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CORRESPONDENCE
Year : 2013  |  Volume : 9  |  Issue : 1  |  Page : 145-147

Scalp metastases - an unusual Presentation of non-small cell lung cancer prognosis of cutaneous metastases in the current era


1 Medical Oncology, Tamworth Base Hospital, Dean Street, Tamworth, NSW 2340, Australia
2 Skin Clinic, 10 Darling Street, Tamworth, NSW 2340, Australia

Date of Web Publication10-Apr-2013

Correspondence Address:
Krishna M Rachakonda
Medical Oncology, Tamworth Base Hospital, Dean Street, Tamworth NSW 2340
Australia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.110375

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 > Abstract 

We report a case of metastatic lung cancer presenting as scalp metastases. Immunohistochemistry and radiological investigations helped in making the diagnosis. We also report better survival as seen in our present case using newer chemotherapeutic agents. The report emphasizes the need to look carefully for skin lesions as they provide easily accessible tissue for histopathology and also aid in proper staging as they can be missed out on routine radiological investigations. The case also reflects improvement in cancer care and outcomes in recent times.

Keywords: Cutaneous, Metastases, Non small cell lung cancer, Scalp


How to cite this article:
Rachakonda KM, George MK, Peek R D. Scalp metastases - an unusual Presentation of non-small cell lung cancer prognosis of cutaneous metastases in the current era. J Can Res Ther 2013;9:145-7

How to cite this URL:
Rachakonda KM, George MK, Peek R D. Scalp metastases - an unusual Presentation of non-small cell lung cancer prognosis of cutaneous metastases in the current era. J Can Res Ther [serial online] 2013 [cited 2019 Nov 22];9:145-7. Available from: http://www.cancerjournal.net/text.asp?2013/9/1/145/110375


 > Introduction Top


Skin metastases from internal malignancies are rare, especially as the initial presentation. Also, prognosis in patients with cutaneous involvement is reportedly quiet poor especially in lung cancer.


 > Case Report Top


We report a 77 year old patient who presented with multiple nodular scalp lesions in [Figure 1] August 2010. A biopsy showed adenocarcinoma. Immmuoperoxidase staining is positive for CK-7 and TTF-1. ER/PR/GCDFP 15/S 100/CK 20/CK 5/CK 6/HMW Keratin/D2-40, stains were negative. Very weakly positive for CEA [Figure 2], [Figure 3], [Figure 4], [Figure 5] and [Figure 6].
Figure 1: Scalp Lesion

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Figure 2: H and E stain of scalp lesion, low power

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Figure 3: H and E stain of scalp lesion I high power

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Figure 4: TTF-1 stain

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Figure 5: CK-7 stain

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Figure 6: D2-40 stain

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Positive staining with CK-7 and TTF-1 and negative D2-40 points towards a metastatic adenocarcinoma of lung origin and this is supported by negative staining for breast, colon and melanoma markers. EGFR mutation testing was negative.

Further investigation with a CT scan of chest [Figure 7], abdomen and pelvis revealed a spiculated mass in the right upper lobe of the lung consistent with lung primary.
Figure 7: CT in August 2010

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Bone scan [Figure 8] showed increased uptake in the mid-sternum consistent with metastasis.
Figure 8: Bone scan showing sternal 'hot spot'

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The patient was treated with palliative chemotherapy with 6 cycles of Carboplatin and Gemcitabine and put on maintenance treatment with Pemetrexed. There has been no further occurrence of skin/scalp lesions, the lung lesion slightly reduced in size [Figure 9] and the patient is maintaining a good performance status currently.
Figure 9: CT in December 2011

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 > Discussion Top


Rates of cutaneous metastases vary from 0.7% to 9% in various autopsy studies. A more recent meta-analysis of data from seven studies including 20,380 patients revealed an overall incidence of 5.3%. [1],[2],[3] In this study, the most common tumor to involve skin is breast cancer with an incidence of 24%. The most common area of skin involved is the chest and was involved in 28.4% cases. Scalp involvement irrespective of the primary site is seen in 6.9% cases. In a retrospective study by Lookingbillet al. including 7316 cancer patients, skin involvement as a presenting sign was seen in only 0.8%. [4] Most studies report poor prognosis in lung cancer patients with cutaneous metastases with average survival of less than 6 months. [5],[6]

Lung cancer treatment has gone a long way since the initial demonstration from clinical trials that palliative chemotherapy improves survival compared to best supportive care alone.

Median survival has risen from 3.6 months with best supportive care alone to 6.5 months with platinum based single agent therapy. [7] Subsequent trials using platinum combination with gemcitabine improved median survival time to 9.1 months. [7] Currently with the use of maintenance treatment with newer agents like pemetrexed shows median survival rates of over 13 months. [8]

We report this case to emphasize that careful skin examination can provide valuable clues to internal malignancy. It will also provide a safe and easy access to tissue for histopathology. Diagnosis of skin metastases helps appropriate staging, altering therapy and a better estimation of prognosis.

Our case also highlights the substantial improvement in cancer care in recent years and previously reported poor prognosis, especially in cutaneous metastatic disease may no longer be true in the current era of cancer management. A recent study from South Korea by Jong Hwan Lee also supports this observation. [9]

 
 > References Top

1.McWhorter JE, Cloud AW. Malignant tumors and their metastases: A summary of the necropsies of eight hundred sixty five cases performed at Bellevue Hospital of New York. Ann Surg 1930;92:434-43.  Back to cited text no. 1
    
2.Spencer PS, Helm TN. Skin metastases in cancer patients. Cutis 1987;39:119-21.  Back to cited text no. 2
    
3.Krathen RA, Orengo IF, Rosen T. Cutaneous metastasis: A meta-analysis of data. South Med J 2003;96:164-7.  Back to cited text no. 3
    
4.Lookingbill DP, Sprangler 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. 4
    
5.Terashima T, Kanazawa M. Lung Cancer with skin metastasis. Chest 1994;106:1448-50.  Back to cited text no. 5
    
6.Mollet TW, Garcia CA, Koester G. Skin metastases from lung cancer. Dermatol Online J 2009;15:1.  Back to cited text no. 6
    
7.Socinski MA, Morris DE, Masters GA, LilenbaumR; American College of Chest Physicians. Chemotherapeutic management of stage IV non-small cell lung cancer. Chest 2003;123 Suppl 1:226S-43.  Back to cited text no. 7
    
8.Ciuleanu T, Brodowicz T, Zielinski C, Kim JH, Krzakowski M, Laack E, et al.Maintenance pemetrexed plus best supportive care versus placebo plus best supportive care for non-small cell lung cancer: Arandomised double- blind phase 3 study. Lancet 2009;374:1432-40.  Back to cited text no. 8
    
9.Lee JH, Ahn SJ, Kim HJ, Jang SE, NohJY, KimHR, et al.Cutaneous Metastasis from Lung Cancer: A Single-Institution Retrospective Analysis. Tuberc Respir Dis 2011;70:139-42.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]



 

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