rectal adenocarcinoma. Both tumors were positive for CK20
(Fig. 3) and negative for CK7 and synaptophysin.
Additionally, the tumor was negative for p63, which
supports the metastatic nature of the lesion (Fig. 4).
Discussion
Cutaneous metastases are an uncommon but important diagnostic consideration as they may be the first
sign of an internal malignancy. Cutaneous metastases

Metastatic colorectal carcinoma

Fig. 1. Low power of the signet ring adenocarcinoma of the rectum

(H&E, 34). The insert shows signet ring cells (H&E, 340). H&E,
hematoxylin-eosin.

were found in approximately 5% of patients with

internal cancer in one study.1 Cutaneous metastases
most often occur on a site relatively close to the
internal primary. Skin metastases from the breast
usually occur on the chest, the lung to the chest and
upper extremities, and the gastrointestinal tract to the
abdomen.2 These metastases usually manifest as a
rapidly growing, mobile nodule.3
Adenocarcinomas from the breast, lung and
gastrointestinal tract are the most common type of
malignancies to develop cutaneous metastases.4 The
differential diagnosis of these lesions includes primary
adnexal tumors of the skin. In our case, with
a metastasis to the lip, the differential also includes
malignancies from the minor salivary glands. Immunoperoxidase studies are widely employed to differentiate the primary adnexal tumors from visceral

Fig. 2. Low power of the metastatic signet ring adenocarcinoma to

the lip with focal epidermal involvement (H&E, 34). The insert
shows signet ring cells identical to the colonic primary (H&E, 340).
H&E, hematoxylin-eosin.

Fig. 3. Lip nodule with strongly positive CK20 (340).

metastases. Along with the stains such as estrogen

receptor, progesterone receptor and the various
cytokeratins, the pathologist can now use staining
for p63 to differentiate a metastatic visceral malignancy to the skin from a primary or metastatic
adnexal tumor.
The p63 gene is expressed in the epidermis and
adnexal structures of the dermis. This expression is
retained in the primary and metastatic tumors of
adnexal origin, allowing these malignancies to be
differentiated from visceral metastases, which lack
p63 expression. In a recent study, 91% of the
primary adnexal tumors strongly expressed p63,
while 100% of the cutaneous metastases from
visceral organs did not express p63.5 In our case,
the lip lesion was negative for the expression of p63,
a finding that is consistent with the results of the
previous study. Additionally, cutaneous metastases
may be differentiated from minor salivary gland
malignancies by the composition of the mucin.

Fig. 4. Lip nodule with strong staining for p63 in the epidermis but
negative in the metastatic colorectal adenocarcinoma (310).

65

Moonda & Fatteh

Mucin from the adenocarcinomas of the gastrointestinal tract, breast and lung is nonsulfated and
hyaluronidase resistant, whereas mucin from the
salivary glands consists primarily of sulfated acid
mucopolysaccharides.6,7
Colorectal carcinomas usually metastasize to
regional lymph nodes and then hematogenously to
the liver and lungs late in the course of the disease.8
Although colorectal carcinomas are one of the most
common visceral primaries to metastasize to the
cutaneous tissues, these metastases are still rather
unusual findings. One study reported 413 patients
with colorectal carcinoma, with only 18 of these
patients developing cutaneous metastases. Eleven of
the patients with cutaneous metastases had lesions
located in the surgical wound itself.9 Metastasis to
the head and neck area are extremely rare and
usually originate from squamous cell carcinomas of
the oral cavity.3 Cutaneous metastases to the head
and neck region from primary colorectal carcinomas
have been reported.10 To our knowledge, there has
been only one reported case of a metastasis to the
lip.11 Interestingly, the signet ring pattern seen in our
case is an uncommon finding in cutaneous metastases from colorectal carcinomas and is seen primarily
with gastric malignancies.12 Cutaneous metastases
from visceral malignancies usually indicate widespread disease and, therefore, a poor prognosis with
death usually occurring within a year from the
diagnosis.9,13
In conclusion, cutaneous metastases from visceral
malignancies are an important differential diagnosis
of adnexal tumors. Expression of p63 aids to differentiate cutaneous metastases from the primary adnexal tumors. This is the second reported case of

66

colorectal carcinoma with metastasis to the lip and the

first with signet ring features.
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