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Isolated squamous cell lung cancer metastasis to the scalp
European Geriatric Medicine 7 (2016) 166–167
Available online at
ScienceDirect www.sciencedirect.com
EGM clinical case
Isolated squamous cell lung cancer metastasis to the scalp S. Taguchi a, T. Ogawa a, N. Takayashiki b, K. Katayama c, H. Satoh d,* a
Division of Dermatology, Mito Medical Center, University of Tsukuba, Mito, Ibaraki, Japan Division of Pathology, Mito Medical Center, University of Tsukuba, Mito, Ibaraki, Japan c Division of General Medicine, Mito Medical Center, University of Tsukuba, Mito, Ibaraki, Japan d Division of Respiratory Medicine, Mito Medical Center, University of Tsukuba, Mito, Ibaraki, Japan b
A R T I C L E I N F O
Article history: Received 24 October 2015 Accepted 25 October 2015 Available online 12 November 2015 Keywords: Squamous cell lung cancer Metastasis Scalp
In the elderly, various kinds of malignant skin diseases develop in the scalp such as squamous cell carcinoma, basal cell carcinoma, and angiosarcoma [1]. Skin metastasis to the scalp is very rare [2–5]. This distant spread implies that cancer cells may reach many sites of the whole body via the bloodstream and the lymphatic system. Like all other metastatic lesions, skin metastasis reflects the progression of the primary malignancy, however, some of patients with lung cancer developed isolated skin metastasis [4,6–8]. This report describes sole metastasis to the scalp, arising from squamous cell carcinoma of the lung. A 71-year-old man was referred to our hospital due to consistent cough for several months. He was ex-smoker, but he smoked 100 packets-years. He has no medical history except for hypertension. Chest radiograph and CT scan showed a mass in the left lower lobe of the lung with ipsilateral mediastinal lymph node swelling. Pathological specimens obtained from the lower lobe bronchus by fiberoptic bronchoscopy revealed squamous cell carcinoma. The patient diagnosed as having T2bN2M0 stage IIIB squamous cell carcinoma of the lung. Systemic chemotherapy was initiated with a combination of carboplatin and gemcitabine. The patient received 3 cycles of the chemotherapy in total, which was eventually stopped due to asymptomatic deterioration of the primary lesion. A second-line chemotherapy of docetaxel was given to the patient. CT scan after
* Corresponding author. Division of Internal Medicine, Mito Medical Center, University of Tsukuba, Miya-machi 3-2-7, Mito, Ibaraki, 310-0015, Japan. Tel.: +81 2923 12371. E-mail address: [email protected] (H. Satoh).
2 courses of the second-line showed an unchanged primary lesion and mediastinal lymph nodes. No distant metastasis was also found. Two weeks after the systemic evaluation by CT scan, he complained two painless nodules in the scalp. His physical examination was unremarkable except for the two firm swellings over the scalp. The skin lesions were pink colored, measuring 10 and 13 mm, arising from the subcutaneous tissue, and with no tendency to blood (Fig. 1). Biopsy from the lesions was performed, and hisopathological examination of the specimen revealed a cutaneous metastasis without no direct connection with epidermis (Fig. 2). The lesion was diagnosed as scalp metastasis from squamous cell carcinoma of the lung. As performance status (PS, ECOG) of the patient was still PS1, the patient received third line chemotherapy with amrubicin. With the increase of the elderly population, incidences of skin tumors have been increasing. The scalp is one of the most common sites where several kinds of primary and metastatic skin tumors develop, therefore, differential diagnosis of them are required. Scalp metastasis is very rare, but rich blood flow may be the reason of metastasis [9,10]. Lung cancer was the most common primary tumor, which developed scalp metastasis [11]. The most common metastatic sites from lung cancer included lung, bone, brain, liver, and adrenal gland [12,13], but the skin is rarely affected [14]. Approximately 1–12% of patients with lung cancer develop cutaneous metastasis [9,15]. Cutaneous metastasis from lung cancer occurs usually at follow-up period of patients. Internal malignancies generally disseminate to a site close to the primary tumor, and this is presumably due to the large body surface area of these regions and the closeness to the site of the
http://dx.doi.org/10.1016/j.eurger.2015.10.010 1878-7649/ß 2015 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved.
S. Taguchi et al. / European Geriatric Medicine 7 (2016) 166–167
167
isolated involvement of the scalp as the manifestation of systemic disease. The patient developed scalp lesions 8 months after his treatment for the primary lesion in the lung, although it is difficult to explain the exact mechanism. It is important to know that skin metastasis in distal part of the body may occur in patients without extensive metastases. In conclusion, we show herein a case with isolated metastatic involvement of the scalp from a primary lesion in the lung, under local control, is an extremely rare feature of distant metastatic presentation. A good history and biopsy of the lesion is necessary to establish the diagnosis. Completely surgical resection instituted as a mode of treatment for palliation in such inoperable lesions could provide excellent relief from distressing symptoms, such as pain, and improve the quality of life. Disclosure of interest
Fig. 1. The skin lesions were pink colored, measuring 10 and 13 mm, arising from the subcutaneous tissue, and with no tendency to blood (arrows).
