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An Innocent Appearing Subcutaneous Nodule Diagnoses a Small Cell Lung Cancer in a Never-Smoker Female

An Innocent Appearing Subcutaneous Nodule Diagnoses a Small Cell Lung Cancer in a Never-Smoker... Hindawi Publishing Corporation Case Reports in Oncological Medicine Volume 2014, Article ID 268404, 4 pages http://dx.doi.org/10.1155/2014/268404 Case Report An Innocent Appearing Subcutaneous Nodule Diagnoses a Small Cell Lung Cancer in a Never-Smoker Female 1 2 1 1 Nupur Sinha, Masooma Niazi, Gilda Diaz-Fuentes, and Richard Duncalf Division of Pulmonary and Critical Care Medicine, Bronx Lebanon Hospital Center, Albert Einstein College of Medicine, Bronx, NY 10457, USA Department of Pathology, Bronx Lebanon Hospital Center, Albert Einstein College of Medicine, Bronx, NY 10457, USA Correspondence should be addressed to Nupur Sinha; nsinha@bronxleb.org Received 5 December 2013; Accepted 6 February 2014; Published 10 March 2014 Academic Editors: L. Beex, P. F. Lenehan, J. I. Mayordomo, and N. Yoshimura Copyright © 2014 Nupur Sinha et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Lung cancer among never-smokers is recognized as the 7th most common cause of cancer death globally. Adenocarcinoma is the most commonly reported histology. Small cell lung cancer (SCLC) has the strongest association with smoking and is rarely reported in never-smokers. Although lung cancer in never-smokers is more common in women, the overall incidence of SCLC in female never-smokers still remains low. Soft tissue metastases from any cancer are rare with an overall prevalence of 1.8%. Soft tissue metastases from lung primary are uncommon, mostly from adenocarcinoma, and portend a poor prognosis. Cutaneous metastases from SCLC are exceptionally rare with reported incidence of 0.3% to 0.8%. We believe ours is the first reported case of SCLC presenting as subcutaneous nodule, in a never-smoker, otherwise asymptomatic female. eTh diagnosis of SCLC was made incidentally by the excisional biopsy of the subcutaneous nodule. Subsequent CT chest and PET scan revealed a hypermetabolic right lower lobe spiculated lung mass with adrenal and liver involvement. Platinum and etoposide chemotherapy with prophylactic cranial irradiation was initiated for advanced SCLC, and she required further irinotecan and taxol for subsequent pancreatic and adrenal metastases. With continued deterioration, she died approximately 36 months from diagnosis, while under hospice care. 1. Introduction 2. Case Presentation Lung cancer in never-smokers is increasingly being recog- A 54-year-old woman presented with a two-month history nizedasadistinct entity andranks as theseventh most of an enlarging, slightly painful left flank nodule. er Th e was common cause of cancer death globally [1, 2]. Worldwide, no preceding history of trauma or insect bite to the involved 15%ofmen and53% of womenwithlungcancerare region.She deniedfever,chills, rash,cough,shortness of never-smokers [2]. Adenocarcinoma is the most commonly breath, hemoptysis, mouth ulcers, arthralgias, dysuria, or reported histology in never-smokers [1, 2]. Recognized as an loss of weight. Her medical history included chronic anemia, entity distinct from other lung cancers in 1926 by Dr. W. G. treated latent TB, cervical dysplasia, and hysterectomy. She Bernard, small cell lung cancer (SCLC) accounts for 15% of denied tobacco use, second hand smoking, or occupational annual lung cancers in the USA and is known to have the exposure. Family history was significant for various cancers: strongest association with tobacco use. More than 95% occur bone cancer in her father, unknown facial cancer in a brother, in smokers, with 95% fatality [3]. Small cell lung cancer in liver cancer in an uncle, and a brain tumor in an aunt. never-smokers is rarely reported. Soft tissue metastases from Physical exam revealed only a single2×2 cm firm, slightly lung cancer are uncommon with reported overall prevalence tender, freely mobile, nonu fl