Fig. 1 : The frontal radiograph of the right shoulder shows soft tissue opacity with destruction of the glenoid, coracoid process and lateral border of the scapula. The zone of transition is narrow. The humeral articular surface is normal..

Fig. 2 : A chest radiograph performed six months previously shows a well defined, oval soft tissue opacity in the right upper and midzones. It measures approximately 8x5 cm. It has spiculated margins. The medial border merges with the right heart border. There are no calcifications or lucencies within. There is cut off of the right main bronchus. The trachea is deviated to the right. There is loss of right lung volume with elevated dome of diaphragm. Both costophrenic angles and the cardiac shadow are normal.

Clinical examination –

There were multiple well defined, hard, erythematous ,raised, nontender and non mobile cutaneous nodules in the epigastric, suprapubic and bilateral inguinal regions.

HRCT and contrast enhanced CT scan of the chest and abdomen was done for further evaluation.

The findings of the radiograph confirmed on the CT scan. There is a a well defined, heterogeneously enhancing soft tissue lesion measuring approximately 6x7x7 cm in the apical and anterior segments of the right upper lobe. The lesions is in contact with the pleura anteriorly for a length of 7 cm. Inferomediallly, it extends up to the right hilum and carina. There is complete cut-off of the right upper lobe bronchus and encasement of the superior vena cava. There is enhancing subcarinal lymph node of size 12x13 mm.

A. Multiple enhancing targetoid lesions are seen in the liver and the kidneys. The adrenals are not involved.

Enhancing soft tissue subcutaneous deposits are seem in the umbilical and inguinal regions. Multiple enlarged preaortic and paraaortic lymph nodes are present.

A. There is Soft tissue deposits with lysis of the glenoid. B. Lytic lesions involving the vertebral body are present along with soft tissue deposits with lysis of the rib.

Radiological diagnosis:

Malignant pulmonary lesion in the right upper lobe with liver, bilateral renal, lymph nodal, subcutaneous and skeletal metastases.

Pathological diagnosis :

Skin biopsy was performed from one of the skin lesions displayed

Metastasis of adenocarcinoma.

Time line

Complaints of the swelling and restricted movement in the right shoulder since two to three months.

The radiograph revealed soft tissue lesion with bone destruction in the right shoulder and incidentally detected the right lung lesion.

On detailed evaluation, the patient had history of fever, cough , weight loss and intermittent hemoptysis since five to six months. He had been diagnosed as pulmonary Koch’s and started on ATT (antitubercular treatment ) since five months.

A chest radiograph done six months previously showed had shown a soft tissue opacity in the right upper and mid zones. Bones were normal.

Clinical examination revealed multiple skin lesions in the epigastrium, suprapubic and both inguinal regions.

CECT of the chest and abdomen revealed lung lesions with multiple metastases.

Biopsy from the one of the skin lesion was done. Histopathology revealed metastasis from adenocarcinoma of the lung.

The patient succumbed due to complications from widespread disease.

Discussion:

Lung cancer is a leading type of cancer, equal in prevalence to breast cancer. It is the leading cause of cancer mortality worldwide; accounting for ~20% of all cancer deaths.

Clinical features: Patients with the lung cancer may be asymptomatic in up to 50% of cases. Cough and dyspnea are rather non-specific symptoms that are common amongst those with the lung cancer.

Central tumors may result in hemoptysis and peripheral lesions with pleuritic chest pain. Pneumonia and pleural effusion are also common. Other symptoms may be secondary to metastases (bone, contralateral lung, brain, adrenal glands, and liver, in frequency order for NSCLC) or paraneoplastic syndromes.