Fig. 2. Hisopathological examination of the scalp lesion revealed a cutaneous metastasis (arrows) without no direct connection with epidermis.
primary tumor. In lung cancer, therefore, the most common metastatic sites are the thorax, back, and abdomen wall [9,16,17]. However, lung cancer is known for their tendency to metastasize not only close to the primary site but also to remote cutaneous sites [18]. Scalp metastasis is very rare [2–5], but the reason of metastatis may be rich blood flow [9,10]. The distant spread usually implies that cancer cells may reach many sites of the whole body via the bloodstream and the lymphatic system. Like all other are metastatic lesions, skin metastasis reflects the progression of the primary malignancy. Scalp metastases from squamous cell carcinoma of the lung are very infrequent and they have been reported on some previous occasions only [2–5], but in most of them scalp involvement was associated with simultaneous metastatic involvement of other sites, but some of them were isolated metastatic involvement [2,4]. In the present case, scalp metastases were found as the sole site of distant metastasis. The interesting feature in our case was
The authors declare that they have no competing interest. Ethics status: informed consent was obtained from the patient. References [1] Scheinfeld N. Review of scalp alopecia due to a clinically unapparent or minimally apparent neoplasm (SACUMAN). Acta Derm Venereol 2006;86: 387–92. [2] Patil C, Permi H. Scalp metastasis from squamous cell carcinoma of the lung. J Cancer Res Ther 2010;6:402–3. [3] Gupta PP, Gupta KB, Gulia J, Agarwal D, Mehta D. Scalp lesion: a presenting feature of squamous cell carcinoma of lung. J Cancer Res Ther 2010;6:370–3. [4] Kuykendall LV, Ching JA, Payne WG. Isolated subcutaneous mass of the scalp as initial presentation of metastatic squamous cell carcinoma of the lung. Eplasty 2013;13:ic61 [eCollection 2013]. [5] Babacan NA, Kilic¸kap S, Sene S, Kacan T, Yucel B, Eren MF, et al. A Case of multifocal skin metastases from lung cancer presenting with vasculitic-type cutaneous nodule. Indian J Dermatol 2015;60:213. [6] Matsuno Y, Watanabe K, Satoh H, Yamashita YT, Sekizawa K. Thenar metastasis from lung cancer. Eur J Cancer Care (Engl) 2002;11:61–2. [7] Kurishima K, Kagohashi K, Ohara G, Miyazaki K, Kawaguchi M, Takayashiki N, et al. Skin metastasis from small cell lung cancer. Tuberk Toraks 2014;62: 147–50. [8] Kurishima K, Kagohashi K, Taguchi S, Satoh H. FDG-PET/CT scan in a skin metastasis from lung cancer. Tuberk Toraks 2014;62:170–1. [9] Hidaka T, Ishii Y, Kitamura S. Clinical features of skin metastasis from lung cancer. Intern Med 1996;35:459–62. [10] Leonard N. Cutaneous metastases: where do they come from and what can they mimic? Curr Diagn Pathol 2007;13:320–30. [11] Chiu CS, Lin CY, Kuo TT, Kuan YZ, Chen MJ, Ho HC, et al. Malignant cutaneous tumors of the scalp: a study of demographic characteristics and histologic distributions of 398 Taiwanese patients. J Am Acad Dermatol 2007;56:448–52. [12] Nakazawa K, Kurishima K, Tamura T, Kagohashi K, Ishikawa H, Satoh H, et al. Specific organ metastases and survival in small cell lung cancer. Oncol Lett 2012;4:617–20. [13] Tamura T, Kurishima K, Nakazawa K, Kagohashi K, Ishikawa H, Satoh H, et al. Specific organ metastases and survival in metastatic non-small-cell lung cancer. Mol Clin Oncol 2015;3:217–21. [14] Ambrogi V, Nofroni I, Tonini G, Mineo TC. Skin metastases in lung cancer: analysis of a 10-year experience. Oncol Rep 2001;8:57–61. [15] Terashima T, Kanazawa M. Lung cancer with skin metastasis. Chest 1994;106:1448–50. [16] Coslett LM, Katlic MR. Lung cancer with skin metastasis. Chest 1990;97:757–9. [17] Krathen RA, Orengo IF, Rosen T. Cutaneous metastasis: a meta-analysis of data. South Med J 2003;96:164–7. [18] Lookingbill DP, Spangler N, Helm KF. Cutaneous metastases in patients with metastatic carcinoma: a retrospective study of 4020 patients. J Am Acad Dermatol 1993;29:228–36.
