LUMPS AND BUMPS: A COMMON COMPLAINT WITH SINISTER IMPLICATIONS

Abstract

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: It is exceedingly uncommon for malignancy to present as cutaneous metastases. In fact, cutaneous metastases as an initial manifestation of internal neoplasias represent only 0.8% of total cases; and implies, in general, aggressive disease and poor prognosis. We present an atypical manifestation of non-small cell lung cancer (NSCLC) initially presenting as tender cutaneous nodules. CASE PRESENTATION: Patient is a 69 year-old female with pertinent medical history of 70 pack-year tobacco abuse who presented with a complaint of multiple painful, ulcerating skin nodules. 2 months prior to admission, she was seen by her physician for skin lesions and was prescribed a short course of antibiotics without resolution. At admission, patient reported a 1 month history of fatigue, unintentional 15 pound weight loss, and diffuse myalgias. Initial vital signs revealed normal temperature, heart rate of 113 bpm, respiratory rate of 16 breaths per minute, saturating 97% on room air. Labs revealed leukocytosis at 19.8 k/mm3 and lactic acid level of 3 mmol/L. She was suspected to have sepsis secondary to cellulitis. She was given 30 mg/kg fluid bolus and started on broad spectrum antibiotics. On examination, she had multiple ulcerated subcutaneous skin nodules on her chest, abdomen, inguinal area, and scalp. Radiographic imaging revealed a large left upper lobe mass with extensive pulmonary nodules concerning for malignancy. Imaging of her head revealed numerous supra and infratentorial metastatic lesions. Punch biopsy of a skin nodule was taken. Immunohistochemical (IHC) testing was positive for pankeratin and cytokeratin 7, but were negative for any neuroendocrine markers. Biopsy and IHC were consistent with poorly differentiated non-small cell lung adenocarcinoma. DISCUSSION: Cutaneous involvement among patients diagnosed with NSCLC is a rare finding, affecting 2.8%. Even less uncommon as the initial presenting symptom. Patterns of cutaneous metastases vary among women and men. Breast cancer, colorectal cancer, and melanoma frequently metastasize to the skin in women. In men; melanoma, lung cancer, and colorectal cancer are the most common sources of cutaneous metastases. Cutaneous metastases can present asymptomatically or be associated with pain and tenderness. Furthermore, they can often be mistaken for inflammatory dermatosis, infectious cellulitis, bullous or papulosquamous lesions. CONCLUSIONS: While rare, cutaneous manifestation can be the first sign of metastatic disease and often purports a poor prognosis. Therefore, it is important to recognize and evaluate abnormal skin lesions in the correct clinical context with appropriate clinical measures such as history, physical exams, imaging, and biopsy with histochemical staining. Reference #1: Alkhayat H, Hong CH. Cutaneous Metastases from Non-Small Cell Lung Cancer. J Cutan Med Surg. 2006 Nov-Dec;10(6):304-7. Reference #2: Ardavanis A, Orphanos G, Ioannidis G, Rigatos G. Skin Metastases from Primary Lung Cancer. Report of Three Cases and a Brief Review. In vivo. 2001; 20(5):671-3. Reference #3: Baldeo C, Ali R, Seeram V, House J. Lung Cancer Presenting as Soft-Tissue Metastasis. Case Rep Oncol. 2015;8:185-188. DISCLOSURES: No relevant relationships by Brandon Cherry, source=Web Response No relevant relationships by Menalee Hapuarachchi, source=Web Response No relevant relationships by Machaiah Madhrira, source=Web Response No relevant relationships by Harsh Patel, source=Web Response