Cutaneous metastases from internal malignancies: a clinicopathologic and immunohistochemical review

Cutaneous metastases: From epidemiology to therapy

Cutaneous metastases are seen in up to 10% of all oncology patients and can occur in different locations depending on the entity. Cutaneous metastases are often associated with a high psychological burden and, especially in the case of exulceration, with shame and social withdrawal. This review discusses the diagnostic and therapeutic options. The most common tumor entities in which cutaneous metastases are observed are discussed, and local and systemic treatment options are presented according to the current state of research.

Perineural Infiltration: A Comprehensive Review of Diagnostic, Prognostic, and Therapeutic Implications

ABSTRACT

Perineural infiltration refers to a neoplastic cell involvement in, around, and through the nerves. It is considered as one of the neoplastic dissemination pathways. Thus, its identification is crucial to establish the prognosis of some malignant skin neoplasms, such as squamous cell carcinoma, and explains the locally aggressive behavior of cutaneous neoplasms, such as microcystic adnexal carcinoma. We have conducted a review of malignant and benign skin tumors in which perineural infiltration has been described, and we also discuss some histopathological findings that may simulate perineural infiltration.

Paraneoplastic Dermatoses and Cutaneous Metastases

Paraneoplastic syndromes include a variety of cutaneous presentations that have an associated internal malignancy. Some syndromes have a strong correlation to specific internal malignancies, whereas others are associated with a multitude of tumors. There are many cutaneous manifestations that suggest hematologic disorders, which will be reviewed in detail. Cutaneous metastases are commonly from breast and lung cancers and can present as nodules, vascular lesions, eczematous dermatitis, or inflammatory lesions. The most common histologic presentation of cutaneous metastasis is that of a dermal-based or subcutaneous-based nodule with sparing of the epidermis. Determination of origin of tumor requires immunohistochemistry and clinical correlation.

A Case Report of Zosteriform Cutaneous Metastases from Breast Carcinoma

We described a 58-year-old female diagnosed with zosteriform cutaneous metastases from breast carcinoma. She was initially diagnosed with herpes zoster. Correct diagnosis was obtained after pathological biopsy. Various forms of cutaneous metastases have various forms, which require careful discrimination by dermatologists to reduce the rate of misdiagnosis.

The Importance of Reading the Skin: Cutaneous Metastases of Pancreatic Cancer, a Systematic Review

BACKGROUND

Pancreatic cancer is notorious for its aggressive nature and low survival rate, with less than 10% of patients surviving beyond five years. Early detection is difficult, but skin metastases can be a rare but significant indicator. This systematic review focuses on the epidemiology, clinical features, and histology of skin metastases from pancreatic cancer to determine their importance in early diagnosis and overall management of the disease.

MATERIALS AND METHODS

Following PRISMA guidelines, we conducted an exhaustive search of MEDLINE/PubMed, EMBASE, and SCOPUS databases up to June 2023, using specific keywords. Four independent investigators screened the studies using predefined criteria, and two investigators checked the accuracy and consistency of the data extraction. We assessed the quality of the trials using adapted criteria from the Joanna Briggs Institute. A narrative synthesis rather than a meta-analysis was chosen because of the different study designs.

RESULTS

The final analysis included 57 patients with skin metastases from pancreatic cancer. Cutaneous metastases, although rare, presented with approximately equal gender distribution and a mean age of 63.4 years. Predominantly non-umbilical (77%), these metastases showed clinical diversity, ranging from asymptomatic nodules to painful or ulcerated lesions. Notably, skin metastases often preceded the diagnosis of primary pancreatic cancer (58%). Primary tumor characteristics revealed different localizations, with adenocarcinoma being the most prevalent histological type (77%). A significant association (p = 0.008) was observed between pancreatic tumor location and the timing of presentation of skin metastases. Tumors located in the body and tail of the pancreas were more likely to manifest skin metastases as an initial clinical manifestation (62.2%) than those in the head of the pancreas (20.8%).

CONCLUSIONS

In conclusion, although skin metastases are rare, they are important indicators of pancreatic cancer, highlighting the need for multidisciplinary healthcare collaboration and thorough skin examination. Recognizing them could lead to earlier diagnosis, which is crucial in a cancer with limited treatment options.

Clinical characteristics and survival analysis of cutaneous metastases in a single tertiary centre in Korea

BACKGROUND

Cutaneous metastasis (CM) refers to the spread of malignancy to the skin. CM is perceived as an advanced stage. It might be the first sign of a primary cancer or an indicator of recurrence.

OBJECTIVES

To identify primary cancers associated with CMs and perform a survival analysis according to advanced stage of cutaneous metastasis at a single tertiary centre in Korea.

METHODS

A total of 219 patients from Samsung Medical Center from January 2009 to April 2020 were retrospectively analysed to identify cases with biopsy-proven CMs. According to advanced stage of metastasis, patients were divided into three stages, CM only (CMO), CM with lymph node metastasis (CM/LM) and CM with distant metastasis (CM/DM), to analyse clinical characteristics and survival rate.

