Abstract
Corresponding Author(s)
Stephanie Aldret, DO, Oklahoma State Univer- sity, Family Medicine, 2345 Southwest Boulevard, Tulsa, OK 74107.
E-mail address: snaldret@gmail.com.
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Cutaneous metastasis is a rare occurrence but may be the presenting sign of a primary internal malignancy. Skin, breast, lung, gastrointestinal, and kidney are the most common primary malignancies to metastasize to skin. Common regions for cutaneous metastasis include the scalp, abdomen, chest, back, and extremities. The appearance of cutaneous metastasis is a preterminal occurrence and clinically a very poor prognostic sign. Skin cancer was the topic chosen, but it was decided to explore skin as a site of metastasis rather than primary melanoma, squamous cell, or basal cell carcinoma. A search and review of the literature on PubMed was performed to identify cases of cutaneous metastasis caused by a variety of primary sources in adults—mainly breast, lung, skin, gastrointestinal, genito- urinary, renal, and thyroid. Inclusion criteria for the review was most common types of cancer in adults, appearance of lesions, and cutaneous metastasis to distant regions rather than direct extension with the exception of breast cancer. Primary malignancies found in children, lymphomas, and leukemias were not included in this review.
© 2012 Published by Elsevier Inc.
Corresponding author: Stephanie Aldret, DO, Oklahoma State Univer- sity, Family Medicine, 2345 Southwest Boulevard, Tulsa, OK 74107.
E-mail address: snaldret@gmail.com.
internal malignancy. Cutaneous metastases account for 2.8% to 4.4% of malignant skin tumors and occur in ap- proximately 10% of patients with cancer.4,5
Even though the incidence of these lesions is rare, it will likely be the family medicine physician who will be faced with detecting and diagnosing these lesions.
Incidence
1877-573X/$ -see front matter © 2012 Published by Elsevier Inc. doi:10.1016/j.osfp.2011.09.005
Table 1 Primary malignancies that metastasize to skin4
Patients with cutaneous
Primary malignancy | metastases | Distant metastasis occurs through lymphatic and hema- |
Melanoma | 44.80% | togenous spreading, which can be difficult to differentiate |
Breast | 30% | because they are interconnected. The scalp is a common site |
Nasal sinuses | 20% | for cutaneous metastasis from a variety of primary internal |
Larynx | 16.30% | malignancies because of its high vascularity. Cutaneous |
Endocrine glands | 12.50% | metastasis to the scalp will appear as smooth areas of hair |
Oral cavity 11.50% Esophagus 8.60% Kidney 4.60% Stomach 2%
| loss; smooth flesh-colored nodules; or hemorrhagic, ulcer- ated lesions.4,6 | |
A primary internal malignancy is usually known before cutaneous metastasis is discovered; however in rare cases, the cutaneous metastasis is the presenting sign of internal malignancy.4
Pathogenesis
Table 2 Most common primary malignancies that result in cutaneous metastases by sex/age4,8
Men Lung, colon, melanoma, oral, renal, gastric Women Breast, colon, melanoma, ovaries, lung Children Rhabdomyosarcoma, leukemia, neuroblastoma
Types of cutaneous metastasis
Renal
Thyroid
Malignant melanoma
Figure 1 Malignant melanoma. (From Wolff K, Johnson RA: Skin signs of systemic cancers. In Fitzpatrick’s Color Atlas and Synopsis of Clinical Dermatology, 6th ed. New York: McGraw- Hill, 2009, pp. 486-503).
Lung
Gastrointestinal
Gastrointestinal cancers, particularly stomach and colon, often metastasize to the skin of the abdomen and pelvis as nodules. Metastatic nodules to the umbilicus are referred to as Sister Mary Joseph nodules. It is also noted that colon cancer cutaneous metastasis may present as an inflamma- tory skin condition in the inguinal or supraclavicular regions or even in the face and neck.4,8
Liver
Cutaneous metastasis of hepatocellular carcinoma devel- ops in approximately 3% of patients affected by the disease.
