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- DOI 10.18231/j.ijoas.2021.024
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Abstract
Lung carcinoma is the most common type of carcinoma seen in males and 4th most common in females.[1] Skin metastasis from lung carcinoma is frequent with an incidence of 1%-12%, with most common site being the anterior chest wall.[2] Skin metastasis from lung carcinoma to the tip of nose is very rare with only 12 cases being reported in literature(Table 1). It can be confused with other benign and malignant conditions, such as infection, lymphoma, hemangioma, rhinophyma, sarcoidosis, tuberculosis and carcinomas, making its diagnosis difficult.[3] Less than 20 cases of cutaneous nasal tip metastasis are reported in literature out of which 12 are from malignancies of lung. Sometimes it can appear earlier than the primary lesion and thus delays the diagnosis of primary lesion. =[4] In this case report, we report a case of nasal tip cutaneous metastasis from squamous cell carcinoma of lung.
Case Report
A 70-year-old male visited ENT opd with complaint of a lesion over nose since 3 months (Fig. 1), which was gradually progressive. Patient did not have any other symptom. It was about 5*5 cm in dimensions, ulcerated, erythematous and vascular on inspection. It was firm and tender on touch. No cervical lymph nodes were palpated. On magnetic resonance imaging of face, a well defined lobulated lesion of size about 3.7*2.5*3.6 cm was seen arising from the tip of nose with external surface bulge extending into the left nasal cavity(Fig. 2a, 2b). Punch biopsy was planned. All blood investigations were normal. Chest x-ray was done for pre anaesthetic check up and it showed homogenous opacity in the left upper lobe.(Fig.3) Punch biopsy was taken from nose which on histopathological examination showed squamous cell carcinoma. Contrast enhanced computed tomography of chest showed large soft tissue mass in left upper lobe, abutting chest wall and showing contrast enhancement with left sided pleural effusion(Fig.4a,4b). Ultrasound guided fine needle aspiration cytology of left lung mass was done which showed squamous cell carcinoma of lung with inflammatory changes. He was referred to radiotherapy department where he was given palliative chemoradiation. Patient died after 2 months of cutaneous diagnosis.
|
Authors |
Age/sex |
Country |
Metastasis |
Primary |
Treatment |
Survival time from diagnosis of cutaneous metastasis |
|
Ledderose GJ,Englhard. 2015 |
59yr/F |
Germany |
Small nodule on upper border of right nostril with extension towards tip and columella |
Squamous cell carcinoma of dorsal thoracic esophagus |
Palliative chemoradiotherapy for 1 yr with resection of painful soft tissue metastasis & palliative chemoradiation |
Survived 18 months |
|
Dong A, et. al, 2015 |
74yr/ F |
china |
Nodule on nasal tip |
Squamous cell carcinoma esophagus |
* |
* |
|
Kataoka A,et. Al. 1997 |
69yr/F |
Japan |
Nasal tip |
Squamous cell carcinoma of uterine cervix |
Radical hysterectomy followed by radiation |
14 months |
|
Itin PH, Heitzmann F, Stamm B. 1999 |
48yr/F |
Switzerland |
Nasal tip Radiation |
Adenocarcinoma cervix |
Preoperative radiotherapy followed by surgery with adnexectomy on right side with removal of urinary vesicle |
Followed up for 5 months, patient was well till then |
|
Antonio AM. 2015 |
58yr/F |
Portugal |
Dorsum of nose |
Bilateral ovarian cystadenocarcinoma with malignant ascites nd hepatic nodule |
Palliative chemotherapy |
3 months |
|
Gainers M, et. al. 2007 |
51yr/ M |
United states of america |
Erythematous indurated plaque nd papules over dorsum of nose (involving tip also) |
Chronic lymphocytic leukemia |
Chemotherapy & local radiation |
Died |
|
Pengfei C et. al. 2019 |
86yr/ M |
china |
Nose tip |
Renal cell carcinoma(clear cell type) |
Chemotherapy |
Stable before submission of paper |
|
Rajasekharan P.2004 |
55yr/ M |
India Mumbai |
Nasal mass |
Renal cell carcinoma |
* |
* |
|
Kohli SP. |
54yr/ M |
India Punjab |
Nasal tip mass |
Anaplastic thyroid malignancy |
Palliative chemoradiotherapy |
2 months |
|
Isa NM, et. Al. |
81/M |
Malaysia |
Left nasal ala mass |
Hepatocellular carcinoma |
Not described |
Not described |
|
Chau C, Siu W, Li MK. |
54 /M |
Hong kong |
Nasal tip |
Squamous cell carcinoma of esophagus |
Not described |
Not described |
|
Cesinaro AM, Maiorana A, Annessi G, Collina G. 1995 |
40/M |
United states of america |
Small, hard nodule on right side dorsum of nose |
Chordoma of sacrum |
Not described |
Not described |
|
Table 1 Cont.. |
||||||
|---|---|---|---|---|---|---|
|
Gault DT, Subbuswamy SG. 1985 |
76/F |
England |
Blue black spherical mass over tip of nose |
Oat cell carcinoma of lung |
Surgical excision of nasal mass with palliative radiotherapy |
Died in 3 months |
|
