eISSN: 2084-9869
ISSN: 1233-9687
Polish Journal of Pathology
Current issue Archive Manuscripts accepted About the journal Supplements Editorial board Abstracting and indexing Subscription Contact Instructions for authors Ethical standards and procedures
Editorial System
Submit your Manuscript
SCImago Journal & Country Rank
vol. 74
Review paper

Cutaneous metastasis of rectal adenocarcinoma: a case report and literature review

Vesa Alexandra Alina
Octavian Maghiar
Laura Maghiar
Romina Cuc
Ovidiu Pop
Andrei Pascalau
Monica Boros
Adrian Maghiar

Morphological Sciences Department, Faculty of Medicine and Pharmacy Oradea, University of Oradea, Romania
Preclinical Sciences Department, Faculty of Medicine and Pharmacy Oradea, University of Oradea, Romania
Surgical Sciences Department, Faculty of Medicine and Pharmacy Oradea, University of Oradea, Romania
Pol J Pathol 2023; 74 (3): 211-215
Online publish date: 2023/10/25
Article file
- PJP-02703.pdf  [0.89 MB]
Get citation
PlumX metrics:


Colorectal cancer is a worrying medical problem in terms of its incidence-according to the latest data provided by Globocan 2020 (third place after breast and lung cancer). As a 5-year prevalence, it will reach 2nd place (by 2025) in both females and males (after breast and prostate cancer, respectively). The GLOBOCAN 2020 data also showed an increase in colorectal cancer mortality, reaching 9.4% (the 2018 mortality rate was 9.2%). Out of a total of 1 931 590 new cases of colorectal cancer in 2020, the number of deaths in both sexes was 935 173 (48.41%), which reflects that approximately half of the newly diagnosed cases are followed by death.
About one-third (25-30%) of patients diagnosed with colorectal cancer are diagnosed with metastatic cancer, with the remaining patients at increased risk of later developing secondary tumors [1]. Colorectal cancer frequently spreads to the lymph nodes, lung, liver, and peritoneum, but only rarely to the skin [2]. Only 0.001% of all skin biopsies result in metastatic skin cancer, which is considered to be very uncommon [3]. The development of cutaneous metastasis from colon cancer is a very rare occurrence that usually occurs in patients with widely disseminated illness and a poor prognosis [4]. Cutaneous metastases of adenocarcinoma of the rectum are considerably rarer, occurring in only 4% of patients [5]. Up until 2018, only 43 cases of cutaneous metastasis secondary to rectal cancer were reported [3, 6].

Case report

A 74-year-old male patient presents to the emergency department complaining of eruptions in the form of indurated, dark red-purple papules with a diameter of 0.7-1.5 cm, disseminated on the lower and upper limbs, with agglomeration on the forearms and legs (Fig. 1). From the patient’s history we found out that 9 years ago he was diagnosed with adenocarcinoma of the prostate and a few months later, the same year, was diagnosed with a rectal tumor having the histological characteristics of a moderately differentiated adenocarcinoma of the rectum. The histopathological report of the primary rectal tumor describes in macroscopic examination a vegetative cauliflower-like, stenotic tumor formation located at 2 cm from the distal resection margin, with areas of ulceration, of increased consistency, of 4.6/3.2 cm, which completely obstructs the intestinal lumen. In the sections examined microscopically from the ulcerated rectal tumor formation, a tumor proliferation was observed, having the histological characteristics of a moderately differentiated rectal adenocarcinoma infiltrating the perirectal tissues, deep through the muscularis propria into the subserosa, the glandular component occupying 80% of the tumor bed. Areas with dystrophic calcification were detected focally. Perineural and vascular tumor invasion was present. The adjacent sigmoid mucosa showed aspects of non-specific chronic sigmoiditis. 26 perirectal lymph nodes with sizes between 1 and 19 mm were isolated, 10 of which showed tumoral infiltration. The resection margins were free of malignancy (T3N2Mx) (Figs. 2, 3). Following this diagnosis, he underwent oncological treatment (26 courses of radiotherapy and chemotherapy with oxaliplatin). The biopsies taken from the skin lesions revealed dermal tumor proliferation composed of glands of different sizes and shapes, lined by columnar cells arranged in several layers, with eosinophilic cytoplasm, moderately pleomorphic vesicular hyperchromatic nuclei with visible nucleolus and frequent atypical mitoses present. Dirty necrosis was observed in the lumen of the atypical glands (Fig. 4).
The tumor stroma with moderate diffuse inflammatory infiltrate composed out of lymphocytes and plasmocytes, and scattered extravasated erythrocytes. Complementary IHC tests reveal the following: CK 7 negative, CK 20 positive, CDx2 positive, TTF1 negative, PSA negative, S100 negative, thus confirming the colorectal origin. Molecular tests for KRAS and BRAF mutations were also documented, both of them being wild-type. The evolution of the patient worsensed and due to the extent of the metastasis he was under palliative chemotherapy regimen for a short period of time. Unfortunately he died 4 months after the diagnosis of skin metastasis.


