|Year : 2015 | Volume
| Issue : 3 | Page : 659
Eczema as the first manifestation of a lung cancer
Xiangjiao Meng1, Renben Wang1, Zhaoqin Huang2, Jinming Yu1
1 Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Jinan, Shandong 250117, China
2 Department of Radiology, Provincial Hospital Affiliated to Shandong University, Jinan, Shandong 250021, China
|Date of Web Publication||9-Oct-2015|
Department of Radiation Oncology, Shandong Cancer Hospital and Institute, No. 440, Jiyan Road, Jinan, Shandong 250117
Source of Support: None, Conflict of Interest: None
Lung cancer combined with eczema is a rare disease. We report a case of 58-year-old man with eczema as the first manifestation of a lung cancer. Skin examination revealed diffuse erythema, dander, itchy rash, and scratch. Chest contrast-enhanced computed tomography showed a heterogeneously enhanced irregular mass in the right lung. Punch biopsy of the tumor confirms squamous cell lung cancer. Eczema vanished nearly completely after one cycle of chemotherapy.
Keywords: Chemotherapy, eczema, erythema, itching, lung cancer, predictor
|How to cite this article:|
Meng X, Wang R, Huang Z, Yu J. Eczema as the first manifestation of a lung cancer. J Can Res Ther 2015;11:659
| > Introduction|| |
Cutaneous involvement is encountered in approximately 1% of lung cancer patients. Polymyositis and dermatomyositis appear as most frequently involved skin complication. However, eczema combined with lung cancer is a quite rare disease. The association between lung cancer and eczema is inclusive.  Here, we report a case of 58-year-old man with eczema as the first manifestation of a lung cancer.
| > Case report|| |
The patient was a 58-year-old man with a history of tobacco smoking for 40 years, without history of asthma or allergy. He had apparently been healthy until 1 year before admission, when he began to suffer from unbearable itching. Gradually, papular erythema appeared on malar, neck, upper anterior thoracic region and upper limbs, without proximal and symmetric muscle weakness. Systemic and topical glucocorticosteroids treatment did not lead to any easement of the disease. He began to suffer from irritating cough 2 months before admission. Skin examination revealed diffuse erythema, dander, itchy rash, and scratch [Figure 1]a. The biopsy of skin showed hyperkeratosis, parakeratosis punctate, irregular epidermal hypertrophy, few inflammatory cells into the epidermis, a little superficial dermal perivascular mononuclear cell infiltration, without microabscesses [Figure 2]a. Chest contrast-enhanced computed tomography (CT) showed a heterogeneously enhanced irregular mass (6.7 × 8 cm) in the right lung, a small amount of pleural effusion and mediastinal lymph node [Figure 3]a. Punch biopsy of the tumor confirms squamous cell lung cancer [Figure 2]b. Blood tests showed CYFRA21-1 42.33 ng/ml (0-3.3); neuron-specific enolase (NSE) 44.67 ng/ml (0-17); carcinoembryonic antigen (CEA) 2.11 ng/ml (0-3.4); lactate dehydrogenase 236 U/L (109-245); creatine kinase (CK) 51U/L (1-174).
|Figure 1: The cutaneous manifestations. (a) Skin examination revealed papules, patches, plaques, dander, itchy rash, and scratch. (b) All the eczema disappeared after one cycle of chemotherapy|
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|Figure 2: The pathology of skin and tumor biopsy. (a) Eczema on skin: Hyperkeratosis, parakeratosis punctate, irregular epidermal hypertrophy, few inflammatory cells into the epidermis, a little superficial dermal perivascular mononuclear cell infiltration. (b) Squamous cell lung cancer|
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Therefore, the final diagnosis was a squamous cell lung cancer presenting as a paraneoplastic syndrome of eczema. According to his clinical and radiological features he was proposed to undergo chemotherapy and radiotherapy. The regimen of chemotherapy was gemcitabine 1000 mg/m 2 d1, 8 and cisplatin 75 mg/m 2 d1. On the 3 rd day of first chemotherapy cycle, he felt the itching relieved and the erythema became dark. Before the second cycle, the itching, irritating cough and erythema vanished nearly completely without any treatment, especially to eczema [Figure 1]b. Blood tests showed CYFRA21-1 2.29 ng/ml (0-3.3), NSE 14.12 ng/ml (0-17) and CEA 1.09 ng/ml(0-3.4). The irregular mass reduced to 3.5 cm × 5.5 cm on the repeated chest contrast-enhanced CT [Figure 3]b.
