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An Earlobe Lesion with a Lung Nodule
cutaneous signs of cardiopulmonary disease An Earlobe Lesion with a Lung Nodule* Louis L. Cregler, M.D.; and Michael Landor, M.D.
A 74-year-old white man presented with a rightsided neck mass of several weeks' duration that
was accompanied by malaise and fatigue. He had a 50 pack-year history of cigarette smoking. He denied chest pains, fever, chills, increase in cough or sputum production. Physical examination revealed a cachectic man with an ulcerated lesion (1 cm xl cm) in his right earlobe, a hard lymph node in the right anterior triangle, and a nontender erythematous hard mass in the right supraclavicular fossa (Fig 1). Chest x-ray film revealed mediastinal enlargement and a supraclavicular mass (Fig 2). A CT scan of the chest demonstrated a 1 cm irregular nodule in the medial portion of the
superior segment of the right lower lobe of his lung (Fig 3). What is the diagnosis? A) Lymphoma B) Metastatic carcinoma of the lung C) Metastatic basal cell carcinoma D) Noduloulcerative squamous cell carcinoma of skin
FIGURE 2. Chest x-ray film.
FIGURE 1. Right ear lesion and neck mass. *From the Division of General Internal Medicine, Department of Medicine. Bronx VA Medical Center, Mt. Sinai School of Medicine (CUNY), New York. Reprint requests: Dr. Cregler; Department of Medicine. 130 West Kingsbridge Road. Bronx 10468
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FIGURE 3. CT scan of chest. An Earlobe Lesion with a Lung Nodule (Cragle" Landor)
The answer is: c) Metastatic.basal cell carcinoma
This 74-ye~0Id white man with a 50 pack-year history of cigarette smoking had a biopsy of the supraclavicular mass which revealed squamous cell carcinoma. A biopsy of the right ear lobe lesion revealed basal cell carcinoma. Computed tomographic scan of the neck demonstrated extension of the mass into the superior mediastinum, invasion of right carotid sheath and the right Cs transverse process. The patient was treated with a full course of radiotherap~ He gradually developed progressive shortness of breath, weight loss, and died five months later of respiratory failure. Basal cell carcinoma is the most prevalent human skin cancer but metastasis is extremely rare. 1.2 Metastasis develops ~rough lymphatic drainage and can also spread hematogenousl~ Basal cell carcinomas that
metastasize are ulually located on the head and neck, of long duration, large in size, and refractory to treatment.:) Head and neck lesions should be periodi· cally examined for focal lymph node involvement, and a chest x-ray film should be performed if metastases is suspected.· Basal cell carcinomas are typically slow growing and patients with metastasis have survived for eight to 12 years. 1 Patients with lymphomas often develop local tumor masses. Hodgkin's disease (nodular sclerosis) may present with a mediastinal mass and is usually found in ages 15 to 35 years. Asymptomatic lymphadenopathy may be found in elderly patients. Large tumor masses are commonly associated with symptoms which in· elude fever, night sweats, and fatigue. 15 Pulmonary involvement occurs in 10 to 20 percent of patients and can appear as a patchy infiltrate in the mediastinum associated with anterior nodes. 6 Invasive squamous cell carcinoma of the sldn rarely
develops in normal appearing skin. It is often preceded by a premalignant lesion such as a chronic ulcer, scar tissue, or prior radiation damage. 7 Progressive invasion and ulceradheres the tumor to the structures belo~ ation occurs typically at the center, causing bruising or crusting. Bronchogenic carcinoma may have distant metastases that are more prominent than the primary tumor. Hilar or mediastinal involvement is typical for nonsmall cell bronchogenic carcinoma. 8 Metastasis of poorly differentiated epidermoid carcinoma of the lung may be hard to differentiate from basal cell 3 The presence of citrulline in carcinoma histologicall~ histochemical staining of keratin from the lesion is highly significant in characterizing the tumor as basal cell carcinoma. 9 REFERENCES 1 Latte. R. Kelaler RW Metuwtzing basal cell epithelioma of the akin, Cancetr 1951; 4:866-78 2 Nelson NL. Kelt E. Gordon M, Advances in the biology and carcinogenelil of basal cell carcinoma, NY State J Me
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A 74-year-old white man presented with a rightsided neck mass of several weeks' duration that
was accompanied by malaise and fatigue. He had a 50 pack-year history of cigarette smoking. He denied chest pains, fever, chills, increase in cough or sputum production. Physical examination revealed a cachectic man with an ulcerated lesion (1 cm xl cm) in his right earlobe, a hard lymph node in the right anterior triangle, and a nontender erythematous hard mass in the right supraclavicular fossa (Fig 1). Chest x-ray film revealed mediastinal enlargement and a supraclavicular mass (Fig 2). A CT scan of the chest demonstrated a 1 cm irregular nodule in the medial portion of the
superior segment of the right lower lobe of his lung (Fig 3). What is the diagnosis? A) Lymphoma B) Metastatic carcinoma of the lung C) Metastatic basal cell carcinoma D) Noduloulcerative squamous cell carcinoma of skin
FIGURE 2. Chest x-ray film.
