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Bronchial carcinoma presenting with a solitary skin metastasis
Brit. 3. Dis. Chest (I964) 58, 13I.
BRONCHIAL CARCINOMA PRESENTING WITH A SOLITARY SKIN METASTASIS By B. H. R. STACK Respiratory Diseases Unit, Northern General Hospital, Edinburgh
Introduction IT is common for a lesion to be discovered in some organ or tissue which is clearly a metastasis from a primary carcinoma elsewhere. Where the neoplastic tissue is poorly differentiated, the site of the primary tumour often cannot be recognized from the histological picture or determined by further investigations. T h a t this may occur with metastasizing bronchial carcinoma is illustrated by the following ease.
CaseReport Mr. W. R., aged 34, a coach builder who had previously been healthy, attended a hospital out-patient department in March, ~959, with a nodule in the skin of his left temporal region. This was thought to be a sebaceous cyst and was excised. The specimen was not sent for histological examination. Five months later, he returned with a recurrence at the same site. This was again excised and was reported as "undifferentiated t u m o u r " . Two further excisions were performed in that region in the next three months, with skin grafting on the second occasion. The first specimen was reported as malignant tumour, "epithelial and almost certainly metastatic". Because of this, an extensive search for a primary tumour was carried out, including radiological examination of the chest, skull and sinuses, intravenous pyelography and barium studies of the alimentary tract. All were negative. The second specimen was thought to resemble a rare vascular tumour (haemangiopericytoma) but this diagnosis has since been revised. Over the next three years he was kept under observation and remained well. A ioo mm. M.M.R. film i n December, i96o , was normal, and a similar film in March, i962 , was also reported negative, but an abnormality in a further film taken in April, I963 (Fig. I), was the reason for his admission to the Northern General Hospital. At that time, his only symptoms were decreased exercise tolerance on moderate exertion and a weak sensation in his back. He had no cough, sputum, haemoptysis or chest pain and no loss of appetite, weight or energy. O n clinical examination, there was no finger clubbing and no lymph nodes were palpable. The physical signs in the chest were in keeping with the radiographic finding of a large mass against the lateral chest wall on the left side. There was no clinical evidence of turnout outside the chest and no suggestion of any local recurrence of the skin tumour. (Reeeivedfor publication April 8, I964)
13 2
STACK
It seemed then that he had pulmonary metastases either from the lesion in the left temporal region or from some primary tumour elsewhere, possibly in the alimentary tract or a kidney. Repeated tests for fmcal occult blood and intravenous pyelography were, however, negative. In view of his youth, good physique, and satisfactory respir~ory function tests (F.E.V. (0.75 sec.) 2050 ml., F.V.C. 3200 ml.) it was considered that an attempt should be made to treat the pulmonary tumours with deep X-rays. However, before a decision on this could be made, two further pieces of information were needed: i. The rate of growth of the pulmonary lesions. That this was relatively slow was shown by review of his i962 M.M.R. film, in which bilateral opacities were in fact visible, about one sixth of their present size. 2. The histology of the pulmonary lesions. No specimen was obtained at bronchoscopy which showed only some lateral compression of the lingular bronchus, but an aspiration biopsy of the left sided mass produced some degenerate h~emorrhagic tissue containing tumour cells with uniform rounded nuclei. A test dose of 500 rads, applied to the right hilar lesion, produced slight shrinkage, indicating that the tumour was only moderately radio-sensitive. In view of this, a single dose of I,ooo fads was given to the same lesion, followed by a week's course of 2,5oo fads to the left sided mass. This treatment produced considerable shrinkage of the opacities on both sides (Fig. 2). He remained well for two months but was then readmitted on account of progressive dyspnoea due to radiation pneumonitis and persistent turnout, from which he died. J u s t before death, a bronchoscopy showed pink nodular tissue arising from the apical segmental bronchus of the right lower lobe, which was found to contain degenerate tumour. At autopsy, a large tumour was found, involving mainly the right middle lobe, but extending across the fissures into adjacent parts of the upper and lower lobes. Two small subpleural nodules were present in right upper lobe, and the mediastinal lymph nodes were also involved. Several grey-white firm excrescences were seen arising from the lower part of left parietal pleura (Fig. 3). The left lung was grossly shrunken. Microscopic examination showed that all the tumour lesions described had a similar structure consisting of groups of small, fairly uniform cells with rounded or oval nuclei, and a well f o r m e d and vascular stroma--the so-called "oat-cell" carcinoma (Fig. 4). This same appearance was also seen in the bronchial and aspiration biopsies and when the skin biopsy specimens of 1959 were reviewed. From these findings, it was concluded that the patient had an "oat-cell" carcinoma of the right middle lobe, the skin lesion in i959 being an early metastasis appearing at least twenty-one months before the bronchial lesion became radiologicaUy apparent, and that this tumour had further given rise to pulmonary, pleural and mediastinal lymph node metastases.
