An 81-year-old white man presented with a rapidly enlarging nodule on his scalp. He had first noticed the lesion 3 weeks earlier. Since then, he had several episodes of bleeding, along with a purulent discharge, from the lesion. His non-Hodgkin's lymphoma was in clinical remission; his history also included Graves' disease and a recent diagnosis of pulmonary squamous-cell carcinoma. Physical examination confirmed the presence of a solitary, well-circumscribed, nontender, 1.3 x 1.3-cm erythematous nodule, with a friable center (Figure 1). No cervical lymphadenopathy was noted. A biopsy of the nodule was performed, and histologic analysis revealed the diagnosis (Figure 2).
Quiz Answer
Metastatic pulmonary squamous-cell carcinoma—Computed tomography (CT) of the chest revealed numerous small masses in both lung lobes that had not been present on previous CT scans. The patient refused any further medical interventions. He developed progressive dyspnea and was placed in hospice care. He died 8 weeks later.
The American Cancer Society estimates that 330,000 Americans are currently living with lung cancer, and that 213,380 new cases will be diagnosed in 2007.1 Lung cancer is the leading cause of cancer deaths in men and women. When combining the number of annual deaths from the next 3 most common cancers—colon, breast, and prostate—the total is still less than the total deaths from lung cancer.
According to the American Lung Association, smoking accounts for 90% of all lung cancer cases in men and women.2 There are 2 major types of lung cancer: non-small cell and small cell. Non–small-cell lung cancer is more common than small-cell cancer and includes squamous-cell carcinoma, adenocarcinoma, and large-cell carcinoma.
Lung cancer metastasizes to the skin less often than to other organ systems. Large-cell carcinoma is associated with the highest rate of skin metastasis, and squamous- and small-cell carcinoma with the lowest. Although the overall incidence of skin metastasis is low, skin metastasis is the initial manifestation in from 7% to 19% of pulmonary carcinoma cases.3 Metastasis can occur anywhere on the body, including the genitourinary region.4 Skin metastases typically occur in advanced stages of lung cancer and carry an ominous prognosis, with a median survival of 4 to 6 months.5
Most cutaneous metastases are typically mobile, painless nodules, which can feel firm or rubbery on palpation. Persistent ulcers and indurated patches of erythema should also raise suspicion for metastasis.6 Cutaneous metastasis from internal malignancy is typically a poor prognostic indicator and is associated with a median survival of 5 months.7
The differential diagnosis of an enlarging nodule on the scalp is lengthy and includes cutaneous cysts, cutaneous carcinoma, pyogenic granuloma, kerion, lymphoma, and hemangioma.
Nodular basal-cell carcinoma is characterized by a pearly papule with telangiectasia or ulceration on its surface. The lesions are slow growing and would not enlarge to the size seen in this patient over a 3-week period.
The lesions of Sweet's syndrome occur on the upper body, including the face and scalp. They are typically tender and violaceous. Patients may experience a prodrome of fevers and arthralgias. Sweet's syndrome may be associated with malignancies, especially hematologic.
Keloids are scars that have grown larger than the original injury site. A keloid feels firm on palpation and does not have a vascular appearance; patients with keloids typically have a history of trauma.
References
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American Cancer Society. Overview: Lung Cancer. Available at www.cancer.org. Accessed August 27, 2007.
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American Lung Association. Lung cancer fact sheet. 2006. Available at www.lungusa.com. Accessed January 6, 2007.
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Molina Garrido MJ, Mora Rufete A, Guillen Ponce C, et al. Skin metastases as first manifestation of lung cancer. Clin Transl Oncol. 2006;8:616-617.
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Jahnke A, Domke R, Makovitzky J, et al. Vaginal metastasis of lung cancer: a case report. Anticancer Res. 2005;25:1645-1648.
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Ardavanis A, Orphanos G, Ioannidis G, et al. Skin metastases from primary lung cancer. Report of three cases and a brief review. In Vivo. 2006;20:671-673.
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Lookingbill DP, Spangler N, Sexton FM. Skin involvement as the presenting sign of internal carcinoma. A retrospective study of 7316 cancer patients. J Am Acad Dermatol. 1990;22:19-26.
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Sariya D, Ruth K, Adams-McDonnell R, et al. Clinicopathologic correlation of cutaneous metastases: experience from a cancer center. Arch Dermatol. 2007;143:613-620.
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