Download Lung Cancer With Skin Metastasis

Lung Cancer With Skin Metastasis*
Takeshi Terashima, M.D.; and Minoru Kanazawa, M.D.
We describe findings in 34 cases of lung cancer with skin
metastases. In 24 men and 10 women, ages ranged from
32 to 85 years (mean, 61 years). In five, a skin lesion was
the first manifestation of the underlying cancer; in another four, it was found coincidentally with detection of
the lung mass. Pathologic findings included adenocarcinoma in 18 patients, large-cell carcinoma in 9,
squamous cell carcinoma in 5, and small-cell carcinoma
in 2. Among 87 patients with large-cell carcinoma, 9
(10.3 percent) developed cutaneous metastases. A review
of 510 autopsies of primary lung cancer at Keio University from 1958 to 1992 showed 25 cases with skin
metastases (4.9 percent), adenocarcinoma in 13 cases,
large-cell carcinoma in 6, squamous cell carcinoma in 4,
and small-cell carcinoma in 2. Skin metastases were
proven in 15.4 percent of autopsy cases of large-cell
carcinoma of the lung. Mean survival time from diagnosis of lung cancer was 10.3 months and that from diagnosis of skin metastasis was 4.9 months. The prognosis for patients having lung cancer with skin metastasis
is thus very poor. In the review of 34 patients and 25
autopsies of lung cancer with skin metastasis, we conclude that the incidence of cutaneous metastasis is high
for large-cell carcinoma and low for squamous and
small-cell carcinoma.
(Chest 1994; 106:1448-50)
Key words: lung cancer, skin metastasis
Cutaneous metastasis from lung cancer is rare. In
general, cancers that tend to metastasize to other
organs also involve the skin. Thus, lung cancer, which
spreads to brain, bone, liver, and adrenal glands, is
responsible for the majority of skin metastases in men
and is second only to breast cancer as the source of
skin metastases in women.1,2 About 1 to 12 percent of
the patients with lung cancer will develop cutaneous
metastases.3-5 Clinically, lung cancer may be signaled
only by cutaneous metastases, since the primary lung
lesion often remains quiescent. Like all other metastatic lesions, skin metastases reflect the progression of
the primary malignancy and often portend a fatal
outcome. Thus, physicians should recognize its significance. We describe herein the clinical features of
34 cases of lung cancer with skin metastasis. We also
reviewed autopsies at the University of Keio Hospital from 1958 to 1992.
RESULTS
METHODS AND MATERIALS
The clinical data used in this retrospective study were obtained
from the University of Keio Hospital between 1973 and 1993. A
diagnosis of lung cancer had been made in 1,084 patients and the
available clinical records and histologic materials from these cases
were reviewed. Patients were included in this study if their age,
sex, and site of cutaneous metastasis were known, and if there was
histologic documentation of the primary tumor, as well as of the
metastastic lesion of the skin. All these criteria were satisfied in 34
patients. We also sought to determine the location of the lung
tumor, lesions of other distant metastases, treatment, and duration
of survival from the time of diagnosis of lung cancer and of skin
metastasis. We also reviewed 510 autopsies of primary lung cancer at Keio University from 1958 to 1992.
*From the Department of Medicine, School of Medicine, Keio
University, Shinjuku-ku, Tokyo, Japan.
Manuscript received October 21, 1993; revision accepted March
16, 1994.
Reprint requests: Dr. Terashima, Dept. of Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku,
Tokyo 160, Japan
1448
Of the 1,084 patients with lung cancer, 34 (3.1
percent) developed cutaneous metastases, and included 24 men and 10 women (Table 1), ranging in
age from 32 to 85 years (mean, 61 years). In 5
patients, the skin lesion was the first sign of cancer,
in 4 it was found coincidentally with detection of a
lung mass, and in 25 others it developed later.
The pathologic findings were adenocarcinoma in
18 patients, large-cell carcinoma in 9, squamous cell
carcinoma in 5, and small-cell carcinoma in 2.
Among the 1,084 patients with lung cancer, adenocarcinoma was seen in 532 patients, squamous cell
carcinoma in 348, small-cell carcinoma in 117, and
large-cell carcinoma in 87. The incidence of cutaneous metastasis was high in patients with large-cell
carcinoma (10.3 percent; 9/87), whereas squamous
cell and small-cell carcinoma showed the least tendency to extend to cutaneous sites: 1.4 percent
(5/348) in squamous cell carcinomas and 1.7 percent
(2/117) in small-cell carcinomas. Adenocarcinoma
was intermediate in the tendency to metastasize to
the skin (3.4 percent; 18/532).
