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CASE REPORT
Year : 2010  |  Volume : 6  |  Issue : 3  |  Page : 370-373

Scalp lesion: A presenting feature of squamous cell carcinoma of lung


1 Department of Respiratory Medicine, Postgraduate Institute of Medical Sciences, University of Health Sciences, Rohtak, India
2 Department of Oto-rhino-laryngology, Postgraduate Institute of Medical Sciences, University of Health Sciences, Rohtak, India
3 Department of Physiology, Postgraduate Institute of Medical Sciences, University of Health Sciences, Rohtak, India

Date of Web Publication29-Nov-2010

Correspondence Address:
Prem Parkash Gupta
9J/17, Medical Enclave, PGIMS, Rohtak - 124 001
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.73364

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 > Abstract 

We describe a 45-year-old man, heavy smoker, presenting with 6.5 Χ 5.3 cm painless solitary growth over right temporal region. Chest radiograph showed opacity over left lung abutting mediastinum. Computed tomogram revealed homogenous ill-defined opacity indicative of bronchogenic carcinoma with metastases to right lung, liver and adrenal glands. The carina was involved with tumor along with partial obliteration of the left main bronchus over bronchoscopy; the biopsy confirmed squamous cell carcinoma. The biopsy from scalp lesion and cervical lymph node also established metastatic squamous cell carcinoma. Although cutaneous metastasis with primary lung cancer has been reported, the scalp lesion as a sole presenting feature of underlying quiescent squamous cell lung cancer, which is described here, has not been reported frequently.

Keywords: Diagnosis, lung neoplasm, scalp, skin neoplasm, soft tissue neoplasm


How to cite this article:
Gupta PP, Gupta KB, Gulia J, Agarwal D, Mehta D. Scalp lesion: A presenting feature of squamous cell carcinoma of lung. J Can Res Ther 2010;6:370-3

How to cite this URL:
Gupta PP, Gupta KB, Gulia J, Agarwal D, Mehta D. Scalp lesion: A presenting feature of squamous cell carcinoma of lung. J Can Res Ther [serial online] 2010 [cited 2019 Sep 21];6:370-3. Available from: http://www.cancerjournal.net/text.asp?2010/6/3/370/73364


 > Introduction Top


Solitary large cutaneous metastases from bronchogenic carcinoma as a presenting feature are not frequently seen in clinical practice. They usually appear when the lung cancer is advanced and the primary lung cancer already had clinical manifestations. Here we describe a case who presented with a large solitary cutaneous metastatic lesion that provided clue to diagnostic work up for quiescent primary lung cancer. Their identification as a possible link to underlying organ malignancy is significant to recognize, as early detection makes it possible to diagnose promptly and ensure timely treatment.


 > Case Report Top


A 45-year-male presented to our Institute with large, painless, solitary irregular growth measuring 6.5 × 5.3 cm over scalp overlying right temporal region for two months which was increasing in size continuously [Figure 1]. He had no chest symptom apart from occasional dry cough and chest tightness that he attributed to smoking. He had lost around 8 kg in weight over the past two months, but had no significant anorexia. The patient was smoking up to two packs of bidis daily for the past 27 years. The patient was a farm worker. He was a vegetarian and consumed alcohol occasionally. His clinical examination apart from scalp lesion revealed enlarged cervical lymph node over right side [Figure 2].
Figure 1: The progressively increasing metastatic scalp lesion

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Figure 2: An enlarged cervical lymph node over right side having metastasis

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The chest radiograph was suggestive of lung opacity over left lung abutting the mediastinum [Figure 3]. Computed tomogram revealed a homogenous ill-defined opacity suggestive of bronchogenic carcinoma [Figure 4] with metastases to right lung, liver and both adrenal glands. Fiber-optic flexible bronchoscopy was carried out that showed tumor involvement of the carina with obliteration of the left main bronchial orifice. Biopsy of the lesion revealed squamous cell carcinoma [Figure 5] and [Figure 6]. The biopsy from scalp lesion and enlarged right cervical lymph node also confirmed metastatic squamous cell carcinoma. As the patient had far advanced stage [stage 4] at the time of presentation, he was explained the prognosis, and was referred to the Oncology Department at our Institute for further management.
Figure 3: Chest radiograph [PA view] showing lung opacity over left lung that was abutting the mediastinum

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Figure 4: Computed tomograms [A to C] showing homogenous illdefined opacity later confirmed to be due to bronchogenic carcinoma, [D] metastatic lesion in right lung

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Figure 5: Photomicrograph of tissue specimen obtained through endobronchial biopsy showing moderately differentiated squamous cell carcinoma (H and E, 100×)

