A 74-year-old female presented acutely to the surgical department with two rapidly growing, painful skin lumps. Her medical history included an emergency right hemicolectomy for perforated transverse colon secondary to a Dukes' C1 T4 N1 M0 poorly differentiated colonic adenocarcinoma one month previously. Physical examination revealed a tender 3 cm cervical nodule (Figure 1) and a 2 cm nodule in left iliac fossa at the previous drain site (Figure 2). Laboratory testing revealed a mild normocytic anaemia (hemoglobin 10.4 g/L) and acutely deranged liver function tests. Computed tomograpy scan of the neck, chest, abdomen and pelvis confirmed a 3x3 cm necrotic left supraclavicular lymph node, 2.8x1.9 cm abdominal wall nodule in the left iliac fossa, and mild ascites. Fine needle aspiration cytology established a diagnosis of poorly differentiated metastatic adenocarcinoma. This patient was not a candidate for chemotherapy and she was treated with palliative care.

Cutaneous metastasis from colonic cancer is rare with an incidence of around 4% [1] and only a few cases have been reported. [2] [3] [4] Cutaneous metastasis may present at a variety of sites such as the abdominal wall, particularly in scar sites, or less commonly as the first sign of an underlying unknown malignancy such as breast or lung cancer. Uniquely our case highlights a rapid occurrence of cutaneous metastasis with the involvement of multiple sites in a treated patient with colonic adenocarcinoma.

Only one lymph node was found to be involved in the resected specimen, and revealed an advanced tumor but a preoperative CT scan was not suggestive of distant metastasis. It is unusual for such advanced lymphatic spread and cutaneous metastasis without CT evidence of liver metastasis. [3] It has been stated that cutaneous metastasis from colorectal cancer usually takes years to develop. [3] In our case the patient had only undergone a right hemicolectomy one month earlier with no evidence of metastasis at that time. Subsequently she presented with not only a metastatic nodule at the previous drain site but also a large rapidly evolving nodule in her neck.

Cutaneous metastases can present as nodules, ulcers, or fibrous deposits and have varied histological classification depending on there type. In this case, the investigation of choice was fine needle aspiration cytology, which provided an accurate diagnosis and can prove vital in cases where the primary tumor is unknown. Cutaneous metastasis is associated with advanced disease and although the basis of treatment is treating the primary tumor the majority of patients are treated with palliative care. With local symptoms there is a role for radiotherapy or surgical resection/ debridement. Median survival in those patients with cutaneous metastasis from colonic adenocarcinoma has been reported at an optimistic 18 months [5] but some reported figures are as low as 3.3 months. [4]

This case of rapidly developing metastasis highlights the unpredictable nature and presentation of colonic adenocarcinoma. Advanced tumor staging should raise the suspicion of metastasis despite negative CT findings. In such cases care must be taken to make an accurate diagnosis and provide the most appropriate and sensitive treatment for the patient.

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