RESULTS

The most common CM from primary cancer was breast cancer, followed by lung cancer, stomach cancer, colorectal cancer and others. When all primary cancers were included, the median survival period was 4.82 years for the CMO stage, 2.15 years for the CM/LM stage and 0.80 years for the CM/DM stage, with a tendency to deteriorate with advancing stage. At 1- and 3-year after occurrence of CM, the CM/DM stage showed a significantly poorer survival rate than the other two stages.

CONCLUSIONS

This study showed a median survival period of 22 months for CM patients overall. Breast cancer has greater accessibility to the skin than other cancers. Therefore, breast cancer can metastasize to the skin without involving lymph nodes or other sites.

Cutaneous Metastasis from Internal Malignancies: The Revealing Role of the Skin

Skin represents the heaviest organ of the human body, covering a surface area of 1 [...].

Athena: Speciality Certificate Examination case for general dermatology and dermatology in primary health care

This Athena case describes possible differential diagnoses in a 76-year-old woman who presented with an 8-month history of multiple painful ulcers on her lower abdominal wall and right anterior thigh.

Metastases to the nail unit and distal phalanx: a systematic review

Metastases to the nail unit/distal phalanx (NU/DP), although rare, carry a poor prognosis and are frequently misdiagnosed due to variable clinical presentation. Metastases to the NU/DP may be the initial presenting sign of a new or recurrent malignancy. Since the most recent systematic review of case reports (133 patients total) was conducted in 2001, we conducted a systematic review from 1900 to 2021 (244 patients total) to assess any changes in trends in demographics, clinical presentation, and morphology and to report on more updated differential diagnoses. We also examined cases for age, sex, race, ethnicity, Fitzpatrick skin type, laterality, distribution, and diagnostic methods. The PubMed database (1900-2021) was used to detect case-level data per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We found that the most common primary tumors were lung, kidney, and esophagus. A NU/DP metastasis was the presenting sign of malignancy in 31.00% of patients without a former cancer diagnosis. Male to female ratio was 2:1, with average age at diagnosis 58 years. Metastases most often affected a single digit (79.91%), particularly the thumb, followed by the fourth digit. This systematic review corroborates that metastases to the NU/DP may be the initial presenting sign of a new or recurrent malignancy and provides updated diagnostic guidelines. NU/DP metastasis should be considered in both healthy patients and patients with a former malignancy diagnosis presenting with nail changes involving a single digit. Prompt diagnosis and treatment may improve prognosis.

An Overview of Clinical Manifestations of Dermatological Disorders in Intensive Care Units: What Should Intensivists Be Aware of?

Acute skin failure is rarely the primary diagnosis that necessitates admission to an intensive care unit. Dermatological manifestations in critically ill patients, on the other hand, are relatively common and can be used to make a key diagnosis of an adverse drug reaction or an underlying systemic illness, or they may be caused by factors related to a prolonged stay or invasive procedures. In intensive care units, their classification is based on the aetiopathogenesis of the cutaneous lesion and, in the meantime, distinguishes critical patients. When evaluating dermatological manifestations, several factors must be considered: onset, morphology, distribution, and associated symptoms and signs. This review depicts dermatological signs in critical patients in order to lay out better recognition.

A single-centre experience of secondary cutaneous tumours with special reference to precocious metastases

BACKGROUND

Secondary involvement of skin by tumour comprises 2% of cutaneous neoplasia, in a small proportion of cases serving as the primary manifestation of occult disease.

METHODS

Cases of cutaneous metastases (CM) were retrieved from our pathology files between 2013 and 2018 and clinical and histopathological data reviewed.

RESULTS

There were 159 cases (median age 70). A majority of clinical presentations comprised isolated, papulonodular lesions. While the anatomic distribution of lesions often bore a proximate relationship to the primary tumour, distant sites of involvement were frequently encountered. Melanoma gave rise to the greatest number of metastases, followed by tumours of the breast, colorectum, and squamous cell carcinoma. In six cases (3.8%), CM served as the presenting feature of occult malignancy. These patients presented at a more advanced age and with distant sites of involvement. The microscopic features of CM include nodules, nests, and cords or single cell infiltrates typically in deeper compartments in the absence of overlying epidermal or adnexal precursor lesions.

CONCLUSIONS

CMs are a frequent development in the natural history of melanoma and breast tumours. In practice, a wide spectrum of tumours may give rise to CM and a small proportion more importantly, signal the existence of previously unknown neoplasia.

Fine-needle aspiration of scalp masses: A review of 30 cases

INTRODUCTION

Scalp masses are often the initial presentation of a widely disseminated malignancy. Fine-needle aspiration (FNA) is an optimal method for obtaining an accurate tissue diagnosis, in these patients with initial presentation and those with a known malignancy.

MATERIALS AND METHODS

We reviewed all FNAs of skin and soft tissue lesions from the scalp at our institution over a period of 31 years (1990-2021). Relevant clinical information was obtained from the review of computerized patient record. The histologic type, presentation, previous diagnoses, and survival after the diagnosis were correlated.

