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Vol 5(2) (2020) 75-78 | jchs-medicine.uitm.edu.my | eISSN 0127-984X
https://doi.org/10.24191/jchs.v5i2.11125
INTRODUCTION
Cutaneous metastases are generally an uncommon
manifestation; however, its presentation is usually a
sign of the dissemination of internal malignancy.
Besides, other malignancies such as melanomas,
haematolymphoid malignancies, germ cell tumours and
sarcomas are also associated with metastasis to the skin.
Multiple studies reported that the incidence of
cutaneous metastasis in lung cancer patients was within
a range of 1 to 12 % [1]. The common sites where lung
cancers typically invade comprise of hilar nodes, liver,
adrenal glands, bones and brain [2, 3] whereas
malignant spread to the skin is deemed unusual.
However, on the infrequent occasion that transmission
through the skin does happen, the metastasis would be
anticipated in the chest, abdomen, head and neck [4-6].
Previous studies also reported that lung cancer has a
higher incidence of cutaneous metastasizing in men as
compared to women [1].
CASE PRESENTATION
A 71-year-old Chinese woman first presented with a
cutaneous nodule on the left lateral axilla was then
progressed to multiple nodules on the upper back and
lower abdomen within a year. Aside from that, she also
recounted episodes of progressive dyspnoea,
haemoptysis, associated constitutional symptoms and
significant loss of body weight amounting to 10 kg in
the span of that year itself. The patient had a past
medical history of hypertension and malignancy.
Besides, her family history revealed that both her
mother and sister were diagnosed with ovarian cancer.
There were no significant abnormalities in her
vital signs on clinical examination except for a low-
grade temperature and the patient being tachypneic,
measuring a respiratory rate of 28 breaths per minute.
Meanwhile, physical examination of the chest detected
bilateral diffuse crackles that were more evident on the
right chest with no obvious lymphadenopathy.
ABSTRACT
Patients with lung cancer may present with respiratory and systemic symptoms. However,
cutaneous metastases from primary lung cancer is a rare phenomenon, especially in women,
that signifies a poor prognosis. This paper reported a case regarding a 71-year-old woman
who was first presented with a cutaneous nodule over the year. Her condition was further
progressed to multiple lesions on the back and abdomen, dyspnoea, haemoptysis and weight
loss. The results of the skin lesion biopsy exhibited metastatic lung adenocarcinoma with
positive immunohistochemistry for thyroid transcription factor 1 (TTF1) and cytokeratin 7 (CK-
7). Computed tomography (CT) scan was conducted, and it revealed a left upper lobe lung
mass. The patient was subsequently scheduled for additional management, but she had
succumbed to complications of pulmonary embolism before the necessary interventions could
be provided. In this particular case presentation, the biopsy of cutaneous lesions obtained had
revealed an undiagnosed primary malignancy.
KEYWORDS: cutaneous metastases, lung adenocarcinoma, skin metastases, lung
malignancy
Received
25th March 2020
Received in revised form
6th May 2020
Accepted
5th June 2020
Corresponding author:
Liyana Dhamirah Aminuddin,
Dermatology Unit,
Faculty of Medicine,
Universiti Teknologi MARA (UiTM)
Sungai Buloh Campus,
47000 Sungai Buloh, Selangor,
Malaysia
Tel: +603-61264800/ +60126480020
Fax: +603-61265164
Email: liyanadhamirah@uitm.edu.my
A Rare Presentation of Cutaneous Metastases in Advanced Lung
Adenocarcinoma
Liyana Dhamirah Aminuddin, Sabrina Ab Wahab, Suhaili Shariffudin, Tarita Taib
Dermatology Unit, Department of Medicine, Faculty of Medicine, Universiti Teknologi MARA (UiTM), Selangor, Malaysia
Cutaneous Metastases in Advanced Lung Adenocarcinoma
Vol 5(2) (2020) 75-78 | jchs-medicine.uitm.edu.my | eISSN 0127-984X
https://doi.org/10.24191/jchs.v5i2.11125
76
Skin examination revealed multiple
subcutaneous nodules on the right upper back, left axilla
and lower abdomen, each approximately 10 to 15 mm
in diameter. These subcutaneous nodules were purplish
and erythematous in appearance with well-defined
borders, being firm, fixed and non-discharging in nature
(Figure 1). The results from other systemic
examinations were normal. The results of laboratory
tests reflected mild anaemia, leucocytosis, an elevated
erythrocyte sedimentation rate (ESR) at 82 mm/hr and
abnormal C-reactive protein (CRP) levelling at 12.6
mg/l. The results from other routine investigations were
normal.
Chest X-ray depicted bilateral interstitial
infiltrates (Figure 2a), whereas CT of the thorax
confirmed the presence of a mass on the anterior
segment of the left upper lobe of the lung (Figure 2b).
Based on the CT scan results, further imaging of the
abdominal and pelvic region proceeded accordingly for
staging. The imaging results showed that the pleural,
nodal and bony areas were positive for metastases, not
ruling out the possibility of liver metastasis owing to the
discovery of hypodense lesions on the said organ.
Samples were extracted from the subcutaneous
nodules on the left axilla and lower abdomen. These
samples were subsequently subjected to
histopathological evaluation using the haematoxylin
and eosin (HE) staining protocol. Microscopic
assessment of the specimens pinpointed tumour
infiltration within the dermis extending up to the
subcutaneous fat layer (Figure 3a; Figure 3b).
