BENEATH THE ORANGE PEEL

Abstract

SESSION TITLE: Lung Cancer 2 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Lung carcinoma is the leading cause of cancer death. Early detection in non-small cell lung carcinoma (NSCLC) has been shown to affect prognosis and survival. We present a case of lung adenocarcinoma with cutaneous metastasis as a first sign of an occult malignancy. CASE PRESENTATION: A 60 year-old man with a 240 pack year smoking history and Stage IV COPD presented with a necrotizing abdominal mass. He had no fever, night sweats, or hemoptysis but had a productive cough and 35 pounds of unintentional weight loss. Physical exam revealed cachexia, diffuse wheezing, and no palpable lymphadenopathy. Skin exam was notable for a 6.7 x 5.4 x 6.0 cm round, tender, ulcerating mass located above the umbilicus with associated erythema, warmth, and peau d’ orange skin changes. Non-ulcerating, tender lesions were also identified on his left anterior thigh and right buttock. Labs and infectious work up were unremarkable, but CT chest showed a spiculated right upper lobe and left lower lobe nodule. The punch biopsy from the abdominal mass stained positive for CK-7 and TTF-1 consistent with metastatic lung adenocarcinoma. PET/CT demonstrated avid lesions in his anterior abdomen, left obturator, right iliac muscle, left adrenal gland, cerebellar vermis and superficial inguinal nodes. The patient decided against further treatment and enrolled in home hospice. DISCUSSION: Cutaneous manifestations may be the first sign of a clinically silent pulmonary malignancy and have been reported in 1-12% of cases [1]. There is no pathognomonic feature, but lesions are described as rarely tender, ulcerative or zosteriform with a preponderance in NSCLC [2]. Thus, including this in our differential is vital for early intervention. Furthermore, acquiring samples from extra-pulmonary sources such as a skin biopsy offers a less invasive, more cost-effective approach that also expedites diagnosis and staging. Cutaneous lesions can serve as a potential tissue reservoir for prognostic biomarkers such as KRAS as well as therapeutic targets such as PD-L1 expression, EGFR status, and ALK driver mutations without the risk of additional procedures. Historically, response to first-line platinum-based or second-line docetaxel-based chemotherapy, and EGFR tyrosine kinase inhibitors has been poor [3]. However, immunotherapy with pembrolizumab offers a new line of therapy for improved survival although not yet documented for metastatic NSCLC with skin manifestations [4]. CONCLUSIONS: While lung cancer most commonly metastasizes to the liver, adrenal glands, bone, and brain, skin metastasis as an initial presentation of lung cancer is rare and should be included in our differential diagnosis when evaluating atypical skin lesions in patients at high risk for lung cancer. Although some documented cases report prolonged survival with treatment, skin involvement is often associated with a poor prognosis owing to its Stage IV presentation [5]. Reference #1: Mollet T.W., Garcia C.A., Koester G. Skin metastases from lung cancer. Dermatol. Online J. 2009;15:1.(PubMed) [PubMed] Reference #2: Pajaziti, Laura et al. “Skin Metastases from Lung Cancer: A Case Report.” BMC Research Notes 8 (2015): 139. PMC. Web. 2 Mar. 2018. Reference #3: Melosky, Barbara. “Current Treatment Algorithms for Patients with Metastatic Non-Small Cell, Non-Squamous Lung Cancer.” Frontiers in Oncology 7 (2017): 38. PMC. Web. 2 Mar. 2018. Reference #4: Reck et al, “Pembrolizumab versus Chemotherapy for PD-L1-Positive Non-Small-Cell Lung Cancer” N Engl J Med. 2016 Nov 10;375(19):1823-1833. Reference #5: Song Z., Lin B., Shao L., Zhang Y. Cutaneous metastasis as an initial presentation in advanced non-small cell lung cancer and its poor survival prognosis. J. Cancer Res. Clin. Oncol. 2012;138(10):1613–1617. [PubMed] DISCLOSURES: No relevant relationships by Hiba Ali, source=Web Response No relevant relationships by Uma Ayyala, source=Web Response No relevant relationships by Nicole Canon, source=Web Response No relevant relationships by Molly Horstman, source=Web Response No relevant relationships by Omar Merchant, source=Web Response No relevant relationships by Dilreet Rai, source=Web Response No relevant relationships by Zachary Yeung, source=Web Response