|Figure 3: Chest contrast-enhanced computed tomography. (a) A heterogeneously enhanced irregular mass (6.7 × 8 cm) in the right lung. (b) The irregular mass reduced to 3.5 × 5.5 cm before third cycle|
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| > Discussion|| |
Dermatomyositis appears as most frequently involved skin complication of lung cancer. In this case, there were no proximal and symmetric muscle weakness, upper and lower limbs edema or stiffness, and the LDH and CK were at the normal levels. The diagnosis of dermatomyositis was excluded. ,
Eczema is an autoimmune pathologic reaction of the skin to endogenous or exogenous factors. Primary lesions may be papules and vesicles that can coalesce to form patches, plaques, itch, and scratch. The case described fits eczema as a lung cancer paraneoplastic syndrome. The diagnosis was confirmed by pathology examination. Eczema symptoms disappeared with the cancer treatment, supporting their paraneoplastic relationship.
Eczema as the first manifestation of a lung cancer is a rare disease. If the patient underwent chest X-ray or chest CT when he began to suffer from unbearable itching, he might be treated by operation at an early stage phase. For this reason, it is essential to pay close attention to the presence of typical manifestations because early treatment of lung cancer is so crucial to evolution and prognosis. A diagnosis of eczema might be a warning sign as malignant tumor to avoid unnecessary glucocorticosteroids treatment and take anticancer therapy earlier.
The association between history of allergy and cancers has been investigated for more than 40 years. In particular, eczema is a suspected protective factor for several cancers. ,, Castaing et al. identified 3116 population to determine the role of eczema in relation to lung cancer. While, overall they concluded an inverse association between history of eczema and lung cancer risk.  The immunosurveillance hypothesis has been proposed to explain the association between history of allergy and cancers. Allergies are associated with reduced cancer risk for an enhanced ability of the immune system to detect and eradicate malignant cells at the beginning of tumor development. ,
In this case, it seemed contradictory to the previous reports for the patient both had eczema and lung cancer simultaneously. However, the case did not fit the above conditions. The eczema was not an independent disease, but a paraneoplastic syndrome. The skin lesions disappeared, while the tumor mass was reduced.
The mechanism underlying the eczema and lung cancer is still unclear. Considering higher level of CYFRA21-1 and NSE before treatment, the eczema might be the skin response to special factors secreted by squamous cancer cells. Epidermal growth factor receptor (EGFR) inhibitors are increasingly used for the treatment of advanced, metastatic, or recurrent tumors. Cutaneous adverse event occurs in 30% of patients. The most common cutaneous adverse event was papulopustular rash, followed by eczema and xerosis.  Given the above evidence, we speculated that eczema in this case might associated with low EGFR signaling activity.
Gemcitabine and cisplatin is the first line chemotherapy regimen for squamous lung cancer.  The patient is quite sensitive to chemotherapy and reached partial response just after one cycle. We hypothesized that eczema might be a predictor for good response to chemotherapy and good prognosis for patients with lung cancer. Until today, there are no studies investigating the relationship of response to chemotherapy and eczema, which worth further study.
With this case report, we want to call attention to the presence of eczema as a warning sign for malignant tumor. Eczema might be a predictor for good response to chemotherapy and prognosis for patients with squamous cell lung cancer.
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[Figure 1], [Figure 2], [Figure 3]