RESULTS

Thirty patients with scalp masses were identified. All the patients were males with a median age of 61 years (27-81 years). The scalp masses ranged from 0.4 to 6 cm in size. Ten cases (33%) were benign, but the majority of cases (n = 20, 67%) were malignant. Of the malignant lesions sampled, 1 case was a primary squamous-cell carcinoma (SCC), and the remaining 19 cases were metastatic tumors. Of these, 13 cases (68.4%) had a previously diagnosed malignancy. Most of the 19 metastatic lesions were adenocarcinomas or poorly differentiated carcinomas (n = 12, 63.2%), followed by melanoma (n = 4), SCC (n = 1), alveolar soft part sarcoma (n = 1) and large cell lymphoma (n = 1). The most common site of primary was the gastrointestinal tract (6/19, 31.5%) and lung (6/19, 31.5%). The average survival after the diagnosis of these scalp metastases was around 6.3 months, signifying a poor prognosis.

CONCLUSION

In our patient population, most scalp masses were metastatic tumors. Metastasis to the scalp signals advanced disease and is associated with a very poor prognosis. FNA is an easy, safe, rapid, cost effective and precise modality for diagnosing these masses. It can also yield material for molecular testing for newer directed therapies, if needed.

Clinical and Histopathologic Profile of Patients with Cutaneous Metastasis in a Tertiary Hospital in the Philippines

INTRODUCTION

Cutaneous metastases represent 2% of skin tumors, with an overall incidence of 5.3%. Although rare, clinical presentations of cutaneous metastasis vary and can be mistaken for benign and malignant skin conditions.

METHODOLOGY

This was a descriptive, retrospective review of all patients diagnosed with cutaneous metastasis seen at the Department of Dermatology from January 2013 to December 2019. Clinical and histopathologic data from the patients were collated from medical records, and slides were retrieved for review.

RESULTS

A total of 115 patients were included and 122 slides reviewed. There were more female than males, the mean age was 52.3 ± 14.0 years of age. The most common primary cancer was the breast, and accordingly, the most common location was anterior chest. Among the 122 slides reviewed from 104 patients, the most common histologic type was adenocarcinoma (72.1%), and showed the infiltrative pattern (26.2%). Other histologic types seen were melanoma (13.1%), leukemic infiltrates (11.5%), squamous origin (2.5%), and epithelioid sarcoma (0.8%). Lymphovascular invasion and dermal sclerosis were observed. Immunohistochemical stains were performed in only 13.9% of the cases. There was a high concurrence of the clinical with the histopathologic diagnosis (95.6%).

CONCLUSION

Although rare, patients with cutaneous metastasis may present in dermatology clinics. Knowledge of clinical features and low threshold for doing biopsies may prove useful for these patients. Similarly, dermatopathologists should be able to recognize histologic features of cutaneous metastasis morphologically. Histologic features may be subtle and may be reminiscent of benign inflammatory conditions, hence judicious use of immunohistochemical staining is recommended.

Signet-Ring Cutaneous Metastasis Presenting with Huge Bunches of Grapes

Signet-ring cell (SRC) is a histologic type in which cells show unique features under the microscope. We mainly found signet-ring cells (SRCs) in gastrointestinal and breast tumors. Cutaneous metastasis from internal carcinomas was an uncommon presentation. The cases of signet-ring cell carcinoma (SRCC) metastasis to the skin were rarely reported. Cutaneous metastasis indicated a poor prognosis for a patient. Here, we report a female who had huge grape-like nodules arising from gastrointestinal SRCC in her trunk and thigh.

Cutaneous Metastasis from Lung Adenocarcinoma

Cutaneous metastases are rare and often portend the aggressive malignancy and poor prognosis. We report a case of a 62-year-old man with a rapidly growing nodule on the left back for 2 months. The patient was diagnosed with lung adenocarcinoma shortly before the skin lesion presented. Physical examination showed a dome-shaped purplish red nodule, with ulceration and hemorrhagic crust. Excision of the skin lesion was performed, and the histopathology showed tumor cells infiltrate with immunohistochemistry (TTF-1+CK7+CD20–) favoring primary lung adenocarcinoma.

Cutaneous Metastasis of Lung Adenocarcinoma: Initially Mimicking and Misdiagnosed as Keloids

Cutaneous metastases have distinct morphologic features that can aid in making the diagnosis clinically even prior to biopsy. Lesions often have a nodular appearance and are firm, fixed, and range from flesh-colored to reddish-purple. A 73-year-old female with a history of lung adenocarcinoma status-post neoadjuvant chemotherapy and lobectomy 20 months prior was referred to our dermatology clinic for evaluation and treatment of suspected keloids on the left flank. The lesions were firm, plum-colored, fibrotic nodules, and were diagnosed clinically in the office as cutaneous metastases of internal malignancy. Punch biopsy was performed and revealed a proliferation of atypical epithelial cells arranged in cords and strands, with neoplastic cells positive for CK7 and TTF-1, confirming the diagnosis of metastatic adenocarcinoma. The patient was referred for chemotherapy and is still alive nine months following the prompt clinical diagnosis of cutaneous metastasis. Cutaneous metastasis signifies a poor prognosis, but knowledge of the clinical characteristics of these lesions can lead to earlier detection and more prompt initiation of treatment.

