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with a mean survival of approximately 7&#46;5 months&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> This report presents the case of a patient with signet ring cells gastric antrum adenocarcinoma&#44; who developed carcinomatous lymphangitis&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Case report</span><p id="par0015" class="elsevierStylePara elsevierViewall">Female&#44; 72 years old&#44; diagnosed with stage IIIA gastric antrum adenocarcinoma&#46; She underwent partial gastrectomy with enlarged lymphadenectomy&#44; with histopathological evidence showing poorly differentiated adenocarcinoma&#44; mixed type in Laur&#233;n&#39;s classification&#44; with signet ring cells&#44; ulcero-infiltrative linitis plastica-type&#44; compromising the gastric antrum and pylorus&#46; Adjuvant chemotherapy with capecitabine<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>oxaliplatin was started&#44; but there was intolerance and therapy was discontinued&#46; A computed tomography &#40;CT&#41; scan performed ten months after surgery showed osteolytic lesion on T2 and lymph node enlargement in the left inguinal region&#46; Palliative radiotherapy was performed for bone lesions&#44; with significant improvement in local pain&#46; After two months&#44; there was volume increase in the left lower limb&#44; which progressed with bilateral involvement&#59; in five months&#44; she was hospitalized due to lower limb lymphedema&#46; On physical examination&#44; she presented cutaneous infiltration in the lower limbs&#44; more pronounced on the left side &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; with extension to the abdomen and root of the upper limbs&#46; The histopathological examination of the skin of the medial surface of the left thigh showed signet ring carcinoma embolizing vessels throughout the dermis and hypodermis&#44; with neoplastic invasion of adipose tissue &#40;<a class="elsevierStyleCrossRefs" href="#fig0010">Figs&#46; 2 and 3</a>&#41;&#44; confirming carcinomatous lymphangitis&#46; Palliative chemotherapy started&#44; but the patient progressed to respiratory failure and eventually death&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Discussion</span><p id="par0020" class="elsevierStylePara elsevierViewall">Lymphedema is a clinical condition marked by increased volume of subcutaneous soft tissues due to impairment of the lymphatic system&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> Lower limb edema is a very common symptom&#59; the mechanisms most often involved in its cause include venous and lymphatic disease&#44; volume overload&#44; increased capillary permeability&#44; and decreased oncotic pressure&#46; The most common associated diseases are deep vein thrombosis and chronic venous insufficiency&#44; heart failure&#44; hepatic or renal failure hypoproteinemia&#44; idiopathic cyclic edema&#44; and drug-induced edema&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In cancer patients&#44; the main etiologies of lymphedema are complications after lymphadenectomy or after radiotherapy&#46; Carcinomatous lymphangitis exhibits extensive cutaneous and subcutaneous lymphatic invasion by tumor cells&#44; caused by lymphogenic dissemination&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> When lymphoedema is diagnosed in patients previously treated for malignancy&#44; it is important to consider whether the symptom corresponds to disease progression or recurrence&#44; or a complication of the initial cancer treatment&#44; and histopathology is very important for etiological differentiation&#46; Lymphedema due to malignant infiltration should be considered&#44; particularly when it develops rapidly&#59; it is constantly present&#44; with visible dilated veins and is associated with severe pain&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The signet ring pattern defines a specific cell shape change&#44; during which the cell nucleus is pushed to the periphery due to cytoplasmic accumulation of mucin&#44; vacuoles&#44; or inclusion bodies&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Metastatic skin biopsy of this type of cancer usually demonstrates infiltration of the affected site&#44; in the present case of the dermis and hypodermis&#44; by inflammatory cells and small rounded mononuclear cells with large cytoplasm&#44; occasionally with the appearance of a signet ring&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5&#44;6</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The histological type most prone to distant metastasis is signet ring cell adenocarcinoma&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> Perisse et al&#46; reported a case of poorly differentiated antrum adenocarcinoma with signet ring cells with cutaneous metastasis&#44; presenting