br Discussion Cutaneous metastases occur in

Discussion Cutaneous metastases occur in 0.7–9.0% of all patients with various kinds of malignancies such as visceral cancer, leukemia, lymphoma, and melanoma. In a retrospective study of 4020 patients with metastatic disease, the origins of common cutaneous metastases in women were the breast, colon, and melanoma. In men, the most common metastases were the lungs, colon, and melanoma. Cutaneous chir99021 manufacturer may be the first presenting feature of an internal malignancy in 7.6% of patients. Breast cancer and melanoma account for 58% of cases. The incidence of skin metastases in newly diagnosed esophageal carcinoma is 1.3%. A SMJN is a rare cutaneous metastasis involving the umbilicus and presents as an umbilical nodule. A SMJN could result from contiguous extension or from hematogenous or lymphatic spread. The umbilicus has an anatomical susceptibility to cutaneous metastasis because it lacks a muscle layer. The transversalis fascia and linea alba (or Scarpa\'s fascia) are the only barriers between a peritoneal tumor and the umbilical skin. The vascular drainage system and embryologic remnants associated with the umbilicus are hints for routes of tumor spreading. A SMJN can be an indurated, bulging, fissured, or ulcerated skin lesion with variable coloring. It is easily ignored by clinicians if the skin lesion presents with only mild erythema. A SMJN almost always originates from an intra-abdominal or intrapelvic malignancy. The most common primary site of SMJN in men is the gastrointestinal tract. Ovarian and gastrointestinal cancers are the most common origin of SMJN in women. It is an indicator of a poor prognosis. The mean life expectancy is 2–11 months without treatment or 17.6–21 months with aggressive management. A SMJN originating from esophageal SCC is extremely rare, and only three cases have been reported. The differential diagnosis of umbilical nodules includes umbilical hernia, pyogenic granuloma, epidermal cyst, hemangioma, endometriosis, hypertrophic scar, and other rare conditions. A dermoscopic examination can provide some important clues for cutaneous metastasis. In one case series, 88% (15/17) of cutaneous metastases showed variable vascular patterns on dermoscopy. The most common subtype was serpentine vessels (77%, 13/17). Other vascular patterns of cutaneous metastasis included arborizing vessels, comma-shaped vessels, dotted vessels, and mixed types (i.e., more than 1 subtype). The dermoscopic image of the SMJN in our patient showed a polymorphous vascular pattern with serpentine, comma-shaped, and dotted vessels, which was quite similar to the findings of a previous case report. A polymorphous vascular pattern on dermoscopy implies neoangiogenesis may have a role in cancer metastasis. Direct compression of the nodule by the dermoscope may produce a white veil caused by blanching of the vessels. Using the noncontact mode with a polarized light in the dermoscope could avoid this problem, but photography is technically difficult because of poor stability. An image study using integrated CT and PET (i.e., PET/CT) allows more accurate information on the localization and extent of SMJN, staging of internal malignancy, and treatment strategy. In our patient, the image findings of SMJN on PET/CT were just “the tip of the iceberg” of the intra-abdominal neoplasm, implying disseminated peritoneal seeding. The gold standard for diagnosis of a SMJN is histopathological and immunohistochemical examination, which can identify the cell origin of the internal malignancy. Sometimes immunohistochemical stains are needed to define the cell origin in lesions without a known primary site or poor differentiation. In this patient, positive results for pankeratin AE1/AE3 confirmed an epithelial origin. Negative results for CK-7 and CK-20 were compatible with metastatic SCC from the esophagus. Cytokeratin-7 and CK-20 are helpful for distinguishing between some common cancers such as cervical SCC, lung adenocarcinoma, colonic adenocarcinoma, and breast cancers.