Dermatologic Manifestations of Metastatic Carcinomas Clinical Presentation

  • Author: Thomas N Helm, MD; Chief Editor: Dirk M Elston, MD   more...
 
Updated: Mar 26, 2012
 

History

  • In most cases, cutaneous metastases develop after the initial diagnosis of the primary malignancy (eg, metastases of breast carcinoma involving the chest wall several years after a mastectomy). In a very small percentage of patients, metastases may be discovered at the same time or prior to the diagnosis of a primary tumor (eg, lung and renal cell carcinoma presenting as scalp metastases in a man who otherwise appears well and gives no history of prior malignancy).
  • Patients may present with rapidly developing nodules or tumors. Although asymptomatic in most instances, pain and tenderness may be noted. Any rapidly developing or eruptive lesions should warrant careful consideration of the possibility of metastasis. The term carcinoma of unknown primary site (CUPS) is used when dealing with a metastasis that occurs before primary tumor diagnosis. In dealing with cutaneous CUPS, the age, the sex, and the affected skin region of the patient as well as the histology of the lesion are important clues that are useful in determining a likely primary tumor. Immunohistochemistry can be invaluable in identifying the tissue of origin.
Next

Physical

  • Most cutaneous metastases occur in a body region near the primary tumor. The most common presentation of cutaneous metastases is nodules. The nodules are often nonpainful, round or oval, firm, mobile, and rubbery in texture. The nodules are usually flesh colored, although they may also be other colors (eg, from flesh colored to brown or blue-black). Often, the nodules from the metastases of renal cell carcinoma and occasionally thyroid carcinoma are red and purple. They vary in size from barely perceptible lesions to large tumors. Multiple nodules appear rapidly before growth slows down.
  • Carcinoma may engender a brisk inflammatory response mimicking cellulitis. This pattern is referred to as inflammatory breast carcinoma. When many telangiectatic blood vessels are encountered, the pattern is referred to as carcinoma telangiectodes. Occasionally, the skin may have an orange peel–like appearance (peau d'orange), and/or changes in the local blood flow may occur. In other cases, the skin may feel firm and have a breastplatelike appearance, which is referred to as carcinoma en cuirasse.
  • Breast cancer is one of the most common malignancies to spread to the skin. The most common sites of cutaneous metastasis are the chest and abdomen.
    • The most likely site for cutaneous metastases in women is the chest; less common sites include the scalp, the neck, the upper extremities, the abdomen, and the back.
    • Occasionally, patients with metastatic breast cancer may have a firm, scarlike area in the skin. When this occurs on the scalp, hair may be lost, and the clinical appearance may mimic alopecia areata, except that the skin exhibits marked induration on palpation. This condition is known as alopecia neoplastica, as shown in the images below. Alopecia neoplastica due to metastatic breast cancAlopecia neoplastica due to metastatic breast cancer. Close-up view of patient with alopecia neoplasticaClose-up view of patient with alopecia neoplastica due to metastatic breast cancer shows telangiectases and nodularity. The plaque was markedly indurated on palpation, unlike alopecia areata, which would exhibit normal skin texture.
  • Lung cancer is the most frequently encountered metastasis in men. The most common site for cutaneous metastases in men is the chest, followed by the abdomen and the back. Other areas (in decreasing order of frequency) include the scalp, the neck, the face, the extremities, and the pelvis. For women, the most common areas (in decreasing order of frequency) are the chest, the abdomen, the back, and the upper extremities.
  • Gastrointestinal cancers (usually colon and stomach cancer) often metastasize to the abdomen and the pelvis. Gastrointestinal carcinomas may spread along the urachus and produce nodules at the umbilicus. The presentation of nodules at the umbilicus has been referred to as a Sister Mary Joseph nodule. Sister Mary Joseph was a nurse at the Mayo Clinic who helped prepare patients prior to operation for gastrointestinal surgery. She noted that the nodules at the umbilicus were an ominous sign of extensive involvement of colorectal carcinoma.
  • About 60,000 Americans develop malignant melanoma each year, but only 9000 deaths are attributed to malignant melanoma annually in the United States. When malignant melanoma metastasizes, the skin is commonly involved. In men, melanomas are likely to metastasize to the chest, the extremities, and the back. A large portion of female patients have metastases to the lower extremities. Metastases of melanoma may simulate blue nevi and may be epidermotropic or simulate primary cutaneous melanoma. A zosteriform appearance reportedly is rare.[2]
  • Cutaneous metastases from squamous cell carcinoma in the oral cavity usually remain in the local area, most often affecting the neck and the face.
  • Renal cell carcinoma may metastasize to the scalp, to operative scars, or on many other surfaces. Because of the prominent vascular supply of renal cell carcinoma, lesions may mimic a hemangioma or a pyogenic granuloma.
  • Metastases from the ovary and the uterus are seen in the skin of the lower abdomen, the groin, or the upper thigh.
  • Common cutaneous metastasis sites and their probable primary sites are as follows:
    • Metastasis to scalp - Breast, lung, kidney
    • Metastasis to neck - Oral squamous cell carcinoma
    • Metastasis to face - Oral squamous cell carcinoma, renal cell, lung
    • Metastasis to extremities - Malignant melanoma, breast, lung, renal, intestinal
    • Metastasis to chest - Breast, lung, malignant melanoma
    • Metastasis to abdomen - Colon, lung, stomach, breast, ovary
    • Metastasis to umbilicus - Stomach, pancreas, colon, ovary, kidney, breast
    • Metastasis to pelvis - Colon
    • Metastasis to back - Lung
Previous
Next