There were 510 autopsies of primary lung cancer
at Keio University from 1958 to 1992, adenocarcinoma in 268 cases, squamous cell carcinoma in 140,
small-cell carcinoma in 63, and large-cell carcinoma
in 39. Among the 510 autopsied cases, 25 cases (4.9
percent) had skin metastases, adenocarcinoma in 13
cases, large-cell carcinoma in 6, squamous cell carcinoma in 4, and small-cell carcinoma in 2. Skin
metastases were proven in 15.4 percent of autopsied
cases of large-cell carcinoma of the lung.
Metastatic lesions appeared in every area of the
skin, with most common locations being the chest
Lung Cancer With Skin Metastasis (Terashima, Kanazawa)
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Table 1-Patients With Cutaneous Metastases*
Case/Age, Pathologic
findings
yr/Sex
Location of
Skin Lesion
Location
of Lung
Lesion
1/65/M
2/77/M
3/69/M
Adeno Scalp, chest
Adeno Chest
Adeno Arm, leg
RUL
RLL
RUL
4/44/M
5/61/M
Adeno Face
Adeno Face, arm, chest,
abdomen
Adeno Scalp, face
Adeno Face, back
RUL
LUL
6/67/M
7/65/M
Other Distant
Metastases
Brain, adrenal gland
Kidney, adrenal gland
Liver, kidney, adrenal
gland, bone
Adrenal gland
Brain, liver adrenal
gland, kidney
LLL
RUL
Brain
Liver, bone, adrenal
RUL
RUL
RUL
RUL
LUL
LLL
None
Brain
Liver,
Brain,
Brain,
Liver,
Survival From
Survival From
Time of Diagnosis Time of Diagnosis
of Lung Cancer, of Skin Metastases,
mo
mo
Treatment
C
7
15
3
C
C
18
3
18
C
C, R
12
2
12
2
C
4
C
C
19
5
8
15
12
4
1
1
7
12
3
C
7
7
13
29
11
19
2
4
21
8
26
4
2
9
4
3
C, R
C, R
8
1
2
1
gland
Chest, arm
Abdomen, leg
Back, abdomen
Chest
Chest, back
Scalp, finger
8/63/M
9/77/M
10/64/M
11/41/M
12/60/M
13/61/F
Adeno
14/72/F
Adeno Chest, abdomen, back
RLL
15/85/F
16/64/F
17/54/F
18/72/F
19/73/M
20/66/M
21/70/M
22/65/M
23/67/F
24/32/M
25/76/M
26/72/M
Adeno
Adeno
Adeno
Adeno
RLL
LLL
RUL
LUL
LLL
LLL
LUL
LLL
LLL
RUL
27/52/M
28/57/M
Large
Large
Chest, abdomen
Chest
Back, leg
Chest
Scalp, finger
Back
Chest
Chest
Chest, abdomen
Chest, arm
Abdomen
Neck, shoulder, back,
leg
Chest, back, abdomen
Chest
29/33/M
Large
Face, chest
Adeno
Adeno
Adeno
Adeno
Adeno
Squam
Squam
Squam
Squam
Squam
Large
Large
Large
0, C, R
adrenal gland
kidney
liver
spleen, kidney,
bone
Adrenal gland, thyroid,
heart
0, C
Brain
Brain, bone
None
Brain, liver
None
Liver, spleen, kidney
Bone, thyroid
Bone
None
None
Brain, lung
Brain
0
0, C
0, C, R
C
C
C
C, R
C
C
C, R
C, R
C
RUL
RUL
Orbita
R
C
5
4
1
4
RUL
Brain, lung, adrenal
C, R
7
3
LLL
RLL
Lung, thyroid, adrenal
0, C
7
1
1
5
1
5
17
1
3
6
gland
gland, bone
Lung, liver, heart
1
8
RUL
0, R
Large Chest
30/55/M
3
17
RUL None
C, R
Large Face, chest
31/33/F
9
12
RUL Brain, bone
0, R
Large Scalp
32/35/M
13
13
C, R
RUL None
Small Chest
33/65/F
1
6
C, R
RUL Liver, bone
Small Chest, arm
34/68/F
*Adeno=adenocarcinoma; Squam=squamous cell; Large=large cell; Small=small cell; RUL=right upper lobe; RLL=right lower lobe; LLL=left
lower lobe; C=chemotherapy; R=radiation; O=operation.
(21), abdomen (8), back (8), upper extremities (7),
face (6), and scalp (5). Uncommon locations were the
lower extremities (4), neck, and shoulder (1 each).
Twenty-two of the 34 primary lung lesions involved the upper lobes and 12 involved the lower
lobes. Eighteen lesions in the upper lobes were on the
right; of lesions in the lower lobes, 4 were on the right
and 8 were on the left. Nine of the 27 patients had
clinically occult visceral metastatic disease at the
time of skin biopsy. Thirty patients had received
chemotherapy and 15 had received chest irradiation.