Case Report: Lung Adenocarcinoma Initially Presenting With Cutaneous and Subcutaneous Metastases

Cutaneous and subcutaneous soft tissue metastases are rare in lung adenocarcinoma and suggest poor prognosis. We report a patient with lung adenocarcinoma who initially presented with cutaneous and subcutaneous metastases to the abdomen that were initially presumed to be herpes zoster and an occult subcutaneous soft tissue mass. Because the lesions progressed over 3 weeks despite routine herpes zoster treatment, magnetic resonance imaging was performed and showed a presumed sarcoma; however, ¹⁸F-fluourodeoxyglucose positron emission tomography/computed tomography demonstrated pulmonary lesions. Biopsy of the abdominal lesion confirmed poorly differentiated lung adenocarcinoma. Early diagnosis of soft tissue metastasis can be difficult. Clinicians should suspect internal organ malignancy when a progressive cutaneous or subcutaneous soft tissue lesion is encountered.

Cutaneous metastases of internal malignancies: a single-institution experience

Aims

Cutaneous metastases of internal malignancies occur in 1–10% of cancer patients. The diagnosis can sometimes be challenging, especially in cases with an unknown primary cancer.

Materials and methods

A retrospective case review was performed including all cases of skin metastases from primary internal malignancies diagnosed at the Department of Pathology at the Maastricht University Medical Centre+ from 2007 to 2021. The clinicopathological data were collected and immunohistochemical and molecular diagnostic tests were performed to confirm the primary origin of the metastases.

Results

We identified 152 cases (71 female; 31 male patients) of cutaneous metastases of internal malignancies. 28 patients (20 women and 8 men) were diagnosed with multiple cutaneous metastases. Among the female patients, the most common primary tumour was breast cancer (50% of the cases), followed by lung (13.6%), gynaecological (7.3%), and gastrointestinal origin (7.3%). Among the male patients, the most common primary sites were gastrointestinal and lung origin (altogether, 50% of the cases). In 19 patients, the cutaneous metastasis was the first presentation of a clinically silent internal malignancy (18.6%), of which most (78.9%) represented metastatic lung carcinomas. Finally, metastasizing patterns were different across tumour types and gender.

Conclusion

Breast, lung, gastrointestinal, and gynaecologic cancers are the most common primary tumours demonstrating skin metastases. Infrequently, cutaneous metastases can be the first clinically visual manifestation of an underlying not yet diagnosed internal malignancy; therefore, occasional broad immunohistochemical profiling, molecular clonal analysis, and a continuous high level of awareness are necessary for a precise diagnosis of cutaneous metastases of internal malignancies.

Phase 1/2 study of topical submicron particle paclitaxel for cutaneous metastases of breast cancer

Purpose

This Phase 1/2 study evaluated safety and efficacy of a topical submicron particle paclitaxel (SPP) in an anhydrous ointment base (SOR007), primarily in breast cancer patients with cutaneous metastases (CM).

Methods

One of three concentrations of SOR007 SPP (0.15%, 1.0%, or 2.0%) was applied twice daily over an area of 50 cm² under a 3 + 3 phase 1 design for up to 28 days, with the option for expansion to an additional 28 days at the highest dose under a Phase 2a once safety was established. Efficacy was analyzed by lesion measurements and photographs to determine overall response rate (ORR), complete response (CR), and progression free survival by day 28 or 56.

Results

Twenty-three subjects were enrolled, 21 with cutaneous metastases of breast cancer (CMOBC). Four subjects received SOR007 0.15% for a median of 28 days (range = 17–29), three at a dose of 1.0% for a median of 28 days (range = 6–29), and sixteen at 2.0% for a median of  55 days (range = 6–60). All doses were well tolerated, and 19 subjects were evaluable for efficacy. At day 28 across all dose levels, 16% (95% CI 3.4 to 39.6%) of subjects achieved an ORR and another 63% (95% CI 34.9–96.8%) had stable disease (SD). The proportion of patients being progression free at 28 days across all treatments was 79% (95 CI 54–94%).

Conclusion

Application of SOR007 0.15%, 1.0%, and 2.0% to CM was safe and well tolerated with some reduction in lesion pain, and minimal systemic absorption of paclitaxel. Lesion stabilization was observed in most subjects over the study period. A randomized, placebo-controlled trial to confirm these findings is warranted.

ClinicalTrials.gov identifier

NCT03101358.

Erythematous Tumour Above the Right Clavicula: A Quiz

Abstract is missing (Quiz)  

Differences in the Molecular Profile between Primary Breast Carcinomas and Their Cutaneous Metastases

Simple Summary

The development of new strategies for the management of cutaneous metastases is a major clinical challenge because of the poor prognosis. To advance in this field, a better understanding of the molecular alterations involved in the metastatic process is needed. In the present study, the clinicopathological characteristics of breast cancer that develop cutaneous metastases were analyzed and the molecular differences between primary breast tumors and their corresponding cutaneous metastases were compared. We observed that the surrogate molecular type of breast cancer with an increased risk to metastasize to the skin was triple negative. In total, 48.5% of the cutaneous metastases presented some additional molecular alteration with respect to the primary tumor. However, no characteristic mutational pattern related to skin metastasis development was observed. Identifying the genes involved in the development of cutaneous metastases is important to gain insights into the biology of the disease and to identify possible diagnostic and therapeutic biomarkers.