It usually develops along sites of liver needle biopsy or percutaneous injection therapies. It may mimic pyogenic granuloma in appearance.8,15
Cervix/Vulva
Cutaneous metastasis of cervical cancer occurs in less than 2% of patients but may occur at the initial diagnosis or a decade later. It is a poor prognostic sign. Most common sites of metastasis are the abdomen, chest, vulva, scalp, and umbilicus. The lesions may mimic dermatitis by appearing as a plaque-like pruritic lesion. It may progress to an ulcer over time that has a purulent drainage.16,17
Cutaneous metastasis from vulvar carcinoma is ex- tremely rare but may metastasize to areas close in proximity to the genitalia such as the thigh and lower abdomen, al- though there have been reports of cutaneous metastasis to the forearm as well.18,19
Breast
Figure 2 Alopecia neoplastica (From Helm TN, Lee TC: Meta- static carcinoma of the skin. Available at: eMedicine from WebMD http://emedicine.medscapecom/article/1101058-overview. Accessed March 2, 2010).
Table 3 Common sites of cutaneous metastasis
Common cutaneous
metastasis sites Probable primary sites
Scalp Breast, lung, kidney
Neck Oral squamous cell carcinoma
Face Oral squamous cell carcinoma, renal cell carcinoma, lung
Extremities Malignant melanoma, breast, lung, renal, intestine
Chest Breast, lung, malignant melanoma
Abdomen Colon, lung, stomach, breast, ovary
Umbilicus Stomach, pancreas, colon, ovary, kidney, breast
Pelvis Colon, lung, stomach, breast, ovary
Back Lung
Figure 3 Carcinoma erysipelatoides (From Wolff K, Johnson RA: Skin signs of systemic cancers. In Fitzpatrick’s Color Atlas and Synopsis of Clinical Dermatology, 6th ed. New York: McGraw-Hill, 2009, pp. 486-503).
Testicle/Prostate/Bladder
Cutaneous metastasis caused by testicular, prostatic, or bladder cancer is extremely rare. Individual cases are re- ported next that show the variability in the appearance of the skin lesions.
The first case presented with progressively enlarging upper abdominal skin lesions and scalp nodules for 3 months that were “stony hard with mild bleeding.” Exci- sional biopsy revealed metastatic germ cell carcinoma.20
A second case presented as a sudden onset of multiple, red, angiomatous, “berry-like” nodules that grew rapidly in a dermatographic distribution and was found to be cutane- ous metastasis from prostatic adenocarcinoma. Cutaneous metastasis from the prostate is rare but will most commonly be found on the lower abdomen, genitalia, groin, or thigh and will have genital swelling associated with the skin lesions.21
Finally, an isolated skin nodule was noted a few weeks after micropapillary bladder carcinoma excision and was
Figure 4 En curiasse metastatic carcinoma (From Mordenti C, Peris K, Concetta Farnoli M, et al: Cutaneous metastatic breast carcinoma. Dermatovernerologica 9, 2000. e-edition.)
found to be a metastatic lesion from the rare variant of transitional cell carcinoma.22
Regions and appearance of cutaneous metastasis
As described previously, cutaneous metastasis may ap- pear as subcutaneous nodules that are flesh-colored or faintly erythematous, or as dermal lesions that are firm and have a visible pigment. Both may evolve to pink/erythem- atous lesions that can ulcerate. There can also be an inflam- matory component caused by lymphatic congestion result- ing in erythema and pitting or nonpitting edema.4,6,8
Palpation of these nodules may reveal a variety of sen- sations. They may be smooth, firm, solitary nodules pal- pated in the subcutaneous tissues that may or may not be visualized but only palpated or a rough cutaneous horn or smooth hair loss. In advanced stages they may ulcerate and hemorrhage. Lesions may be nontender to palpation, tender, or pruritic.4,6,8
Figure 5 Scalp nodule (From Koca R, Ustundag Y, Kargi E, et al: A case with widespread cutaneous metastases of unknown primary origin: grave prognostic finding in cancer. Dermatology Online J 11:16, 2005).
Prognosis
Conclusion
Acknowledgments
We thank Lou Ann Thompson for her assistance in the literature review and the reviewers for their time, com- ments, and recommendations.
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