In eight patients, skin lesions appeared after surgical
therapy. In case 1, multiple skin metastases on the
scalp (Fig 1) were resected and the patient received
chemotherapy. However, the skin lesions recurred
during therapy.
Mean survival from the diagnosis of lung cancer
was 10.3 months (median, 7 months) and 4.9 months
(median, 3 months) from the diagnosis of skin
metastasis. Only three patients, two of whom had no
metastastic involvement of other organs, lived more
than 1 year after appearance of the skin metastasis.
DISCUSSION
Although skin metastases of lung cancer are rare,
physicians are likely to see them and should be
CHEST / 106 1 5 I NOVEMBER, 1994
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1449
FIGURE 1. Metastatic tumor on the scalp of the patient in case 1.
The overlying skin is reddish.
informed about this phenomenon. Among 1,084 patients with lung cancer in the University of Keio
Hospital, 34 (3.1 percent) developed cutaneous metastases. They lacked a uniform or distinctive gross
appearance,5 being painless, movable, and round
solitary or multiple masses. Some were ulcerated and
exudative. They ranged in diameter from 5 mm to 6
cm in diameter. Some extended deep into the dermis
and subcutaneous tissue while others were superficial.
Clinically, skin metastases vary considerably, but
their recognition is important because they can be the
first clinical manifestation of a still occult neoplasm.
Brownstein and Helwig' found this to be particularly
true for lung and kidney tumors. Among our cases,
five patients had their conditions diagnosed at the
time of skin biopsy and subsequent roentogenogram;
an additional four patients had cutaneous metastases
at the initial finding of primary lung cancer. Although other widespread metastases were usually
present, seven of the patients showed no other distant
spread when a biopsy specimen of the skin lesion was
taken.
Of the 87 patients with large-cell carcinoma, 9
patients (10.3 percent) developed cutaneous metas1450
tases. Among the 510 autopsy cases, 25 cases (4.9
percent) had skin metastases, 6 cases (24 percent) of
which were large-cell carcinoma. Skin metastases
were proven in 15.4 percent of autopsied cases of
large-cell carcinoma of the lung. Of the 348 patients
with squamous cell carcinoma, only 5 (1.4 percent)
developed cutaneous metastases. Dreizen et a15 reported that adenocarcinomas showed the greatest
tendency to extend to skin sites and that large-cell
carcinomas showed the least. Of the 117 autopsied
cases of the lung cancer with cutaneous metastases
reviewed by Brownstein and Helwig,2 adenocarcinoma and squamous cell carcinoma were each found
in nearly 30 percent. In our study, however, the incidence of cutaneous metastases was high for the
large-cell carcinomas and low for the squamous cell
and small-cell carcinomas.
While any area of the skin can be involved,
metastases occur primarily near the primary tumor.1'2 Common sites of cutaneous metastasis are the
chest, back, abdomen, scalp, and neck; occurrence on
the upper and lower extremities is rare.14'5 In our
study, most cutaneous metastases were seen on the
chest, back, and abdomen. Finger metastasis was seen
in two patients, both of whom also had scalp metastasis. This distant spread, involving the scalp and
the finger, shows that lung cancer can reach every
part of the skin surface via the blood and the
lymphatic system.
The prognosis for patients with lung cancer with
skin metastasis is very poor because, in general, their
disease is advanced, with the involvement of such
other sites as brain, liver, bone, and adrenal gland.
The average survival after diagnosis of skin metastasis of lung cancer ranges from 3 to 5 months.3'4 In our
cases, 17 of 34 patients died within 3 months of the
diagnosis of skin metastasis. Two of the seven patients
who had no other distant metastasis survived more
than 1 year after the diagnosis of skin metastasis.
In the review of 34 patients and 25 autopsies of
lung cancer with skin metastasis that we describe, the
incidence of cutaneous metastasis was high for largecell carcinoma and low for squamous and small-cell
carcinoma.
REFERENCES
1 Brownstein MH, Helwig EB. Patterns of cutaneous metastasis.
Arch Dermatol 1972; 105:862-68
2 Brownstein MH, Helwig EB. Metastic tumors of the skin.
Cancer 1972; 29:1298-1307
3 Rosen T. Cutaneous metastases. Med Clin North Am 1980;
64:885-900
4 Coslett LM, Katlic MR. Lung cancer with skin metastasis. Chest
1990; 97:757-59
5 Dreizen S, Dhingra HM, Chiuten DF, Umsawasdi T, Valdivieso
M. Cutaneous and subcutaneous metastases of lung cancer;
clinical characteristics. Postgrad Med 1986; 80:111-16
Lung Cancer Wfth Skin Metastasis (Terashima, Kanazawa)
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