Erysipeloid Carcinoma As the Primary Clinical Presentation of a Pulmonary Adenocarcinoma.

Abstract

Cutaneous metastases are rare, occurring in fewer than 2% of cancers, but may be the first manifestation of an internal neoplasia and involve a poor prognosis.1 Lung cancer is the most common cause of skin metastases, responsible for 24% of cases.2 The manifestations can vary dramatically. There is no pathognomonic presentation, and the skin lesions are usually initially diagnosed as benign.3 This is a report of a rare case of erysipeloid carcinoma as the first sign of a pulmonary adenocarcinoma. An 85-year-old man presented to the emergency department reporting a 2-month history of painful skin lesions on his right anterior thorax. He also reported appetite loss, asthenia, fever, and weight loss. Physical examination revealed infiltrated erythematous papules with hardened consistency and areas of ulceration and crusts over a large well-defined erythematous plaque (erysipelas-like) in the right anterior thoracic region (Figure 1A). A diagnosis of erysipelas was made, and amoxicillin-clavulanate was prescribed. After 15 days, no improvement was seen, and hard, painless cervical lymph nodes, adhered to deep planes in the cervical and right retroauricular region, and right-sided facial nerve paralysis were discovered (Figure 1B). He was admitted with the initial diagnosis of cutaneous lymphoma. Skin biopsy and cervical excisional lymph node were performed. Computed tomography of the thorax identified a 3-cm primary lung tumor at the right upper lobe without contiguity with the chest wall. Microscopy of the skin lesion showed neoplastic epithelial cell blocks infiltrating the deep and superficial dermis, without compromising the epidermis (Figure 1C). Immunohistochemical study indicated a pulmonary adenocarcinoma (Figure 1D-F). A diagnosis of pulmonary adenocarcinoma with erysipeloid carcinoma was made. He started palliative chemotherapy and died after 2 months of treatment. Cutaneous metastasis may be the first manifestation of an internal malignancy, but in most cases, it is a late manifestation of widespread disease.1 It appears most commonly in the fifth to seventh decades and affects more women than men.4 Metastatic spread to skin can occur by lymphatic spread, hematogenous dissemination, direct contiguity, and rarely, iatrogenic deployment.5 Cutaneous metastasis from lung cancer usually presents as a solitary, painless, mobile nodule, but multiple nodules, plaques, ulcerated nodules, infiltrated scars, and erysipelas-like lesions have also been reported. The most-frequent site of cutaneous metastasis of lung cancer is the anterior chest wall, followed by the back and abdomen.6 Erysipeloid carcinoma is a rare form of cutaneous metastasis. It is clinically characterized as a well-defined erythematous plaque, referred to as an erysipelas-like lesion. These metastases suggest an inflammatory skin disorder caused by direct spread of tumor cells through the dermal lymphatics. Erysipeloid carcinoma originating from pulmonary adenocarcinoma has been observed rarely.5, 6 It is even more rare that it is the initial manifestation of this neoplasia.7 Erysipelas-like lesions are commonly mistaken for an infection, as evidenced in this case. Histological examination of skin metastases often reveals no specific adenocarcinoma, a pattern of squamous cells, or an undifferentiated tumor that can be from a variety of primary sites. It appears as a nodular growth with few stromal cells and infiltrating strands into the fibrotic dermis.1, 8 Adenocarcinoma and squamous cell carcinoma are the most highly related tumors.1, 5 The man described above died 3 months after diagnosis. Studies have shown that average survival after the onset of cutaneous metastasis of lung cancer varies from 3 to 5 months.6 In conclusion, cutaneous metastasis with a single nodule or more-widespread lesions can be the first manifestation of cancer and requires urgent clinical investigation. Conflict of Interest: The authors declare that they have no conflict of interest. Author Contributions: All authors: planning the report, writing and approval of manuscript. Sala, Marasca, Scuro: treatment of patient. Aprahamian: study concept and design. Pinto: histology and immunochemical evaluation. Sponsor's Role: None.