ctuant, left flank mass without of 2.3% [4], and rarely reported from SCLC. We report the induration, erythema, or involvement of the skin. No other first case of SCLC in a never-smoker woman presenting as nodules, masses, or lymphadenopathy was found. Laboratory subcutaneous nodule. demonstrated a mildly elevated erythrocyte sedimentation 2 Case Reports in Oncological Medicine (a) (b) Figure 1: (a) Subcutaneous tissue with neuroendocrine carcinoma (s mall cell type) composed of sheets of small spindle cells with finely granular chromatin and mitoses. (b) Tumor cells immunoreactive to chromogranin A. adrenal metastases. She continued to maintain a good func- tional status for the most part despite recurrent metastases anddied36monthsfromdiagnosis,whileunderhospicecare. 3. Discussion The differential diagnosis of a subcutaneous nodule is exten- sive and mostly benign, including traumatic, infectious, inflammatory, and neoplastic etiology. Metastasis to soft tissue, defined as metastasis to skeletal muscle, skin, and subcutaneous tissues, has only rarely been reported [4]. The available literature does not distinguish between cutaneous and subcutaneous metastases. While earlier studies inves- Figure 2: CT chest: right lower lobe spiculated mass. tigating the prevalence of cutaneous metastases from any cancer have reported an overall incidence of 0.75%–9% [4, 5], a more recent study on 500 patients with cancer reported rate at 35 mm/hr and a lactate dehydrogenase of 220 IU/L. soft tissue metastases in 1.8% of cases [ 5]. The most common Autoimmune, HIV, and hepatitis work ups were negative, primary cancers associated with cutaneous metastases are and thyroid function was normal. A chest X-ray (CXR) and lung and colon in males and breast in females [6]. subsequentwholebodycomputerizedaxialtomography(CT) Cutaneous metastases with a lung primary are relatively scan done three years earlier as part of an anemia work up uncommon and portend a poor prognosis. Skin metastases were unremarkable with no evidence of lymphadenopathy or areseenin1to 12%ofpatientswithlungcancerduring malignancy. their life time [7], with up to 24% of these presenting with With a presumptive diagnosis of neurolipoma, the patient a cutaneous lesion upon initial presentation [8]. Common underwent excision with wide margins. Operative ndin fi gs sites of metastases include the chest, back, abdomen, head, were signica fi nt for reddish brown appearing 2 cm rm fi , and neck [5, 8]. Adenocarcinoma has been shown to be the subcutaneous mass supercfi ial to the fascia, surrounded by histological variant of lung cancer most commonly associated fat. Histopathology revealed a small cell type neuroendocrine with soft tissue metastasis [ 8]. Cutaneous metastases from tumor. Immunohistochemical stain favored lung primary, SCLC are exceptionally rare with reported incidence of 0.3% with staining positive for TTF-1, CD56, synaptophysin, and to 0.8% [9, 10]. chromogranin A (Figure 1). Subsequent CXR and CT demon- SCLC has been historically described to be extremely strated a 3.4 cm right lower lobe spiculated mass, distal rare in female never-smokers. More recent studies have atelectasis, and ipsilateral hilar lymph nodes, the largest being revealed that lung cancer in never-smokers is more com- 17 mm (Figure 2). Positron emission tomography (PET) scan mon in women [1, 2, 11]. The overall incidence of SCLC confirmed a hypermetabolic right lower lobe lung mass with in female never-smokers still remains low accounting for hilar adenopathy and possible liver and adrenal involve- approximately 2.9% of all female patients diagnosed with ment. In view of sufficient diagnostic evidence, further lung cancer [11]. Genetic predisposition has been studied as invasive workup was not pursued. Platinum and etoposide an important risk factor in never-smokers with lung cancer, chemotherapy was initiated for advanced SCLC. Despite pro- although reported incidence remains rare at 1% with more phylactic cranial irradiation, she developed cerebral metas- than 