as asymptomatic nodules on the face&#44; neck&#44; chest&#44; and scrotum&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In general&#44; cutaneous metastases occur in the final course of the disease&#44; but may also be the presenting sign of underlying cancer&#44; related both to poor prognosis and decreased survival&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">8&#44;9</span></a> These lesions are often cutaneous or subcutaneous&#44; normochromic or erythematous nodules&#44; often asymptomatic&#44;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#44;10</span></a> rarely presenting as inflammatory metastases&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> as in the present case&#44; in which cutaneous metastasis manifested as a carcinomatous lymphangitis&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Financial support</span><p id="par0045" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Authors&#8217; contributions</span><p id="par0050" class="elsevierStylePara elsevierViewall">Beatriz da Silva Souza&#58; Drafting and editing of the manuscript&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Renan Rangel Bonamigo&#58; Intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Gabriela Lusa Viapiana&#58; Intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Andr&#233; Cartell&#58; Intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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Dermatopathology
Signet ring cells in carcinomatous lymphangitis due to gastric adenocarcinoma
Beatriz da Silva Souzaa,
Corresponding author
beatrizsouza1987@gmail.com

Corresponding author.
, Renan Rangel Bonamigoa, Gabriela Lusa Viapianaa, André Cartellb
a Dermatology Service, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
b Department of Pathology, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
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with a mean survival of approximately 7&#46;5 months&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> This report presents the case of a patient with signet ring cells gastric antrum adenocarcinoma&#44; who developed carcinomatous lymphangitis&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Case report</span><p id="par0015" class="elsevierStylePara elsevierViewall">Female&#44; 72 years old&#44; diagnosed with stage IIIA gastric antrum adenocarcinoma&#46; She underwent partial gastrectomy with enlarged lymphadenectomy&#44; with histopathological evidence showing poorly differentiated adenocarcinoma&#44; mixed type in Laur&#233;n&#39;s classification&#44; with signet ring cells&#44; ulcero-infiltrative linitis plastica-type&#44; compromising the gastric antrum and pylorus&#46; Adjuvant chemotherapy with capecitabine<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>oxaliplatin was started&#44; but there was intolerance and therapy was discontinued&#46; A computed tomography &#40;CT&#41; scan performed ten months after surgery showed osteolytic lesion on T2 and lymph node enlargement in the left inguinal region&#46; Palliative radiotherapy was performed for bone lesions&#44; with significant improvement in local pain&#46; After two months&#44; there was volume increase in the left lower limb&#44; which progressed with bilateral involvement&#59; in five months&#44; she was hospitalized due to lower limb lymphedema&#46; On physical examination&#44; she presented cutaneous infiltration in the lower limbs&#44; more pronounced on the left side &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; with extension to the abdomen and root of the upper limbs&#46; The histopathological examination of the skin of the medial surface of the left thigh showed signet ring carcinoma embolizing vessels throughout the dermis and hypodermis&#44; with neoplastic invasion of adipose tissue &#40;<a class="elsevierStyleCrossRefs" href="#fig0010">Figs&#46; 2 and 3</a>&#41;&#44; confirming carcinomatous lymphangitis&#46; Palliative chemotherapy started&#44; but the patient progressed to respiratory failure and eventually death&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Discussion</span><p id="par0020" class="elsevierStylePara elsevierViewall">Lymphedema is a clinical condition marked by increased volume of subcutaneous soft tissues due to impairment of the lymphatic system&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> Lower limb edema is a very common symptom&#59; the mechanisms most often involved in its cause include venous and lymphatic disease&#44; volume overload&#44; increased capillary permeability&#44; and decreased oncotic pressure&#46; The most common associated diseases are deep vein thrombosis and chronic venous insufficiency&#44; heart failure&#44; hepatic or renal failure hypoproteinemia&#44; idiopathic cyclic edema&#44; and drug-induced edema&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In