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 Table of Contents  
CORRESPONDENCE
Year : 2015  |  Volume : 2  |  Issue : 1  |  Page : 73-75

Adenocarcinoma lung presenting as multiple cutaneous metastasis: A rare initial presentation of lung carcinoma


Department of Pulmonary Medicine, King George's Medical University, Lucknow, Uttar Pradesh, India

Date of Web Publication23-Jun-2015

Correspondence Address:
Dr. Surya Kant
Department of Pulmonary Medicine, King George's Medical University, Lucknow, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2349-4220.159179

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How to cite this article:
Prakash V, Verma AK, Joshi A, Kant S, Bhatia A, Mishra AK. Adenocarcinoma lung presenting as multiple cutaneous metastasis: A rare initial presentation of lung carcinoma. Int J Adv Med Health Res 2015;2:73-5

How to cite this URL:
Prakash V, Verma AK, Joshi A, Kant S, Bhatia A, Mishra AK. Adenocarcinoma lung presenting as multiple cutaneous metastasis: A rare initial presentation of lung carcinoma. Int J Adv Med Health Res [serial online] 2015 [cited 2020 Nov 26];2:73-5. Available from: https://www.ijamhrjournal.org/text.asp?2015/2/1/73/159179

Sir,

Lung cancer is the most common cancer in the world, accounting for the highest cancer-related deaths. [1] It is a disease of the older age group mainly affecting in 55-65 years of age. The 5-year survival rate is only around 15%. The disease presents in most of the cases in late stages only, that is stage III and IV. This implies that the presentation with a distant metastasis itself at the time of diagnosis is not unusual. The usual sites for metastasis of lung cancer include hilar and mediastinal lymph nodes, adrenal glands, liver, brain, and bone. [2] However, lung cancer presenting as cutaneous metastases at the time of diagnosis is a rare phenomenon. That is the reason we are reporting this case where the fine-needle aspiration cytology (FNAC) from cutaneous lesions lead to the diagnosis of lung cancer. This case highlights the importance of the fact that since lung cancer is a highly malignant disease and in most cases the patients present only in late stages suspicious skin lesions may be the only initial presenting complaint of a lung cancer patient. Hence, any skin nodule particularly in the older age group should be subjected to cytopathology/histopathology to rule out metastasis.

A 60-year-old nondiabetic, nonhypertensive male who was farmer by occupation presented to our department with complaints mainly of nonhealing ulcer over right hip, nodular skin lesions over left hypochondrium and left lumbar region associated with chest pain and loss of appetite since last 4 months. Patient was a heavy cigarette smoker with a pack years of about 20. General examination revealed single large, firm, fixed, non-tender, ulcerative skin lesion with hyperemic and necrotic center located on the right hip [Figure 1]. He also had 2 nodular lesions over left hypochondrium and left lumbar region. Rest of the systemic examination was not significant. Respiratory examination showed findings suggestive of some space occupying pathology on the right side in the form of diminished air entry with dullness on percussion. Routine blood investigations were within the normal range. Detailed evaluation was carried out to confirm and characterize the nature of skin lesions and also confirm the probable respiratory pathology. In this process, FNAC from the ulcer and swelling were carried out along with a chest X-ray also. FNAC revealed poorly differentiated adenocarcinoma [Figure 2] and X-ray was suggestive of right-sided collapse and probable intrathoracic mass along with hyperinflation of left lung. For confirmation of X-ray findings and further evaluation contrast enhanced computed tomography thorax was requested, which was suggestive of right-sided pleural-based mass with obliteration of right main bronchus with right-sided collapse along with fibrocavitatory lesions in right lower lobe [Figure 3]. Bronchoscopy was done that revealed a friable growth in right main bronchus, which was completely obliterating the same [Figure 3]. Histopathology of the tissue from the endobronchial growth showed adenocarcinoma lung [Figure 4]. Since both histopathologies were similar a diagnosis of adenocarcinoma lung with cutaneous metastasis was labeled. As the overall prognosis was very poor the patient refused any further workup or intervention and passed away after 1.5 months of discharge.
Figure 1: Ulcerative skin lesion over the right hip

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Figure 2: Fine-needle aspiration cytology from right hip and abdominal swelling suggestive of malignant cells suggestive of metastasis from adenocarcinomas

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Figure 3: Computed tomography — Thorax showing pleural base soft tissue attenuated mass lesion obliterating right main bronchus with compensatory hyperinfl ation of contralateral lung with fibrocavitatory lesions in right lower lobe and the corresponding bronchoscopic picture showing necrotizing mass occluding the right main bronchus encroaching the carina

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Figure 4: Endobronchial biopsy suggestive of malignant cells suggestive of adenocarcinomas

