See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/273765731

Case Report Lung Cancer with Skin and Breast Metastasis: A Case Report and Literature
Review

Article in Case Reports in Pulmonology · February 2015

DOI: 10.1155/2015/136970

CITATIONS
READS
10
1,787

13 authors, including:

Bikash Bhattarai Frances Schmidt

State University of New York Interfaith Medical Center
59 PUBLICATIONS 75 CITATIONS 124 PUBLICATIONS 791 CITATIONS

Abhisekh Sinha Ray

Good Samaritan Hospital, Kearney, NE
15 PUBLICATIONS 50 CITATIONS

Some of the authors of this publication are also working on these related projects:

Case report View project

Pulmonary View project

All content following this page was uploaded by Saroj Kandel on 20 March 2015.
The user has requested enhancement of the downloaded file.
Hindawi Publishing Corporation
Case Reports in Pulmonology
Volume 2015, Article ID 136970, 6 pages
http://dx.doi.org/10.1155/2015/136970

Case Report
Lung Cancer with Skin and Breast Metastasis:
A Case Report and Literature Review

Bikash Bhattarai, Marie Frances Schmidt, Meenakshi Ghosh, Abhisekh Sinha Ray,
Saveena Manhas, Vikram Oke, Chidozie Charles Agu, Md. Rawshan Basunia,
Danilo Enriquez, Joseph Quist, Catherine Bianchi, Ravi Hans, and Saroj Kandel
Department of Medicine, Interfaith Medical Center, 1545 Atlantic Avenue, Brooklyn, NY 11213, USA

Correspondence should be addressed to Bikash Bhattarai; [email protected]

Received 30 December 2014; Accepted 28 February 2015

Academic Editor: Akif Turna

Copyright © 2015 Bikash Bhattarai et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.

Lung cancer is one of the most common cancers in America. Frequent sites of metastasis include the Hilar lymph nodes, adrenal
glands, liver, brain, and bone. The following case report is of a primary lung cancer with metastases to the breast and skin. Case.A
48- year-old African American male with a past medical history of poorly differentiated left breast cancer status after modified
radical mastectomy (MRM), chronic obstructive pulmonary disease, and smoking (20 pack-years) presents to the ER with
progressive shortness of breath on exertion, upper back pain, and weight loss for 2 months in duration. On physical examination
he is found to have a MRM scar on his left breast and a left periumbilical cutaneous mass. Chest X-ray and chest CT reveal a
right upper lobe mass and biopsies from the breast, lung, and the periumbilical mass indicate a poorly differentiated carcinoma
of unclear etiology; all tumor markers are negative. The patient is male and a chronic smoker; therefore the diagnosis is made as
lung carcinoma with metastases to the breast and skin. Conclusion. A high index of suspicion for cutaneous metastases should be
cast when investigating cutaneous pathologies in patients at risk for primary lung malignancy.

1. Introduction skin [4]. Although rare, these cutaneous metastases are an

important diagnostic clue since primary lung lesions are
Every year thousands of Americans across the country are often quiescent making the initial diagnosis of lung cancer
diagnosed with lung cancer and for the majority of these very difficult. In general, cutaneous lesions as an initial
patients the diagnosis is terminal. Lung cancer is among the manifes- tation of internal neoplasia represent only 0.8% of
most common cancers worldwide. In the United States and total cases but if they are present, they imply a very
other industrialized countries it is the major cause of cancer advanced grade of disease and a very poor prognosis [5].
mortality, primarily because of exposure to cigarette smoke.
Lung cancer is the leading cause of cancer deaths
worldwide in men and is second most common in women. 2. Case History
In 2012, lung cancer occurred in approximately 1.8 million
patients and caused an estimated 1.6 million deaths [1]. A 48-year-old African American male with a past medical
In the United States, lung cancer will occur in an estimated history of infiltrating poorly differentiated left breast cancer
224,000 patients and cause about 159,000 deaths [2]. The (Figure 1) without lymph node involvement s/p modified
prognosis of lung cancer is poor with a 5-year survival rate radical mastectomy (MRM) along with axillary dissection 2
standing at approx- imately 15%. The most common months earlier, COPD, bipolar disorder, and chronic
histologic type is adenocar- cinoma, followed by squamous smoking (20 pack-years) presented to the ER with
cell carcinoma, small cell car- cinoma, and large cell progressive SOB for the past 2 months. The patient
carcinoma [3]. Frequent sites of metas- tasis often include complained of being dyspneic on minimal exertion and also
the hilar lymph nodes, adrenal glands, liver, brain, and complained of upper back pain for the last 2 months which
bone, with rare cases metastasizing to the was progressive, 10/10 in intensity,
2 Case Reports in Pulmonology

