Dermatologic Manifestations of Metastatic Carcinomas Clinical Presentation

Updated: Jul 07, 2022
  • Author: Thomas N Helm, MD; Chief Editor: Dirk M Elston, MD  more...
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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.


Physical Examination

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.

Breast cancer

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 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 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, known as alopecia neoplastica, is shown in the images below.

Alopecia neoplastica due to metastatic breast canc Alopecia neoplastica due to metastatic breast cancer.
Close-up view of patient with alopecia neoplastica Close-up view of patient with alopecia neoplastica due to metastatic breast cancer shows telangiectases and nodularity. The plaque was markedly indurated on palpation; in contrast, patients with alopecia areata would exhibit normal skin texture.

Lung cancer

The most frequently encountered metastases in men come from lung cancer. 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, neck, face, extremities, and pelvis. For women, the most common areas (in decreasing order of frequency) are the chest, abdomen, back, and upper extremities.

Gastrointestinal cancer

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; those at the umbilicus have been referred to as Sister Mary Joseph nodules. (Sister Mary Joseph was a nurse at the Mayo Clinic who helped to 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.)

Malignant melanoma

About 60,000 Americans develop malignant melanoma each year, but only 9000 deaths are attributed to the disease annually in the United States. When malignant melanoma metastasizes, the skin is commonly involved. In men, melanomas are likely to metastasize to the chest, extremities, and back. A large portion of female patients have metastases to the lower extremities. Recent reviews indicate that the proportion of metastases due to melanoma is increasing. This finding is not unexpected as the incidence of melanoma continues to rise. [7]

Metastases of melanoma may simulate blue nevi and may be epidermotropic or simulate primary cutaneous melanoma. A zosteriform appearance reportedly is rare. [10]

Other cancers

Cutaneous metastases from squamous cell carcinoma in the oral cavity usually remain in the local area, most often affecting the neck and face.

Renal cell carcinoma may metastasize to the scalp, operative scars, or 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