ARTICLE
Cutaneous metastases can be found in about 1 to 12% of patients with
lung cancer [1, 2]. About 30% of these pulmonary cutaneous metastases
show histological patterns of adenocarcinoma, 30% squamous cell carcinoma
and 40% undifferentiated carcinoma [3]. Cutaneous metastases of small-cell
carcinoma are much less common [4]. The presentation of cutaneous metastases
as the first manifestation of lung cancer is very rare. In a large review
of Lookingbill et al. [5], skin involvement was the first sign
of cancer in 0.8% of systemic cancer patients.
We describe a rare case of lung cancer with cutaneous metastases as
the first sign of the disease.
Case report
A 75-year-old man, a smoker (50 cigarettes per day for 55 years), had
worked as a miner in uranium mines. In 1984, he had a Bilroth I a stomach
resection for a gastric ulcer. In 1989, he had a transurethral prostatic
resection which showed myofibroadenomatous hyperplasia. At that
time the patient was also treated for ischemic heart disease and chronic
bronchitis.
In 1982, a well-differentiated papillary transitional cell carcinoma
of the urinary bladder was diagnosed. The carcinoma was repeatedly treated
by endoscopic transurethral electroresection, the last time being in 1995.
In spite of local recurrences, neither metastases, nor local tumors expansion
could be detected. Screening chest X-rays and ultrasound examinations
of the liver, spleen, kidneys and abdominal lymph nodes were negative.
In June 1996, the patient was referred to the
department of dermatology for two tumors in the left clavicular region.
They were sharply demarcated, dark red tumors measuring 3 and 2 cm in
diameter and protruding 2 cm above the surrounding skin. The patient reported
a history of rapid growth and intermittent spontaneous bleeding (Fig.
1). Thorough examination of the patient revealed 16 additional
skin lesions in the form of dark red macules and papules, 2-3 mm in diameter,
situated on the left side of the chest (Fig.
2).
Histological examination of three excisions
(tumor, papular and macular lesions) showed an intact epidermis and massive
dermal and subcutaneous infiltration by a poorly differentiated carcinoma.
The infiltrates were organized into nests and large complexes, without
organoid patterns. The histocytological appearance of the tumor cells
corresponded to a small-cell carcinoma of the "intermediate" type. Immunohistochemically,
the tumor cells showed dot-like paranuclear positivity for cytokeratin
filaments (using KL-1 antibody, Immunotech and AE1/AE3 antibody, BioGenex)
and cytoplasmic NSE positivity (Dakopatts). Stainings for chromogranin
A (BioGenex) and carcinoembryonal antigen (BioGenex) were negative. These
findings were consistent with cutaneous metastatic involvement by a small
cell carcinoma with neuroendocrine differentiation, most likely originating
in the lung (Fig. 3).
Subsequent chest X-rays and CT investigations revealed multiple lung,
pleural and costal metastases. Further investigations, such as bronchoscopy
with lavage, or biopsy from extracutaneous masses were refused by the
patient, because of his poor general health. Rapid progression of the
small-cell carcinoma followed, with great numbers of new metastases to
the skin of the chest, abdominal region and both arms, as well as occipital
and parietal regions of the scalp with the development of alopecia neoplastica.
The patient died six months after the first appearance of cutaneous metastases.
Permission for autopsy was refused.
Discussion
Cutaneous metastases tend to appear first near the primary tumor [3].
Thus the common sites of cutaneous metastases are the chest, back, abdomen,
scalp and neck, while occurence on the upper and lower extremities is
rare [2, 3]. Cutaneous metastases portend a poor prognosis. Patients with
carcinoma of the lung generally die 3-5 months after the first appearance
of cutaneous metastases [2], and a similar poor prognosis is evident in
patients with cutaneous metastases from other types of tumors [4].
In the present case, the patient had a history of reccurrent transitional
cell carcinoma of the urinary bladder. Thus, the multiple cutaneous metastases
at the time of presentation, were considered to be metastatic transitional
cell carcinoma. The histological appearance of the cutaneous lesions however,
was unlike papillary transitional cell carcinoma and instead showed a
small cell carcinoma. The differential diagnoses of small-cell carcinoma
include small-cell carcinoma metastatic from the lung, oesophagus, or
gut, as well as medullary carcinoma of the thyroid, lymphoma, Merkel cell
tumor and melanoma [4]. The absence of typical cytological findings of
Merkel cell carcinoma, including the lack of finely dispersed "lymphoblastoma
like" chromatin, caused us to favor a cutaneous metastasis [6, 7]. The
origin of the tumor appears to be the lung, as the CT scan showed multiple
pulmonary lesions, pleural and costal metastases.
Transitional cell carcinoma is rarely metastatic to the skin. The knowledge
of the relative tendency of two different tumors to metastasize, as well
as the location to where they tend to metastasize can lead the clinician
to the likely diagnosis.
REFERENCES
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4. Schwartz RA. Histopathological aspect of cutaneous metastatic disease.
J Am Acad Dermatol 1995; 33: 649-57.
5. Lookingbill DP, Spangler N, Sexton FM. Skin involvement as the presenting
sign of internal carcinoma. J Am Acad Dermatol 1990; 22: 19-26.
6. Eusebi V, Capella C, Cossu A, Rosai J. Neuroendocrine carcinoma within
lymph nodes in the absence of a primary tumor, with special reference
to Merkel cell carcinoma. Am J Surg Pathol 1992; 16: 658-66.
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