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Figure 6: Photomicrograph of tissue specimen obtained through endobronchial biopsy showing sheets of tumor cells that are pleomorphic with high N:C ratio suggestive of moderately differentiated squamous cell carcinoma (H and E, 200×)

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 > Discussion Top


In human body, soft tissues comprise nearly 55% of body mass, still hematogenous metastases to soft tissues are not frequent. A primary tumor directly extends to soft tissues more frequently than it metastasizes to distant soft tissues possibly due to differences in pH, accumulation of metabolites, and the local temperature at soft tissue sites. [1] Moreover, the organs that commonly bear the burnt of a high incidence of metastatic carcinomas, like liver or lung, have a constant blood flow, whereas in soft tissues the blood flow is not constant and is subject to variation due to influence by adrenergic receptors and variations in tissue pressure affecting tumor implantation. [1] There has been conflicting reports in medical literature whether traumatic injury to soft tissue plays any role in attracting cancer metastases to site; though one study observed no case associated with traumatic injury at the site of the metastases. [2] In our case, the patient was a farmer by occupation and might has had unidentified / unremembered trauma over scalp.

Almost 1-12% of patients with lung cancer are reported to develop cutaneous metastases. [3],[4],[5],[6],[7],[8] Skin ranks thirteen among common sites for metastases from the lung. [4] In up to 20-60% of patients, skin lesions may present concomitantly or prior to primary tumor. [8],[9],[10] As mentioned, internal malignancies generally disseminate to a site close to the primary tumor; [11] however, lung cancers are known for their tendency to metastasize to remote cutaneous sites [12] like anterior chest, abdomen, head or neck. [7],[10],[11] The diagnosis of cutaneous metastasis should be particularly looked for in a patient with a history suggestive of lung malignancy or significant smoking. The lung malignancies in the upper lobes have a greater propensity to metastasize to the skin. [6],[13] Skin metastases from the lung are often moderately or poorly differentiated. [6],[14] All histological types of lung cancer may metastasize to the skin and clinical lesions are variable. The most common type is adenocarcinoma, followed by squamous-cell carcinoma, small-cell carcinoma, and large-cell carcinoma. [5],[7],[10],[14] Metastatic squamous-cell carcinomas from the lung are often moderately or poorly differentiated. [9] In such scenario, metastasis from primaries at upper gastrointestinal tract must be ruled out. [3]

Among scalp lesions, metastases from lungs are responsible as the third most common malignancy, behind only to primary basal cell carcinoma and primary squamous cell carcinoma. [15] In a series by Spitz et al, the most common primary tumor to metastasize to the scalp was lung carcinoma followed by hematopoietic malignancies and melanoma. [16] Cutaneous metastases from lung cancer do not have any specific presentation. [7] They often have painless, nodular, mobile/fixed, hard/flexible, and single/multiple presentations. [7],[14] Their colors may vary from flesh-colored, red, pink, purple, or bluish black; size may vary from 2 mm to 6 cm in diameter. [7] Less commonly, these lesions appear as papular, plaque-like, ulcerated, vascular, zosteriform, erysipelas-like, and on the scalp as scarring alopecia. [7],[17],[18] The zosteriform metastases are often painful, believed to be a result of penetration of the dorsal root ganglion, and usually present on the chest or abdomen. [17] The erysipelas-like metastases may mimic localized infections and generally results from traumatic seeding after chest wall procedures, [18] or from simple lymphatic invasion. [10]

Ultrasonography with color Doppler imaging is a good initial modality to distinguish benign from malignant soft-tissue masses. Benign lesions do not have infiltrated margins or a scalloped shape and malignant tumors tend to be large. However, there may be no differences between the benign and malignant soft-tissue tumors in terms of echogenecity, composition and color Doppler features. A tumor with size over 5 cm and having infiltrated margin highly suggests malignancy. [19] MRI is useful in determining whether a soft tissue mass is malignant or not. The parameters favoring malignancy over MRI scan include large lesion size, peritumoral edema, necrosis, and absence of calcification, absence of fibrosis, and lack of fat rim. [20] The definite diagnosis of metastatic carcinoma hinges on histopathological evaluation of involved skin; FNA can provide a rapid and accurate diagnosis. [16] Tumors may show characteristics of the underlying tumor, or they may have a more anaplastic appearance. In the situation of an anaplastic tumor, immunohistochemistry (IHC) and electron microscopy may help to delineate the tissue of origin. Immunohistochemistry (IHC) tools available include anti-thyroid transcription factor (TTF) and CK7/20. [21] Anti-TTF is reported to be both sensitive and specific for primary adenocarcinomas, bronchioalveolar carcinomas, and small-cell carcinomas when a thyroid primary is ruled-out. [22] However, CK7+/20- pattern is sensitive but not specific for primary adenocarcinomas and bronchioalveolar carcinomas. [22] IHC staining for cutaneous metastases from the lung is likely less sensitive than hoped and is recommended only in cases where clinical and histological clues are inconclusive. [23]

To conclude, the present case report seems to endorse the fact that a scalp metastasis may lead to the detection of quiescent lung cancer and a high level of awareness in this regard may lead to early detection of primary malignancy.