cancer patients&#44; the main etiologies of lymphedema are complications after lymphadenectomy or after radiotherapy&#46; Carcinomatous lymphangitis exhibits extensive cutaneous and subcutaneous lymphatic invasion by tumor cells&#44; caused by lymphogenic dissemination&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> When lymphoedema is diagnosed in patients previously treated for malignancy&#44; it is important to consider whether the symptom corresponds to disease progression or recurrence&#44; or a complication of the initial cancer treatment&#44; and histopathology is very important for etiological differentiation&#46; Lymphedema due to malignant infiltration should be considered&#44; particularly when it develops rapidly&#59; it is constantly present&#44; with visible dilated veins and is associated with severe pain&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The signet ring pattern defines a specific cell shape change&#44; during which the cell nucleus is pushed to the periphery due to cytoplasmic accumulation of mucin&#44; vacuoles&#44; or inclusion bodies&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Metastatic skin biopsy of this type of cancer usually demonstrates infiltration of the affected site&#44; in the present case of the dermis and hypodermis&#44; by inflammatory cells and small rounded mononuclear cells with large cytoplasm&#44; occasionally with the appearance of a signet ring&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5&#44;6</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The histological type most prone to distant metastasis is signet ring cell adenocarcinoma&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> Perisse et al&#46; reported a case of poorly differentiated antrum adenocarcinoma with signet ring cells with cutaneous metastasis&#44; presenting as asymptomatic nodules on the face&#44; neck&#44; chest&#44; and scrotum&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In general&#44; cutaneous metastases occur in the final course of the disease&#44; but may also be the presenting sign of underlying cancer&#44; related both to poor prognosis and decreased survival&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">8&#44;9</span></a> These lesions are often cutaneous or subcutaneous&#44; normochromic or erythematous nodules&#44; often asymptomatic&#44;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#44;10</span></a> rarely presenting as inflammatory metastases&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> as in the present case&#44; in which cutaneous metastasis manifested as a carcinomatous lymphangitis&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Financial support</span><p id="par0045" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Authors&#8217; contributions</span><p id="par0050" class="elsevierStylePara elsevierViewall">Beatriz da Silva Souza&#58; Drafting and editing of the manuscript&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Renan Rangel Bonamigo&#58; Intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Gabriela Lusa Viapiana&#58; Intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Andr&#233; Cartell&#58; Intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Cutaneous metastases are rare&#46; They usually present as nodules or tumors&#46; Diagnosis is based on histopathological examination and prognosis is unfavorable&#46; This report describes the case of a female patient&#44; 72 years old&#44; with surgically treated gastric antrum adenocarcinoma&#46; Pathology showed poorly differentiated adenocarcinoma with signet ring cells&#46; It evolved with bone involvement&#44; lymph node enlargement in the inguinal region&#44; and skin infiltration in the lower limbs&#44; abdomen&#44; and root of the upper limbs&#46; Skin biopsy demonstrated signet ring carcinoma embolizing the dermal and hypodermic vessels and invasion of adipose tissue&#44; confirming carcinomatous lymphangitis&#46; Carcinomatous lymphangitis is the cutaneous and subcutaneous lymphatic invasion by tumor cells&#46; Cutaneous metastasis is relatively uncommon and presents mainly as cutaneous or subcutaneous nodules&#44; and more rarely as inflammatory lesions&#46; The present case reports carcinomatous lymphangitis associated with gastric cancer&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">How to cite this article&#58; Souza BS&#44; Bonamigo RR&#44; Viapiana GL&#44; Cartell A&#46; Signet ring cells in carcinomatous lymphangitis due to gastric adenocarcinoma&#46; An Bras Dermatol&#46; 2020&#59;95&#58;490&#8211;2&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Study conducted at the Hospital de Cl&#237;nicas de Porto Alegre&#44; Universidade Federal do Rio Grande do Sul&#44; RS&#44; Brazil&#46;</p>"
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