PLATE IV
FIG. t.--Chest radiograph (4.7.63), two weeks after bilateral irradiation of tumour masses.
FIG. 2.--Chest radiograph (I.5.63) , showing tumour masses.
V ~7
FIo, 3.--Necropsy specimen showing paravertebral and diaphragmatic pleura with large tumour nodules.
Fro, 4.--Tumour, stained H and E (× 225), showing "oat-eelIs" and well-developed vascular fibrous stroma,
To face p, x3~.
BP..ONGHIAL GARGINOMA P R E S E N T I N G W I T H A S O L I T A R Y SKIN MI~TASTASIS
t33
Discussion Skin metastases from bronchial carcinoma are reported in between 1.5 and 7"5 per cent. of cases (Simpson, i928 , Frissell and Knox, i937, Ask-Upmark, I932), the skin being the thirteenth most frequent site of metastatic spread in one series (Ask-Upmark, i932 ). In 94 per cent. of a series of 442 cases with skin metastases reported by Gates (i937) , the lesions were multiple. In most reported cases, the skin nodules appeared after the symptoms and signs of the primary tumour had been present for some time, and were often accompanied by widespread metastases elsewhere. A few cases have, however, been described where a solitary skin nodule was the presenting feature of a bronchial carcinoma. Simpson (I928) described the case of a woman, aged 54, who had noticed a lump in her scalp which grew slowly for three and a half years before she developed symptoms, a pleural effusion and cervical lymphadenopathy. A biopsy of the swelling showed histological features of bronchial carcinoma and the diagnosis was confirmed at autopsy. Unfortunately, there is no record of clinical or radiological examination at the time of appearance of the skin lesion. A man of 63, described by Tibaudin and Guruceaga (1959) presented with a 3 cm. nodule in his scapular region. A chest radiograph and bronchoscopy, carried out only after biopsy had shown this to be a carcinomatous metastasis, revealed a bronchial carcinoma. In the case reported here, all chest radiographs taken for nearly two years after the skin nodule appeared, were negative. A negative chest radiograph does not exclude the lung as a possible primary source of cutaneous metastases. The scalp is a common site of cutaneous carcinomatous metastases, 20 per cent. (excluding those from breast carcinoma) occurring there. It is not unknown, as in the case reported here, for such lesions to be mistaken for sebaceous cysts and excised (Montgomery, i937). In this case, the patient survived four and a half years after the skin nodule appeared and, even then, died as much from pulmonary irradiation damage as from the effects of his turnout. Apart from Simpson's case, described above, the longest recorded survival following appearance of skin metastases from a visceral carcinoma was two years, while in one large series, the average survival was only eight weeks (Gates, i937).
Summary The case is described of a 34-year-old man who developed a cutaneous metastasis from an "oat-cell" carcinoma of the bronchus twenty-one months before the primary tumour became radiologically visible, and four and a half years before his death. I wish to thank Dr. I. W. B. Grant for permission to publish this report, Dr. I. W. B. Grant, Dr. N. Maclean, and Dr. J. G. Pearson for helpful criticism and advice in its preparation, and Miss W. A, M. Tait for secretarial assistance.
STACK
‘34 REFERENCXS ASK-UPWARK, E. (x932). Actu@‘z. microbial. scat& g, 239. FRISSELL, L. F. & KNOX, L. C. (1937). Amer.J. Cancer,30, GATES, 0. (1937). Amer.J. Cancer,30, 718. MONTGOMERY, H. (1937). Surg. Cl&t. N. Amer., r7, 1249. SIMPSON, S. L. (1929). Quart. J. Med., 22, 413. TIBAIJDIN, H. A. & GURUGEAGA, M. (1959). 46, 2148.
