Cutaneous Metastasis of Bronchogenic Carcinoma with an Unusually Long Survival : A Case Report

Cutaneous metastasis is uncommon [1,2] and more so from bronchogenic carcinoma. Cutaneous metastasis portends a poor prognosis, since it is a sign of very advanced disease. And in some cases it actually heralds the diagnosis of the internal malignancy [3]. We present the case of multiple cutaneous metastasis of bronchogenic carcinoma, in which the cutaneous lesions actually preceded the diagnosis, and also a much longer survival than in most reported cases. The clinical significance of this case is firstly, the unusually long survival after the appearance of the lesions, and secondly, adding to the data of the few instances where the lesions predate the diagnosis.


Introduction
Cutaneous metastasis is uncommon [1,2] and more so from bronchogenic carcinoma.Cutaneous metastasis portends a poor prognosis, since it is a sign of very advanced disease.And in some cases it actually heralds the diagnosis of the internal malignancy [3].We present the case of multiple cutaneous metastasis of bronchogenic carcinoma, in which the cutaneous lesions actually preceded the diagnosis, and also a much longer survival than in most reported cases.The clinical significance of this case is firstly, the unusually long survival after the appearance of the lesions, and secondly, adding to the data of the few instances where the lesions predate the diagnosis.

Case Report
This 55-year old woman was seen with a 9-month history of multiple skin lesions, 8-month history of cough and haemoptysis and dyspnoea of 6 weeks duration.She was not a smoker, and neither was her husband.There was no significant weight loss at the time, no digital clubbing nor peripheral lymphadenopathy.There was no history of tuberculosis.The subcutaneous nodules were multiple and rubbery.They were on the back, the breast and the chest, scalp, arms, and thighs.The chest x-ray showed a collapse of the right lower lobe.The chest CT scan additionally showed hilar lymphadenopathy with mild compression of the upper lobar bronchus and tumour seedling of the right main bronchus.She was prepared for exploratory thoracotomy because of the non-availability of flexible bronchoscopy at the time.The findings were a right lower lobe tumour, frozen mediastinum and matted mediastinal lymph nodes.The tumour was unresectable.A peribronchial lymph node was thus biopsied.The histology reported an invasive high grade malignant epithelioid bronchogenic carcinoma.She was then referred to the radiation oncologist where she had several sessions of cisplatin-based chemotherapy.The cutaneous lesions started getting larger, measuring 1-3 cm in diameter.One of them was biopsied, and the histopathology came out as metastatic poorly differentiated cancer.This was stage IV disease (T 4 N 2 M 1 ).She gradually deteriorated and passed away 34 months after the initial appearance of the skin lesions (Figure 1).

Discussion
Cutaneous metastasis is uncommon, occurring in 0.6-10.4% of all patients with cancer [2,3].Concerning only bronchogenic carcinoma, the incidence of skin metastasis is 1-12% [3][4][5].In its appearance as the first manifestation of the disease, it is 7-23.8%[2].In this patient, the cutaneous lesions predated the onset of the constitutional symptoms of cough and haemoptysis that led to the diagnosis.However, whether the cutaneous lesions predate or postdate the primary malignancy, their appearance is a sign of advanced disease [1][2][3][4]6,7].Survival after the manifestation has been reported as 2.9-6.5 months [1,5,[7][8][9].This patient's cutaneous lesions appeared 9 months before the diagnosis of the bronchogenic carcinoma, and survived additional 25 months after the diagnosis.This survival is much longer than in most reported cases.She was 55 years.The study by Terashima et al. had an age range of 32 to 85 years (mean 61 years) [9].They also found that the incidence of cutaneous metastasis is high for large cell carcinoma and adenocarcinoma, and low for squamous cell, small cell and epidermoid carcinoma [8][9][10][11].The commonest sites noted are the back, 8 anterior chest, abdomen, upper and lower limbs [10], and the breast [12].She had her lesions at the back, anterior chest, the breast, scalp and the neck.And her lesions were 1-3 cm in diameter and nodular.Hidaka  [8].However, a wide spectrum of various morphologic types like nodules, papules, plaques, and ulcers have been described [3,11] The response to chemotherapy, as reported, is poor [8,10].And indeed while our patient was still on chemotherapy, her lesions got bigger, she deteriorated and passed away.But the notable thing here was the unusually long survival.Why she survived that long, we do not know.

Conclusion
Cutaneous metastasis of bronchogenic carcinoma is uncommon, and it is a sign of poor prognosis.Most cases reported survived a few months after the appearance of the lesions.We have presented a case that survived 34 months after the appearance of the skin lesions.

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Figure 1: Nodular lesions at the back of the chest.