Journal of Cancer Research and Therapeutics Medknow Publications on behalf of the Association of Radiation Oncologists of India (AROI) ISSN: 0973-1482 EISSN: 1998-4138 Vol. 6, Num. 3, 2010, pp. 370-373

Journal of Cancer Research and Therapeutics, Vol. 6, No. 3, July-September, 2010, pp. 370-373

Case Report

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

Prem Parkash Gupta¹, Krishan B Gupta¹, Jogender Gulia², Dipti Agarwal³, Dinesh Mehta¹

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

Correspondence Address:Prem Parkash Gupta, 9J/17, Medical Enclave, PGIMS, Rohtak - 124 001, India, gparkas@yahoo.co.in

Code Number: cr10091

PMID: 21119281

DOI: 10.4103/0973-1482.73364

Abstract

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

Introduction

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

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].

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.

Discussion

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

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