A Case of Multifocal Skin Metastases from Lung Cancer Presenting with Vasculitic-type Cutaneous Nodule.

Although cutaneous metastasis occurs usually at the terminal stage of the disease, it may be rarely concurrent with the diagnosis and may also present as the first sign of the illness. A 55-year-old male patient presented with vasculitic-type cutaneous nodular lesions and a necrotic distal phalangeal lesion developed over the last month. He was a tradesman and smoked 40 packets year. On physical examination, he was found to have multiple cutaneous lesions on the skin of the face, limbs, neck, scalp, dorsal side, fingers, subungual side, right leg, and feet. A skin lesion punch biopsy was performed and squamous cell carcinoma metastasis was detected. He was diagnosed as having squamous cell lung cancer with bronchoscopic biopsy. Although it is very rare, cutaneous metastases that is concurrent with the diagnosis of lung cancer may be the first sign of the disease. In patients with suspicious skin lesions, the patient's age, smoking history, and other symptoms should be evaluated and a biopsy should be performed.

What was known?

Aproximatelly, 1-12% of patients with lung cancer develop cutaneous metastasis.

Introduction

Non-small cell lung cancer (NSCLC) is the most common cause of cancer death in the world. Most patients with lung cancer are diagnosed as advanced stage and 5-year survival is about 10% in the setting metastatic disease.[1] The most common sites of metastasis from lung cancer include the bones, liver, adrenal gland, and brain, while the skin is rarely affected and is associated with poor prognosis. Approximately 1-12% of patients with lung cancer develop cutaneous metastases.[23]

Although cutaneous metastasis occurs usually at the terminal stage of the disease, it may be rarely concurrent with the diagnosis and may present as the first sign of the illness.[45678] The hands, subungual side, and digital skin are extremely unusual site of metastasis and account for approximately 0.2% of metastases of the lung carcinomas.[9] Subungual metastasis may be confused with other benign inflammatory diseases such as vasculitis. However, some vasculitic lesions that are also called “pseudovasculitis” can be mimicked by other disease such as malignancies metastasized to the skin. As a result, these lesions that mimic vasculitic lesions may cause a delay in cancer diagnosis. Herein, we have reported a case of patient who was preliminarily diagnosed with vasculitis and was later diagnosed with skin metastases of non-small cell lung cancer.

Case Report

A 55-year-old male patient presented to our rheumatology clinic with cutaneous nodular lesions and a necrotic distal phalangeal lesion, which had developed over the last month. In his medical history, he had been diagnosed with tuberculosis 23 years ago and had been treated with anti-tuberculosis therapy. He smoked 40 packets-years. There were no fever, weight loss, and night sweats. His physical examination revealed multiple cutaneous lesions on the skin of the face, limbs, neck, scalp, dorsal side, fingers, subungual side, right leg, and feet. The lesions were painless, fragile, dark purple colored, measuring 1-3 cm, arising from the subcutaneous tissue, and with a tendency to bleed, one of them caused distal finger auto-necrosis [Figure 1]. His complete blood count and serum biochemistry was unremarkable. Erythrocyte sedimentation rate was 51 mm/h (↑), C-reactive protein: 105 mg/L (↑), lactate dehydrogenase: 212 IU/L (↑), carcinoembryogenic antigen: 3.69 ng/ml, (N), anti-microsomal antibody: 220.54 IU/ml (↑) (N < 5.61), and anti-thyroglobulin antibody: 29,25 IU/ml (↑), (N < 4.11). Necrotic and nodular skin lesions were thought to be symptomatic of vasculitis. Rheumatologist evaluated the patient and clinical and laboratory findings of the patient were not consistent with vasculitis. A punch biopsy from the skin lesion was performed. Histopathological examination of the biopsy specimen revealed a cutaneous metastasis, probably from squamous cell carcinoma of the lung. Biopsy material was immunohistologically negative for surfactant and TTF-1, and positive for P 63. On thorax computerized tomography (CT), a left hilar mass with 5.5 × 3.5 × 6 cm dimensions was detected. He was diagnosed with squamous cell lung cancer after bronchoscopic biopsy. Staging work-up including abdominal CT and Tc-99m bone scan revealed liver and bone metastasis. The patient received palliative radiotherapy to the metastatic bones. Then, he was treated with combination chemotherapy regimen consisted of docetaxel (75 mg/m2/day for every 3 weeks) and cisplatin (75 mg/m2/day for every 3 weeks) with support granulocyte stimulating factor. After 3 chemotherapy courses, his skin lesions tended to disappear with scar tissue [Figure 2]. But his liver metastasis progressed and a new lesion on surrenal gland was detected. Therefore, a second-line chemotherapy protocol was given 6 courses, but only partial response was obtained. The patient died 10 months after the initial diagnosis due to disease progression.

Figure 1

Multifocal skin metastases before the therapy

Figure 2

Imaging skin metastases after the therapy

Discussion

Cutaneous metastasis from lung cancer is uncommon at the presentation of disease. It occurs usually at follow-up period of patients with cancer. All histologic types of lung cancer can metastasize to the skin. However, the most common histologic type causing metastasis to the skin is adenocarcinoma, followed by squamous cell carcinoma, small cell carcinoma, and large cell carcinoma.[2310] In our case, it was the histologic type was squamous cell carcinoma. Interestingly, it has been reported that upper lobe malignancies are susceptible to skin metastasis.[4]

Cutaneous metastasis is often painless, nodular, single, or multiple lesions and may be mobile or fixed presentations. The hand, subungal side, and digital skin are an extremely unusual site of metastasis. Their size can be various from 2 mm to 6 cm in diameter.[9] Metastatic tumorun metastasisows: Them caused distal finger autonecrosis can be located anywhere on the skin, but they tend to be near the primary tumor site. The most common cutaneous metastasis sites are the thorax, back, and abdomen wall.[246] The scalp is a favorite site of cutaneous metastasis of lung cancer, representing 54% of all cutaneous metastases of this cancer. The reason of higher scalp metastasis may be rich blood flow.[25] A skin biopsy should be performed for differential diagnosis of vasculitis and metastasis. In our case, the nodular skin lesions were more than ten in number and these lesions were different localizations including the back, chest wall, scalp, soles, lips, and nails. The metastatic lesions showing necrosis, which were evaluated as vasculitic lesions, were at the finger tip and toe nail bed.

Radiotherapy, amputation, or observations are treatment options for digital metastasis. Response to chemotherapy is poor, possibly because of poor blood supply to the skin.[11] Interestingly, skin metastases of our patient responded well to chemotherapy, but progression was determined in solid internal organ metastases under first-line treatment. The median survival is approximately 3 months in patients with skin and organ metastasis, whereas the survival reaches 10 months in patients with only skin metastasis.[12] Our patient survived about 10 months after the time of diagnosis, although the patient had liver and bone metastases.

Although it is very rare, cutaneous metastases, which may be concurrent with the diagnosis of lung cancer, may be the first sign of the disease. The metastatic lesions at the skin may be confused with other benign diseases such as vasculitis and inflammatory disease. Therefore, patients with suspicious skin lesions should be evaluated with biopsy.

What is new?

Cutaneous metastasis may be presenting with vasculitic-type noduls.