FIgURe 1: Subcutaneous mass invading left breast tissue (from

previous admission).

sharp in quality, nonradiating, aggravated with exertion,

and alleviated with supine posture and analgesic
medication (ibuprofen). The pain was not associated with FIgURe 2: Left abdominal wall mass.
any sensory or motor symptoms and the patient denied
tingling, weakness, or numbness of the lower extremities,
bowel, and bladder incontinence. He gave a history of
approximately 30 lb. weight loss associated with anorexia for
the past 6 months but denied fever, cough, chills, chest pain,
nausea, vomiting, or any other systemic complaints. He had
no known drug allergies and was on home medications of
Ibuprofen, Trazodone, Citalopram, Albuterol, and
Tiotropium inhaler. He was an active smoker and admitted
to using alcohol and marijuana occasionally. His family
history was positive only for colon cancer in his mother.
On admission, the patient was tachycardic (pulse
105/min) and tachypneic (respiratory rate 20) but was
saturat- ing at 100% on room air. He was afebrile and
normotensive. On general examination, he appeared FIgURe 3: Chest X-ray: Rt upper lobe mass.
cachectic and in moderate respiratory distress. The head
was atraumatic and normocephalic; pupils were bilaterally
equal and reactive. There was no evidence of neck vein
distension or pedal edema. A well-healed surgical scar of
MRM was noted extending from his left axilla to his
sternum. On percussion, the right chest appeared to be dull
and on auscultation breath sounds were decreased in the
right base in comparison to the left. There was a soft,
nontender mobile mass in the periumbilical area which
was 2 cm × 2 cm × 2 cm in size and appeared to be
superficial on examination (Figure 2). Other than the mass,
the abdomen was soft, nontender, and nondis- tended with
normoactive bowel sounds. Tenderness was elicited on
palpation of the upper thoracic spine and right scapular
area and range of motion of both arms was mildly restricted
FIgURe 4: Chest CT scan: Rt upper lobe density.
due to pain and discomfort. Cardiovascular and
neurological examination was noncontributory.
On laboratory examination, the patient was found to
have normocytic normochromic anemia with hemoglobin The patient was admitted to the medical floor and work-
of 9 gm/dL and thrombocytosis (platelet count of 713). The up was done. CT scan reported a large right upper lobe lung
leukocyte count was normal. Metabolic panel and liver mass suspicious for malignancy, bullous emphysematous
func- tion test results were within normal limits except that disease with pulmonary fibrosis, and mediastinal lymphad-
there was a mildly elevated alkaline phosphatase of 125. enopathy with small pleural effusion on the right (Figure 4).
CT scan of the thoracolumbar spine did not reveal any
The coag- ulation panel was normal. The chest X-ray was
osseous erosions or lytic lesions but bone scan showed a
reported as a deviation of the tracheal lumen to the left
small focus of intake uptake in the right scapular
without obstruc- tion and a right upper hemithorax mass
region. PET
(Figure 3).
FIgURe 5: Lung transbronchial biopsy specimen: poorly differenti- FIgURe 7: Left breast tissue (high power): poorly differentiated
ated cluster of neoplastic cells with abundant cytoplasm with hyper- malignant cells, prominent nucleoli.
chromatic nuclei. No gland or sheets of squamous cell formation.

