INTRODUCTION: Metastatic skin lesions has been rarely presented as an early sign of advanced lung cancer and often misdiagnosed. We present a case of metastatic non small cell carcinoma of the lung who presented with painful zosteriform skin rash.
CASE PRESENTATION: A 59 year old Caucasian female with history of 40 pack year smoking , presented with a painful, blistering skin rash in her chest which was initially diagnosed with Shingles in December 2010. The skin rash has progressively worsened and extended to her left axillary and breast and she started developing hoarseness, dyspnea and neck swelling over the next few months. In April 2011, the CT of neck revealed multiple cervical lymphadenopathy causing deviation of the trachea. Chest x-ray showed a left upper lobe mass. A whole body CT confirmed a 5.9 x 7 x 5 cm mass involving the anterior segment of the left upper lobe, extensive mediastinal and supraclavicular adenopathy which displaces the trachea to the right, also large bony metastasis to the manubrium with lytic destruction, multiple hepatic lesions, and bilateral adrenal metastasis. A CT guided biopsy of sternal mass was consistent with adenocarcinoma of lung. The skin biopsy showed extensive expansion of the dermis by multiple nests of a moderately differentiated lung adenocarcinoma with associated mucin.
DISCUSSION: Cutaneous metastases are rare and they are usually diagnosed in patients with a known primary malignancy. Skin nodules or masses are the most common patterns however an inflammatory pattern mimicking infection, condyloma, epidermal inclusion cyst, chancre, and herpes zoster are not uncommon. Although cutaneous metastases in lung cancer without obvious primary lesions are very rare, this diagnosis should still be considered, particularly in patients with history of smoking. The percentage of patients with lung cancer that develop cutaneous metastases ranges from 1 to 12 percent. In 20-60 percent of cases the skin lesions present before or synchronously with the diagnosis of the primary tumor. Histologically, cutaneous metastases from the lung are frequently moderately or poorly differentiated adenocarcinoma. Immunohistochemistry markers including anti-thyroid transcription factor (TTF) and CK7/20 are usually helpful to distinguish the primary tumor. Treatment of solitary cutaneous metastases usually includes surgery alone or combined with chemotherapy, and/or radiation. If multiple cutaneous lesions or internal metastases exist, chemotherapy is the primary option.
CONCLUSIONS: Zosterioform rash is a rare presentation of cutaneous metastases in non small cell carcinoma of the lung and suggests multiple distant metastases with a poor prognosis. Persistent zosteriform lesions without response to treatment should raise the probability of underlying lung cancer particularly in smokers.
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DISCLOSURE: The following authors have nothing to disclose: Mostafa Tabassomi, Haifaa Abdulhaq, Eyad Almasri, Nastran Hashemi
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