Cutaneous metastatic lung cancer: Literature review and report of a tumor on the nose from a large cell undifferentiated carcinoma.

Abstract

Cutaneous metastatic disease is a prognostically important diagnosis. We report the case of a 64-year-old man who had an uncommon histologic type of lung cancer--a large cell undifferentiated carcinoma, which was metastatic to the skin of the nose. The relative frequency of cutaneous metastasis is similar to that of primary cancers. Cutaneous disease as the first sign of metastasis is most often seen in cancer of the lung. However, its appearance as a large tumor on the nose, which was observed in this case, is unusual.

Introduction

Cutaneous metastatic disease is an important finding [1-25] Cutaneous metastases occur in 0.7 to 9% of all patients with cancer. [17] They can be the first sign of visceral cancer. Brownstein and Helwig reported that in a series of patients with skin metastases who were seen during dermatologic consultation, the underlying cancer had been undiagnosed in 60% of patients with lung cancer. [7] Lung cancer is more common in men and tends to metastasize early.

The relative frequency of metastatic skin disease tends to correlate with that of the type of primary cancer in each sex [8] Women with skin metastases have primary malignancies in the breast 69% of the time, in the lung 4%, and in the oral cavity 1% [24] In men, the primary disease is most frequently in the lung, with the frequency in the oral cavity and breast being 12 and 2%, respectively. [24]

We report the case of a 64-year-old male smoker who had an unusual histologic type of lung cancer--a large cell undifferentiated carcinoma in an uncommon site: the tip of the nose.

Case report

A 64-year-old man who had smoked 1 pack of cigarettes per day for the previous 30 years was seen for an evaluation of a cutaneous tumor on the tip of his nose of 3 months' duration. The lesion first appeared as a small papule and was diagnosed clinically at another institution as a probable furuncle. A 10-day course of erythromycin was prescribed without benefit, and the nodule continued to enlarge. The patient had a history significant for a right upper lobe bronchoalveolar large cell undifferentiated carcinoma, which had been diagnosed 8 months earlier (stage T3N3M0) and for which he had undergone three cycles of doxorumbicin, vinblastine, and external-beam radiotherapy.

On examination, a solitary cutaneous tumor was observed on the tip of the nose. The lesion was a 1.5-cm, oval, reddish, cauliflower-like tumor, with central yellowish crusting (figure 1). A skin biopsy showed a large cell undifferentiated tumor similar to the lung tumor (figure 2). The nasal skin tumor was treated with 8 weeks of external-beam radiation (3,700 cGy), which resulted in a nearly complete resolution. Although the patient developed no new cutaneous metastases, other metastatic lesions resulted in his death 6 months after the original diagnosis of the cutaneous metastasis.

Discussion

Metastatic lung cancer to the skin is a common form of cutaneous metastasis. It is seen more often in men than in women, and it is sometimes recognized before the primary tumor is diagnosed.[5,8,18-22,26-43] One study of 2,080 cases of lung cancer found macroscopic metastases to the skin in 1.5% of patients. [21] In another series of 56 patients with skin metastases from lung malignancies, 7% developed a metastatic skin nodule before the primary tumor was diagnosed, and 16% had a cutaneous metastasis diagnosed simultaneously with the primary lung tumor. [22] Another report noted that in 11 of 21 patients (52%) with cutaneous metastases from lung cancer, the skin metastasis was the first site of extranodal involvement. [18]

Skin metastases can appear on any cutaneous surface, including the scrotum. [30] The most common sites are the chest wall and posterior abdomen. Oat cell carcinoma of the lung has a predilection for the skin of the back. [18] Most patients with oat cell cancer develop a localized cluster of cutaneous nodules. At times, these nodules resemble those of vascular origin. [9] In rare cases, a zosteriform pattem is seen, [32] as well as that of a metastatic inflammatory carcinoma. [26] Tumors can also be found at the site of a bum scar.[26,35,39] Pulmonary mesothelioma tends to involve skin more often by direct extension than by a distant metastasis. [37,38] It can also be evident in a surgical scar or along needle biopsy tracts. Carcinoid tumors of the lung and from a variety of other anatomic locations can metastasize to the skin. [41,42] They can appear as solitary cutaneous nodules or as multiple cutaneous or subcutaneous nodules anywhere on the skin. The bronchus appears to be the most common site of carcinoi d tumors that metastasize to the skin. Some patients with carcinoid tumor metastases to the skin develop carcinoid syndrome.

A lung cancer metastasis is usually classified only as an adenocarcinoma, a squamous cell carcinoma, or an undifferentiated carcinoma. In men, the most common cancer seen in each of these three nondiagnostic patterns is lung cancer. Brownstein and Helwig found that the histology of pulmonary cutaneous metastases was about 30% adenocarcinoma, 30% squamous cell carcinoma, and 40% undifferentiated carcinoma. [8] Much less common are the patterns of bronchiolar carcinoma, large cell undifferentiated carcinoma, mucoepidermoid carcinoma, carcinoid, pulmonary sarcoma, small cell carcinoma, and the rare intravascular bronchoalveolar tumor. [8,29,33,34] When they appear adenocarcinomatous, well-formed mucin-secreting glandular structures can sometimes be seen. [3] Undifferentiated cutaneous metastases of pulmonary origin are often of the small cell type that histologically resembles a lymphoma. [9] Small cell carcinoma of the lung has a distinctive histologic picture, with small hyperchromatic cells that can display characteristic dense core granules in their cutaneous metastases. [44] Metastatic clear cell adenocarcinoma usually arises from the kidney, but it occasionally does so from primary tumors of the lung. [44-46]

Metastatic disease to the skin of the nose can occur from a number of primary tumors, including renal cell carcinoma. [43,46] The patient in this case report had an unusual histologic type of lung cancer--a large cell undifferentiated carcinoma, in an uncommon site: the tip of the nose. This case highlights the importance of maintaining a high index of suspicion for cutaneous metastatic disease.

From the Section of Otolaryngology--Head and Neck Surgery, University of Medicine and Dentistry of New Jersey, Newark (Dr. Rubinstein, Dr. Baredes, Dr. Caputo, and Dr. Schwartz), and the Albany (N.Y.) Medical Center (Dr. Galati).

Reprint requests: Ran Rubinstein, MD, Hudson Valley Facial Plastic Surgery, 1200 Stony Brook Ct., Newburgh, NY 12550.

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