3 affected relatives [ 12]. tasis requiring further radiotherapy. Irinotecan and taxol Chemotherapy is the standard therapeutic modality for chemotherapy were required for subsequent pancreatic and extensive disease, with a median survival of 7–12 months [13]. Case Reports in Oncological Medicine 3 ForextensivestageSCLC,theroleofetoposideandcisplatinis the need for studying more closely the causative as well as well studied and described in literature. Prophylactic cranial prognostic associations in this unique subset of population. irradiation in chemotherapy-responding patients modestly We recommend reporting rare cases of SCLC in never- improves a disease-free and an overall survival and may smokers for further analysis of potential risk factors and decrease the risk of developing brain metastases [13]. Patients management options. In addition, our case demonstrates how presenting with skin lesions at the time of diagnosis have been even a single, new subcutaneous lesion can represent serious showntohavealowersurvivalratethanpatientswho develop occult pathology in a patient with low suspicion for internal skin metastasis later in the disease course. Treatment of soli- malignancy, thus warranting a low threshold for biopsy. tary skin metastasis includes surgery combined with either or both chemotherapy and radiation [8]. Although studies Abbreviations have shown that females have a higher objective response CT: Computerized axial tomography rate, median survival and 2-year disease-free survival rate CXR: Chest X-ray compared to males, the overall median survival reported aer ft diagnosis of cutaneous metastasis remains low at 5–7.5 HIV: Human immunodeficiency virus NSCLC: Nonsmall cell lung cancer months [11]. PET: Positron emission tomography Our case presented with a seemingly benign small abdominal wall nodule. Most common benign etiologies SCLC: Small cell lung cancer. were ruled out by history and the absence of systemic complaints made it unlikely to be a manifestation of systemic Disclosure disease. Although she had strong family history of various cancers, her younger age and prior normal sex and age None of the authors has a financial relationship with a appropriate screenings placed her at low risk for malignancy. commercial entity that has an interest in the subject of the Only two cases of lung cancer with metastasis to soft manuscript. No na fi ncial support was used for the study. tissue in females have been reported, both were NSCLC, smoking status unknown, and neither had soft tissue metas- Conflict of Interests tasisasthe sole presenting complaint[5]. Literature also describes three cases of lung carcinoids with subcutaneous eTh authors declare that there is no conflict of interests metastasis [14]and asinglecasereportofSCLCinafemale regarding the publication of this paper. presenting with multiple systemic complaints along with a subcutaneous nodule [8], but they were all smokers and References did not have subcutaneous metastasis as the sole presenting complaint. We believe ours is the first reported case of [1] A. G. Pallis and K. N. Syrigos, “Lung cancer in never smokers: SCLC presenting as subcutaneous nodule, in a never-smoker, disease characteristics and risk factors,” Critical Reviews in otherwise asymptomatic female, diagnosed incidentally by Oncology/Hematology, vol. 88, no. 3, pp. 494–503, 2013. excisional biopsy of the presenting nodule. As noted in [2] S. Sun, J. H. Schiller, and A. F. Gazdar, “Lung cancer in never earlier reports, the presentation was associated with extensive smokers–a different disease,” Nature Reviews Cancer,vol.7,no. 10, pp. 778–790, 2007. disease and systemic metastases, and she continued to have recurrent metastases despite standard therapy. Still, her good [3] C. L. Hann and C. M. Rudin, “Fast, hungry and unstable: finding functional status and unusual survival of approximately the Achilles’ heel of small-cell lung cancer,” Trends in Molecular Medicine,vol.13, no.4,pp. 150–157, 2007. 