FIgURe 6: Abdominal wall biopsy specimen: poorly differentiated FIgURe 8: Infiltrating poorly differentiated carcinoma and surgical
neoplastic cells with abundant cytoplasm with hyperchromatic margin free of tumor. No ductal and no parenchymal tissues
nuclei. No gland or sheets of squamous cell formation. identified.

scan showed hypermetabolic activities in the right lung,

mediastinum, and the subcutaneous abdominal nodule. The
patient underwent biopsy of the right upper lobe lung mass
and abdominal mass. Biopsy results of the abdominal mass
came back as high-grade malignant neoplasm with unclear
etiology whereas the lung mass biopsy was reported as poorly
differentiated non-small-cell lung cancer (Figures 5 and 6).
Retrospectively, upon reviewing the presurgical chest
X- ray there was a right upper lobe mass that was not
described before breast surgery. The markers for breast
and lung cancer (ER, PR, HER2, GCDPF-15, Mammaglobin,
BCA225, GATA3, anti-TTF, CK7/20, and napsin A) were
negative in all biopsies taken (breast (Figures 7 and 8), lung,
and abdominal wall); however since the patient was male
and a chronic smoker the diagnosis was made as Stage IV FIgURe 9: Head CT scan showing multiple brain metastases left
non-small-cell lung cancer with soft tissue metastases to breast tissue (low power field).
both the abdominal wall and breast. Furthermore, head CT
indicated multiple brain metastases (Figure 9).
As the histopathology from all three biopsy sites revealed
poorly differentiated cancer with metastases and all tumor 3. Discussion
markers to be negative, the oncology team recommended
In this case report a patient with an erroneous diagnosis
pal- liative chemotherapy for non-small-cell carcinoma of of primary male breast cancer s/p MRM with radical axil-
lung. The patient was treated with carboplatin and lary dissection is in actuality found to have non-small-cell
paclitaxel for 3 cycles. After the 3rd chemotherapy cycle he lung cancer with cutaneous metastases to both the breast
developed brain metastases and passed away 11 months and abdomen. Around 80 to 90 percent of all cutaneous
after the primary diagnosis. metastases in adults are due to malignancies originating
from
internal organs such as the lungs, breasts, melanoma, oral
cavity, colon, kidney, ovary, or stomach [4, 6, 7]. The treatment of solitary cutaneous masses is either
However, there are notable differences in gender and surgery alone or surgery combined with radiation and or
cutaneous metas- tases in men are mainly due to primary chemotherapy [27, 28]. It has been proposed that surgery
lung malignancies (12%–28%), GI malignancies (11–19%), may increase survival in patients with solitary cutaneous
and melanomas (13%– 32%) whereas in women the lungs masses and that patients who receive surgical treatment
are the fifth most common primary site (4%) after the breast survive an average of 12.5 months after diagnosis [27–29].
(69%), large intestine (9%), melanoma (5%), and ovaries This is in contrast to the shorter survival of 6.5 to 8 months
(4%). The percentage of patients with primary lung cancer of patients who receive chemotherapy alone. However,
that develop cutaneous metastases ranges from 1 to 12 despite the shorter survival, if there are multiple cutaneous
percent, and in a large series the skin was only the 13th lesions or internal metastases, then chemotherapy is the
most common site for metastasis from the lung [4, 8]. primary option and the response of the skin lesions to
Although lung cancer does not metastasize to the skin often, chemotherapy may actually be used to monitor the
when it does metastasize it does so very quickly with response of the internal malignancy. Similarly, radiation
5.75 months being the average time for a primary lung can be effectively used alone and/or in combination with
cancer to present with skin lesions [9] and in 20 to 60 both chemotherapy and surgery. However, radiation is
percent of cases the skin lesions are present before or usually not very effective and instead is used as a palliative
