Cutaneous metastases in non-small cell lung cancer.

To cite: McGrath RB, Flood SP, Casey R. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2014205752 DESCRIPTION A 61-year-old man presented with right pleuritic chest pain, 15 kg weight loss, shortness of breath and two painful scalp lesions (figure 1). He had a 40-pack a year smoking history with exposure to asbestos. Thoracocentesis of a right pleural effusion demonstrated atypical cytology. Staging CT showed osseous metastases and right lung apical scarring. Bone and scalp biopsies revealed poorly differentiated squamous cell carcinoma and marrow infiltration by poorly differentiated tumour, respectively, both suggestive of lung primary. Pleural biopsy confirmed stage IV adenosquamous lung carcinoma. The patient’s course post-thoracoscopy was complicated by pneumothorax, subcutaneous emphysaema and a malpositioned emergent thoracostomy tube with resultant haemoptysis. Palliative radiotherapy of cutaneous metastases was performed. Further adjuvant treatment was postponed due to iatrogenic decline in functional status, highlighting the value of less invasive procedures, such as skin biopsy, in the evaluation of metastatic processes of unknown primary. Cutaneous metastases occur in 1–12% of lung cancers. Pathogenesis is by lymphovascular invasion, with poor differentiation and upper lobe tumours increasing the risk of metastasis. Histology most commonly shows adenocarcinoma, then squamous/small-cell, followed by large-cell carcinoma. Lesions present with or before the primary in 20–60% of cases, can be single or multiple and are usually painless. Common sites include chest, back, head and neck. Treatment modalities include surgery, chemotherapy and radiotherapy, and treatment varies based on prognosis and symptoms. 2 Non-resectability, small-cell histology and multiple/ distant metastases confer a poor prognosis.