Gault DT, Subbuswamy SG. 1985 |
67/M |
England |
Lump overlying the cartilage of left side of nasal tip |
Squamous cell carcinoma of lung |
X-ray therapy to chest |
Not described |
|
Nesi R, Lynfield Y. 1996 |
71/M |
United states of america |
Rhinophyma like lesion over nose |
Squamous cell carcinoma of lung |
* |
Died with in a week |
|
GAL TJ, KERSCHNER JE. 1997 |
65/M |
United states of america |
Tip of nose |
Adenosquamous carcinoma of lung |
Radiotherapy |
Died several weeks later |
|
De Simoni I et. al |
64/M |
SPAIN |
Tip of nose |
Squamous cell carcinoma of lung |
Palliative radiotherapy |
Died after 1 month |
|
Viera Mota A et. Al |
63/M |
Portugal |
Tip of nose |
Anaplastic carcinoma of lung |
Died after 2 weeks |
|
|
Hammert WC, Champagne L, Heckler FR. 1999 |
59/M |
United states |
Tip of nose |
Squamous cell carcinoma of lung |
Chemoradiation with surgical resection of nasal mass |
Not described |
|
Rubinstein RY et. Al |
64/M |
United states |
Mass over nose |
Large cell undifferentiated carcinoma |
* |
* |
|
Chun SM et. Al |
62/M |
Korea |
Tip of nose |
Squamous cell carcinoma of lung |
Chemoradiation for primary |
Died after 5 months |
|
Chun SM et. Al |
76/M |
Korea |
Tip of nose |
Squamous cell carcinoma of lung |
Palliative radiation therapy |
Died after 1 month |
|
Chun SM et. Al |
57/M |
Korea |
Tip of nose |
Squamous cell carcinoma of lung |
chemoradiation |
Died after 9 months |
Discussion
Skin metastasis are common in lung carcinoma with anterior chest wall being the most common site followed by the abdomen, extremities, neck, back and; head and neck. [5] Metastasis to the tip of nose is however a very rare condition with only about 24 cases reported in the literature till now including our case. Cutaneous metastasis from lung carcinoma may appear earlier than the diagnosis of primary malignancy. Renal cell carcinoma is considered the most common malignancy metastasizing to the nose and paranasal sinuses. However on reviewing literature, lung carcinoma was seen to be the most common malignancy metastasizing to the nose tip. [6] Among lung carcinomas, adenocarcinoma of lung is the most common type metastasizing to skin, followed by squamous cell carcinoma. [7] The upper lobe tumours have more tendency of metastasizing to the skin. [8] Squamous cell carcinoma was the most common malignancy of lung metastasizing to the tip of nose. [9] It may appear as firm to rubbery with or without ulceration, blue to reddish in colour and may be single or multiple. [10], [11] Different theories are explained for its pathogenesis. Its spread may occur via the pulmonary vascular and lymphatic routes, the vertebral plexus, the arterial embolus and the venous sinuses of the skull which on communication with the vertebral system metastasize the tumour cells to the nose. [12], [13] Patient of internal malignancies presenting with cutaneous metastasis have poor prognosis with life expectancy of about 3-5 months.[14-16][14], [15] Nasal tip skin metastasis are also reported in literature from malignancies of thyroid, hypopharynx, esophagus, chordoma and leukemia. [12] There are different opinions regarding its management, ranging from wide surgical excision with reconstruction to chemoradiation. Due to very short life span of these patients, wide surgical excision with reconstruction doesn’t seem to be feasible. The tumour mass can be excised and raw area can be left for healing by secondary intention or patient can be given chemoradiation for it. On reviewing literature for nasal tip metastasis, we found that the age of cutaneous nasal metastasis varied from 40 years with chordoma to 86 years with renal cell carcinoma with a mean age of 63.45 ± 10.8 years. Out of 24 cases, only 6 were females(25%) and 18 were males(75%). Female dominance was seen in extrapulmonary primaries(45%) than pulmonary primaries(9%). Tip of nose was the most common site of meatastasis in both pulmonary and extrapulmonary primaries. Histologically squamous cell carcinoma was the most common primary that metastasized to nasal tip. Survival time ranged fromless than a week to 18 months with a mean life of 4.57 ± 5.45 months with mean survival life of metastasis from pulmonary primaries less than that of extrapulmonary.
Conclusion
Nose is a part of facial skeleton and due to its asthetic value patients usually presents with lesions of nose while neglecting symptoms of internal malignancies. This usually delays the diagnosis and also lead to misdiagnosis in some cases. So it is the part of clinicians to examine internal systems in patients presenting with isolated malignancy of nose. Considering the low life expectancy of these patients, conservative approach should be taken for its management.
Source of Funding
None.
Conflict of Interest
None.
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