Causes

  • Metastases arise as disconnected extensions of a primary tumor. This occurs when cancerous cells break away from a primary tumor and spread elsewhere. By definition, this makes the primary tumor malignant. Determining whether a primary neoplasm will metastasize is difficult because of many factors, but, generally, the larger and faster a neoplasm grows, the more likely it will metastasize.
  • The mechanism for metastasis varies, and several different pathways are thought to be important. Regional spread through tissue most often occurs through body cavities, especially the peritoneal cavity. Transplantation can be caused by mechanical transport of tumor fragments by instruments during surgery or other invasive procedures but rarely occurs. Lymphatic and vascular routes are the most common pathways, although differentiating the routes is difficult because they are interconnected. Lymphatic spread is the most common pathway for the initial spread of carcinoma. Hematogenous spread is commonly associated with metastasis from sarcomas, although carcinomas may also use this pathway.
  • Cells may have a predictable metastatic spread, but unusual sites of metastasis may be encountered. The use of sentinel lymph node studies is an attempt to define likely paths of metastasis to identify whether metastasis has occurred. Unfortunately, for some tumors like melanoma, there is as of yet no clear evidence that lymphatic spread is the predominant mode of metastasis. Although sentinel node studies may provide useful information on prognosis, this does not enhance overall survival.
  • Many steps have to be met for metastasis to occur. The primary tumor has to be large enough to release a sufficient amount of neoplastic cells into the circulatory or lymphatic system. These cells need certain properties, such as cell suspension and mitotic rate, to survive while in circulation. Most single neoplastic cells released are destroyed by the immune system, whereas clusters of 6 or 7 cells have a better chance of metastases. To establish metastases once the neoplastic cells are in the circulation system, the neoplastic cells need to attach and penetrate vessel walls. The most common attachment sites are based on the circulatory path, but the neoplastic cells also have affinities to certain target tissues. Once attachment occurs, a thrombus forms around the neoplastic cells through endothelial cell injury. This thrombus serves as protection for the neoplastic cells. The new metastasis establishes itself and obtains nutrition initially through diffusion and then it forms its own vessels.
Previous
Proceed to Differential Diagnoses
 
 
Contributor Information and Disclosures
Author

Thomas N Helm, MD  Clinical Professor of Dermatology and Pathology, University of Buffalo, State University of New York School of Medicine and Biomedical Sciences; Director, Buffalo Medical Group Dermatopathology Laboratory

Thomas N Helm, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Society for Dermatologic Surgery, and American Society of Dermatopathology

Disclosure: Nothing to disclose.

Coauthor(s)

Thomas C Lee, MD  Intern, Department of Internal Medicine, New York University School of Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Robert A Schwartz, MD, MPH  Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, University of Medicine and Dentistry of New Jersey-New Jersey Medical School

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi

Disclosure: Nothing to disclose.

Michael J Wells, MD  Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

Michael J Wells, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, and Texas Medical Association

Disclosure: Nothing to disclose.

Warren R Heymann, MD  Head, Division of Dermatology, Professor, Department of Internal Medicine, University of Medicine and Dentistry of New Jersey-New Jersey Medical School

Warren R Heymann, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Catherine M Quirk, MD  Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania

Catherine M Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD  Director, Ackerman Academy of Dermatopathology, New York

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

References

  1. Krathen RA, Orengo IF, Rosen T. Cutaneous metastasis: a meta-analysis of data. South Med J. Feb 2003;96(2):164-7. [Medline].

  2. Savoia P, Fava P, Deboli T, Quaglino P, Bernengo MG. Zosteriform cutaneous metastases: a literature meta-analysis and a clinical report of three melanoma cases. Dermatol Surg. Sep 2009;35(9):1355-63. [Medline].

  3. Sharma S, Kotru M, Yadav A, Chugh M, Chawla A, Makhija M. Role of fine-needle aspiration cytology in evaluation of cutaneous metastases. Diagn Cytopathol. Dec 2009;37(12):876-80. [Medline].