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BRONCHIAL CARCINOMA PRESENTING WITH A SOLITARY SKIN METASTASIS By B. H. R. STACK Respiratory Diseases Unit, Northern General Hospital, Edinburgh
Introduction IT is common for a lesion to be discovered in some organ or tissue which is clearly a metastasis from a primary carcinoma elsewhere. Where the neoplastic tissue is poorly differentiated, the site of the primary tumour often cannot be recognized from the histological picture or determined by further investigations. T h a t this may occur with metastasizing bronchial carcinoma is illustrated by the following ease.
CaseReport Mr. W. R., aged 34, a coach builder who had previously been healthy, attended a hospital out-patient department in March, ~959, with a nodule in the skin of his left temporal region. This was thought to be a sebaceous cyst and was excised. The specimen was not sent for histological examination. Five months later, he returned with a recurrence at the same site. This was again excised and was reported as "undifferentiated t u m o u r " . Two further excisions were performed in that region in the next three months, with skin grafting on the second occasion. The first specimen was reported as malignant tumour, "epithelial and almost certainly metastatic". Because of this, an extensive search for a primary tumour was carried out, including radiological examination of the chest, skull and sinuses, intravenous pyelography and barium studies of the alimentary tract. All were negative. The second specimen was thought to resemble a rare vascular tumour (haemangiopericytoma) but this diagnosis has since been revised. Over the next three years he was kept under observation and remained well. A ioo mm. M.M.R. film i n December, i96o , was normal, and a similar film in March, i962 , was also reported negative, but an abnormality in a further film taken in April, I963 (Fig. I), was the reason for his admission to the Northern General Hospital. At that time, his only symptoms were decreased exercise tolerance on moderate exertion and a weak sensation in his back. He had no cough, sputum, haemoptysis or chest pain and no loss of appetite, weight or energy. O n clinical examination, there was no finger clubbing and no lymph nodes were palpable. The physical signs in the chest were in keeping with the radiographic finding of a large mass against the lateral chest wall on the left side. There was no clinical evidence of turnout outside the chest and no suggestion of any local recurrence of the skin tumour. (Reeeivedfor publication April 8, I964)
13 2
STACK
It seemed then that he had pulmonary metastases either from the lesion in the left temporal region or from some primary tumour elsewhere, possibly in the alimentary tract or a kidney. Repeated tests for fmcal occult blood and intravenous pyelography were, however, negative. In view of his youth, good physique, and satisfactory respir~ory function tests (F.E.V. (0.75 sec.) 2050 ml., F.V.C. 3200 ml.) it was considered that an attempt should be made to treat the pulmonary tumours with deep X-rays. However, before a decision on this could be made, two further pieces of information were needed: i. The rate of growth of the pulmonary lesions. That this was relatively slow was shown by review of his i962 M.M.R. film, in which bilateral opacities were in fact visible, about one sixth of their present size. 2. The histology of the pulmonary lesions. No specimen was obtained at bronchoscopy which showed only some lateral compression of the lingular bronchus, but an aspiration biopsy of the left sided mass produced some degenerate h~emorrhagic tissue containing tumour cells with uniform rounded nuclei. A test dose of 500 rads, applied to the right hilar lesion, produced slight shrinkage, indicating that the tumour was only moderately radio-sensitive. In view of this, a single dose of I,ooo fads was given to the same lesion, followed by a week's course of 2,5oo fads to the left sided mass. This treatment produced considerable shrinkage of the opacities on both sides (Fig. 2). He remained well for two months but was then readmitted on account of progressive dyspnoea due to radiation pneumonitis and persistent turnout, from which he died. J u s t before death, a bronchoscopy showed pink nodular tissue arising from the apical segmental bronchus of the right lower lobe, which was found to contain degenerate tumour. At autopsy, a large tumour was found, involving mainly the right middle lobe, but extending across the fissures into adjacent parts of the upper and lower lobes. Two small subpleural nodules were present in right upper lobe, and the mediastinal lymph nodes were also involved. Several grey-white firm excrescences were seen arising from the lower part of left parietal pleura (Fig. 3). The left lung was grossly shrunken. Microscopic examination showed that all the tumour lesions described had a similar structure consisting of groups of small, fairly uniform cells with rounded or oval nuclei, and a well f o r m e d and vascular stroma--the so-called "oat-cell" carcinoma (Fig. 4). This same appearance was also seen in the bronchial and aspiration biopsies and when the skin biopsy specimens of 1959 were reviewed. From these findings, it was concluded that the patient had an "oat-cell" carcinoma of the right middle lobe, the skin lesion in i959 being an early metastasis appearing at least twenty-one months before the bronchial lesion became radiologicaUy apparent, and that this tumour had further given rise to pulmonary, pleural and mediastinal lymph node metastases.