Available online at
ScienceDirect www.sciencedirect.com
EGM clinical case
Isolated squamous cell lung cancer metastasis to the scalp S. Taguchi a, T. Ogawa a, N. Takayashiki b, K. Katayama c, H. Satoh d,* a
Division of Dermatology, Mito Medical Center, University of Tsukuba, Mito, Ibaraki, Japan Division of Pathology, Mito Medical Center, University of Tsukuba, Mito, Ibaraki, Japan c Division of General Medicine, Mito Medical Center, University of Tsukuba, Mito, Ibaraki, Japan d Division of Respiratory Medicine, Mito Medical Center, University of Tsukuba, Mito, Ibaraki, Japan b
A R T I C L E I N F O
Article history: Received 24 October 2015 Accepted 25 October 2015 Available online 12 November 2015 Keywords: Squamous cell lung cancer Metastasis Scalp
In the elderly, various kinds of malignant skin diseases develop in the scalp such as squamous cell carcinoma, basal cell carcinoma, and angiosarcoma [1]. Skin metastasis to the scalp is very rare [2–5]. This distant spread implies that cancer cells may reach many sites of the whole body via the bloodstream and the lymphatic system. Like all other metastatic lesions, skin metastasis reflects the progression of the primary malignancy, however, some of patients with lung cancer developed isolated skin metastasis [4,6–8]. This report describes sole metastasis to the scalp, arising from squamous cell carcinoma of the lung. A 71-year-old man was referred to our hospital due to consistent cough for several months. He was ex-smoker, but he smoked 100 packets-years. He has no medical history except for hypertension. Chest radiograph and CT scan showed a mass in the left lower lobe of the lung with ipsilateral mediastinal lymph node swelling. Pathological specimens obtained from the lower lobe bronchus by fiberoptic bronchoscopy revealed squamous cell carcinoma. The patient diagnosed as having T2bN2M0 stage IIIB squamous cell carcinoma of the lung. Systemic chemotherapy was initiated with a combination of carboplatin and gemcitabine. The patient received 3 cycles of the chemotherapy in total, which was eventually stopped due to asymptomatic deterioration of the primary lesion. A second-line chemotherapy of docetaxel was given to the patient. CT scan after
* Corresponding author. Division of Internal Medicine, Mito Medical Center, University of Tsukuba, Miya-machi 3-2-7, Mito, Ibaraki, 310-0015, Japan. Tel.: +81 2923 12371. E-mail address: [email protected] (H. Satoh).
2 courses of the second-line showed an unchanged primary lesion and mediastinal lymph nodes. No distant metastasis was also found. Two weeks after the systemic evaluation by CT scan, he complained two painless nodules in the scalp. His physical examination was unremarkable except for the two firm swellings over the scalp. The skin lesions were pink colored, measuring 10 and 13 mm, arising from the subcutaneous tissue, and with no tendency to blood (Fig. 1). Biopsy from the lesions was performed, and hisopathological examination of the specimen revealed a cutaneous metastasis without no direct connection with epidermis (Fig. 2). The lesion was diagnosed as scalp metastasis from squamous cell carcinoma of the lung. As performance status (PS, ECOG) of the patient was still PS1, the patient received third line chemotherapy with amrubicin. With the increase of the elderly population, incidences of skin tumors have been increasing. The scalp is one of the most common sites where several kinds of primary and metastatic skin tumors develop, therefore, differential diagnosis of them are required. Scalp metastasis is very rare, but rich blood flow may be the reason of metastasis [9,10]. Lung cancer was the most common primary tumor, which developed scalp metastasis [11]. The most common metastatic sites from lung cancer included lung, bone, brain, liver, and adrenal gland [12,13], but the skin is rarely affected [14]. Approximately 1–12% of patients with lung cancer develop cutaneous metastasis [9,15]. Cutaneous metastasis from lung cancer occurs usually at follow-up period of patients. Internal malignancies generally disseminate to a site close to the primary tumor, and this is presumably due to the large body surface area of these regions and the closeness to the site of the
http://dx.doi.org/10.1016/j.eurger.2015.10.010 1878-7649/ß 2015 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved.
S. Taguchi et al. / European Geriatric Medicine 7 (2016) 166–167
167
isolated involvement of the scalp as the manifestation of systemic disease. The patient developed scalp lesions 8 months after his treatment for the primary lesion in the lung, although it is difficult to explain the exact mechanism. It is important to know that skin metastasis in distal part of the body may occur in patients without extensive metastases. In conclusion, we show herein a case with isolated metastatic involvement of the scalp from a primary lesion in the lung, under local control, is an extremely rare feature of distant metastatic presentation. A good history and biopsy of the lesion is necessary to establish the diagnosis. Completely surgical resection instituted as a mode of treatment for palliation in such inoperable lesions could provide excellent relief from distressing symptoms, such as pain, and improve the quality of life. Disclosure of interest
Fig. 1. The skin lesions were pink colored, measuring 10 and 13 mm, arising from the subcutaneous tissue, and with no tendency to blood (arrows).
