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Urticaria and large cell undifferentiated carcinoma of lung

  • Author(s): De, Pradip
  • Abbasi, Rashid
  • Senadhira, T
  • Orr, P
  • Ullah, A
  • et al.
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Urticaria and large cell undifferentiated carcinoma of lung
Dr Pradip De MRCP, Dr Rashid Abbasi FRCP, Dr T Senadhira, Dr P Orr, Dr A Ullah
Dermatology Online Journal 11 (3): 45

Department of Respiratory Medicine, General Hospital, Cockton Hill Road, Bishop Auckland, County Durham, DL3 8LF, UK. p_de62@yahoo.co.uk

Abstract

The association of urticaria with internal cancer is known mostly with lymphoreticular system malignancies. Rarely, it occurs with cancer of lung, mostly with adenocarcinoma or small cell carcinoma. We report a unique occurrence of urticaria on a patient who suffered from Large cell undifferentiated carcinoma of lung. Only the treatment for malignancy relieved the patient from his long standing cutaneous manifestation.


A very fit 57-year-old farmer was referred to the Dermatology clinic in November 1996 for non-resolving itchy erythematous maculopapular rash on his trunk, buttocks, and proximal limbs. The clinical diagnosis was urticaria. His other physical examination was unremarkable. He was on no regular medication. There was no relevant family history. His past medical history included sciatica and spondylosis. He was a smoker (50 pack year). His hemoglobin, white cell and platelet count, erythrocyte sedimentation rate, renal and liver functions, Anti-streptolysin-O titers, serum C3, C4 and C1 esterase inhibitor levels were normal on repeated testing.


Figure 1 Figure 2
Figure 1. Chest Xray showing bulky right hilum
Figure 2. CT scan of chest showing soft tissue mass at right hilum

Figure 3
Bronchial biopsy showing large cell undifferentiated carcinoma

He was treated with various antihistamines, steroid-based ointments, emollients, and oral corticosteroids for nearly 4 years without any benefit. In June 2000 he presented to casualty department with right-sided pleuritic pain. The chest x-ray revealed a prominent right hilum and suggestion of right lower lobe collapse. Subsequently CT scan of chest confirmed a soft tissue mass at right main bronchus causing ipsilateral lower lobe collapse (T4N2M0). Endobronchial histology confirmed large cell undifferentiated carcinoma.

He was treated by external beam high dose palliative radiotherapy (39 Gray in 13 fractions). His uriticaria disappeared for the first time since 1996.

One year following his radiotherapy his rash returned in the similar distribution along with swelling of his face. Clinical examination and CT chest confirmed recurrence of tumor and superior vena cava obstruction. Chemotherapy with mitomycin, ifosamide and cisplatin helped not only in regression of the size the tumor mass but the rash disappeared as well.

About 10 months following his chemotherapy he again had similar cutaneous manifestation and clinically supraclavicular spread of tumor was confirmed. A second course of the same chemotherapy regime helped physical and symptomatic improvement.

He died of cerebral metastasis 4 years following diagnosis of his cancer. During the end stage of his illness no particular attention was given to look for any rash.

Urticaria is generally associated with lymphoproliferative diseases and malignancies. Association of brochogenic malignancy with urticaria is very rare. Earlier, only two cases with adenocarcinoma [1, 2] and two other with small cell [3, 4] were reported. Large cell undifferentiated type is the first one to be known. Following positive response to the treatment of bronchial malignancy and disappearance of urticaria indirectly suggests a probable unknown biochemical or hormonal abnormality responsible for a possible paraneoplastic feature. Our case, therefore, once again stressed the importance of performing a plain chest x-ray on patients suffering from chronic urticaria.

Acknowledgment: The patient (who died) and his family. All the staff working in the department of Respiratory Medicine, Radiology, Histopathology and Dermatology.

References

1. Conget I, Agusti C, Montserrat JM, Lung adenocarcinoma and urticaria, Med Clin (Barc). 1987 Oct 24;89(13):573

2. Hills EA, Adenocarcinoma of the bronchus with Cushing's syndrome, carcinoid syndrome, neuromyopathy and urticaria, Br J Dis Chest. 1968 Apr;62(2):88-92

3. Greiner D, Schofer H, Boehncke WH, Urticaria associated with a small cell carcinoma of the lung, Cutis. 2002 Jan;69(1):49-50

4. Ross TF, Coleman DL, Naughton JL, Angioedema and small-cell carcinoma of the lung, Thorax. 1982 Dec;37(12):950-1

© 2005 Dermatology Online Journal