Rarely occurring, skin metastases from solid tumors typically occur late in the course of an advanced visceral malignancy. Following the removal of the primary colorectal tumor, the surgical scar located in the abdomen is the most common site for skin metastasis, followed by the extremities, perineum, head, neck, and penis [7]. Although clinical presentations might vary significantly, lesions often manifest as single nodules. Nevertheless, clustered nodules, red-purple or skin-colored, hard or soft, erythematous plaques, non-healing ulcers, and infiltrating scars are further possibilities [8]. Rarely, it may mimic an infection, in which case it is known as inflammatory metastatic carcinoma or erysipeloid carcinoma [9]. Along with these forms, various other clinical presentations recorded in the literature also include ulcers, blisters, alopecia plaques, lesions similar to herpes zoster, epidermal cysts, neurofibromas, lymphomas, annular erythema, condylomas, and elephantiasis verrucosa [10, 11]. In our case, most of the lesions were hard, indurated nodules, violaceous and at the level of the foot, non-healing ulcers were observed.
An uncommon occurrence, cutaneous metastases from colorectal cancer typically portends a dismal prognosis and there is a 1 to 34 month range in survival following diagnosis [12, 13], but according to a more recent study performed by Schoenlaub et al., the median survival period for people with cutaneous metastases from colorectal original tumors is 4.4 months [14]. The status of our patient started to deteriorate after the diagnosis of cutaneous metastases despite being under chemotherapy, and died after 4 months after diagnosis.
The morphologic characteristics, histo-morphology, and immunohistochemistry of the cutaneous lesion are used to make the diagnosis in the majority of metastases [15]. An essential auxiliary tool for histopathological examinations is the immunohistochemistry study. More than 70% of lesions in cutaneous metastases arising from colorectal cancer have the CK7-negative/CK20-positive pattern [10]. From the proximal duodenum to the distal rectum, intestinal epithelial cells contain the transcription factor caudal-type homeobox 2 (CDX2), which controls gut epithelial development and maturation [16, 17]. Approximately 90-95% of colorectal adenocarcinomas have elevated CDX2 expression, which is thought to be a highly sensitive and specific diagnostic marker for adenocarcinomas of intestinal origin [18, 19].
Routine KRAS and BRAF mutation testing has completely changed how metastatic colorectal carcinoma is molecularly characterized over the past two decades. BRAF and KRAS mutations are reportedly associated with very poor prognoses. Patients with these mutations respond poorly to anti-EGFR therapy in terms of treatment. Compared to patients with wild type KRAS and wild type BRAF, patients with these mutations exhibited poorer progression-free survival and overall survival rates. Because of this, finding BRAF or KRAS mutations can help treat metastatic colorectal carcinoma more effectively and increase patient survival [20, 21]. In our case, both KRAS and BRAF were wild type.
Management of these secondary tumors located in the skin depends on their location and extent. Surgical removal of a single cutaneous metastases is required. Since they are associated with much greater odds of distant metastases, uncontrolled local illness, and worse survival rates, large cutaneous metastases only get palliative care [22].


