IP Journal of Otorhinolaryngology and Allied Science

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Singh, Poonia, Kumari, Bansal, and Aman: Unusual presentation of lung carcinoma as nasal tip metastasis: A review of literature


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.

Figure 1
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Figure 2

          

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Figure 3
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Figure 4
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Table 1

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 0

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.

References

1 

T Rosen Cutaneous metastasesMed Clin North Am198064885900

2 

M H Brownstein E B Helwig Metastatic tumors of the skinCancer19722951298130710.1002/1097-0142(197205)29:5<1298::aid-cncr2820290526>3.0.co;2-6

3 

G J Ledderose S Reu A S Englhard E Krause Endonasal resection of early stage squamous cell carcinoma of the nasal vestibuleEur Arch Otorhinolaryngol 201427151051610.1007/s00405-013-2660-4

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D P Lookingbill N Spangler K F Helm Cutaneous metastases in patients with metastatic carcinoma: a retrospective study of 4020 patientsJ Am Acad Dermatol19932922286410.1016/0190-9622(93)70173-q

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R A Krathen I F Orengo T Rosen Cutaneous metastasis: a meta-analysis of dataSouth Med J20039621647110.1097/01.SMJ.0000053676.73249.E5

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M Shindo Y Yoshida K Tominaga O Yamamoto Skin Metastasis of Hypopharyngeal Carcinoma to the Nasal TipYonago Acta medica20135625765

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T W Mollet C A Garcia G Koester Skin metastases from lung cancerDermatol Online J20091551

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L M Coslett M R Katlic Lung cancer with skin metastasisChest19909737576610.1378/chest.97.3.757

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S M Chun Y C Kim J B Lee S J Kim Nasal Tip Cutaneous Metastases Secondary to Lung Carcinoma: Three Case Reports and a Review of the LiteratureActa Derm Venereol20139355697210.2340/00015555-1529

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S Dreizen H Dhingra D Chiuten T Umsawasdi M Valdivieso Cutaneous and subcutaneous metastases of lung cancerPostgrad Med1986808111710.1080/00325481.1986.11699635

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M V Justribo C Seuma J M Portero L Egido Skin metastasis as the lst manifestation of bronchogenic carcinomaArch Bronconeumol199430631420

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P H Itin F Heitzmann B Stamm Metastasis to the nasal tip from a cervical carcinomaDermatology19991992171410.1159/000018231

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A Kataoka T Nishida Y Tomioka N Hirai M Ohbuchi M Yakushiji A metastasis to the nasal tip from a cervical carcinoma- a case reportKurume Med J19984511275810.2739/kurumemedj.45.127

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L Coslett M Katlic Lung cancer with skin metastasisChest1990973757910.1378/chest.97.3.757

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W C Hammert L Champagne F R Heckler Metastatic squamous cell carcinoma of the nasal tip: a case reportJ Oral Maxillofac Surg572186910.1016/s0278-2391(99)90237-9



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© This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


Article type

Case Report


Article page

122-126


Authors Details

Jagat Singh, Usha Poonia, Manisha Kumari, Sukriti Bansal, Aman


Article History

Received : 13-08-2021

Accepted : 16-09-2021

Available online : 01-11-2021


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