Age and Ageing Advance Access originally published online on April 5, 2007
Age and Ageing 2007 36(4):468-469; doi:10.1093/ageing/afm042
Case Reports |
Paraneoplastic rash as the presenting feature of squamous cell carcinoma of the lung
Older Persons Unit, Royal United Hospital, Bath, 1 Combe Park, Bath BA1 3NG, UK
Address correspondence to: N. John. Tel: 01225 428 331; Fax: 01225 821287. Email: Nicholas.John{at}ruh-bath.swest.nhs.uk
Abstract
We report on the case of a man who presented with a severe, pruritic rash 5 months prior to diagnosis of a resectable lung malignancy. A rash is a rare presentatinof squamous cell carcinoma of the lung but may be the only feature of a potentially curable malignancy. Treatment of the underlying malignancy resulted in complete resolution of the rash.
Keywords: paraneoplastic rash, squamous cell carcinoma lung, elderly
A 74-year-old man presented with a 5-month history of skin rash. The rash was treated initially by dermatologists with topical emollients and steroids and then oral prednisolone. The presumptive diagnosis was bullous pemphigoid; however, skin biopsy was not diagnostic (immunofluorescence negative). He required admission to hospital for intensive topical treatment, owing to the severity of the pruritis that disturbed his sleep and was refractory to antihistamines.
His past medical history was significant for a dominant hemispheric cerebrovascular event 4 years previously. He had ceased smoking 35 years previously but had a 50 pack-year history, and had treated hyperlipidaemia and hypertension. He also had seropositive rheumatoid arthritis well controlled on a low dose of prednisone.
On admission to hospital, a widespread urticarial eczematous rash was evident symmetrically over his trunk, arms, abdomen and thighs. He was moderately dysphasic and had a right hemiplegia. The rest of the clinical examination was unremarkable.
Routine blood tests including a full blood count, electrolytes and liver function tests were unremarkable. A chest radiograph performed because of his past smoking history revealed a left apical lesion. Computerized tomography scans confirmed a 3-cm malignancy that was not amenable to biopsy either percutaneously or transbronchially. Open lung biopsy revealed squamous cell carcinoma: FEV1 1.89 (61%), FVC 2.02 (49%), performance status (ECOG) 0, Dyspnoea Score 2. He underwent a left upper lobectomy and his post-operative course was complicated by wound infection and Clostridium difficile diarrhoea but he was discharged home after 23 days. Histology confirmed a moderately differentiated squamous carcinoma (2.5 x 3.0 x 2.0 cm) with complete resection margins, and none of the nine resected lymph nodes were involved. He was seen a month after this surgery and his rash had improved dramatically without any further dermatological intervention (Figure 1 pre- and post-surgery). The oncologist estimated he had a 60% chance of tumour-free survival of 5 years and he elected not to have chemotherapy owing to the very small extra potential benefits.
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Discussion
The prevalence of paraneoplastic syndromes in squamous cell malignancy is unknown. Paraneoplastic syndromes seen in bronchogenic carcinoma include endocrine and neurological syndromes as well as arthropathy, clubbing and dermatoses [1]. To our knowledge, paraneoplastic rashes are very rarely described in association with squamous cell carcinoma of the lung. One case report describes leukocytoclastic vasculitis [2]. The mechanism of cutaneous changes in lung malignancy is not well understood. It is believed to be immune mediated; however, immunosuppressive treatments are often disappointing.
In those patients presumed to have a paraneoplastic condition, most of the cancers can be detected with simple history-taking, physical examination and age-appropriate cancer screening. Current guidelines remain that there is no indication for screening radiography (chest radiograph or CT scan) in previous or current smokers unless there is another clinical indication [3]. However, clinicians should have a low threshold for performing further investigations if unusual symptoms persist.
Although there is some evidence that patients who present with other paraneoplastic syndromes (such as neurological symptoms in small cell lung cancer) may have a better prognosis, it is unclear whether paraneoplastic dermatoses also provide this opportunity [4].
- Recognition of paraneoplastic syndromes may result in early detection of potentially treatable malignancy.
- Non-small-cell lung cancer may present with paraneoplastic phenomena as the first sign of disease and this may be the only feature.
- The skin symptoms typically run a parallel course with the cancer. Most paraneoplastic dermatoses disappear when the primary tumour is removed and reappear in the case of recurrence or metastases of the cancer.
References
- Gerber R, Mazzone P, Arrologa A. Paraneoplastic syndromes associated with bronchogenic carcinoma. Clin Chest Med (2002) 23:257–64.[CrossRef][Web of Science][Medline]
- Odeh M, Misselevich I, Oliven A. Squamous cell carcinoma of the lung presenting with cutaneous leukocytoclastic vasculitis. Angiology (2001) 52:641–44.[Web of Science][Medline]
- Manser RL, Irving LB, Byrnes G. Screening for lung cancer: a systematic review and meta-analysis of controlled trials. Thorax (2003) 58:784–9.
[Abstract/Free Full Text] - Darnell RB, DeAngelis LM. Regression of small-cell lung carcinoma in patients with paraneoplastic neuronal antibodies. Lancet (1993) 341:21–2.[CrossRef][Web of Science][Medline]
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