36 months from presentation are remarkable and warrant [4] C. Perisano, M. S. Spinelli, C. Graci et al., “Soft tissue metastases further studies in such cases. in lung cancer: a review of the literature,” European Review for Medical and Pharmacological Sciences,vol.16, no.14, pp.1908– 4. Conclusion 1914, 2012. [5] N.C.Nguyen, B. T. Chaar, andM.M.Osman,“Prevalence and Lung cancer in never-smokers is emerging as a distinct patterns of soft tissue metastasis: detection with true whole- clinical entity, with different genetic mutations and response body F-18 FDG PET/CT,” BMC Medical Imaging,vol.7,article to novel targeted therapies. Subcutaneous metastasis from a 8, 2007. primary lung cancer is unusual and ominous. Being more [6] D. Brinkman, L. Roche, K. Ullah, and T. M. O. ’Connor, “Multi- commonly accepted as a disease of smokers, there is a ple cutaneous nodules as the presenting sign of small cell lung potential for failure or delay in the diagnosis of lung cancer cancer,” BMJ Case Reports,2013. in a young, never-smoker patient presenting with atypical [7] T. Terashima and M. Kanazawa, “Lung cancer with skin metas- manifestations such as subcutaneous nodules. While there is tasis,” Chest,vol.106,no. 5, pp.1448–1450,1994. extensive work ongoing on identifying causative factors other [8] K. Ussavarungsi, M. Kim, and L. Tijani, “Skin metastasis in a thansmokinginnonsmallcelllungcancer(NSCLC)resulting patient with small-cell lung cancer,” The Southwest Respiratory in major therapeutic advances and improved outcome in and Critical Care Chronicles,vol.1,no. 1, pp.35–38,2013. NSCLC, there is paucity of similar studies in SCLC. [9] K.Shaheen,A.H.Alraiyes, M. Baibars, A. Paintsil,and M. C. Our case, with an atypical presentation in otherwise Alraies, “Ulcerative cutaneous lesions synchronously present asymptomatic and low risk patient, and her remarkable with the diagnosis of primary lung cancer,” Case Reports in survival aer ft the incidental diagnosis draws attention to Medicine,vol.2013, ArticleID136564, 3pages,2013. 4 Case Reports in Oncological Medicine [10] S. C.-S. Hu, G.-S. Chen, C.-S. Wu, C.-Y. Chai, W.-T. Chen, and C.-C. E. Lan, “Rates of cutaneous metastases from different internal malignancies: experience from a Taiwanese medical center,” Journal of the American Academy of Dermatology,vol. 60, no. 3, pp. 379–387, 2009. [11] R. Govindan, N. Page, D. Morgensztern et al., “Changing epidemiology of small-cell lung cancer in the United States over the last 30 years: analysis of the surveillance, epidemiologic, and end results database,” Journal of Clinical Oncology,vol.24, no. 28, pp. 4539–4544, 2006. [12] M. Furrukh, “Tobacco smoking and lung cancer, perception- changing facts,” Sultan Qaboos University Medical Journal,vol. 13, no. 3, pp. 345–358, 2013. [13] Y.Zhang andJ.He, “ed Th evelopment of targeted therapyin smallcelllungcancer,” JournalofThoracic Disease ,vol.5,no. 4, pp.538–548,2013. [14] R. Yua, E. Wolina, and X. Fanb, “Single subcutaneous nodule as initial presentation of atypical lung carcinoid,” World Journal of Oncology,vol.1,no. 5, pp.204–207,2010. MEDIATORS of INFLAMMATION The Scientific Gastroenterology Journal of World Journal Research and Practice Diabetes Research Disease Markers Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 International Journal of Journal of Immunology Research Endocrinology Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Submit your manuscripts at http://www.hindawi.com BioMed PPAR Research Research International Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Journal of Obesity Evidence-Based Journal of Journal of Stem Cells Complementary and Ophthalmology International Alternative Medicine Oncology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Parkinson’s Disease Computational and Behavioural Mathematical Methods AIDS Oxidative Medicine and in Medicine Research and Treatment Cellular Longevity Neurology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Case Reports in Oncological Medicine Hindawi Publishing Corporation