alongside the diagnosis of the primary tumor [6, 10, 11]. measure in lesions that are either painful or bleeding [12,
Although quite uncommon, skin lesions are very 20, 22, 29, 30].
important in the workup of patients presenting with a More recently improved understanding of the pathobi-
history of tobacco use [12] since they may be the first sign ology of non-small-cell lung cancer (NSCLC) has led to the
of a primary lung malignancy or even of a recurrence [6]. development of small molecules that target genetic
Our case illustrates a lung cancer which has mutations known to play critical roles in the progression to
metastasized both to the breast and the abdomen; metastatic disease. Mutations in epidermal growth factor
however, this is quite rare; instead, most lung cancers receptor (EGFR), KRAS, and anaplastic lymphoma kinase
usually involve the anterior chest, abdomen, and head and (ALK) are mutually exclusive in patients with NSCLC, and
neck [11, 13–15] while less common locations include the the presence of one mutation in lieu of another can influence
shoulder, flank, and lower and upper extremities [11, 13, 14]. response to targeted therapy. Therefore, testing for these
Rare sites of metastasis include the gingiva, scrotum, mutations and tailoring therapy accordingly is widely
perianal skin, lip, nose, burn scars, fingers, and toes [11, accepted as standard practice. Use of the EGFR-TKIs
16, 17]. Cutaneous metastases from lung cancer do not have erlotinib and afatinib is lim- ited to patients with
a characteristic presentation and are often described as adenocarcinomas who have known acti- vating EGFR
nodular, mobile or fixed, hard or flexible, single or multiple, mutations [9, 31, 32]. Because EGFR and ALK mutations
and painless. Furthermore, less commonly, these lesions are mutually exclusive, patients with ALK rear- rangements
may also present as either papular, plaque like, ulcerated,
are not thought to benefit from EGFR-targeting TKIs.
vascular, zosteriform, erysipelas type, or lastly scarring
Instead, treatment with an ALK inhibitor (crizotinib,
alopecia on the scalp [13, 18, 19]. The colors of the lesions
ceritinib) is indicated [33–35]. Also crizotinib has shown
vary from flesh colored to red, pink, purple, or bluish black
potent antitumor activity in a second subgroup of patients
and the sizes vary from 2 mm to 6 cm in diameter [12].
with non-small-cell lung cancer (NSCLC)—those with
Furthermore, cutaneous metastases from the lung are
frequently poorly differentiated [12, 20] and they may typi- advanced ROS1 protooncogene receptor tyrosine kinase-
cally invade the lymphovascular system but are usually lim- (ROS1-) rearranged tumors, which are found in about 1% of
ited to the dermis and subcutaneous layers of skin [21]. The NSCLC patient adenocarcinomas [36].
Cutaneous metastases associated with primary lung can-
most common lung cancer to present with cutaneous mani-
festations is adenocarcinoma, followed by squamous cell cer suggest a poor prognosis and some poor prognostic
indi- cators include multiple cutaneous metastases,
car- cinoma or small cell carcinoma and then large cell
nonresectable or small cell primary tumors, or other
carcinoma (LCC) [11, 13, 20–22].
distant metastases [28]. Survival rates vary with each
Histopathology is the best method to correctly clas- individual case; however, patients initially presenting with
sify cutaneous lesions; however, in addition to histology, cutaneous metastases live approximately 3-4 months less
immunohistochemical markers may be useful classification than patients who develop cutaneous metastases later in
tools when the primary site of the malignancy is unknown their disease process. Further- more, after the diagnosis of a
and both the clinical and histological information are incon- cutaneous metastasis the mean survival is usually about 5-6
clusive [21, 23]. Furthermore, two markers that may be useful months, but some patients may survive for longer than one
in cases where the primary malignancy is unknown include year [12, 21, 22, 30]. In our case our patient died within 11
