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Multiple Skin Metastases from Cancer of Internal Organs1

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Multiple Skin Metastases from Cancer of Internal Organs1 MULTIPLE SKIN METASTASES FROM CANCER OF INTERNAL ORGANS1 NOBWOSHI SUZUKI From the Institute of Pathology and the Medical Division of Kyoto Imperial University Medical School, Japan Received for publication, December 6, 1917 INTRODUCTION In cancer of the internal organs, metastasis into the skin is so rare that Gurlt observed not a single case among 16,637 patients, and neither Reichelmann (71 1 cases), nor Gussenbauer and Winiwarter (903 cases of gastric cancer), mentioned the occur- rence of secondary tumors in the skin. Redlich, Heimanp, and Krasting, however, recorded 2 oases out of 496, 2 out of 20,000, and 2 out of 12,730 patients respectively, Lex 7 out of 1183, and Mielecki 3 out of 487 cases. Daus collected 38, Sudo 72, and Kaufmann and Wolf 78 cases from the literature and from among their own patients. The present paper is an analysis of 110 cases which the writer has collected from the literature, to which are added 5 cases that have come under his own observation. One of the 5 was very kindly brought to his attention by Dr. Hojo. THE AUTHOR’S OWN CASES The fragments examined were taken from various organs which had been preserved in alcohol after formalin fixation, and stained with hematoxylin and eosin, Van Giesen’s stain, or when necessary, by Mallory’s, Bielshowsky’s, or Weigert’s (elastic fiber) method. 1 The author has not read the proof of this article. 357 358 NOBUYOSHI SUZUKI Case I. M.M., farmer, forty-six years old Status prcesens. There is a tumor on the right side of the neck about half the diameter of the palm, and multiple nodules in the integument of the chest and back; these are of various sizes, bluish, indistinctly defined, flat, firm, painless, and freely movable. The cervical and submaxillary lymph-nodes are not palpable, but those of both inguinal regions and both axillae, particularly the latter, are enlarged and firm. The entire body, especially the lower limbs, is very edematous. There are no other findings of importance. Autopsy findings. Well nourished male of large frame; general edema. Skin. There is a hard flat tumor of irregular and indistinct outline, about half a hand’s breadth in diameter, on the right side of the neck. In the integument overlying the front and lateral regions of the chest and the upper half of the back, there are nodules varying in size from a hazel-nut to a child’s palm; in the epigastric region there is one about the size of a small peach, while a little below the right costal arch there lies still another, this one about the diameter of a hazel-nut, flat, irregu- lar in shape and indistinctly defined. Many lymph-nodes in both axillae and both inguinal regions (es- pecially on the left side) are enlarged, varying from the size of a bean to that of a sparrow’s egg. A number of the broncbial nodes are equally involved, but those of the cervical and supraclavicular regions are not so much affected. Suprarenals. Around the left one the connective tissue is greatly increased, and the gland has increased to the size of a hen’s egg. Stomach. At the lesser curvature especially there is a distinct cancerous change and in the middle of this curvature a small shallow ulcer. The cardiac end and the lower part of the esophagus are involved by some slight cancerous infiltration, but in the pylorus and the other parts there is no pathological change worthy of note. Duodenum and small intestine. Negative. Large intestine. There is a hard tumor about the size of a bean in the upper part of the sigmoid flexure. Mesentery. Many mesenteric lymph-nodes are swollen to the size of a hazel-nut or a pea. In the middle of the small intestine there is a hard thickening 3 cm. in diameter, nearly round in shape, with a center about two finger-breadths from the intestinal canal. Its mar- gin is formed by fat, and the thickening itself presents a radiating structure like a chrysanthemum. BKIN METASTASES FROM CANCER OF INTERNAL ORGANS 359 Retroperitoneal lyrhph-nodes. Not greatly enlarged. Microscopical examination. Stomach. Carcinomatous ulcer of the lesser curvature, invading the muscular layer, the subserous connective tissue, the lymph-channels, and the blood-vessels. Skin. The epithelium is normal. In the coriuni and the suhcu- taneous stratum the connective tissue is greatly increased, and cancer cells are embedded in it singly or in groups. Hair-follicles, sebaceous glands, and the region around them show no pathological change, but cancer cells are to be seen about the sweat glands, some of which show traces of atrophy. There are cancer cells in the lymph-vessels here and there, but none are visible in the blood-vessels. The corium and the subcutaneous layer show a great increase of the lattice-fibers in addition to a distinct increase of the collagenous