An Innocent Appearing Subcutaneous Nodule Diagnoses a Small Cell Lung Cancer in a Never-Smoker Female

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Hindawi Publishing Corporation
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Copyright © 2014 Nupur Sinha et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Hindawi Publishing Corporation Case Reports in Oncological Medicine Volume 2014, Article ID 268404, 4 pages http://dx.doi.org/10.1155/2014/268404 Case Report An Innocent Appearing Subcutaneous Nodule Diagnoses a Small Cell Lung Cancer in a Never-Smoker Female 1 2 1 1 Nupur Sinha, Masooma Niazi, Gilda Diaz-Fuentes, and Richard Duncalf Division of Pulmonary and Critical Care Medicine, Bronx Lebanon Hospital Center, Albert Einstein College of Medicine, Bronx, NY 10457, USA Department of Pathology, Bronx Lebanon Hospital Center, Albert Einstein College of Medicine, Bronx, NY 10457, USA Correspondence should be addressed to Nupur Sinha; nsinha@bronxleb.org Received 5 December 2013; Accepted 6 February 2014; Published 10 March 2014 Academic Editors: L. Beex, P. F. Lenehan, J. I. Mayordomo, and N. Yoshimura Copyright © 2014 Nupur Sinha et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Lung cancer among never-smokers is recognized as the 7th most common cause of cancer death globally. Adenocarcinoma is the most commonly reported histology. Small cell lung cancer (SCLC) has the strongest association with smoking and is rarely reported in never-smokers. Although lung cancer in never-smokers is more common in women, the overall incidence of SCLC in female never-smokers still remains low. Soft tissue metastases from any cancer are rare with an overall prevalence of 1.8%. Soft tissue metastases from lung primary are uncommon, mostly from adenocarcinoma, and portend a poor prognosis. Cutaneous metastases from SCLC are exceptionally rare with reported incidence of 0.3% to 0.8%. We believe ours is the first reported case of SCLC presenting as subcutaneous nodule, in a never-smoker, otherwise asymptomatic female. eTh diagnosis of SCLC was made incidentally by the excisional biopsy of the subcutaneous nodule. Subsequent CT chest and PET scan revealed a hypermetabolic right lower lobe spiculated lung mass with adrenal and liver involvement. Platinum and etoposide chemotherapy with prophylactic cranial irradiation was initiated for advanced SCLC, and she required further irinotecan and taxol for subsequent pancreatic and adrenal metastases. With continued deterioration, she died approximately 36 months from diagnosis, while under hospice care. 1. Introduction 2. Case Presentation Lung cancer in never-smokers is increasingly being recog- A 54-year-old woman presented with a two-month history nizedasadistinct entity andranks as theseventh most of an enlarging, slightly painful left flank nodule. er Th e was common cause of cancer death globally [1, 2]. Worldwide, no preceding history of trauma or insect bite to the involved 15%ofmen and53% of womenwithlungcancerare region.She deniedfever,chills, rash,cough,shortness of never-smokers [2]. Adenocarcinoma is the most commonly breath, hemoptysis, mouth ulcers, arthralgias, dysuria, or reported histology in never-smokers [1, 2]. Recognized as an loss of weight. Her medical history included chronic anemia, entity distinct from other lung cancers in 1926 by Dr. W. G. treated latent TB, cervical dysplasia, and hysterectomy. She Bernard, small cell lung cancer (SCLC) accounts for 15% of denied tobacco use, second hand smoking, or occupational annual lung cancers in the USA and is known to have the exposure. Family history was significant for various cancers: strongest association with tobacco use. More than 95% occur bone cancer in her father, unknown facial cancer in a brother, in smokers, with 95% fatality [3]. Small cell lung cancer in liver cancer in an uncle, and a brain tumor in an aunt. never-smokers is rarely reported. Soft tissue metastases from Physical exam revealed only a single2×2 cm firm, slightly lung cancer are uncommon with reported overall prevalence