Lung carcinomas are broadly divided into non-small cell carcinoma and small cell carcinoma as they differ clinically regarding presentation, treatment, and prognosis:

Non-small cell lung cancer (NSCLC) (80%)

Adenocarcinoma (35%)

-Most common cell type overall

-Most common in women

-Most common cell type in non-smokers but still most patients are smokers

-Peripheral

Squamous cell carcinoma (30%)

-Strongly associated with smoking

-Most common carcinoma to cavitate

-Poor prognosis

Large-cell carcinoma (15%)

-Peripherally located 

-Very large, usually >4 cm

Small cell lung cancer (SCLC) (20%)

-Almost always in smokers

-Metastasizes early

-Most common primary lung malignancy to cause paraneoplastic syndromes and SVC obstruction

-Worst prognosis

It may metastasize to almost all organs, but more frequent sites are hilar nodes, liver, adrenal glands, bones and brain, however it can rarely involve the skin and kidneys. Cutaneous metastasis from a primary visceral malignancy is a relatively uncommon manifestation that occurs as an initial presentation in 1% to 12% of patients with internal malignancies.

Additionally, cutaneous metastases are often late signs of an internal malignancy, and in very rare cases they may occur at the same time or before the primary cancer has been detected. Cutaneous metastasis as an initial presentation occurs in 0.8% of patients with internal malignancies, and is poorly understood in its molecular pathogenesis [1]

Metastasis to the skin has a poor prognosis and is often a sign of widespread malignant tumor. Distant metastases at the time of non-small-cell lung cancer (NSCLC) presentation are a frequent clinical problem [2,3]. The most common sites of metastases from the lung cancer are the liver, bones, brain, adrenal glands, lymph nodes, and, rarely, skin. The incidence of cutaneous metastasis increases with age and more so after the fifth decade of life [4]. 

In men younger than 40 years, the most common source of cutaneous metastasis is melanoma, whereas in males older than 40 years, the most common source is carcinoma of the lung. Metastasis to skin occur by a hematogenous route or via lymphatics. Furthermore, the most common primary sites for males and females are the lungs and breast, respectively[5,6].

The presentation of cutaneous metastasis in the lung cancer portends a poor prognosis, with an average survival ranging between three and six months in the majority of studies [7].

The presence of a firm, rapidly growing papular or nodular lesion should prompt the clinician to suspect internal malignancy. Adenocarcinomas give rise to cutaneous metastases at a higher frequency than other histologic subtypes [8]. Adenocarcinoma is the most common type of metastasis from lung cancer, followed by squamous cell carcinoma (SCC) [9]. The clinical presentations of skin metastases are often highly variable, nonspecific, and subtle and are easily mistaken for other dermatological conditions[10,11]. The anterior chest and the head and neck are the most common sites of metastatic lesions for men, whereas women tend to present with metastases at the abdomen and anterior chest wall.

Cutaneous metastases may present with different clinical features; typical features include painless nodules of firm or elastic consistency that develop within a short time. These lesions can be single or multiple and commonly appear as a dermal nodule, sometimes ulcerated; however, several other presentations can occur .The size of the skin lesions is very variable and can fluctuate from 5 mm to 6 cm diameter [12]. The cutaneous metastasis observed in our case consisted of multiple nodules that were immobile, hard, and painless. Cutaneous metastasis in visceral cancers portends a poor prognosis and is often a signal of a widely spread malignancy[13]. Such malignancies are usually associated with an advanced neoplastic process with metastasis to other organs. 

Unfortunately, half of the patients with cutaneous metastasis die within the first six months after the diagnosis.  Treatment of cutaneous metastasis emphasizes primary cancer therapy, and combinations of chemotherapy and radiation therapy tend to be applied in clinical practice[14]. If multiple lesions are present, chemotherapy alone is an option but may cause inadequate response. Radiation therapy can be used if the chemotherapy is associated with severe pain or bleeding.

Conclusion: Lung cancer is a leading type of cancer, equal in prevalence to breast cancer. Metastases in skin may be the first sign of lung cancer. Although rare appearing, we should raise suspicion in cases of atypical lesions in the skin not only of the smokers, but also of the non-smokers. Skin metastases lung carcinoma are a poor prognostic indicator. The appearance of multiple skin metastases with other internal metastases shorten the survival time.

Staging[15]

In our case it was T4N3M1c.

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Acknowledgment:

We are grateful to the Department of Pathology at our institution for providing the histopathology images and their description.