fibrils, especially around the sweat glands. Where the cancer cells lie in groups, the lattice-fibers surround every cancer cell like the strands of a net. Suprarenals. Cancerous infiltration. Lymph-nodes. Mesenteric, retroperitoneal, bronchial, both axil- lary, cervical, inguinal, and supraclavicular groups infiltrated by cancer cells; increase of connective tissue, and infiltration by eosinophiles. In the blood-capillaries and small veins of the medulla of the left kidney and the submucous stratum of the bladder, and in the small arteries of the lung, emboli of cancer cells. The cells of the metastatic growths have undergone mucous degen- eration and contain small vacuoles. On account of these ,vacuoles, the cells are enlarged, their nuclei being pressed to the margin making them look like signet-rings. The cells in the chrysanthemum-shaped thickening in the mesentery contain particularly large nuclei (giant nuclei), some of them four or five times as large as those in the other metastatic growths. Case II. N. N., forty-three years old Status prmsens. The skin and the mucous membranes are icteric. On the front and lateral parts of the chest and abdominal wall there are innumerable small hard tumors varying from the size of a hempseed to that of a pea, distinctly outlined, tender, and freely movable on the underlying tissues. Lymph-nodes not palpable. There is peristaltic unrest of the stomach. In the epigastric region it is possible to feel a resistance, but no tumor. Autopsy findings. A medium-sized, delicately built, emaciated male. 360 NOBUYOSHI SUZUKI Skin. Universally icteric. On the front and lateral parts of the trunk, and especially on the abdominal wall, there- are innumerable tumors varying from the size of a millet seed to that of a sparrow’s egg; these are hard, distinctly outlined, and freely movable. Heart. Many small hard nodules under and in the serous membrane of both vestibules. Lungs. Intact. Bronchial lymph-nodes not enlarged. Great omentum and mesentery. Many small firm tumors in the neighborhood of the lesser and the greater curvatures of the stomach. Kidneys. Multiple small hard tumors in the fat capsules of both kidneys. Suprarenals. Both of normal size; a nodule about the size of a pea in the connective tissue around the left one. Liver. Periportal lymph-nodes enlarged. Metastatic growths in the gall-bladder. Stomach. The pyloric part contains an annular ulcerated swelling. In the anterior wall of the pylorus are many minute grayish white nodules. Duodenum. Mucous membrane 1 cm. from the pyloric ring is firm and uneven. Small intestine. Grayish white tumor the size of a lentil 50 cm. from its uppermost part. All along the small intestine there are about twelve similar growths, especially numerous at the ileocecal part. Pancreas. Normal size, but very hard. Hemorrhage into the head of the organ; small tumor at the opposite extremity. Wetroperitoneum. Lymph-nodes enlarged and very hard, with a marrowy appearance on the cut surface. The fat 7 cm. below the ileo- cecal portion, the great omentum, ileocecal fold, transverse mesocolon, and pancreatico-gastric ligament contain many small firm nodules. Similar growths in the subperitoneal connective tissue of the diaphragm. Prostate. Somewhat enlarged and shows on section metastatic knots which look marrowlike. Microscopical examination. Stomach. The tumor at the pyloric end is an adcnocarcinoma, which is invading the stomach wall and its small blood-vessels anu lymph-channels. ‘The lymph-nodes of the pyloric and cardiac regions are also involved. Skin, Extension of the secondary growths by way of the lymphatics. Heart. Metastatic carcinoma. Lungs. Cancer cell embolus in a small bronchial artery of the right lung. The bronchial lymph-nodes contain metastatic cells only in the marginal lyniph-sinus. SKIN METASTASES FROM CANCER OF INTERNAL ORGANS 361 Liver. Many cancer cells in the lymph- and blood-capillaries of Glisson’s capsule. Metastases in the wall of the gall-bladder, and can- cer cell emboli in its smaller arteries. Pancreas. Metastases only in the connective tissue septa; these contain a few giant cells. Suprarenals. Metastases in medulla, cortex, and capsule. Retroperitoneum. The tumors in the fat 7 cm. below the ileocecal region, the great omentwn, the transverse mesocolon, the pancreatico- gastric ligament, and the subperitoneal connective tissue of the dia- phragm, are metastatic adenocarcinomata. They are sharply defined and their cells are closely pressed together into solid masses; the amount of connective tissue is very small. Prostate. Similar secondary growths. Kidney. Cancer cells in the blood-capillaries and the small veins of the left kidney. Retroperitoneal lymph-nodes. Metastatic adenocarcinoma. Axilrary and inguinal lymph-nodes. Not enlarged. Microscopi- cally only a few cancer cells are to be observed in the marginal sinus of some of the inguinal nodes. Case III. K.
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