tender, freely mobile, nonu fl ctuant, left flank mass without of 2.3% [4], and rarely reported from SCLC. We report the induration, erythema, or involvement of the skin. No other first case of SCLC in a never-smoker woman presenting as nodules, masses, or lymphadenopathy was found. Laboratory subcutaneous nodule. demonstrated a mildly elevated erythrocyte sedimentation 2 Case Reports in Oncological Medicine (a) (b) Figure 1: (a) Subcutaneous tissue with neuroendocrine carcinoma (s mall cell type) composed of sheets of small spindle cells with finely granular chromatin and mitoses. (b) Tumor cells immunoreactive to chromogranin A. adrenal metastases. She continued to maintain a good func- tional status for the most part despite recurrent metastases anddied36monthsfromdiagnosis,whileunderhospicecare. 3. Discussion The differential diagnosis of a subcutaneous nodule is exten- sive and mostly benign, including traumatic, infectious, inflammatory, and neoplastic etiology. Metastasis to soft tissue, defined as metastasis to skeletal muscle, skin, and subcutaneous tissues, has only rarely been reported [4]. The available literature does not distinguish between cutaneous and subcutaneous metastases. While earlier studies inves- Figure 2: CT chest: right lower lobe spiculated mass. tigating the prevalence of cutaneous metastases from any cancer have reported an overall incidence of 0.75%–9% [4, 5], a more recent study on 500 patients with cancer reported rate at 35 mm/hr and a lactate dehydrogenase of 220 IU/L. soft tissue metastases in 1.8% of cases [ 5]. The most common Autoimmune, HIV, and hepatitis work ups were negative, primary cancers associated with cutaneous metastases are and thyroid function was normal. A chest X-ray (CXR) and lung and colon in males and breast in females [6]. subsequentwholebodycomputerizedaxialtomography(CT) Cutaneous metastases with a lung primary are relatively scan done three years earlier as part of an anemia work up uncommon and portend a poor prognosis. Skin metastases were unremarkable with no evidence of lymphadenopathy or areseenin1to 12%ofpatientswithlungcancerduring malignancy. their life time [7], with up to 24% of these presenting with With a presumptive diagnosis of neurolipoma, the patient a cutaneous lesion upon initial presentation [8]. Common underwent excision with wide margins. Operative ndin fi gs sites of metastases include the chest, back, abdomen, head, were signica fi nt for reddish brown appearing 2 cm rm fi , and neck [5, 8]. Adenocarcinoma has been shown to be the subcutaneous mass supercfi ial to the fascia, surrounded by histological variant of lung cancer most commonly associated fat. Histopathology revealed a small cell type neuroendocrine with soft tissue metastasis [ 8]. Cutaneous metastases from tumor. Immunohistochemical stain favored lung primary, SCLC are exceptionally rare with reported incidence of 0.3% with staining positive for TTF-1, CD56, synaptophysin, and to 0.8% [9, 10]. chromogranin A (Figure 1). Subsequent CXR and CT demon- SCLC has been historically described to be extremely strated a 3.4 cm right lower lobe spiculated mass, distal rare in female never-smokers. More recent studies have atelectasis, and ipsilateral hilar lymph nodes, the largest being revealed that lung cancer in never-smokers is more com- 17 mm (Figure 2). Positron emission tomography (PET) scan mon in women [1, 2, 11]. The overall incidence of SCLC confirmed a hypermetabolic right lower lobe lung mass with in female never-smokers still remains low accounting for hilar adenopathy and possible liver and adrenal involve- approximately 2.9% of all female patients diagnosed with ment. In view of sufficient diagnostic evidence, further lung cancer [11]. Genetic predisposition has been studied as invasive workup was not pursued. Platinum and etoposide an important risk factor in never-smokers with lung cancer, chemotherapy was initiated for advanced SCLC. Despite pro- although reported incidence remains rare at 1% with more phylactic cranial