Cutaneous (skin) metastasis occurs when cells from a cancer in the body spread to the skin. Metastatic skin lesions may originate from melanoma, breast, lung, colon, and various other types of cancer. The cancer cells travel through the lymphatics or blood to reach the skin or the cancer may spread directly to the skin through a surgical scar. Skin metastases typically present after the primary cancer has been diagnosed, but in some cases these lesions may be the presenting sign of cancer. The non-specific skin findings are fast growing firm, mobile, painless pink lesions that may ulcerate. Any cancer can produce metastatic skin lesions but the cancers described below are the types more likely to spread to the skin.
Metastatic breast cancer is one of the most common cancers to present with cutaneous metastasis because of its high prevalence rate. It is the most common form of cutaneous metastasis in women. It may appear on the skin in a number of different ways, although it usually develops on the chest. One of the patterns called carcinoma erysipeloides appears as pink or red raised areas of skin resembling erysipelas or cellulitis, a severe skin infection. Carcinoma telangiectoides is another form of skin metastases that appears as red-violet skin growths. Carcinoma en cuirasse presents on the chest as a firm area of skin resembling the texture of an orange peel. Paget’s disease of the breast resembles skin dermatitis around the nipple and areola. Alopecia neoplastica is a presentation of cutaneous metastatic breast cancer that presents on the scalp as a scarred area of hair loss.
Lung cancer is the most common cancer to metastasize to the skin in men. The lesions may appear as firm, red nodules on the chest, abdomen, or back. When the lesions present on the chest, they may have spread directly from a lung biopsy site. Some lesions of cutaneous lung cancer metastases have been found to run parallel to the blood vessels of the rib cage.
Colorectal carcinoma is the second most common primary source of metastatic skin disease in both men and women. The abdomen and pelvis are the common locations for these skin metastases to appear. The gastrointestinal cancers are often late stage at the time of diagnosis. Not uncommonly, the primary cancer is discovered at the same time as metastatic lesions in the liver or other organs (i.e. skin). A Sister Mary Joseph node at the umbilicus is a hallmark sign of an underlying gastrointestinal cancer.
Skin metastases from malignant melanoma often appear black or blue and nodular, mimicking harmless blue nevi (moles) on the skin. The amelanotic form is a less common presentation and appears as a skin-colored, pink or red skin lesion. The three types of melanoma are ocular, cutaneous, and mucosal malignant melanoma. All of these subtypes have the potential to spread to the skin with advanced disease. However, cutaneous melanoma is the most common source of skin metastases of the three types. Melanoma skin metastases tend to occur on the chest, back, and extremities of men and on the lower extremities of women.
Other cancers that have the potential for cutaneous metastasis include the kidney, oral cavity, cervix, ovaries, and pancreas. Skin metastases from kidney and oral cavity cancers are more often seen in men and appear on the head and neck regions.
The medical provider must have a high index of suspicion for cutaneous metastases because these skin lesions generally have no specific clinical features and can be mistaken for other skin issues. Skin metastasis may be mistaken for a fungal or bacterial infection or other inflammatory process, all of which would require very different treatment plans. Early diagnosis and management of skin metastasis is essential for the best patient outcome. A skin biopsy, either punch or excisional, is the preferred test for diagnosis. Special laboratory testing such as immunohistochemical marker studies may be performed on the tissue sample to help determine the primary cancer type.
Treatment for skin metastasis involves first treating the underlying malignancy. However, in many cases, the disease is already widespread throughout the body. Prognosis is often poor, and treatment options are limited. Conservative measures such as keeping the lesions clean and dry are important to prevent infection. Cryotherapy, photodynamic therapy, excision, laser therapy, intralesional chemotherapy, electrochemotherapy, and imiquimod cream have shown some effectiveness in select cases. Preserving quality of life and avoiding disfigurement are important reasons to treat skin metastases. Unfortunately, the overall outcome is dictated by the primary malignancy. A person with history of cancer and new suspicious skin lesions should be evaluated by a dermatologist.
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