The Cutaneous Manifestations of Metastatic Lung Cancer: Case Report and Review

Sarah Ferrer-Bruker, DO*

*Third-year Dermatology Resident PGY-6, Palm Beach Consortium for Graduate Medical Education, West Palm Hospital, West Palm Beach, FL; West Palm Beach VA Medical Center, West Palm Beach, FL

Abstract Cutaneous metastasis comprises a tiny minority of skin tumors, estimated at 2%, and its timely diagnosis is extremely important to the clinical course of patients. Cutaneous metastasis of all primary systemic cancers usually indicates a poor prognosis with only a few months of survival time. Lung cancer remains the leading cause of cancer-related death among men and women in the United States. This article highlights an atypical presentation of lung metastasis to the skin and provides an overview of other uncommon and common cutaneous effects of lung cancer in general.

Introduction intestinal resection for colon cancer resulting in Figure 2 Although uncommon in clinical practice, the use of an ostomy bag for more than 18 years. cutaneous metastasis is important to keep on a He also had a history of lung cancer for which clinical provider’s list of differential diagnoses. he underwent partial lobectomy of the right Lung cancer continues to earn listings as the lower lobe along with radiation two years prior “most common cause of cancer-related deaths for a T2aN0M0 lung tumor non-small-cell type in both men and women,” “cancer most likely (adenocarcinoma). He had regular follow-ups to metastasize in general,” and, affecting with all of his subspecialists and primary care dermatologists particularly, “most common tumor providers, and review of systems was negative. to metastasize to the skin in males,” particularly in On exam, his left lower abdomen was significant 1-3 men over 40. The data reinforce the importance for an intact ostomy bag, with superior of having a low threshold for biopsy, especially if and bilateral lower abdominal quadrants patient history directs. demonstrating large, indurated, erythematous and violaceous blanchable plaques oriented Figure 3 Case Presentation horizontally, not extending below his pannus fold. An 83-year-old male presented to our The left aspect of the rash had a “peau d’orange,” dermatology clinic with a complaint of a rash palpable nodularity (Figure 1). on his lower abdomen for approximately two Two 4.0 mm punch biopsies were performed at months. The patient’s rash was asymptomatic. initial consultation, with an initial differential He had cataract surgery planned, which was put diagnosis inclusive of infection; panniculitis; on hold due to this rash, which he attributed to erysipeloid and/or carcinoma en cuirasse-like a reaction from EKG leads placed in the area of presentation of underlying carcinoma; atypical the rash upon his pre-op clearance studies. He angiosarcoma, due to patient history of radiation was sent to the ER for a suspected cellulitis-type to the area; and interstitial granulomatous infection, and subsequently we were consulted. dermatitis. His past medical history was notable for Figure 4

