Photo Quiz

Subcutaneous Nodules on the Chest, with Cough and Weight Loss

 

Am Fam Physician. 2019 Apr 1;99(7):451-452.

A 60-year-old woman presented with cough and hemoptysis. She reported anorexia and a 30-lb weight loss that occurred over several months. She had no significant medical history. Although she smoked more than one pack of cigarettes per day for many years, she had recently decreased her smoking to six or seven cigarettes per day. Subcutaneous nodules had developed on her chest wall and left and right abdominal wall over several months. These nodules were increasing in size and tender to palpation.

On physical examination, the most prominent nodule measured approximately 4.5 × 4 cm (Figure 1). It was located on the left upper abdominal wall and appeared fixed to the underlying muscle. Computed tomography of the chest showed mediastinal and hilar lymphadenopathy with a soft tissue mass in the hilar and perihilar region with collapse of the right middle lobe.

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FIGURE 1


FIGURE 1

Question

Based on the patient's history, physical examination, and imaging findings, which one of the following is the most likely diagnosis?

A. Cutaneous metastasis.

B. Dermatofibroma.

C. Keratoacanthoma.

D. Lipoma.

E. Neurofibromatosis.

Discussion

Answer is A: cutaneous metastasis of adenocarcinoma of the lung. Lung cancer is a common malignancy with a high mortality rate. Lung cancer can metastasize to virtually any organ, most commonly the hilar lymph nodes, brain, liver, adrenal glands, and skeleton.1,2 Metastasis of internal cancers to the skin is uncommon, occuring in 1% to 12% of individuals with lung cancer.2,3 However, skin lesions may be the initial sign of disease in 7% to 24% of those with lung cancer.3,4 The most common sites for cutaneous metastasis of lung cancer are the anterior chest and abdominal wall, although metastasis to the head and neck has also been reported.25

Cutaneous metastasis of lung cancer presents as firm, round or oval nodules that are fixed or mobile. They may be skin-colored, pink, red, purple, or bluish-black.4,6 The nodules are typically painless but may be painful and ulcerate.

F

Address correspondence to Darrell R. Over, MD, MSc, FAAFP, at OverDarrellR@uams.edu. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

show all references

1. Riihimäki M, Hemminki A, Fallah M, et al. Metastatic sites and survival in lung cancer. Lung Cancer. 2014;86(1):78–84....

2. Mollett T, Garcia CA, Koester G. Skin metastases from lung cancer. Dermatol Online J. 2009;15(5):1.

3. Ussavarungsi K, Kim M, Tijani L. Skin metastasis in a patient with small-cell lung cancer. SWRCCC. 2013;1(1):35–38.

4. Singh G, Batra A, Kataria SP, Yadav H, Sen R. Cutaneous metastasis in a case of adenocarcinoma of the lung: a cytological diagnosis. Middle East J Cancer. 2015;6(3):195–198.

5. Kamble R, Kumar L, Kochupillai V, Sharma A, Sandhoo MS, Mohanti BK. Cutaneous metastases of lung cancer. Postgrad Med J. 1995;71(842):741–743.

6. Dreizen S, Dhingra HM, Chiuten DF, Umsawasdi T, Valdivieso M. Cutaneous and subcutaneous metastases of lung cancer. Clinical characteristics. Postgrad Med. 1986;80(8):111–116.

7. Geramizadeh B, Marzban S, Karamifar N, Omidifar N, Shokripour M, Mokhtareh M. Diagnosis of subcutaneous metastatic deposits by fine needle aspiration. J Cytol Histol. 2012;3:151.

8. Saeed S, Keehn CA, Morgan MB. Cutaneous metastasis: a clinical, pathological and immunohistochemical appraisal. J Cutan Pathol. 2004;31(6):419–430.

9. Goto H, Omodaka T, Yanagisawa H, et al. Palliative surgical treatment for cutaneous metastatic tumor is a valid option for improvement of quality of life. J Dermatol. 2016;43(1):95–98.

10. Fitzpatrick TB, Goldsmith LA, Wolff K, eds. Fitzpatrick's Dermatology in General Medicine. 8th ed. New York, N.Y.: McGraw-Hill; 2012.

This series is coordinated by John E. Delzell Jr., MD, MSPH, Associate Medical Editor.

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