irradiation, she developed cerebral metas- than 3 affected relatives [ 12]. tasis requiring further radiotherapy. Irinotecan and taxol Chemotherapy is the standard therapeutic modality for chemotherapy were required for subsequent pancreatic and extensive disease, with a median survival of 7–12 months [13]. Case Reports in Oncological Medicine 3 ForextensivestageSCLC,theroleofetoposideandcisplatinis the need for studying more closely the causative as well as well studied and described in literature. Prophylactic cranial prognostic associations in this unique subset of population. irradiation in chemotherapy-responding patients modestly We recommend reporting rare cases of SCLC in never- improves a disease-free and an overall survival and may smokers for further analysis of potential risk factors and decrease the risk of developing brain metastases [13]. Patients management options. In addition, our case demonstrates how presenting with skin lesions at the time of diagnosis have been even a single, new subcutaneous lesion can represent serious showntohavealowersurvivalratethanpatientswho develop occult pathology in a patient with low suspicion for internal skin metastasis later in the disease course. Treatment of soli- malignancy, thus warranting a low threshold for biopsy. tary skin metastasis includes surgery combined with either or both chemotherapy and radiation [8]. Although studies Abbreviations have shown that females have a higher objective response CT: Computerized axial tomography rate, median survival and 2-year disease-free survival rate CXR: Chest X-ray compared to males, the overall median survival reported aer ft diagnosis of cutaneous metastasis remains low at 5–7.5 HIV: Human immunodeficiency virus NSCLC: Nonsmall cell lung cancer months [11]. PET: Positron emission tomography Our case presented with a seemingly benign small abdominal wall nodule. Most common benign etiologies SCLC: Small cell lung cancer. were ruled out by history and the absence of systemic complaints made it unlikely to be a manifestation of systemic Disclosure disease. Although she had strong family history of various cancers, her younger age and prior normal sex and age None of the authors has a financial relationship with a appropriate screenings placed her at low risk for malignancy. commercial entity that has an interest in the subject of the Only two cases of lung cancer with metastasis to soft manuscript. No na fi ncial support was used for the study. tissue in females have been reported, both were NSCLC, smoking status unknown, and neither had soft tissue metas- Conflict of Interests tasisasthe sole presenting complaint[5]. Literature also describes three cases of lung carcinoids with subcutaneous eTh authors declare that there is no conflict of interests metastasis [14]and asinglecasereportofSCLCinafemale regarding the publication of this paper. presenting with multiple systemic complaints along with a subcutaneous nodule [8], but they were all smokers and References did not have subcutaneous metastasis as the sole presenting complaint. We believe ours is the first reported case of [1] A. G. Pallis and K. N. Syrigos, “Lung cancer in never smokers: SCLC presenting as subcutaneous nodule, in a never-smoker, disease characteristics and risk factors,” Critical Reviews in otherwise asymptomatic female, diagnosed incidentally by Oncology/Hematology, vol. 88, no. 3, pp. 494–503, 2013. excisional biopsy of the presenting nodule. As noted in [2] S. Sun, J. H. Schiller, and A. F. Gazdar, “Lung cancer in never earlier reports, the presentation was associated with extensive smokers–a different disease,” Nature Reviews Cancer,vol.7,no. 10, pp. 778–790, 2007. disease and systemic metastases, and she continued to have recurrent metastases despite standard therapy. Still, her good [3] C. L. Hann and C. M. Rudin, “Fast, hungry and unstable: finding functional status and unusual survival of approximately the Achilles’ heel of small-cell lung cancer,” Trends in Molecular Medicine,vol.13, no.4,pp. 150–157, 2007. 