Scalp Ulcer as First Sign of Cholangiocarcinoma

Abstract

Metastases from distant primary tumors are rarely the first indicators of cancer. However, cutaneous metastases are not uncommon in cases of internal malignancy. This article describes the case of a 65-year-old man with cutaneous metastasis of cholangiocarcinoma who presented with a scalp ulcer as the only initial sign. This is only the third reported case of cholangiocarcinoma with distant cutaneous metastasis.

Cutaneous Metastasis from Cholangiocarcinoma as the First Clinical Sign: A Report of Two Cases

“…2 Moreover, cutaneous metastases from cholangiocarcinomas have only been reported in two patients in whom a cutaneous lesion was the first sign of the carcinoma (Table 1). 4,5 In both of these patients, the cutaneous lesion was found on the scalp. In one, there was a poorly circumscribed, firm, subcutaneous nodule on the occipital area, and the lesion was approximately 2 cm in diameter with slight tenderness and erythema.…”

“…3 Cholangiocarcinoma is a neoplasm of the bile duct, which frequently invades or metastasizes to adjacent organs or other visceral organs, such as the lungs, bones, adrenal glands, and brain. 4,5 Cutaneous metastases of cholangiocarcinoma are extremely rare and have been reported to occur in only 0.4-5.3% 6,7 of cases. Most of the literature reporting cutaneous metastases of cholangiocarcinoma describes cases in which cancer cells were disseminated through catheter tracts used for percutaneous biliary drainage, or cases where cutaneous metastases were discovered after the diagnosis of cholangiocarcinoma was made.…”

“…4 The other patient had a well-circumscribed, indurated, painless ulcer on his scalp, which was fixed to the underlying tissue. 5 Both patients had erythematous, subcutaneous nodules on the scalp, and one of them also presented with an ulcerofungating mass on the back. The most common presentation of a metastatic skin lesion is a firm, painless nodule (multiple nodules are found in 46.4% of patients and a single nodule in 37.7% of patients; these can be macules, plaques, erythematous plaques, and ulcers).…”

“…3 Previous reports indicate that the most common presentation of cutaneous metastases of cholangiocarcinoma is the nodular type; other skin lesions described include erythematous plaques, abscesses, and ulcers. [4][5][6][7][8][9][10][11] Most nodular lesions are firm, painless, and nonulcerative and covered by a normal appearing epithelium; this results in some lesions being misdiagnosed as benign. Clinicians should therefore consider the possibility of cutaneous metastases when examining patients with skin nodules, especially those with a history of malignancy.…”

Extensive, Non-Healing Scalp Ulcer Associated with Trauma-Induced Chronic Osteomyelitis

“…Several previous reports have described them in Marjolin ulcer3, ulcerative carcinomas4, giant cell arteritis5, pyoderma gangrenosum6, trigeminal trophic syndrome7 and even cholangiocarcinoma8. Other differential diagnoses include viral, bacterial and mycotic infections as well as erosive pustular dermatosis of the scalp.…”