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 Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 4  |  Issue : 2  |  Page : 100-102

Cutaneous metastasis: A rare manifestation of squamous cell carcinoma of lung


1 Department of Radiodiagnosis, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India
2 Department of Dermatology, Venereology and Leprosy, The Institute of Post Graduate Medical Education and Research and Seth Sukhlal Karnani Memorial Hospital, Kolkata, West Bengal, India

Date of Web Publication10-Apr-2015

Correspondence Address:
Shweta Khanna
Department of Radiodiagnosis, Indira Gandhi Medical College, Shimla - 171 001, Himachal Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-344X.153634

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  Abstract 

Cutaneous metastasis from lung carcinoma is rare and has ominous prognosis. Due to the absence of any pathognomonic appearance, it is usually misdiagnosed as benign skin lesion. Clinically, lung carcinoma may present first time with cutaneous lesions alone whilst the primary lesion in lung remains quiescent. We present the case of 62-year-old male who presented with cutaneous nodules and on further investigations they turned out be cutaneous metastasis from squamous cell carcinoma of lung.

Keywords: Cutaneous metastasis, cutaneous lesions, squamous cell carcinoma


How to cite this article:
Sood S, Bakshi S, Khanna S, Aggarwal I. Cutaneous metastasis: A rare manifestation of squamous cell carcinoma of lung. Int J Health Allied Sci 2015;4:100-2

How to cite this URL:
Sood S, Bakshi S, Khanna S, Aggarwal I. Cutaneous metastasis: A rare manifestation of squamous cell carcinoma of lung. Int J Health Allied Sci [serial online] 2015 [cited 2020 Oct 31];4:100-2. Available from: https://www.ijhas.in/text.asp?2015/4/2/100/153634


  Introduction Top


Lung cancer is a common neoplasm and in most cases fatal which affects men and women usually after the age of 50 years. Like other organs, skin is also a site of metastasis from various carcinomas. Lung cancer, which spreads to brain, bone, liver, and adrenal glands, is responsible for majority of skin metastasis in men. The skin is reported to be the first site of metastasis in about 25% of lung cancer cases. [1] Like other metastasis, cutaneous metastasis indicates progression of the disease and often portends a fatal outcome.

We present an interesting case report of 62-year-old male who presented with cutaneous nodules, and on further investigation it turned out to be cutaneous metastasis from squamous cell carcinoma of lung.


  Case report Top


A 62-year-old male smoker presented in the dermatology department with painless, skin-colored swelling over the right side of scalp and right lower chest for the past 2 months with progressive increase in their size and history of loss of weight and appetite. On examination, there were well- to ill-defined skin-colored nontender nodules ranging in size from 1 × 0.5 to 3 × 2 cm with no surface change in the right frontal, subcostal region and on left wrist [Figure 1]. The overlying skin was normal and not pinchable. The nodules were not attached to the the underlying tissue and were freely mobile. On X-ray lateral view of skull, there was presence of localized area of decreased bone density in the frontal and parietal region with erosion of the inner table of skull in the frontal region. On X-ray left wrist (anteroposterior (AP) view), there was presence of erosion of the cortex medially at the lower end of shaft of ulna. On X-ray chest (posteroanterior (PA) view), there was presence of ill-defined inhomogeneous air space opacities in the left upper and right lower zone [Figure 2]. On contrast-enhanced computed tomography (CECT) head, a large heterogeneously enhancing soft tissue lesion having both intra- and extracranial components was seen in right frontal region with erosion of underlying frontal bone [Figure 3]. On CECT chest, a heterogeneously enhancing mass was seen in the right hilum and posterior mediastinum measuring 7 × 5.6 cm in size, representing a hilar mass with adjacent mediastinal lymphadenopathy. The mass was compressing the right main bronchus, its branches, and the right branch of the pulmonary arterywith loss of fat planes between them [Figure 4].

Fine-needle aspiration cytology (FNAC) as well as excisional biopsy of the nodule in the right frontal region showed evidence of metastatic squamous cell carcinoma [Figure 5] and [Figure 6]. Transbronchial biopsy from the mass showed findings suggestive of squamous cell carcinoma of lung. In view of the imaging and constellation of clinical features, the final diagnosis of squamous cell carcinoma right hilum with cutaneous metastasis with osseous metastasis to frontal and left ulnar bone was made.
Figure 1: (a) A 62-year-old male with well-defined, skin-colored nodules with no surface change in forehead; (b) Nodules were also seen in the chest wall on right side

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Figure 2: (a) X-ray lateral view skull showing focal osteopenia in frontal and parietal bone with erosion of inner table; (b) Chest X-ray (posteroanterior (PA) view) showing air space opacities in left upper and right lower zone; (c) X-ray bilateral (B/L) wrists showing erosion of cortex medially at lower end of shaft of left ulna