36 months from presentation are remarkable and warrant [4] C. Perisano, M. S. Spinelli, C. Graci et al., “Soft tissue metastases further studies in such cases. in lung cancer: a review of the literature,” European Review for Medical and Pharmacological Sciences,vol.16, no.14, pp.1908– 4. Conclusion 1914, 2012. [5] N.C.Nguyen, B. T. Chaar, andM.M.Osman,“Prevalence and Lung cancer in never-smokers is emerging as a distinct patterns of soft tissue metastasis: detection with true whole- clinical entity, with different genetic mutations and response body F-18 FDG PET/CT,” BMC Medical Imaging,vol.7,article to novel targeted therapies. Subcutaneous metastasis from a 8, 2007. primary lung cancer is unusual and ominous. Being more [6] D. Brinkman, L. Roche, K. Ullah, and T. M. O. ’Connor, “Multi- commonly accepted as a disease of smokers, there is a ple cutaneous nodules as the presenting sign of small cell lung potential for failure or delay in the diagnosis of lung cancer cancer,” BMJ Case Reports,2013. in a young, never-smoker patient presenting with atypical [7] T. Terashima and M. Kanazawa, “Lung cancer with skin metas- manifestations such as subcutaneous nodules. While there is tasis,” Chest,vol.106,no. 5, pp.1448–1450,1994. extensive work ongoing on identifying causative factors other [8] K. Ussavarungsi, M. Kim, and L. Tijani, “Skin metastasis in a thansmokinginnonsmallcelllungcancer(NSCLC)resulting patient with small-cell lung cancer,” The Southwest Respiratory in major therapeutic advances and improved outcome in and Critical Care Chronicles,vol.1,no. 1, pp.35–38,2013. NSCLC, there is paucity of similar studies in SCLC. [9] K.Shaheen,A.H.Alraiyes, M. Baibars, A. Paintsil,and M. C. Our case, with an atypical presentation in otherwise Alraies, “Ulcerative cutaneous lesions synchronously present asymptomatic and low risk patient, and her remarkable with the diagnosis of primary lung cancer,” Case Reports in survival aer ft the incidental diagnosis draws attention to Medicine,vol.2013, ArticleID136564, 3pages,2013. 4 Case Reports in Oncological Medicine [10] S. C.-S. Hu, G.-S. Chen, C.-S. Wu, C.-Y. Chai, W.-T. Chen, and C.-C. E. Lan, “Rates of cutaneous metastases from different internal malignancies: experience from a Taiwanese medical center,” Journal of the American Academy of Dermatology,vol. 60, no. 3, pp. 379–387, 2009. [11] R. Govindan, N. Page, D. Morgensztern et al., “Changing epidemiology of small-cell lung cancer in the United States over the last 30 years: analysis of the surveillance, epidemiologic, and end results database,” Journal of Clinical Oncology,vol.24, no. 28, pp. 4539–4544, 2006. [12] M. Furrukh, “Tobacco smoking and lung cancer, perception- changing facts,” Sultan Qaboos University Medical Journal,vol. 13, no. 3, pp. 345–358, 2013. [13] Y.Zhang andJ.He, “ed Th evelopment of targeted therapyin smallcelllungcancer,” JournalofThoracic Disease ,vol.5,no. 4, pp.538–548,2013. [14] R. Yua, E. Wolina, and X. Fanb, “Single subcutaneous nodule as initial presentation of atypical lung carcinoid,” World Journal of Oncology,vol.1,no. 5, pp.204–207,2010. MEDIATORS of INFLAMMATION The Scientific Gastroenterology Journal of World Journal Research and Practice Diabetes Research Disease Markers Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 International Journal of Journal of Immunology Research Endocrinology Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Submit your manuscripts at http://www.hindawi.com BioMed PPAR Research Research International Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Journal of Obesity Evidence-Based Journal of Journal of Stem Cells Complementary and Ophthalmology International Alternative Medicine Oncology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Parkinson’s Disease Computational and Behavioural Mathematical Methods AIDS Oxidative Medicine and in Medicine Research and Treatment Cellular Longevity Neurology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014

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