 
 > References Top

1.Herring CL Jr, Harrelson JM, Scully SP. Metastatic carcinoma to skeletal muscle. A report of 15 patients. Clin Orthop 1998;272-81.   Back to cited text no. 1
    
2.Magee T, Rosenthal H. Skeletal muscle metastases at sites of documented trauma. Am J Roentgenol 2002;178:985-8.  Back to cited text no. 2
    
3.Rosen T. Cutaneous Metastases. Med Clin North Am 1980;65:885-900.  Back to cited text no. 3
    
4.Ask-Upmark E. Clinical aspects of tumor metastases. Nord Med 1956;56:1433-40.  Back to cited text no. 4
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6.Coslett LM, Katlic MR. Lung cancer with skin metastasis. Chest 1990;97:757-9.  Back to cited text no. 6
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7.Dreizen S, Dhingra H, Chiuten D, Umsawasdi T, Valdivieso M. Cutaneous and subcutaneous metastases of lung cancer. Postgrad Med 1986;80:111-6.  Back to cited text no. 7
    
8.Lookingbill DP, Spangler N, Sexton FM. Skin involvement as the presenting sign of internal carcinoma. A retrospective study of 7316 cancer patients. J Am Acad Dermatol 1990;22:19-26.  Back to cited text no. 8
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9.Brownstein MH, Helwig EB. Metastatic tumors of skin. Cancer 1972;29:1298-307.  Back to cited text no. 9
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11.Brownstein MH, Helwig EB. Patterns of cutaneous metastasis. Arch Dermatol 1972;105:862-8.  Back to cited text no. 11
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12.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. 12
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14.Kamble R, Kumar L, Kochupillai V, Sharma A, Sandoo MS, Mohanti BK. Cutaneous metastases of lung cancer. Postgrad Med J 1995;71:741-3.  Back to cited text no. 14
    
15.Chiu CS, Lin CY, Kuo TT, Kuan YZ, Chen MJ, Ho HC, et al. Malignant cutaneous tumors of the scalp: A study of demographic characteristics and histologic distributions of 398 Taiwanese patients. J Am Acad Dermatol 2007;56:448-52.  Back to cited text no. 15
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16.Spitz DJ, Reddy V, Selvaggi SM, Kluskens L, Green L, Gattuso P. Fine-needle aspiration of scalp lesions. Diagn Cytopathol 2000;23:35-8.   Back to cited text no. 16
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17.Kikuchi Y, Matsuyama A, Nomura K. Zosteriform metastatic skin cancer: Report of three cases and review of the literature. Dermatology 2001;202:336-8.  Back to cited text no. 17
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18.Homler HJ, Goetz CS, Weisenburger DD. Lymphangitic cutaneous metastases from lung cancer mimicking cellulitis. Carcinoma Erysipeloides. West J Med 1986;144:610-2.  Back to cited text no. 18
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19.Chiou HJ, Chou YH, Chiu SY, Wang HK, Chen WM, Chen TH, et al. Differentiation of benign and malignant superficial soft-tissue masses using grayscale and color doppler ultrasonography. J Chin Med Assoc 2009;72:307-15.   Back to cited text no. 19
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20.Chen CK, Wu HT, Chiou HJ, Wei CJ, Yen CH, Chang CY, et al. Differentiating benign and malignant soft tissue masses by magnetic resonance imaging: Role of tissue component analysis. J Chin Med Assoc 2009;72:194-201.   Back to cited text no. 20
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21.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. 21
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22.Jerome Marson V, Mazieres J, Groussard O, Garcia O, Berjaud J, Dahan M, et al. Expression of TTF-1 and cytokeratins in primary and secondary epithelial lung tumours: Correlation with histological type and grade. Histopathology 2004;45:125-34.  Back to cited text no. 22
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23.Azoulay S, Adem C, Pelletier F, Barete S, Frances C, Capron F. Skin metastases from unknown origin: Role of immunohistochemistry in the evaluation of cutaneous metastases of carcinoma of unknown origin. J Cutan Pathol 2005;32:561-6.  Back to cited text no. 23
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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