Abstract

Background: The characterization of molecular alterations of primary breast carcinomas (BC) and their cutaneous metastases (CM) to identify genes involved in the metastatic process have not yet been completely accomplished. Methods: To investigate the molecular alterations of BC and their CM, a total of 66 samples (33 BC and 33 CM) from 33 patients were analyzed by immunohistochemical and massive parallel sequencing analyses. In addition, the clinicopathological characteristics of patients and tumors were analyzed. Results: Triple negative (TN) BCs were overrepresented (36.4%) among tumors that developed CM. A change of tumor surrogate molecular type in metastases was found in 15% of patients and 48.5% of the CM presented some additional molecular alteration with respect to the primary tumor, the most frequent were amplification of MYC and MDM4, and mutations in TP53 and PIK3CA. Survival was related to histological grade, tumor surrogate molecular type and TP53 mutations in the univariate analysis but only the tumor surrogate molecular type remained as a prognostic factor in the multivariate analysis. Conclusions: The TN molecular type has a greater risk of developing skin metastases. There are phenotypic changes and additional molecular alterations in skin metastases compared to the corresponding primary breast tumors in nearly half of the patients. Although these changes do not follow a specific pattern and varied from patient to patient, they could impact on the treatment. More studies with larger patient and sample cohorts are needed.

Solitary lower limb cutaneous metastasis in a case of esophageal adenocarcinoma: a rare presentation

Esophageal cancer is the ninth most common cancer all over the world and is sixth in the list of cancer-related mortality. Here in this report, we present an elderly male with solitary subcutaneous metastasis to right thigh 2 years following esophagectomy for esophageal adenocarcinoma. Operative notes revealed inadequate margins on frozen section analysis during initial resection, which were subsequently revised. Postoperative histopathology showed ypT3N0M0 Grade 3 mucin-secreting adenocarcinoma. A wedge biopsy from the thigh growth revealed metastatic mucinous adenocarcinoma. Positron Emission Tomography (PET) was done, which showed a higher tracer uptake in the ulcero-proliferative lesion arising from the subcutaneous plane in the right thigh with no evidence of any other metastasis or recurrence at the primary site. As the reported incidence of distant unexpected metastases is growing, careful physical examination with a preoperative PET-CT is indispensable. Further knowledge on options on treatment of such isolated cutaneous metastasis needs to be studied by the scientific community.

Subcutaneous Soft Tissue Metastases in Lung Adenocarcinoma: A Surprising Initial Presentation on Bone Scintigraphy

ABSTRACT

Initial disease presentations are often surprising compared with expected clinical trajectories. We present a case of metastatic lung adenocarcinoma where the initial presentation was masquerading as a musculoskeletal soft tissue mass. Initial concern was for a hematoma after light trauma, but due to a pacemaker, MRI was contraindicated. Workup included a 99mTc-MDP bone scan where the lesion demonstrated activity. Further workup imaging was serendipitous, revealing a left upper lobe mass. Biopsy demonstrated poorly differentiated adenocarcinoma of lung origin. Soft tissue metastasis can occur with lung adenocarcinoma, and although it constitutes a less frequent metastatic route, it is nevertheless clinically important.

Cutaneous Metastases of Solid Tumors: Demographic, Clinical, and Survival Characteristics

BACKGROUND

Cutaneous metastasis (CM), while uncommon, is usually an indicator of poor prognosis. With cancer patients living longer, the incidence of CM has increased, which justifies its analysis.

OBJECTIVES

The objective of this study was to carry out a descriptive study of CM diagnosed for 18 years in a dermatology department of a tertiary care hospital and to assess the epidemiological, clinical, and histological variables that condition them, as well as data on their survival and prognosis.

METHODS

We performed a descriptive study of cases of CM diagnosed over 18 years in the dermatology department of a tertiary referral hospital analyzing the following variables: patient age and sex, site of primary neoplasm, pathochronology, survival time, histological findings, immunohistochemical markers, the anatomical area affected, the clinical appearance of the metastasis, therapeutic plan, and existence of metastases in other regions. We checked normal distribution using the Kolmogorov-Smirnov test and then compared the quantitative variables using the Student's t-test (unpaired samples), Mann-Whitney test (non-normal distribution), analysis of variance (ANOVA; for more than two groups), and categorical variables using the chi-square or Fisher's exact test.

RESULTS

We included 37 cases (20 men and 17 women), of whom 32 had died. The mean age was 62 ± 15 years. CM detection was defined early in 8% of cases, synchronous in 32%, and metachronous in 60%. The most frequent primary tumor sites were lungs (24%), breasts (21%), and bladders (11%). Most metastases were solitary. The most frequent locations for CM were the scalp, trunk, armpits, and groin. Most lesions had a nodular presentation (81%). Squamous cell carcinoma and adenocarcinoma showed the same frequency in lung cancer CM. Breast cancer leading to CM was the most common invasive ductal carcinoma. The most aggressive cases, with the worst survival, originated in lung neoplasms. Therapeutic management for most patients involved surgery in combination with other procedures. The only difference detected between the lung and breast cancer CM was the predominance of lung tumors in men (89%) and breast tumors in women compared with metastases from other sites; breast cancer CM manifested more frequently as plaques and less frequently as nodules (p < 0.05) and was less frequently associated with multisystemic metastasis. In lung cancer CM, time from tumor diagnosis to CM occurrence was shorter (p < 0.01) and multisystemic metastasis was more frequent than in CM of other tumors.

