Not just skin deep: Multiple cutaneous nodules as first presenting sign of small cell cancer

A 65 years old male, chronic smoker (30 pack years), presented with complaints of dyspnea (mMRC grade2), cough (dry in nature), loss of appetite, loss of weight ( > 5 kgs), weakness, bony pains, feverish feeling and easy fatigability for last 2-3 months.Contrast enhanced CT chest showed bilateral extensive paraseptal and centriacinar emphysematous changes, right upper lobe spiculated heterogeneously enhancing soft tissue lesion and significant conglomerate mediastinal lymphadenopathy encasing lower trachea and great vessels.As patient was high risk for development of pneumothorax related to image guided sampling of right upper lobe lesion in view of extensive emphysema; patient was referred to us for EBUS-TBNA (endobronchial ultrasound guided transbronchial needle aspiration) guided mediastinal lymph nodes sampling. But on head to toe examination revealed round, firm, non-tender, skin coloured, 2-3 cm size skin nodules (2 on left lateral chest wall, 1 on right lateral chest wall and 1 in proximity to umbilicus).Fine needle aspiration cytology (FNAC) was attempted from two of skin nodules which was suggestive of small cell lung cancerSkin metastasis as initial presentation is reported rarely in small cell lung cancer.The index case emphasize on importance of detailed physical examination in cases of lung cancer to look for any skin manifestation of the disease, although encountered rarely.Moreover detection of skin nodules helps in staging and prognosis of diseases.