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Figure 3: (a) Contrast-enhanced computed tomography (CECT) head axial images showing heterogeneously enhancing mass in right frontal region (both intra-and extracranial component); (b) Bone window images showing erosion of outer as well as inner cortex of frontal bone

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Figure 4: (a) CECT chest axial images showing heterogeneously enhancing mass in right hilum and posterior mediastinum measuring 7.0 × 5.6 cm in size with a post-contrast CT value of 80-100 Hounsfield units (HU) and (b) coronal image showing the mass has compressed the right main bronchus, its branches, and the right pulmonary artery

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Figure 5: Fine-needle aspiration cytology (FNAC) from skin nodule showing malignant tumor aggregates and squamous cells in aggregates and in isolation

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Figure 6: (a and b) Photomicrographs taken from skin nodule biopsy showing metastatic deposits from squamous cell carcinoma of lung

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  Discussion Top


Clinically, skin metastases vary considerably, but their recognition is important because they can be the first clinical manifestation of a still occult neoplasm. Skin areas usually affected by lung cancer metastasis are chest wall, neck, abdominal wall, scalp, and face; but metastasis [1],[2],[3] to scrotum, lip, nose, perianal region, [4] and fingers [5] have also been reported. Dreizen et al., [6] reported that adenocarcinoma of lung has the highest tendency to metastasize to skin. Brownstein and Helwig [7] reported that adenocarcinoma and squamous cell carcinoma show the equal tendency to involve the skin; while Terashima and Kanazawa [8] and Hidaka et al., [9] noted that the cutaneous metastasis rate was high for large cell carcinomas and low for squamous and small cell variants. Therefore, the histological type of lung cancer with the highest incidence of cutaneous metastases seems to be debated yet. About 1-12% of the patients with lung cancer will develop cutaneous metastases. [6],[10],[11]

There is no typical cutaneous appearance of metastatic lesions which can present as inflammatory, ulcerative, or erythematous papules. Response to chemotherapy is poor in such patients probably because of poor blood supply to the skin. [6]

With no pathognomonic appearance of skin lesions, poor response to treatment and grave prognosis, physicians should be alert about this presentation of lung carcinoma and atypical skin lesions should be evaluated with biopsy and other necessary investigations to find out the spread of disease to guide further adjuvant and supportive treatment.


  Conclusion Top


Skin metastasis can be a manifestation of an occult neoplasm. Metastasis should be kept as a possibility in a patient presenting with cutaneous nodules especially in old age group.

 
  References Top

1.
Ambrogi V, Nofroni I, Tonini G, Mineo TC. Skin metastases in lung cancer: Analysis of a 10-year experience. Oncol Rep 2001;8:57-61.  Back to cited text no. 1
    
2.
Brownstein MH, Helwig EB. Patterns of cutaneous metastases. Arch Dermatol 1972;105:862-8.  Back to cited text no. 2
[PUBMED]    
3.
Kamble R, Kumar L, Kochupillai V, Sharma A, Sandhoo MS, Mohanti BK. Cutaneous metastases of lung cancer. Postgrad Med J 1995;71:741-3.  Back to cited text no. 3
    
4.
Perng DW, Chen CH, Lee YC, Perng RP. Cutaneous metastases of lung cancer: An ominous prognostic factor. Zhonghua Yi Xue Za Zhi (Taipei) 1996;57:343-7.  Back to cited text no. 4
    
5.
Sweldens K, Degreef H, Sciot R, Van Damme B, Peeters C. Lung cancer with skin metastases. Dermatology 1992;185:305-6.  Back to cited text no. 5
    
6.
Dreizen S, Dhingra HM, Chiuten DF, Umsawasdi T, Valdivieso M. Cutaneous and subcutaneous metastases of lung cancer. Clinical characteristics. Postgrad Med 1986;80:111-6.  Back to cited text no. 6
[PUBMED]    
7.
Browntein MH, Helwig EB. Metastatic tumors of the skin. Cancer 1972;29:1298-307.  Back to cited text no. 7
    
8.
Terashima T, Kanazawa M. Lung cancer with skin metastasis. Chest 1994;106:1448-50.  Back to cited text no. 8
    
9.
Hidaka T, Ishii Y, Kitamura S. Clinical features of skin metastasis from lung cancer. Intern Med 1996;35:459-62.  Back to cited text no. 9
    
10.
Rosen T. Cutaneous metastases. Med Clin North Am 1980;64:885-900.  Back to cited text no. 10
[PUBMED]    
11.
Coslett LM, Katlic MR. Lung cancer with skin metastasis. Chest 1990;97:757-9.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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