Cutaneous metastasis due to colorectal cancer, although very rare, indicate a severe and accelerated progression of the disease, conferring a poor prognosis for the patient.
The latest data from the literature show an incidence of less than 4%, much more frequent in this anatomical site are metastasis with the origin of the primary tumor in the lungs and breasts. The diagnosis of skin metastasis is quite complicated in the absence of a history that would indicate evidence of a primary tumor.
The concrete and correct diagnosis is based on the histopathological examination, together with the complementary immunohistochemical examinations, which are otherwise very useful. The identification of BRAF and KRAS mutations can be of great help in the subsequent establishment of a targeted treatment in the case of these patients.
The authors declare no conflict of interest.
1. Riihimäki M, Hemminki A, Sundquist J, Hemminki K. Patterns of metastasis in colon and rectal cancer. Sci Rep 2016; 6: 29765.
2. Qi L, Ding Y. Analysis of metastasis associated signal regulatory network in colorectal cancer. Biochem Biophys Res Commun 2018; 501: 113-118. 
3. Hakami R, Alali MN, Alshammari T, et al. A cutaneous metastasis of unresectable rectal adenocarcinoma: A case report and literature review. Int J Surg Case Rep 2020; 71: 95-101.
4. Faenza M, Del Torto G, Di Costanzo P, et al. Large single cutaneous metastasis of colon adenocarcinoma mimicking a squamous cell carcinoma of the skin: A case report. Int J Surg Case Rep 2019; 56: 96-100.
5. Lee TG, Lee SJ. Unusual case of solitary perineal subcutaneous metastasis from sigmoid colon cancer. Ann Coloproctol 2013; 29: 34-37.
6. Dehal A, Patel S, Kim S, et al. Cutaneous Metastasis of Rectal Cancer: A Case Report and Literature Review. Perm J 2016; 20: 74-78. 
7. Parente P, Ciardiello D, Reggiani Bonetti L, et al. Cutaneous Metastasis from Colorectal Cancer: Making Light on an Unusual and Misdiagnosed Event. Life (Basel) 2021; 11: 954.
8. Beachkofsky TM, Wisco OJ, Osswald SS, et al. Pulmonary cutaneous metastasis: a case report and review of common cutaneous metastases. Cutis 2009; 84: 315-322.
9. Nesseris I, Tsamakis C, Gregoriou S, et al. Cutaneous metastasis of colon adenocarcinoma: case report and review of the literature. An Bras Dermatol 2013; 88 (6 Suppl 1): 56-58.
10. Saeed S, Keehn CA, Morgan MB. Cutaneous metastasis: a clinical, pathological, and immunohistochemical appraisal. J Cutan Pathol 2004; 31: 419-430.
11. Ocampo-Candiani J, Castrejón-Pérez AD, Ayala-Cortés AS, et al. Cutaneous Colon Metastases Mimicking Elefantiasis Verrucosa Nostra. Am J Med Sci 2015; 350: 517-518.
12. Kemal Y, Aliş Odabaşı E, Kemal O, Bakırtaş M. Cutaneous metastasis of colon adenocarcinoma. Turk J Surg 2018; 34: 237-239.
13. Lookingbill DP, Spangler N, Sexton FM. Skin involvement as the presenting sign of internal carcinoma. A retrospective study of 7316 cancer patients. J Am Acad Dermatol 1990; 22: 19-26.
14. Schoenlaub P, Sarraux A, Grosshans E, et al. Survival after cutaneous metastasis: a study of 200 cases. Ann Dermatol Venereol 2001; 128: 1310-1315.
15. Wang DY, Ye F, Lin JJ, Xu X. Cutaneous metastasis: a rare phenomenon of colorectal cancer. Ann Surg Treat Res 2017; 93: 277-280.
16. Grainger S, Savory JG, Lohnes D. Cdx2 regulates patterning of the intestinal epithelium. Dev Biol 2010; 339: 155-165.
17. Gao N, White P, Kaestner KH. Establishment of intestinal identity and epithelial-mesenchymal signaling by Cdx2. Dev Cell 2009; 16: 588-599.
18. Saad RS, Ghorab Z, Khalifa MA, Xu M. CDX2 as a marker for intestinal differentiation: Its utility and limitations. World J Gastrointest Surg 2011; 3: 159-166.
19. Barbareschi M, Murer B, Colby TV, et al. CDX-2 homeobox gene expression is a reliable marker of colorectal adenocarcinoma metastases to the lungs. Am J Surg Pathol 2003; 27: 141-149.
20. Li ZN, Zhao L, Yu LF, Wei MJ. BRAF and KRAS mutations in metastatic colorectal cancer: future perspectives for personalized therapy. Gastroenterol Rep (Oxf) 2020; 8: 192-205.
21. Ducreux M, Chamseddine A, Laurent-Puig P, et al. Molecular targeted therapy of BRAF-mutant colorectal cancer. Ther Adv Med Oncol 2019; 11: 175883591985649.
22. Gu Y, Tang R, Gong DQ, Qian YL. Reconstruction of the abdominal wall by using a combination of the human acellular dermal matrix implant and an interpositional omentum flap after extensive tumor resection in patients with abdominal wall neoplasm: a preliminary result. World J Gastroenterol 2008; 14: 752-757.
Copyright: © 2023 Polish Association of Pathologists and the Polish Branch of the International Academy of Pathology This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International (CC BY-NC-SA 4.0) License (http://creativecommons.org/licenses/by-nc-sa/4.0/), allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material, provided the original work is properly cited and states its license.
Quick links
© 2023 Termedia Sp. z o.o.
Developed by Bentus.