CONCLUSIONS

CM tends to affect patients aged above 60 years and arises predominantly from lung cancer in men and breast cancer in women. The most typical locations are the chest and scalp, and the appearance is usually nodular. Survival after CM detection is low, particularly in lung cancer CM.

Clinical, Pathological, and Molecular Features of Breast Carcinoma Cutaneous Metastasis

Cutaneous metastases (CMs) account for 2% of all skin malignancies, and nearly 70% of CMs in women originate from breast cancer (BC). CMs are usually associated with poor prognosis, are difficult to treat, and can pose diagnostic problems, such as in histopathological diagnosis when occurring long after development of the primary tumor. In addition, the molecular differences between the primary tumors and their CMs, and between CMs and metastases in other organs, are not well defined. Here, we review the main clinical, pathological, and molecular characteristics of breast cancer CMs. Identifying molecular markers in primary BC that predict CM and can be used to determine the molecular differences between primary tumors and their metastases is of great interest for the design of new therapeutic approaches.

Clear Cell Proliferations of the Skin: A Histopathologic Review

ABSTRACT

Cutaneous clear cell proliferations encompass a heterogenous group of several primary cutaneous neoplasms and metastatic tumors with different histogenesis. Many of these clear cell proliferations may seem strikingly similar under the microscope resulting in challenging diagnosis. In many of these clear cell lesions, the reason for the clear or pale appearance of proliferating cells is unknown, whereas in other ones, this clear cell appearance is due to intracytoplasmic accumulation of glycogen, mucin, or lipid. Artifacts of tissue processing and degenerative phenomenon may also be responsible for the clear cell appearance of proliferating cells. Awareness of the histopathologic findings as well as histochemical and immunohistochemical techniques are crucial to the accurate diagnosis. This review details the histopathologic features of clear cell cutaneous proliferations, classifying them according their type of differentiation and paying special attention to the histopathologic differential diagnosis among them.

Extensive cutaneous metastasis of recurrent gastric cancer: A case report

BACKGROUND

Cutaneous metastasis is a rare event associated with poor prognosis for gastric cancer and has been rarely reported in the literature.

CASE SUMMARY

A 69-year-old male patient who had undergone salvage gastrectomy and a few courses of adjuvant chemotherapy 3 mo earlier for recurrent gastric cancer developed widespread cutaneous metastases. Due to the patient’s intolerance to further adjuvant chemotherapy, he was placed in hospice care and expired 1 mo later. In the literature, gastric cancers are rarely reported as the primary malignancies for cutaneous metastasis. We, thus, provide an update on a case review published in 2014 by reviewing 10 more case reports dated from 2014 to 2020. The average age for the new group of patients was 59.4 ± 18.88-years-old. Thirty percent of the patients presented with cutaneous lesions and advanced gastric cancer synchronously while 70% developed cutaneous metastases 1.3 years to 14 years after the initial treatment for primary gastric cancer. Eighty percent of the patients received either local excision or chemo ± radiation therapy to treat their cutaneous metastases.

CONCLUSION

This report highlights cutaneous metastasis as a late and untreatable metastasis of gastric cancer.

Cutaneous metastases of endometrial carcinoma: report of an unusual case and literature review

PURPOSE

Cutaneous metastases of endometrial carcinoma are rare. We report a case of a 54-year-old woman who developed cutaneous metastases from an endometrial carcinoma, and review the related literature to offer insight into this rare and serious condition.

METHODS

The clinical and pathological data and therapy delivered to a patient from Peking University People's Hospital, were retrieved from her medical records. A systematic literature search regarding this unusual disease progression was conducted through PubMed/MEDLINE.

RESULTS

A postmenopausal patient diagnosed with stage IB endometrioid carcinoma rapidly developed cutaneous metastases. 10 months postoperatively, the patient developed multiple lymph node metastases, and 22 months later, cutaneous metastases appeared on both breasts. She was then treated with chemotherapy, immunotherapy and hormone therapy. The skin lesions eased temporarily but deteriorated quickly. Ultimately, she died in 7 months subsequent to the appearance of cutaneous lesions.

CONCLUSION

Cutaneous metastases from endometrial carcinoma have usually been incurable and associated with a limited prognosis.

Histopathologic and molecular profiling of lung adenocarcinoma skin metastases reveals specific features

AIMS

Little is known regarding the histopathological and molecular features of lung adenocarcinoma skin metastases. Our study is the largest to comprehensively explore these to date.

METHODS AND RESULTS

We performed a retrospective cohort study analysing 42 lung adenocarcinoma skin metastasis samples obtained from a database of 2659 lung adenocarcinomas collected between 2010 to 2020. EGFR exon 19 deletion was detected in one patient, and KRAS mutations were detected in 12 (33.3%) patients. The PD-L1 tumour proportion score was <1% in 27 patients, ≥1% and <50% in 8 patients, ≥50% in 6 patients, and not assessable in one patient. We showed that the predominant histopathologic subtype is different from that at other metastatic sites (p=0.024). TTF-1 was more often negative in skin metastases compared to other sites (p<0.001). The EGFR mutation rate tended to be lower for skin metastases compared to other sites (p=0.079). Skin metastases were associated with a high rate of PD-L1-negative cases (p=0.022).