Figure 1

Figure 5

Page 34 THE CUTANEOUS MANIFESTATIONS OF METASTATIC LUNG CANCER: CASE REPORT AND REVIEW Pathology revealed findings consistent with When approached broadly, one retrospective within a fibrotic stroma. metastatic carcinoma, lymphangitic-type spread study of 4,020 patients showed that breast, The most common type of lung cancers reported (Figure 2, H&E). The immunostain pattern melanoma, and lung, in that order, top the list for to metastasize to the skin are adenocarcinoma of CK-7 positive (Figure 3), TTF-1 positive most common cancers to spread to the skin.6 For and large-cell carcinoma, followed by squamous- (Figure 4), and CK-20 negative (Figure 5) older men who present with skin metastases, lung 10 cell. A couple of studies from Japan have favored primary lung carcinoma. cancer is the most common primary, at about demonstrated that large-cell carcinoma has the 24%, followed by colorectal cancer, melanoma, 4 The patient was then referred to hematology/ highest incidence of metastasis to the skin. and carcinoma of the oral cavity. In women, lung oncology. On close review of past records cancer ranks fourth after primary breast cancer, On histology, metastatic adenocarcinoma of the and considering findings on new imaging colon cancer, and melanoma.5-6 Overall, if a lung may display glandular, well-differentiated demonstrating two new masses at an area adjacent patient has lung cancer, their chance of cutaneous structures with mucin, in which case GI, ovarian, to his previous partial lobectomy, this was metastasis varies, ranging 1% to 12%. Although breast and kidney metastases must be ruled thought to be a recurrence of a previous diagnosis the skin is not the first organ it usually spreads to, out. CK 20 paranuclear dot positivity helps of non-small-cell cancer. He was quickly started when it does it does so quickly, with mean time of differentiate from Merkel-cell carcinoma. Other on a chemotherapy regimen of gemcitabine and less than six months.6 types of lung cancer that rarely metastasize to followed regularly in dermatology clinic to track the skin include mesothelioma and bronchial his metastatic lesions. Although initially given an carcinoid, which usually show more of a ominous prognosis, the patient is doing very well. Clinical Presentation trabecular pattern and sometimes present with In most cases, skin metastases present after the 10,11 His abdominal lesions are fading, which correlate carcinoid syndrome. to his overall response to treatment (Figure 6, diagnosis of a known primary. Occasionally, these almost one year after initial biopsy). lesions may be the inciting event that eventually Immunohistochemistry (IHC) has evolved into leads to diagnosis of underlying disease. In one a reliable tool in diagnosis. An IHC battery of study, 11 out of 21 patients with metastatic lung an unknown cutaneous metastasis helps narrow Discussion down the differential diagnosis. Although not Although usually detected in a patient with known cancer had their metastatic skin lesions present as 6 originally studied in the skin, useful markers and widespread disease, on occasion cutaneous the first sign of extranodal disease. include CK 7 and CK 20 and anti-thyroid metastasis may be the presenting sign of clinically Skin metastasis from lung cancer does not have transcription factor (TTF). CK 7 is very silent lung cancer. Early detection of cutaneous a typical presentation. Anatomically, the chest, sensitive and is positive in virtually all cases of metastasis, then, affects how fast a patient may be abdomen, and head and neck are common sites. primary lung adenocarcinoma; however, it has diagnosed and placed on appropriate therapy by Morphologically, lesions are usually nodular, lower specificity since it is also positive in may hematology/oncology. Further, depending on the painless, and may be either single or multiple. The other types of lung carcinoma (70% of large- morphologic presentation, cutaneous metastasis scalp, head and neck are the most common sites, 3,6 cell neuroendocrine, 40% of large-cell, and 23% may not only help with diagnosis of otherwise along with anterior chest and abdomen. Several 12 of squamous-cell). Anti-TTF is a sensitive asymptomatic disease, as with the case presented atypical presentations of metastatic lung cancer and specific marker that identifies pulmonary in this article, but may also serve as a marker in have been described including spread to both origin of an adenocarcinoma, bronchoalveolar monitoring response to chemotherapy. upper and lower limbs, gingiva, genitalia, and 7-8 carcinoma, and small-cell carcinoma if a thyroid incision sites. Although nodules are the most 12 Reviewing statistics involving cancers most likely origin is excluded. common presentation, different patterns have to metastasize to the skin may be confusing. The been reported including zosteriform, ulcerative, Overall, IHC panels are not substitutes for the proportion of patients with metastatic disease fungating, and erysipeloid-like presentations.6-9 big-picture approach to diagnosis, incorporating with cutaneous involvement depends upon the a thorough review of systems and history, exam, particular malignancy. When looking at the and screening tools such as appropriate bloodwork percentage of all patients with metastatic disease Diagnosis and radiologic studies. Communication of the who have developed metastasis particularly to Diagnosis is made on biopsy. Patterns on H&E above to pathology and consulting specialists may the skin, melanoma dominates.6 Differences also are generally either nodules of tumor cells within prove to be invaluable. occur when factoring in age and sex of patients. the dermis or cords of atypical tumor cells mixed

Figure 6 Treatment and Prognosis Treatment approach for any cutaneous metastasis is multidisciplinary. If the cutaneous metastases are localized and discrete, surgery alone or combined with chemotherapy and/or radiation may be possible for functional or even cosmetic reasons. Some studies have shown that treatment of localized disease with surgery or combination modalities may increase survival.13 If disease is more disseminated, chemotherapy remains the best option. Sometimes during chemotherapy, cutaneous lesions may be thought of as a marker for response to therapy. Patients without cutaneous metastasis tend to live longer than those who present with them. Mean survival is short, usually five to six months after diagnosis of cutaneous metastasis. Living past a year, as with our patient, is unusual but has been reported.4-5

Conclusion Although uncommon, cutaneous metastasis may occasionally be the presenting sign of an internal

FERRER-BRUKER Page 35 malignancy. Since lung cancer is so prevalent, 13. Garrido M, Ponce C, Martinez J, Martinez it is an important differential diagnosis of any C, Sevilla J. Cutaneous metastases of lung cancer. unexplained, fresh lesion in someone with risk Clin Transl Oncol. 2005 May;8:330-3. factors. These lesions are usually on the trunk, head and neck, but could present practically anywhere and with many morphologies, like the Correspondence: Sarah Ferrer-Bruker, DO; erysipeloid and peau d’orange presentation in [email protected] this case. Despite an ominous prognosis, early recognition and timely diagnosis usually confers a better survival time, as with our patient. Biopsy is essential, with immunohistochemical panels proving to be helpful and guiding tools. Likely these panels will become more sophisticated and expand their utility in terms of determining prognosis and targets for therapy.

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