A Case of Trousseau's Syndrome Associated to Advanced Gastric Cancer With Skin Metastasis

Introduction: Unprovoked thrombotic events can be the initial manifestation of occult malignancies. The hypercoagulable state observed in many cancer patients places them at risk of venous thromboembolic events (VTE) such as visceral vein thrombosis, deep vein thrombosis and pulmonary embolism. The risk for VTE in cancer patients has shown to be several-fold higher when compared to the general population or noncancer patients. We present a case of a VTE as the initial presentation of gastric adenocarcinoma. Case Description/Methods: 61-year-old female with history cervical cancer status post hysterectomy, past smoker and untreated chronic hepatitis C virus infection presented to the emergency department with a 2-week history of left side neck and arm swelling, erythema and pain associated with abdominal pain and nausea. Chest CT showed diffuse lymphadenopathy (LAD), left jugular vein thrombosis, left axillary vein partial thrombosis, complete thrombosis of the left subclavian vein and thoracic wall collaterals in the brachiocephalic trunk. She reported early satiety, loss of appetite and weight loss for the past 3 months. Abdominopelvic CT revealed intra-abdominal LAD and PET/CT showed bilateral supraclavicular, left axillary, diffuse abdominal LAD and hypermetabolic lesions involving the bone marrow. Left axillary node biopsy showed evidence of metastatic adenocarcinoma with signet ring cell-like features. In view of this, an upper endoscopy was done, identifying an infiltrative lesion at the antrum which was the primary cancer. In view of these findings and patient’s desire palliative chemotherapy was started. The patient later developed an erythematous plaque on the chest. Skin biopsy showed extensive lymphatic permeation of reticular dermis by metastatic adenocarcinoma. Discussion: Armand Trousseau was one of the first to note that migratory or unexpected thrombophlebitis could be associated to occult malignancies. A prospective study in Asian patients showed there was a 3.8% incidence of VTE after the diagnosis of gastric cancer. It has been estimated that around 20% to 30% of VTE are associated to cancer. The benefits of whether to screen for an occult malignancy at the time of an idiopathic or unprovoked VTE remain unclear. Complete history, physical exam and age-related cancer screening can help determine subsequent testing to establish the site and treatment. In this case, a complete and focused evaluation aided in the proper identification of the occult malignancy and avoiding unnecessary workup.Figure 1.: Erythematous plaque on the chest. Punch biopsy of the skin showed evidence of metastatic adenocarcinoma infiltrating the reticular dermis, consistent with the primary tumor.