A case of rectal carcinoma with skin and bone marrow metastasis with concurrent extensive visceral involvement; unusual and dismal co-incidence

Abstract

Novel systemic therapies and modern surgical and ablative approaches have improved the survival rates for the patients with metastatic colorectal cancer. However, there are still patients with poor prognosis and underlying mechanisms that could not be defined clearly. Metastatic colorectal cancer patients with skin metastasis have a poor prognosis. A 45-year-old man, who presented with large bowel obstruction, was diagnosed with metastatic rectal adenocarcinoma. Unresectable liver metastases were found at diagnosis. FOLFOX plus bevacizumab treatment was started, but the patient developed bowel obstruction after the third cycle. Therefore, ileostomy was performed. Multiple skin, lung, liver and bone metastases appeared during that time. Bone marrow biopsy demonstrated diffuse infiltration by adenocarcinoma cells. Even though partial remission was achieved after 4 cycles of FOLFIRI–cetuximab, the disease progressed after the 8th cycle. The patient lost his life due to disease progression 8 months after the diagnosis. Bone marrow and skin are unusual sites of metastasis for colorectal carcinoma. Metastases in bone marrow and skin develop at later stages of metastatic disease. This patient lived only 4 months after the development of skin and bone marrow metastases. Skin and bone marrow metastases may be the harbingers of short survival. Biopsy of metastatic sites is crucial for diagnosis and detailed molecular analysis. Molecular pathway alterations underlying worse disease course may be found, and hence probable targets for drug improvement may be indicated.

Keywords:

• bone marrow
• rectal carcinoma
• skin metastasis

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Survival rate in metastatic colorectal cancer (mCRC) has improved thanks to novel systemic therapeutics, surgical approaches and ablative techniques. However, a subgroup of these patients still have poor prognosis.

• Skin and bone marrow metastases of mCRC are unusual, and the patients with these unusual signs have poor survival.

• There is an unmet medical need for poor prognostic subgroups of mCRC.

• There is limited data on prognostic and predictive markers for mCRC.

• Skin and bone marrow metastases may be harbingers of short survival. These metastases are generally seen at later stages of the disease and with extensive visceral involvement.

• Defining poor prognostic groups in mCRC patients may direct the investigators’ interest into these groups of patients.

• Such patient groups might have priority for detailed molecular analyses of metastatic tumor specimens for molecular pathway alterations underlying worse disease course.

• Defining new targets may be helpful for drug improvement studies in such poor prognostic subgroups of mCRC patients.