Clinical Dermatology Review

CASE REPORT
Year
: 2020  |  Volume : 4  |  Issue : 2  |  Page : 179--181

Cutaneous metastasis as a presenting feature of adenocarcinoma of lung


Rashmi Mahajan, Srishti Jain, Kishan Ninama, Yogesh S Marfatia 
 Department of Skin and VD, SBKS MI and RC, Sumandeep Vidyapeeth, Vadodara, Gujarat, India

Correspondence Address:
Srishti Jain
Department of Skin and VD, SBKS MI and RC, Sumandeep Vidyapeeth, Piparia, Vadodara, Gujarat
India

Abstract

Metastasis is a neoplastic lesion which arises from another neoplasm with which it is no longer in continuity. Cutaneous metastasis is the spread of malignant cells from a primary malignancy to the skin. Skin metastases occur in about 5.3% of patients with internal malignancies and represent 2% of all skin tumors. Breast cancer, in women, and lung cancer, in men, are the most common origins of cutaneous metastasis. It mostly occurs late in the course of disease. Herein, we report the case of a 97-year-old male who presented with asymptomatic, hyperpigmented, indurated plaques with crusting and few overlying tense bullae over the right side of the chest extending to the right axilla for 4 months. On evaluation, he was diagnosed as a case of metastatic adenocarcinoma, the primary being from the lung. He succumbed to his illness within 2 months of diagnosis.



How to cite this article:
Mahajan R, Jain S, Ninama K, Marfatia YS. Cutaneous metastasis as a presenting feature of adenocarcinoma of lung.Clin Dermatol Rev 2020;4:179-181


How to cite this URL:
Mahajan R, Jain S, Ninama K, Marfatia YS. Cutaneous metastasis as a presenting feature of adenocarcinoma of lung. Clin Dermatol Rev [serial online] 2020 [cited 2020 Oct 24 ];4:179-181
Available from: https://www.cdriadvlkn.org/text.asp?2020/4/2/179/292473


Full Text



 Introduction



Cutaneous metastases from lung carcinoma have been estimated at a rate of 1.7%–3%. It signifies a poor prognosis indicating advanced disease.[1],[2],[3] In approximately 8% of patients, it may be the presenting sign of underlying malignancy or a clue to tumor recurrence.[3],[4],[5] The detection of skin metastases hence requires a high index of clinical suspicion. The final diagnosis is established by histopathology, followed by thorough clinical workup to identify the site of primary malignancy.[3]

 Case Report



A 97-year-old male patient presented with painful gradually progressive skin lesions over the right side of the chest for 4 months. The history of cough with expectoration with breathlessness and pain was present. The patient had a history of significant weight loss.

On examination, well-defined erythema and induration were seen over the right side of the chest with ulcerated plaques, nodules, and few tense bullae [Figure 1]a and [Figure 1]b. Cervical lymph nodes, inguinal lymph nodes, and right axillary lymph nodes were palpable, nontender, and fixed to underlying tissue. Significant edema of the right upper limb was noted [Figure 1]c.{Figure 1}

Complete blood count and liver and renal function tests were all within the normal limits. Serum lactate dehydrogenase level was raised (924 U/L). Chest X-ray revealed right-sided gross pleural effusion with septations with collapse of underlying lung [Figure 2]. Ultrasonography of local part revealed metastatic nodule/primary nodule with infiltration of anterior, lateral, and posterior aspects of the right chest wall – muscle and skin plane. Heterogenous lymph node with internal necrotic area and internal calcification seen in the right axillary region and cervical lymph node, largest measuring 3.3 cm × 2.2 cm, suggestive of metastatic lymph node. Computed tomography scan of the thorax with abdomen and pelvis (contrast) revealed possibility of malignant mass lesion in the upper lobe of right lung. The left lower lobe and left apical region also showed contralateral extension of the same. Skeletal metastasis, skin involvement over the right chest, and multiple lymph node involvement were noted. Fine-needle aspiration cytology (FNAC) from the right axillary lymph nodes did not show any abnormality. Skin biopsy showed glandular complexity, moderate to marked nuclear atypia with marked pleomorphism, prominent nucleoli, and frequent mitosis in the background of fibrous stroma [Figure 3]a and [Figure 3]b. Overall features were suggestive of metastatic adenocarcinoma. The skin lesions were metastatic lesions from the underlying primary lung adenocarcinoma.{Figure 2}{Figure 3}

The patient succumbed to his illness within 2 months of diagnosis.