Fig. 2. Hisopathological examination of the scalp lesion revealed a cutaneous metastasis (arrows) without no direct connection with epidermis.
primary tumor. In lung cancer, therefore, the most common metastatic sites are the thorax, back, and abdomen wall [9,16,17]. However, lung cancer is known for their tendency to metastasize not only close to the primary site but also to remote cutaneous sites [18]. Scalp metastasis is very rare [2–5], but the reason of metastatis may be rich blood flow [9,10]. The distant spread usually implies that cancer cells may reach many sites of the whole body via the bloodstream and the lymphatic system. Like all other are metastatic lesions, skin metastasis reflects the progression of the primary malignancy. Scalp metastases from squamous cell carcinoma of the lung are very infrequent and they have been reported on some previous occasions only [2–5], but in most of them scalp involvement was associated with simultaneous metastatic involvement of other sites, but some of them were isolated metastatic involvement [2,4]. In the present case, scalp metastases were found as the sole site of distant metastasis. The interesting feature in our case was
The authors declare that they have no competing interest. Ethics status: informed consent was obtained from the patient. References [1] Scheinfeld N. Review of scalp alopecia due to a clinically unapparent or minimally apparent neoplasm (SACUMAN). Acta Derm Venereol 2006;86: 387–92. [2] Patil C, Permi H. Scalp metastasis from squamous cell carcinoma of the lung. J Cancer Res Ther 2010;6:402–3. [3] Gupta PP, Gupta KB, Gulia J, Agarwal D, Mehta D. Scalp lesion: a presenting feature of squamous cell carcinoma of lung. J Cancer Res Ther 2010;6:370–3. [4] Kuykendall LV, Ching JA, Payne WG. Isolated subcutaneous mass of the scalp as initial presentation of metastatic squamous cell carcinoma of the lung. Eplasty 2013;13:ic61 [eCollection 2013]. [5] Babacan NA, Kilic¸kap S, Sene S, Kacan T, Yucel B, Eren MF, et al. A Case of multifocal skin metastases from lung cancer presenting with vasculitic-type cutaneous nodule. Indian J Dermatol 2015;60:213. [6] Matsuno Y, Watanabe K, Satoh H, Yamashita YT, Sekizawa K. Thenar metastasis from lung cancer. Eur J Cancer Care (Engl) 2002;11:61–2. [7] Kurishima K, Kagohashi K, Ohara G, Miyazaki K, Kawaguchi M, Takayashiki N, et al. Skin metastasis from small cell lung cancer. Tuberk Toraks 2014;62: 147–50. [8] Kurishima K, Kagohashi K, Taguchi S, Satoh H. FDG-PET/CT scan in a skin metastasis from lung cancer. Tuberk Toraks 2014;62:170–1. [9] Hidaka T, Ishii Y, Kitamura S. Clinical features of skin metastasis from lung cancer. Intern Med 1996;35:459–62. [10] Leonard N. Cutaneous metastases: where do they come from and what can they mimic? Curr Diagn Pathol 2007;13:320–30. [11] Chiu CS, Lin CY, Kuo TT, Kuan YZ, Chen MJ, Ho HC, et al. Malignant cutaneous tumors of the scalp: a study of demographic characteristics and histologic distributions of 398 Taiwanese patients. J Am Acad Dermatol 2007;56:448–52. [12] Nakazawa K, Kurishima K, Tamura T, Kagohashi K, Ishikawa H, Satoh H, et al. Specific organ metastases and survival in small cell lung cancer. Oncol Lett 2012;4:617–20. [13] Tamura T, Kurishima K, Nakazawa K, Kagohashi K, Ishikawa H, Satoh H, et al. Specific organ metastases and survival in metastatic non-small-cell lung cancer. Mol Clin Oncol 2015;3:217–21. [14] Ambrogi V, Nofroni I, Tonini G, Mineo TC. Skin metastases in lung cancer: analysis of a 10-year experience. Oncol Rep 2001;8:57–61. [15] Terashima T, Kanazawa M. Lung cancer with skin metastasis. Chest 1994;106:1448–50. [16] Coslett LM, Katlic MR. Lung cancer with skin metastasis. Chest 1990;97:757–9. [17] Krathen RA, Orengo IF, Rosen T. Cutaneous metastasis: a meta-analysis of data. South Med J 2003;96:164–7. [18] Lookingbill DP, Spangler N, Helm KF. Cutaneous metastases in patients with metastatic carcinoma: a retrospective study of 4020 patients. J Am Acad Dermatol 1993;29:228–36.