antithyroid transcription factor (TTF) and CK7/20. Anti- months of the primary diagnosis.
TTF is a marker that is both sensitive and specific for
primary adenocarcinomas, bronchoalveolar carcinomas,
and small cell carcinomas when a thyroid primary is 4. Conclusion
ruled out [24], whereas CK7+/20 is a marker that is sensitive
but not specific for primary adenocarcinomas and In this case study we discuss a patient with a 20 pack-
bronchoalveolar carcino- mas [24–26]. year history of smoking who initially presented with skin
mani- festations suggesting primary breast cancer in a male
which upon further investigation were diagnosed as the
cutaneous
manifestations of a non-small-cell lung cancer. A high index
Subsection 123, B. C. Decker Incorporated, Danbury, Conn,
of suspicion should always be present when cutaneous
USA, 2003.
pathology is seen ina patient witha clinical history suggestive
of primary lung cancer. If cutaneous metastases are sus- [16] R. Y. Rubinstein, S. Baredes, J. Caputo, L. Galati, and R. A.
Schwartz, “Cutaneous metastatic lung cancer: literature review
pected the prognosis is extremely unfavorable and the use
and report of a tumor on the nose from a large cell undifferen-
of appropriate tests like histology from a skin biopsy, tiated carcinoma,” Ear, Nose and Throat Journal, vol. 79, no.
immuno- histochemical stains and/or electron microscopy 2, pp. 96–101, 2000.
should always be pursued. Cutaneous metastases embark a
[17] S. Weitzner, “Cutaneous metastasis confined to the scrotum.
poor prognostic feature and although treatment is available Report of two cases,” Rocky Mountain Medical Journal, vol.
it does not improve survival significantly. 67, no. 9, pp. 40–42, 1970.
[18] I. Ahmed, “Cutaneous metastases,” in Dermatology, J. Bolognia,
Conflict of Interests J. Jorrizo, T. Horn et al., Eds., pp. 1953–1956, Elsevier, 2003.
[19] Y. Kikuchi, A. Matsuyama, and K. Nomura, “Zosteriform
The authors declare that there is no conflict of interests metastatic skin cancer: report of three cases and review of the
regarding the publication of this paper. literature,” Dermatology, vol. 202, no. 4, pp. 336–338, 2001.
[20] R. Kamble, L. Kumar, V. Kochupillai, A. Sharma, M. S.
References Sandoo, and B. K. Mohanti, “Cutaneous metastases of lung
cancer,” Postgraduate Medical Journal, vol. 71, pp. 741–743,
[1] E. Brambilla and W. D. Travis, “Lung cancer,” in World Cancer 1995.
Report, B. W. Stewart and C. P. Wild, Eds., World Health [21] S. Saeed, C. A. Keehn, and M. B. Morgan, “Cutaneous
Organization, Lyon, France, 2014. metastasis: a clinical, pathological, and immunohistochemical
[2] R. Siegel, J. Ma, Z. Zou, and A. Jemal, “Cancer statistics, 2014,” appraisal,” Journal of Cutaneous Pathology, vol. 31, no. 6, pp.
CA Cancer Journal for Clinicians, vol. 64, no. 1, pp. 9–29, 2014. 419– 430, 2004.
[3] http://seer.cancer.gov/csr/1975 2004/results merged/sect 15 [22] T. Hidaka, Y. Ishii, and S. Kitamura, “Clinical features of skin
lung bronchus.pdf. metastasis from lung cancer,” Internal Medicine, vol. 35, no.
[4] T. Rosen, “Cutaneous metastases,” Medical Clinics of North 6, pp. 459–462, 1996.
America, vol. 65, no. 5, pp. 885–900, 1980. [23] S. Azoulay, C. Adem, F. L. Pelletier, S. Barete, C.
[5] F. Altintoprak, H. F. Baytekin, and C. Tasdemir, “Primary France`s, and F. Capron, “Skin metastases from unknown
small cell carcinoma of the lung presenting with breast and origin: role of immunohistochemistry in the evaluation of
skin metastases,” The Korean Journal of Internal Medicine, vol. cutaneous metas- tases of carcinoma of unknown origin,”
26, no. 2, pp. 207–209, 2011. Journal of Cutaneous Pathology, vol. 32, no. 8, pp. 561–566,
[6] M. H. Brownstein and E. B. Helwig, “Metastatic tumors of the 2005.
skin,” Cancer, vol. 29, no. 5, pp. 1298–1307, 1972. [24] V. J. Marson, J. Mazieres, O. Groussard et al., “Expression of
[7] D. H. Connor, H. B. Taylor, and E. B. Helwig, “Cutaneous TTF-1 and cytokeratins in primary and secondary epithelial
metastasis of renal cell carcinoma,” Archives of Pathology, lung tumours: correlation with histological type and grade,”