 Discussion



A skin nodule or tumor, especially the one that is recently discovered, noninflammatory associated with painless, persistent-indurated erythema, and nonhealing ulcers should raise the suspicion of metastasis. Such lesions offer an easily accessible tissue sample for histopathological diagnosis, and their detection may alter the staging and prognosis of internal malignancy. Skin metastases may herald a recurrence of a malignancy after its successful treatment. A thorough clinical examination of the skin for any suspicious lesions is, therefore, recommended in a patient with any type of cancer.[6]

Skin metastases from internal malignancies occur in approximately 5.3% of patients with cancer and represent 2% of all skin tumors.[1],[3] In approximately 8% of patients, cutaneous lesions may be the presenting sign of underlying malignancy or clue to tumor recurrence, especially in the cases of carcinoma of the lung, kidney, and ovary.[3],[4],[5] The dissemination occurs through hematogenous, lymphatic, direct or iatrogenic spread.[1] The most common origins of cutaneous metastases are breast cancer in women and lung cancer in men.[1]

The various clinical presentations of cutaneous metastasis are broadly divided into three groups: nodular, sclerodermoid carcinoma en cuirasse (CEC), and inflammatory (carcinoma erysipeloides).[5] Histopathologically, there are four main morphologic patterns of cutaneous metastases involving the dermis, namely nodular, infiltrative, diffuse, and intravascular.[3]

Lung cancer may metastasize as clusters of papules or nodules or sometimes a solitary nodule, which are asymptomatic, moveable, firm and are flesh-colored, pink, or violaceous. Occasionally, carcinoma erysipeloides or CEC has been reported.[1] The most common sites are the anterior chest wall, back, and scalp.[1],[2],[3],[7] In a study by Brady et al., 7% of patients were found to have a skin nodule before diagnosis of the primary lung tumor and 16% had cutaneous metastases at the time of diagnosis.[8] They may be of undifferentiated type in 40% of patients and adenocarcinomatous and squamous cell carcinoma types in 30% each.[9] Adenocarcinoma of the lung with metastases to the skin and skull has been reported previously.[1],[10] Simsek et al. reported a case of cutaneous metastasis due to small cell lung carcinoma.[7]

This case is being reported to highlight the clinical features of cutaneous metastasis in adenocarcinoma of the lung. In our case, FNAC from ipsilateral axillary lymph nodes did not show any abnormality. However, cytomorphology (FNAC) done from dermatological metastasis often gives a clue to possible primary sites. Nodular lesions are amenable to FNAC, hence obviating the need for a surgical biopsy. The presence of malignant cells on cytology indicates the development of secondary malignancies or a failure of therapy. Tissue smears from metastatic neoplasms may help in diagnosing the primary tumor by paying careful attention to nuclear configuration, chromatin patterns, nucleoli, cytoplasmic details, and cellular configuration. Both FNAC and tissue smear may help in reducing the time and cost required for surgical biopsies. Histopathological diagnosis of the malignancy can be done easily from cutaneous lesions. They can serve as a diagnostic clue to recurrence. Dermatologists can play a crucial role in picking up internal malignancy.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Brown DN, Chibnall R, Sheinbein D, Rosman IS, Musiek A. An unusual presentation of metastatic disease: Cutaneous metastases from pulmonary adenocarcinoma manifesting as widespread plaques. JAAD Case Rep 2015;1:378-80.
2Rajagopal R, Arora PN, Ramasastry CV, Kar PK. Skin changes in internal malignancy. Indian J Dermatol Venereol Leprol 2004;70:221-5.
3Alcaraz I, Cerroni L, Rütten A, Kutzner H, Requena L. Cutaneous metastases from internal malignancies: A clinicopathologic and immunohistochemical review. Am J Dermatopathol 2012;34:347-93.
4Kaur J, Puri T, Julka PK, Gunabushanam G, Iyer VK, Singh MK, et al. Adenocarcinoma of the gall bladder presenting with a cutaneous metastasis. Indian J Dermatol Venereol Leprol 2006;72:64-6.
5Kaur S, Aggarwal P, Dayal S, Sangwan A, Jain VK, Jindal N. Cutaneous metastasis from signet-ring gastric adenocarcinoma in a carcinoma en Cuirasse pattern: An unusual clinical-diagnostic sequence. Indian J Dermatol 2015;60:637.
6Oberoi C, Viswanath V, Sathe RK, Gala AH. Skin Manifestations of internal diseases. In: Sacchidanand S, Oberoi C, Inamadar AC, editors. IADVL Textbook of Dermatology. 4th ed. Mumbai: Bhalani Publishing House; 2015. p. 1977.
7Simsek GG, Karadag AS, Turksen Z. Cutaneous metastasis of the small cell lung cancer. Indian J Dermatol Venereol Leprol 2011;77:537.
8Brady LW, O'Neill EA, Farber SH. Unusual sites of metastases. Semin Oncol 1977;4:59-64.
9Brownstein MH, Helwig EB. Metastatic tumors of the skin. Cancer 1972;29:1298-307.
10Farley R, Manolidis S, Ratner D. Adenocarcinoma of the lung metastatic to the skull presenting as a scalp cyst. J Am Acad Dermatol 2006;54:916-7.