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Systemic metastasis is a common finding in lung cancer. Nearly 43% of lung cancer patients may have distant metastasis at the time of diagnosis. [3] However, skin metastasis in lung cancer is rare and when present implies very bad prognosis. [4],[5] The frequency of metastasis to skin in lung cancer varies with the histological type. It is 0.81% for small cell lung cancer, 2.95% for adenocarcinomas and 1.16% for squamous cell carcinoma. Clinical presentation may range from a red-pink, ulcerated nodule to a hard fixed swelling beneath the skin, and can be the first and only sign of the tumor. [4],[6] This same was the scenario in our case also where the retrograde approach to look for the primary in a cutaneous metastasis confirmed the presence of a suspicious lung lesion which on further workup eventually came out to be adenocarcinoma lung. The patient was not having any respiratory and systemic complaints. This unusual and rare way of initial presentation of lung cancer where the FNAC from cutaneous lesions has paved the pathway for diagnosis has been rarely reported. The most common sites for skin metastasis in lung cancer are skin over the chest, back, abdomen, and scalp. [6],[7] Rarely metastasis may involve skin over gingiva, scrotum, perianal skin, lip, nose, burn scars, fingers and toes. [8] After the diagnosis of a cutaneous metastasis, median survival is between 2.9 and 4.9 months. [9]

Lung malignancy is the quickest to metastasize to the skin after the establishment of initial diagnosis with a mean time of approximately 5.75 months. [10] Cutaneous metastases from the lung are frequently moderately or poorly differentiated on histopathology. [6],[11] The metastasis to skin occurs after invasion of the lymphovascular system and is usually limited to the dermis and subcutaneous layer. [12]

Immunohistochemistry may be useful when there is a cutaneous metastasis with unknown primary to locate the origin. [12] A similar histological finding from the primary and the suspect cutaneous metastasis confirms the diagnosis of a cutaneous metastasis. Molina et al. proposed that lung primary in the upper lobes have a greater tendency for cutaneous metastasis.

Solitary skin metastases can be treated through surgery alone or in combination with chemotherapy, and/or radiation. For multiple cutaneous metastatic lesions or if associated with internal metastases chemotherapy is the primary option. During the course of chemotherapy response, monitoring for the entire malignancy can be done by observing the response of these lesions. A bleeding or painful metastatic lesion may require irradiation. [6]


  Conclusion Top


Lung cancer usually presents with a wide variety of respiratory and systemic complaints. But, skin nodules or ulcers due to cutaneous metastasis though rare may also be the initial presentation in a lung cancer patient. Hence while dealing with any skin nodule particularly in the older age group and heavy smokers cutaneous metastasis should be kept in mind as a differential and the lesion should be subjected to cytopathology/histopathology to rule out metastasis.

 
  References Top

1.
Rolz-Cruz G, Kim CC. Tumor invasion of the skin. Dermatol Clin 2008;26:89-102, viii.  Back to cited text no. 1
    
2.
Golijan EF. Rapid Review Pathology. 2 nd ed. St. Louis: Mosby; 2006. p. 321-4.  Back to cited text no. 2
    
3.
Alamoudi OS. Lung cancer at a University Hospital in Saudi Arabia: A four-year prospective study of clinical, pathological, radiological, bronchoscopic, and biochemical parameters. Ann Thorac Med 2010;5:30-6.  Back to cited text no. 3
[PUBMED]  Medknow Journal  
4.
Rosen T. Cutaneous metastases. Med Clin North Am 1980;64:885-900.  Back to cited text no. 4
    
5.
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. 5
    
6.
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. 6
    
7.
Neel V, Sober A. Metastatic tumors to the skin. Cancer Medicine. Danbury: B. C. Decker; 2003.  Back to cited text no. 7
    
8.
Perng DW, Chen CH, Lee YC, Perng RP. Cutaneous metastasis of lung cancer: An ominous prognostic sign. Zhonghua Yi Xue Za Zhi (Taipei) 1996;57:343-7.  Back to cited text no. 8
    
9.
Lookingbill DP, Spangler N, Helm KF. Cutaneous metastases in patients with metastatic carcinoma: A retrospective study of 4020 patients. J Am Acad Dermatol 1993;29:228-36.  Back to cited text no. 9
    
10.
Marcoval J, Moreno A, Peyrí J. Cutaneous infiltration by cancer. J Am Acad Dermatol 2007;57:577-80.  Back to cited text no. 10
    
11.
Coslett LM, Katlic MR. Lung cancer with skin metastasis. Chest 1990;97:757-9.  Back to cited text no. 11
    
12.
Saeed S, Keehn CA, Morgan MB. Cutaneous metastasis: A clinical, pathological, and immunohistochemical appraisal. J Cutan Pathol 2004;31:419-30.  Back to cited text no. 12
    


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



 

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