vol. 76, pp. 339–346, 1963. Histopathology, vol. 45, no. 2, pp. 125–134, 2004.
[8] E. AskUpmark, “Clinical aspects of tumor metastases,” [25] R. Koca, Y. Ustundag, E. Kargi, G. Numanoglu, and H. C.
Nordisk Medicin, vol. 56, no. 40, pp. 1433–1440, 1956. Altinyazar, “A case with widespread cutaneous metastases of
[9] National Comprehensive Cancer Network, NCCN Clinical unknown primary origin: grave prognostic finding in cancer,”
Practice Guidelines in Oncology, Non-Small Cell Lung Cancer Dermatology Online Journal, vol. 11, no. 1, p. 16, 2005.
V2, National Comprehensive Cancer Network, 2012, [26] J. Rosai, “Special techniques in surgical pathology,” in Rosai
http://www and Ackerman's Surgical Pathology, vol. 1, pp. 37–91, Mosby,
.nccn.org/professionals/physician gls/PDF/nscl.pdf. Philadelphia, Pa, USA, 9th edition, 2004.
[10] D. P. Lookingbill, N. Spangler, and F. M. Sexton, “Skin [27] V. Ambrogi, G. Tonini, and T. C. Mineo, “Prolonged survival
involve- ment as the presenting sign of internal carcinoma. after extracranial metastasectomy from synchronous resectable
A retro- spective study of 7316 cancer patients,” Journal of the lung cancer,” Annals of Surgical Oncology, vol. 8, no. 8, pp. 663–
American Academy of Dermatology, vol. 22, no. 1, pp. 19–26, 666, 2001.
1990.
[28] V. Ambrogi, I. Nofroni, G. Tonini, and T. C. Mineo, “Skin
[11] D. W. Perng, C. H. Chen, Y. C. Lee, and R. P. Perng, metastases in lung cancer: analysis of a 10-year experience,”
“Cutaneous metastasis of lung cancer: an ominous prognostic Oncology Reports, vol. 8, no. 1, pp. 57–61, 2001.
sign,” Chinese Medical Journal, vol. 57, no. 5, pp. 343–347, 1996.
[29] M. J. Molina Garrido, C. G. Ponce, J. L. Soto Mart´ınez, C.
[12] L. M. Coslett and M. R. Katlic, “Lung cancer with skin Mart´ınez Y Sevila, A. C. Mena, and F. M. Anto´n,
metastasis,” Chest, vol. 97, no. 3, pp. 757–759, 1990.
“Cutaneous metastases of lung cancer,” Clinical and
[13] S. Dreizen, H. M. Dhingra, D. F. Chiuten, T. Umsawasdi, and Translational Oncology, vol. 8, no. 5, pp. 330–333, 2006.
M. Valdivieso, “Cutaneous and subcutaneous metastases of lung
cancer. Clinical characteristics,” Postgraduate Medicine, vol. 80, [30] T. Terashima and M. Kanaqawa, “Lung cancer with skin
metastasis,” Chest, vol. 106, no. 5, pp. 1448–1450, 1994.
no. 8, pp. 111–116, 1986.
[14] M. H. Brownstein and E. B. Helwig, “Patterns of cutaneous [31] V. L. Keedy, S. Temin, M. R. Somerfield et al., “American
metastasis,” Archives of Dermatology, vol. 105, no. 6, pp. Society of clinical oncology provisional clinical opinion:
862– 868, 1972. epidermal growth factor receptor (EGFR) mutation testing
for patients with advanced non-small-cell lung cancer
[15] V. Neel and A. Sober, “Metastatic tumors to the skin,” in considering first- line EGFR tyrosine kinase inhibitor
Cancer Medicine, D. Kufe, R. Bast, E. Frei et al., Eds.,
therapy,” Journal of Clinical Oncology, vol. 29, no. 15, pp. 2121–
Section 32,
2127, 2011.
[32] G. M. Stella, R. Scabini, S. Inghilleri et al., “EGFR and
KRAS mutational profiling in fresh non-small cell lung
cancer (NSCLC) cells,” Journal of Cancer Research and
Clinical Oncol- ogy, vol. 139, no. 8, pp. 1327–1335, 2013.
[33] E. L. Kwak, Y. J. Bang, D. R. Camidge et al., “Anaplastic lym-
phoma kinase inhibition in non-small-cell lung cancer,” The
New England Journal of Medicine, vol. 363, no. 18, pp. 1693–
1703, 2010.
[34] L. Crino`, D. Kim, G. J. Riely et al., “Initial phase II results
with crizotinib in advanced ALK-positive non-small cell lung
cancer (NSCLC): PROFILE 1005,” Journal of Clinical Oncology,
vol. 29, supplement 15, 2011, ASCO Annual Meeting, Abstract
7514.
[35] A. T. Shaw, D.-W. Kim, R. Mehra et al., “Ceritinib in ALK-
rearranged non-small-cell lung cancer,” The New England Jour-
nal of Medicine, vol. 370, no. 13, pp. 1189–1197, 2014.
[36] A. T. Shaw, S.-H. I. Ou, and Y.-J. Bang, “Crizotinib in ROS1-
rearranged non-small-cell lung cancer,” The New England Jour-
nal of Medicine, vol. 371, no. 2030-2031, pp. 1963–1971, 2014.
 MEDIA TORS of