CONCLUSION

Our work shows that the skin metastases of lung adenocarcinoma have a specific histopathologic profile.

Retrospective review of cutaneous metastasis among 11,418 patients with solid malignancy: A tertiary cancer center experience

Cutaneous metastasis (CM) occurs infrequently and usually presents during the later stages of cancer, and has a poor prognosis. Although there are insufficient current data, cancer treatment changes could have a positive impact on the outcome. This retrospective study aimed to review the pattern and prognosis of CM in patients with solid malignancy in a tertiary cancer center in Thailand.We reviewed the medical records of cancer patients diagnosed with CM between October 2009 and August 2015 at Chulabhorn Hospital, a tertiary cancer center in Thailand. Patients with primary skin cancer and hematological malignancies were excluded. We collected and analyzed data, including the time of cancer diagnosis and CM, type of cancer, clinical characteristics, and survival outcome.Of 11,418 patients, there were 33 (0.3%) were diagnosed with CM. Breast cancer was the most common primary cancer (12 cases, 36%). Skin nodules were commonly detected on the anterior chest wall. Also, 79% of CM patients had concomitant visceral metastasis. The median overall survival of those with CM was 9.21 months (95% confidence interval 4.75-83.38 months) regardless of presentation either at onset or disease recurrence (P = .083). However, the change of management was affected in 78% diagnosed with a later stage of CM. No statistical difference in survival was observed between breast cancer and non-breast cancer patients (8.79 vs 9.21 months, P = .613).Despite CM being a sign of poor prognosis, it may still be an indicator for changing cancer patients' treatment. Hence, early CM diagnosis and prompt novel therapy may positively affect outcomes for cancer patients.

Cutaneous metastasis on the nasal tip: first clinical sign of pulmonary carcinoid tumor

Skin metastases are rare and may occur in the context of a known metastatic disease or be the first clinical sign of an underlying primary tumor. In the case of carcinoid neoplasms, determining whether the cutaneous tumor is primary or secondary and identifying the tumor origin in metastatic cases is not always an easy task. This is the report of a case of cutaneous metastasis presenting as the first clinical manifestation of a previously unknown pulmonary carcinoid tumor, including the discussion of histopathological and immunohistochemical findings that allowed an adequate diagnosis of the tumor etiology and reinforces the importance for dermatologists and dermatopathologists to be familiar with these findings.

Cutaneous Adenosquamous Carcinoma of the Scalp With Intestinal Phenotype

Cutaneous adenosquamous carcinoma is a mixed, squamous and glandular, rare malignant tumor of the skin characterized by a mixed, squamous, and glandular differentiation. Few cases of this tumor have been so far reported, and even fewer have been thoroughly studied by immunohistochemistry. We report here an exceptional case of cutaneous adenosquamous carcinoma which showed immunohistochemically features of intestinal differentiation, namely because of the expression of keratin 20 and CDX2, a marker of gastrointestinal tumors.

A long-term survival case with recurrent esophageal adenosquamous carcinoma

We experienced an extremely rare case of recurrent esophageal adenosquamous carcinoma showing cutis, bone and adrenal gland metastases. Furthermore, the patient showed complete remission by chemotherapy and irradiation, with a long-term survival of over 8 years. A 46-year-old man with esophago-gastric junction cancer of clinical stage II was administered two cycles of neo-adjuvant chemotherapy with FP (5FU 800 mg/mm² Cisplatin 80 mg/mm² every 3 weeks), subsequently, underwent esophagectomy and mediastinal and celiac lymph node dissection. However, at 1 month after the surgery, he was admitted again due to a 1 cm cutaneous metastasis at the anterior chest wall and left side adrenal gland metastasis. Furthermore, magnetic resonance imaging showed bone metastasis at the second cervical vertebra. He was administered weekly docetaxel at 40 mg/body (3 times every 4 weeks) for 27 cycles. Irradiation therapy (liniac 36 Gy/16Fr) was performed for the vertebral metastasis. The cutaneous and adrenal metastases were diminished and complete remission persisted for over 8 years.

Cutaneous Metastatic Breast Cancer Masked by Hidradenitis Suppurativa

The appearance of cutaneous metastases from breast carcinoma is variable and can present as nodules or inflammation of the skin, mimicking benign skin conditions. In addition, the skin lesions may be the initial presentation of unsuspected visceral malignancy or the site of either persistence or recurrence of metastatic disease in an oncology patient with a history of a solid tumor. The features of a woman with metastatic breast cancer that presented as a nodule that was masked by her concurrent, new-onset, hidradenitis suppurativa are reported. The diagnosis was suspected when the skin nodule persisted after her hidradenitis suppurativa improved; the diagnosis of cutaneous metastasis was confirmed with a skin biopsy. Occult breast cancer (primary or recurrent disease) may be masked by an inflammatory condition, such as hidradenitis suppurativa. Therefore, if a primary dermatologic condition does not appropriately respond to therapy, pathologic evaluation may be warranted to exclude the possibility of another disease, such as cutaneous metastases from underlying visceral cancer.

