Cutaneous metastasis from carcinoma of lung.

A 65-year-old male with a history of smoking since 30 years presented with breathlessness, hemoptysis, multiple swellings all over the body, and weakness in September 2010 at our hospital. Clinically, a diagnosis of chronic obstructive pulmonary disease (COPD) with cutaneous lymphoma or soft tissue tumor was made. Chest X-ray (CXR) and computed tomography (CT) scan revealed a neoplastic lesion in the right lung with secondary cavitation. Biopsy of the cutaneous nodules showed metastatic deposits from squamous cell carcinoma. Metastatic skin cancer is a relatively rare complication of internal malignancy. The clinical features of metastatic skin disease vary enormously. They may present as erysipeloid, sclerodermoid, alopecia neoplastica or in an inflammatory or bullous form or as multiple nodules as in our case. A high index of suspicion for metastatic deposits is required in an elderly male patient who is a known case of lung cancer or even one who is a chronic smoker and presents with such cutaneous lesions.

CASE REPORT

A 65-year-old male who was a chronic smoker for the last 30 years presented with generalized weakness, breathlessness, occasional hemoptysis, and multiple cutaneous nodules (8 in number) all over the body since two months. The nodules were present over the chest (2), abdomen (1), back (2), face (1), and both the extremities (2). They were of varying sizes, ranging from 2 to 6 cm and were firm, nontender, and mobile. Some of them were infected [Figure 1]. Systemic examination was normal except for the presence of occasional crepitations and rhonchi. A clinical diagnosis of chronic obstructive pulmonary disease (COPD) with cutaneous lymphoma or soft tissue tumor was made.

Figure 1

Clinical photograph showing nodule over abdominal wall

Hematological investigations revealed the following:

Hb (hemoglobin): 14.4 gm%; TLC (total leukocyte count): 19,100/cmm; DLC (differential leukocyte count): P87L10E0M03.

ESR (erythrocyte sedimentation rate): 28 mm at the end of one hour.

Sputum examination was negative for malignant cells.

Chest X-ray (CXR) and computed tomography (CT) showed neoplastic right lung and bronchial mass with secondary cavitation.

Excision biopsy of the noninfected nodule from the back was done and the specimen was received by the department of pathology.

On gross examination, it was an irregular tissue measuring 6×3.5×1 cm with a nodule 3 cm in diameter which was surrounded by adipose tissue and muscle.

The cut section of the nodule was grayish white and firm in consistency.

The histopathological sections from the nodule showed metastatic deposits from squamous cell carcinoma, moderately differentiated (grade II) [Figures 2 and 3].

Figure 2

Photomicrograph showing metastatic deposits from squamous cell carcinoma (grade II) [H & E, 10X]

Figure 3

Photomicrograph showing pleomorphic tumor cells infiltrating muscle fibers [H & E, 40X]

DISCUSSION

Cutaneous metastasis refers to the growth of cancer cells in the skin originating from internal cancer.[1] In most cases, cutaneous metastasis develops after initial diagnosis of the primary internal malignancy and late in the course of the disease. In very rare cases, skin metastasis may occur at the same time or before the primary cancer has been detected.[12]

In the present case skin metastases and primary cancer were diagnosed at the same time.

Cutaneous metastases occur in 0.7–9 % of all patients with cancer. The most frequent source of metastases in men are the lung (24%), colon (19%), melanoma (13%), and oral cavity (12%).

In women, they are the breast (69%), colon (9%), melanoma (5%), ovaries (4%), and lung (4%).

In men younger than 40 years, the most common source of cutaneous metastases is melanoma, whereas in males older than 40 years, the most common source is carcinoma of the lung.[3]

Our case was a 65-year-old male and the source of cutaneous metastases was carcinoma of the lung.

The percentage of patients with lung cancer who develop cutaneous metastases ranges from 1 to 12%.[2]

Most cutaneous metastases occur in a body region near the primary tumor.[3]

Commonly, the skin metastases are seen over the chest, abdomen, followed by the scalp, head and neck, extremities, and back.[12345]

Clinically, the common presentation of cutaneous metastases is in the form of solitary or multiple nodules. Other morphological patterns include carcinoma erysipeloides, carcinoma en cuirrase, carcinoma telangiectaticum, Sister Mary Joseph's nodule, alopecia neoplastica, and cicatricial and bullous forms.[6]

Metastases from lung cancer are macroscopically indistinguishable from metastases of other cancers. Usually they present as fast-growing solitary or multiple nodules with a diameter of 5 mm–10 cm and are firm, mobile, and covered with normal skin. Sometimes exudative or ulcerative lesions are also seen.[7]

In the present case, the nodules varied in size from 2 to 5 cm in diameter, and were firm and mobile. Majority of them were covered with normal skin; however, some were ulcerated.

The most common histologic type of carcinoma of the lung that metastasizes to skin is adenocarcinoma followed by squamous cell carcinoma, and small-cell and large-cell carcinoma. Metastatic deposits from squamous cell carcinoma are often moderately to poorly differentiated.[2]

The metastatic deposits from our case showed moderately differentiated squamous cell carcinoma.

Metastases to skin may occur by a hematogenous route or via lymphatics. Carcinoma of the breast and carcinoma of the oral cavity spread via lymphatics, whereas the rest of the cancers spread mainly via a hematogenous route. Lymphatic dissemination may explain why skin metastases tend to be close to the primary site of the tumor.[8]

However, in our case, the metastatic nodules were seen all over the body, suggesting lymphatic as well as hematogenous spread.

The prognosis of cutaneous metastases is extremely poor.[8] Despite the combination of radiotherapy and chemotherapy, patients with lung cancer with cutaneous metastases have a poor prognosis; median survival of patients with lung cancer metastases is 3–6 months.[7]

Unfortunately, our patient went home against medical advice. So, further follow-up was not possible.