Morphologically, small, scattered clusters of tumour
cells were arranged in a glandular pattern, illustrating
mild-to-moderate nuclear pleomorphism and round-to-
oval vesicular nuclei with prominent nucleoli. Apart
from that, a desmoplastic reaction was noted between
the stromal component of the cells and the existing
scanty fibroadipose tissue. The specimens showcased
affinity for thyroid transcription factor 1 (TTF1) and
cytokeratin 7 (CK7) markers and thus, being conclusive
of underlying lung adenocarcinoma (Figure 3c; Figure
3d). Following that, bronchoscopy, bronchoalveolar
lavage (BAL) and biopsy were performed, and their
respective results supported the diagnosis of lung
adenocarcinoma. Based on the interpretation of the
aforementioned outcomes, the patient was diagnosed
with stage IV lung adenocarcinoma with cutaneous
metastasis. However, she was unfortunately passed
away after two weeks of hospitalization with the cause
of death attributing to a massive pulmonary embolism.
Figure 1: Purplish and erythematous subcutaneous nodules on the
(a) left axilla and (b) lower abdomen
Figure 2: (a) Chest X-ray showed the bilateral interstitial infiltrates, which mainly concentrated over the lower and middle lobes; (b) CT of the
thorax showed a heterogeneously enhancing mass with spiculated margin occupying the anterior segment of left upper lobe measuring 5.0 x 5.5
x 6.9 cm
Cutaneous Metastases in Advanced Lung Adenocarcinoma
Vol 5(2) (2020) 75-78 | jchs-medicine.uitm.edu.my | eISSN 0127-984X
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77
Figure 3: (a) The skin stained with HE stain at 40x magnification showed tumour infiltration in the dermis; (b) The skin stained with HE stain at
100x magnification showed tumour infiltration up to the subcutaneous fat layer in which they were arranged in small clusters, some were having
ample cytoplasm while some displayed prominent nuclei; (c) The skin stained with immunohistochemistry (IHC) staining for TTF1 at 400x
magnification showed tumour cells with positive focal nuclear staining; (d) The skin stained with IHC for CK7 at 40x magnification showed
tumour cells with positive cytoplasmic staining
DISCUSSION
Cutaneous metastases may spread via venous, arterial
or lymphatic systems before the identification of the
primary tumour and usually, it is indicative of poor
prognosis. Previous studies reported an average
survival time between 3 to 5 months [7, 8], and such
malignant metastases are often associated with
disseminated diseases [9, 10]. Cutaneous metastases are
usually manifested as a painless solitary nodular lesion,
which is predominantly located at the head and neck
areas and followed by the chest, lower limbs and upper
limbs. Nonetheless, cases with multiple skin lesions
were also reported, albeit rare. Also, they may manifest
as inflammatory lesions, epidermoid cysts, lipomas or
basal cell carcinoma of the skin. Even though less
common, they can be painful, itchy, exudative and
ulcerated [12]. It was reported that tumours from the
upper and right lobes were more frequently associated
with skin metastases [11]. Besides, adenocarcinoma is
the most frequent histology observed in such lesion.
Thus, it is recommended to further investigate to
exclude other distant metastatic diseases if cutaneous
metastases are observed [12].
While cutaneous metastases are commonly
known to be rare in women and usually manifested as a
solitary nodule, our patient was presented with multiple
Cutaneous Metastases in Advanced Lung Adenocarcinoma
Vol 5(2) (2020) 75-78 | jchs-medicine.uitm.edu.my | eISSN 0127-984X
https://doi.org/10.24191/jchs.v5i2.11125
78
painful skin lesions all over her trunk. Excisional skin
biopsy for histology, IHC and electron microscopy
examinations is the gold standard for diagnosis
confirmation. Hence, in the present case, the diagnosis
was confirmed with the positive results from both the
TTF1 and CK-7 IHC staining, which are used to detect
immunohistochemical markers for lung
adenocarcinoma diagnosis. Moreover, CT thorax and
bronchoscopy were also performed to confirm the
diagnosis as her symptoms pointing to lung malignancy.
However, the prognosis was poor, as expected, and the
patient inevitably succumbed to her ailment as a
consequence.
The presentation of skin metastases aids the
diagnosis in asymptomatic patients or patients with
delayed symptoms. However, lung cancers with
cutaneous metastases are generally having poor
prognosis and are less likely to be cured despite
aggressive chemotherapy and/or radiation therapy,
which is possibly due to inadequate blood supply to the
skin [11]. Therefore, they are usually offered palliative
chemotherapy, with or without radiation. Radiation
therapy is usually ordered for the patient with skin
lesions that are associated with severe pain or bleeding
[12].
CONCLUSION
Skin metastases are a rare manifestation of lung cancer
in women and even more so if they are identified in
multiple anatomical sites. In view of that, any cutaneous
lesion accompanied by plausible signs of malignancy
should warrant suspicion of skin metastasis or a
paraneoplastic growth. To verify such differential
diagnoses, histology and IHC techniques should be
utilized to aid the diagnosis of the primary malignancy.
Conflict of Interest
Authors declare none.
Acknowledgement
We would like to dedicate our utmost appreciation to Dr
Nur Amalina Abdul Mokhtar, the medical officer
assigned to the patient, for disclosing detailed
information on the case. We would also like to express
our gratitude to all clinicians involved in the care of the
patient, as well as her family members for consenting to
the publication of this case report.
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