INFLAMMATION

The ScientificGastroenterology Research and Practice Journal of

World Journal Hindawi Publishing Corporation

Hindawi Publishing Corporation

Diabetes Research Disease Markers
Hindawi Publishing Corporation
Hindawi Publishing Corporation Volume 2014 Hindawi Publishing Corporation
Volume 2014 Volume 2014 Volume 2014 Volume 2014

Journal of International Journal of

Immunology Research
Hindawi Publishing Corporation
Volume 2014
Endocrinology
Hindawi Publishing Corporation
Volume 2014

Submit your manuscripts at

BioMed
PPAR Research
Hindawi Publishing Corporation
Research International
Hindawi Publishing Corporation
Volume 2014 Volume 2014

Evidence-Based Complementary and Alternative Medicine

Hindawi Publishing Corporation

Journal of
Ophthalmology
Hindawi Publishing Corporation
Volume 2014
Stem Cells International
Hindawi Publishing Corporation
Volume 2014

Volume 2014

Journal of
Obesity

Journal of

Hindawi Publishing Corporation

Volume 2014
Oncology
Hindawi Publishing Corporation
Volume 2014

Parkinson’s Disease
Computational and Mathematical Methods in Medicine
Hindawi Publishing Corporation
Behavioural Neurology
Hindawi Publishing Corporation AIDS Oxidative Medicine and Cellular Longevity
Research and Treatment
Hindawi Publishing Corporation

Hindawi Publishing Corporation

Hindawi Publishing Corporation
Volume 2014 Volume 2014 Volume 2014 Volume 2014 Volume 2014

View publication stats