FIGURE 1. Right ear lesion and neck mass. *From the Division of General Internal Medicine, Department of Medicine. Bronx VA Medical Center, Mt. Sinai School of Medicine (CUNY), New York. Reprint requests: Dr. Cregler; Department of Medicine. 130 West Kingsbridge Road. Bronx 10468
908
FIGURE 3. CT scan of chest. An Earlobe Lesion with a Lung Nodule (Cragle" Landor)
The answer is: c) Metastatic.basal cell carcinoma
This 74-ye~0Id white man with a 50 pack-year history of cigarette smoking had a biopsy of the supraclavicular mass which revealed squamous cell carcinoma. A biopsy of the right ear lobe lesion revealed basal cell carcinoma. Computed tomographic scan of the neck demonstrated extension of the mass into the superior mediastinum, invasion of right carotid sheath and the right Cs transverse process. The patient was treated with a full course of radiotherap~ He gradually developed progressive shortness of breath, weight loss, and died five months later of respiratory failure. Basal cell carcinoma is the most prevalent human skin cancer but metastasis is extremely rare. 1.2 Metastasis develops ~rough lymphatic drainage and can also spread hematogenousl~ Basal cell carcinomas that
metastasize are ulually located on the head and neck, of long duration, large in size, and refractory to treatment.:) Head and neck lesions should be periodi· cally examined for focal lymph node involvement, and a chest x-ray film should be performed if metastases is suspected.· Basal cell carcinomas are typically slow growing and patients with metastasis have survived for eight to 12 years. 1 Patients with lymphomas often develop local tumor masses. Hodgkin's disease (nodular sclerosis) may present with a mediastinal mass and is usually found in ages 15 to 35 years. Asymptomatic lymphadenopathy may be found in elderly patients. Large tumor masses are commonly associated with symptoms which in· elude fever, night sweats, and fatigue. 15 Pulmonary involvement occurs in 10 to 20 percent of patients and can appear as a patchy infiltrate in the mediastinum associated with anterior nodes. 6 Invasive squamous cell carcinoma of the sldn rarely
develops in normal appearing skin. It is often preceded by a premalignant lesion such as a chronic ulcer, scar tissue, or prior radiation damage. 7 Progressive invasion and ulceradheres the tumor to the structures belo~ ation occurs typically at the center, causing bruising or crusting. Bronchogenic carcinoma may have distant metastases that are more prominent than the primary tumor. Hilar or mediastinal involvement is typical for nonsmall cell bronchogenic carcinoma. 8 Metastasis of poorly differentiated epidermoid carcinoma of the lung may be hard to differentiate from basal cell 3 The presence of citrulline in carcinoma histologicall~ histochemical staining of keratin from the lesion is highly significant in characterizing the tumor as basal cell carcinoma. 9 REFERENCES 1 Latte. R. Kelaler RW Metuwtzing basal cell epithelioma of the akin, Cancetr 1951; 4:866-78 2 Nelson NL. Kelt E. Gordon M, Advances in the biology and carcinogenelil of basal cell carcinoma, NY State J Me
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