  4. Bhargava R, Dabbs DJ. Immunohistology of Metastatic Carcinomas of Unknown Primary. In: Dabbs, DJ, ed. Diagnostic Immunohistochemistry: theranostic and genomic applications. 3rd ed. Philadelphia, Pa: Saunders Elsevier; 2010:206-55.

  5. Krug B, Crott R, Lonneux M, Baurain JF, Pirson AS, Vander Borght T. Role of PET in the initial staging of cutaneous malignant melanoma: systematic review. Radiology. Dec 2008;249(3):836-44. [Medline].

  6. Chung MH, Gupta RK, Essner R, Ye W, Yee R, Morton DL. Serum TA90 immune complex assay can predict outcome after resection of thick (> or =4 mm) primary melanoma and sentinel lymphadenectomy. Ann Surg Oncol. Mar 2002;9(2):120-6. [Medline].

  7. Cassarino DS, Cabral ES, Kartha RV, Swetter SM. Primary dermal melanoma: distinct immunohistochemical findings and clinical outcome compared with nodular and metastatic melanoma. Arch Dermatol. Jan 2008;144(1):49-56. [Medline].

  8. Requena L, Sangueza M, Sangueza OP, Kutzner H. Pigmented mammary Paget disease and pigmented epidermotropic metastases from breast carcinoma. Am J Dermatopathol. Jun 2002;24(3):189-98. [Medline].

  9. Hill S, Thomas JM. Use of the carbon dioxide laser to manage cutaneous metastases from malignant melanoma. Br J Surg. Apr 1996;83(4):509-12. [Medline].

  10. Lingam MK, McKay AJ. Carbon dioxide laser ablation as an alternative treatment for cutaneous metastases from malignant melanoma. Br J Surg. Oct 1995;82(10):1346-8. [Medline].

  11. Kubota Y, Mir LM, Nakada T, Sasagawa I, Suzuki H, Aoyama N. Successful treatment of metastatic skin lesions with electrochemotherapy. J Urol. Oct 1998;160(4):1426. [Medline].

  12. Brownstein MH, Helwig EB. Metastatic tumors of the skin. Cancer. May 1972;29(5):1298-307. [Medline].

  13. Healey PM, Malott K, Chalet MD. Cancers metastatic to the skin. In: Friedman RJ, Rigel DS, Harris MN, Baker D. Cancer of the Skin. Philadelphia, Pa: WB Saunders; 1991:347-63.

  14. Lookingbill DP, Helm KF. Metastatic tumors. In: Demis J. Clinical Dermatology. Philadelphia, Pa: Lippincott-Raven; 1997:1-7.

  15. Resnik KS, DiLeonardo M, Gibbons G. Clinically occult cutaneous metastases. J Am Acad Dermatol. Dec 2006;55(6):1044-7. [Medline].

  16. Sahin S, Hindioglu U, Benekli M, Sivri B, Sokmensuer C, Sungur A. Peculiar inflammatory cutaneous metastasis from stomach adenocarcinoma. Br J Dermatol. Apr 1997;136(4):650-2. [Medline].

  17. Schwartz RA. Metastatic cancer of the skin. In: Skin Cancer Recognition and Management. New York, NY: Springer-Verlag; 1998:185-93.

  18. Spencer PS, Helm TN. Skin metastases in cancer patients. Cutis. Feb 1987;39(2):119-21. [Medline].

  19. Steck WD, Helwig EB. Tumors of the Umbilicus. Cancer. Jul 1965;18:907-15. [Medline].

  20. Strohl RA. Cutaneous manifestations of malignant disease. Dermatol Nurs. Feb 1998;10(1):23-5. [Medline].

  21. Tschen EH, Apisarnthanarax P. Inflammatory metastatic carcinoma of the breast. Arch Dermatol. Feb 1981;117(2):120-1. [Medline].

  22. Zalla MJ, Roenigk RK. Metastatic carcinoma. In: Maloney M, Helm KF. Surgical Dermatopathology. Malden, Mass: Blackwell; 1999:389-436.

 
Previous
Next
 
Alopecia neoplastica due to metastatic breast cancer.
Close-up view of patient with alopecia neoplastica due to metastatic breast cancer shows telangiectases and nodularity. The plaque was markedly indurated on palpation, unlike alopecia areata, which would exhibit normal skin texture.
Low-power view of breast cancer metastasis with surrounding fibrosis.
Breast cancer metastasis with hyperchromatic cells extending between thickened collagen bundles. Dilated lymphatics are noted.
Breast cancer with an Indian file pattern of metastasis.
A well-circumscribed metastasis of renal cell carcinoma is surrounded with compressed collagen, indicative of rapid growth.
Pleomorphic clear cells with prominent vasculature are characteristic of metastatic renal cell carcinoma.
Metastatic carcinoma of the skin. Metastatic squamous cell cancer typically does not involve the epidermis, allowing for differentiation from a primary cutaneous squamous cell cancer.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.