Scalp metastasis from esophageal adenocarcinoma: comparative histopathology dictates surgical approach

Cutaneous metastasis of esophageal cancer, in particular esophageal adenocarcinoma, is rare and metastasis to the scalp is extremely rare. We describe such a case that was originally diagnosed as an adnexal carcinoma. A 77-year-old male with a history of esophageal adenocarcinoma status after esophagectomy at our institution 4.5 years prior, presented to our plastic surgery clinic with a 2-month history of 2 temporoparietal scalp lesions. He was referred to our clinic by a community dermatologist who had performed a shave biopsy of the lesions. The clinical diagnosis was adnexal cyst. The history of esophageal carcinoma was not provided to the pathologist. The dermatopathology report came back as malignant adnexal neoplasm and considerations included apocrine carcinoma. We reexamined the pathologist's slides from the outside facility, comparing them to the histopathology from his esophagectomy. Histopathologic changes were identical. Thus, our surgical and postoperative approach changed significantly. Clinical suspicion should be high for cutaneous metastases in patients with a history of solid organ cancers. It is important for clinicians to illicit a history of malignancy. A biopsy should be performed on any suspicious lesions, and clinical data along with histopathology of the prior cancer resection(s) should be provided to the pathologist for comparison. Diagnosis of the suspicious lesion should be made before definitive excision, as this may change the approach, with the potential for postoperative chemotherapy and radiation. The definitive operative approach consists of surgical debulking with the evidence of negative margins. On the scalp, we feel that 5-mm margins are appropriate to obtain clear margins. One should appreciate the subdermal extent of metastases and adjust the margins accordingly. We recommend excising the galea with the skin as an en bloc resection. This will both assure clear deep margins of resection and assist in a tension-free closure of the scalp.