"Clown nose" as first manifestation of squamous cell carcinoma of the lung

Abstract

Background

Skin metastases occur in 0.7% to 9% of all patients with cancer and are usually considered a late event in the evolution of most visceral carcinomas. The development of a nodular metastatic lesion on the nasal tip is known as clown nose sign.

Main observation

We report a 64-year-old man that developed a nodular lesion on his nasal tip as first manifestation of squamous lung carcinoma.

Conclusion

The biopsy of the cutaneous metastasis may be helpful to histopathologically confirm the suspected primary tumour avoiding invasive diagnostic procedures.

Introduction

Skin metastases are uncommon and are usually considered a late event in the evolution of most visceral carcinomas. Their frequency has been reported to range between 0.7% to 9% of all patients with cancer and when appear the disease is usually disseminated.[1,2] However, in some cases cutaneous metastasis may be the first manifestation of a visceral neoplasm.[3] The development of a nodular metastatic lesion on the nasal tip is known as clown nose sign. We report a patient that developed a nodular lesion on his nasal tip as first manifestation of squamous carcinoma of the lung.

Case Report

A 64-year-old man presented to the emergency department with progressive left hemiparesia from 15 days ago and a nasal tip tumour of 3 months evolution. He had smoked 40 cigarettes per day for 40 years. He also suffered from chronic bronchitis, hypertension, hyperuricemia, and ischemic cardiopathy. At admission, the patient also complained of asthenia, anorexia, and discrete hemoptysis. The patient was admitted to the hospital and at this point the Dermatology department was consulted. On physical examination a solitary, well demarcated, nodular lesion was observed on the tip of the nose. The lesion was a 2 cm round, reddish tumour with yellowish small nodules suggestive of keratin cysts (Fig. 1 and 2). Biopsy of the lesions revealed a dermal proliferation of atypical cells with squamous differentiation not connected with the overlying epidermis [Fig. 3]. A cranial computer tomography was consistent with cerebral metastasis. Chest X-ray and thoracic computer tomography showed a mass in the upper right lobule of the lung with mediastinal infiltration and right paratracheal lymphadenopathy. A bone scan showed hot areas in the left scapula and left femur. A diagnosis of metastatic squamous cell carcinoma of the lung was made. The patient received only palliative treatment and died 1 month after admission.

Figure 1.

Quickly enlarging spherical tumoral lesion on the tip of the nose.

Figure 2.

Quickly enlarging spherical tumoral lesion on the tip of the nose.

Figure 3.

Dermal proliferation of atypical cells with squamous differentiation.

Discussion

Lung cancer is the one of the most frequent source of cutaneous metastases in men.[3] However, in one study of 2080 cases of lung cancer, macroscopic metastases to the skin were found in only 1,5% of patients.[4] Interestingly, although it cannot be considered a frequent event, when lung carcinoma spreads to the skin it usually occurs before or simultaneously to the diagnosis of the primary tumor.[3] In one series, the underlying cancer had been undiagnosed in 60% of patients with lung cancer and cutaneous metastasis.[1] Another study found that in 11 of 21 patients (52%) with cutaneous metastases from lung cancer, the skin metastasis was the first site of extranodal involvement.[2]

The nasal tip is a very unusual location of cutaneous metastases. The development of clown nose has been described in a few patients with chordoma,[5] kidney tumor,[6-8] hepatocellular carcinoma,[9] seminoma,[6] leukemia,[10] breast cancer,[6,11] cervix carcinoma,[12] and esophageal carcinoma.[13,14] Several cases has been described originated from lung carcinoma, including anaplastic large cell carcinoma and small cell carcinoma.[15-18] Squamous lung cell carcinoma with nasal tip metastasis have also been reported.[16,19-21]

Although cutaneous metastatic lesions to the nasal tip are rare there are several signs that may suggest a metastatic spread of an internal malignancy. Signs suggestive of metastasis include rapid growth, lack of local inflammatory response, and intact overlying epithelium in the early stages.[20]

Conclusion

Our patient developed the cutaneous lesion before systemic symptoms of lung cancer and the cutaneous biopsy was helpful to histopathologically confirm the suspected primary tumour avoiding invasive diagnostic procedures.