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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) Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21703/ on 05/10/2017 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 Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21703/ on 05/10/2017 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) Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21703/ on 05/10/2017