Cutaneous Metastasis as the First Presentation of Non-Small-Cell Lung Cancer with a BRAF Mutation: A Case Report

Cutaneous metastasis from a primary visceral malignancy is a relatively uncommon clinical manifestation that occurs as an initial presentation in 1% to 12% of patients with internal malignancies. Additionally, cutaneous metastases are often late signs of an internal malignancy, and in very rare cases they may occur at the same time or before the primary cancer has been detected. Metastasis to the skin has a poor prognosis and is often a sign of widespread malignant tumors. In the present study, we report a 72-year-old male who presented with multiple rapidly growing subcutaneous nodules. Positron emission tomography-computed tomography (PET-CT) revealed a hypermetabolic concentration of radiotracer in the left lower lung and multiple organ metastases associated with multiple skin masses. Biopsy of one of the skin nodules and gene detection indicated metastatic adenocarcinoma consistent with a primary lung origin with a BRAF mutation. BRAF mutations are emerging therapeutic targets in non-small-cell lung cancer (NSCLC), as they are present in 2–4% of NSCLC cases. To the best of our knowledge, this is the first case report to show that BRAF-mutant lung adenocarcinoma can be associated with cutaneous metastasis. Early diagnosis and individualized treatment strategies may prolong patient survival.

Cutaneous lesions as the first manifestation of breast cancer: a rare case

Cutaneous metastases due to internal malignancies are rare but, in some cases, may present as the first manifestation of an undiagnosed malignancy. A 62-year-old female presented with itchy reddish patch on the left neck which spread to the left shoulder, arm, breast, and back four weeks prior to admission. Ten days later, vesicles emerged, ruptured, and ulcerated. The patient denied any history of breast lump. Skin biopsy showed diffuse dermal nests of tumor cells infiltrating to the collagen bundles and fat tissue, which was consistent with cutaneous metastasis from the breast cancer. The patient refused further workup and treatment and eventually passed away. This case showed the importance of conducting a comprehensive evaluation in cutaneous lesions presenting with early or sudden onset, rapid evolution, tendency to bleed, that do not resolve with treatment.

Dermatologic sequelae of breast cancer: From disease, surgery, and radiation

The care of breast cancer patients is important to dermatologists. Breast cancer's initial presentation, clinical progression, and its associated treatments can result in a variety of cutaneous complications. Dermatologists may be the first to identify a breast cancer diagnosis, as a subset of patients first present with direct extension of an underlying tumor or with a cutaneous metastasis. The surgical treatment of breast cancer also begets a variety of skin sequelae, including postoperative lymphedema, soft tissue infections, seromas, pyoderma gangrenosum, and scarring disorders. Moreover, breast cancer radiation treatment commonly results in skin changes, which can range from mild and temporary dermatoses to chronic and disfiguring skin ulceration, fibrosis, and necrosis. Radiation may also precipitate secondary malignancies, such as angiosarcoma, as well as rarer dermatologic diseases, such as radiation-induced morphea, lichen planus, and postirradiation pseudosclerodermatous panniculitis. Finally, breast cancer is also associated with an array of paraneoplastic phenomena, including Sweet's syndrome and the rarer intralymphatic histiocytosis. Herein, we review the dermatological manifestations of breast cancer, including conditions associated with its presentation, progression, and treatment sequelae. Chemotherapy-induced cutaneous side effects are beyond the scope of this review. This article provides a comprehensive review for dermatologist to be able to identify, diagnose, and manage breast cancer patients from initial presentation to treatment monitoring and subsequent follow-up.

Cutaneous Metastasis in the Setting of Both Colon and Breast Primary Malignancies

Colorectal cancer (CRC) is the third most diagnosed cancer in the United States, and many patients unfortunately have metastases at the time of their diagnosis. Cutaneous metastases of CRC have been reported in few journals and primarily as case reports due to their rarity. Here, we present the case of an 83-year-old woman with recently resected colon cancer, T4aN1bMx stage IIIB. She presented to our clinic for evaluation of a right midback mass, and a punch biopsy revealed dermal involvement by invasive, poorly differentiated carcinoma with epidermoid features. The mass was excised, and we ordered a PET scan in search of the primary tumor, which at that time was suspected to be of skin cancer origin. Surprisingly, this revealed a second malignancy triple-negative invasive ductal carcinoma of the left breast. The back mass stained positive for CK20, which was compatible with a metastasis from a colonic primary. After initially declining adjuvant therapy, the patient completed one cycle of capecitabine and oxaliplatin, which she tolerated poorly. She continued to further decline, developed widespread cutaneous metastases, and went home on hospice. Cutaneous lesions are an exceedingly rare site of metastasis for colon adenocarcinoma, and their clinical presentation can vary widely. It is important for providers to investigate any new skin lesion in a patient with a recent or remote history of malignancy, even if there were no sites of distant metastasis at initial diagnosis.

Clinical and Histopathologic Characteristics of the Main Causes of Vascular Occusion - Part II: Coagulation Disorders, Emboli, and Other

Vascular occlusion has multiple, diverse clinical manifestations, some of which can have grave consequences for patients. It also has a wide variety of causes, including thrombi, which we recently addressed in partI of this review. In this second part, we look at additional causes of vascular occlusion.