PLATE IV
FIG. t.--Chest radiograph (4.7.63), two weeks after bilateral irradiation of tumour masses.
FIG. 2.--Chest radiograph (I.5.63) , showing tumour masses.
V ~7
FIo, 3.--Necropsy specimen showing paravertebral and diaphragmatic pleura with large tumour nodules.
Fro, 4.--Tumour, stained H and E (× 225), showing "oat-eelIs" and well-developed vascular fibrous stroma,
To face p, x3~.
BP..ONGHIAL GARGINOMA P R E S E N T I N G W I T H A S O L I T A R Y SKIN MI~TASTASIS
t33
Discussion Skin metastases from bronchial carcinoma are reported in between 1.5 and 7"5 per cent. of cases (Simpson, i928 , Frissell and Knox, i937, Ask-Upmark, I932), the skin being the thirteenth most frequent site of metastatic spread in one series (Ask-Upmark, i932 ). In 94 per cent. of a series of 442 cases with skin metastases reported by Gates (i937) , the lesions were multiple. In most reported cases, the skin nodules appeared after the symptoms and signs of the primary tumour had been present for some time, and were often accompanied by widespread metastases elsewhere. A few cases have, however, been described where a solitary skin nodule was the presenting feature of a bronchial carcinoma. Simpson (I928) described the case of a woman, aged 54, who had noticed a lump in her scalp which grew slowly for three and a half years before she developed symptoms, a pleural effusion and cervical lymphadenopathy. A biopsy of the swelling showed histological features of bronchial carcinoma and the diagnosis was confirmed at autopsy. Unfortunately, there is no record of clinical or radiological examination at the time of appearance of the skin lesion. A man of 63, described by Tibaudin and Guruceaga (1959) presented with a 3 cm. nodule in his scapular region. A chest radiograph and bronchoscopy, carried out only after biopsy had shown this to be a carcinomatous metastasis, revealed a bronchial carcinoma. In the case reported here, all chest radiographs taken for nearly two years after the skin nodule appeared, were negative. A negative chest radiograph does not exclude the lung as a possible primary source of cutaneous metastases. The scalp is a common site of cutaneous carcinomatous metastases, 20 per cent. (excluding those from breast carcinoma) occurring there. It is not unknown, as in the case reported here, for such lesions to be mistaken for sebaceous cysts and excised (Montgomery, i937). In this case, the patient survived four and a half years after the skin nodule appeared and, even then, died as much from pulmonary irradiation damage as from the effects of his turnout. Apart from Simpson's case, described above, the longest recorded survival following appearance of skin metastases from a visceral carcinoma was two years, while in one large series, the average survival was only eight weeks (Gates, i937).
Summary The case is described of a 34-year-old man who developed a cutaneous metastasis from an "oat-cell" carcinoma of the bronchus twenty-one months before the primary tumour became radiologically visible, and four and a half years before his death. I wish to thank Dr. I. W. B. Grant for permission to publish this report, Dr. I. W. B. Grant, Dr. N. Maclean, and Dr. J. G. Pearson for helpful criticism and advice in its preparation, and Miss W. A, M. Tait for secretarial assistance.
STACK
‘34 REFERENCXS ASK-UPWARK, E. (x932). Actu@‘z. microbial. scat& g, 239. FRISSELL, L. F. & KNOX, L. C. (1937). Amer.J. Cancer,30, GATES, 0. (1937). Amer.J. Cancer,30, 718. MONTGOMERY, H. (1937). Surg. Cl&t. N. Amer., r7, 1249. SIMPSON, S. L. (1929). Quart. J. Med., 22, 413. TIBAIJDIN, H. A. & GURUGEAGA, M. (1959). 46, 2148.
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