Cutaneous metastasis from internal carcinomas: a review of 45 years

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.

Advanced Appendiceal Cancer with Systematic Metastasis without Gastrointestinal Symptoms Found by Subcutaneous Tumor

An 86-year-old woman with a subcutaneous nodule in her left axilla visited our hospital. She had no gastrointestinal symptoms, but contrast-enhanced computed tomography revealed a cecal mass and systemic metastasis, including cutaneous, bone, peritoneal dissemination and ascites. Colonoscopy revealed a circumferential, elevated cecal lesion. She underwent right hemicolectomy to prevent colon obstruction. The pathological diagnosis was poorly differentiated adenocarcinoma (por1>tub2>muc) arising from the appendix with a BRAFV600E mutation and microsatellite instability-high. Chemotherapy was administered, and she is currently still alive and undergoing chemotherapy. We describe a rare case of advanced appendiceal cancer without gastrointestinal symptoms diagnosed due to cutaneous metastasis.

Cutaneous metastases from solid neoplasms - Literature review

Cutaneous metastases from solid tumors are uncommon events in clinical practice. Most of the time, the patient already has the diagnosis of a malignant neoplasm when the cutaneous metastasis is detected. However, in up to one-third of cases, cutaneous metastasis is identified before the primary tumor. Therefore, its identification may be essential for starting treatment, although it is usually indicative of poor prognosis. The diagnosis will depend on clinical, histopathological, and immunohistochemical analysis. Sometimes the identification of the primary site is difficult; however, a thorough analysis using imaging tests and constant surveillance is important.

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.

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.

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 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.

Clinicopathologic features of cutaneous metastases from internal malignancies

Background

Cutaneous metastasis (CM) is the spread of cancer cells from a primary site to the skin and is rarely the first sign of silent cancer. We investigated the clinicopathological characteristics of CM from internal malignancies in Korean patients treated at our institution over 20 years.

Methods

The clinicopathological findings of 112 patients (62 females, 50 males) with CM diagnosed at Yeungnam University Hospital between 2000 and 2020 were retrospectively reviewed.

Results

Mean patient age was 58.6 years (range, 26 to 87 years), and the most common primary cancer site was breast (74.2%) in women and lung (36.0%) in men. Ninety-six patients (85.7%) presented with CM after primary tumor diagnosis. CM from the lung or biliary tract usually occurred within 2 years of primary tumor diagnosis, whereas metastases from the breast and kidney occurred several years later. The chest, abdomen, and scalp were common sites of CM. Breast cancer usually metastasized to chest skin, while gastrointestinal tract cancers commonly metastasized to the abdomen. The scalp was a common location for CM from various tumors. The most common dermatologic presentations were nodules and masses. Immunohistochemical studies helped identify underlying malignancies when primary tumors were unknown.

Conclusions

The relative frequency of CM parallels the overall incidence of primary malignant tumors, and CMs usually occur at anatomic sites close to the primary tumor. CM can be diagnosed based on clinical, radiological, and histological features; however, immunohistochemical study is required in some cases.

Update of Clown Nose-Like Lesion, a Underrecognized Manifestation of Metastatic Malignancies and Genetic Cancer Predisposition Syndromes

Clown nose-like lesion refers to the manifestation of a reddish or skin-colored bulge on the tip of the nose or the manifestation of bulbous tip of the nose. More and more clinical cases show that clown nose-like lesion can also be the indication of some genetic syndromes, not just the manifestation of metastatic visceral tumor as it initially proposed. However, the clinical features of clown nose-like lesion indicated by metastatic malignancies, genetic cancer predisposition syndromes or primary diseases involving the nasal tip are lacking. In this study, patients with clown nose-like lesion in our clinical practices and from published literatures were collected and reviewed. We found that clown nose-like lesions caused by metastatic malignancies including lung cancer are often solitary and more common in male (24/31) older individuals (average age 62.3, ranging 40–78 years old). In addition, they usually appear for a short time, and are prone to be misdiagnosed as primary nasal diseases, leading to a poor prognosis (all patients with data available died within 4 months). Clown nose-like lesions associated with genetic cancer predisposition syndromes usually develop at a young age (mean age 15.3) with female preference (9/10). They are accompanied by multiple-systemic involvements, including low hair volume, developmental delay, cancer predisposition or neurological diseases. They show slow development and often positive family history (6/10). These two kinds of clown nose-like lesions are often asymptomatic, which delays the diagnosis and treatment of underlying malignancies or syndromes. In brief, the term of clown nose-like lesion is underrecognized, and should be updated. Clown nose-like lesions can serve as indicators to at least three categories of clinical issues: metastatic visceral tumors, genetic syndromes, and primary diseases involving the nasal tip. Increased awareness of clinical features of updated clown nose-like lesions can alert physicians to these underlying malignancies or syndromes, render earlier detection of associated medical issues, and allow for genetic counseling of family members.

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.

Frequency and Spectrum of Cutaneous Metastases of Visceral Malignancies: A Retrospective Observational Study of Three Years Duration in a Tertiary Care Hospital

BACKGROUND

In spite of the skin being the largest organ of the body, cutaneous malignancies are uncommon especially in people of color as compared to the white population. The incidence of cutaneous metastases of visceral malignancies is further low and accounts for 0.5% to 10% of cancer cases as per written literature. Cutaneous metastasis as the presenting sign of underlying internal malignancy is extremely rare and is a marker of poor prognosis. Limited data is available in written literature about the frequency and spectrum of metastatic skin lesions in the Asian population.

OBJECTIVE

1) To find the frequency of metastasis of visceral malignancies in skin biopsies. 2) To evaluate the clinicopathological presentation and immunohistochemistry (IHC) profile of cutaneous metastases.

SUBJECTS AND METHODS

It is a retrospective analysis of all the skin biopsies received in our department of Pathology for HPE from 01 Jan 2017 till 31 Dec 2019. Cases of cutaneous malignancy were segregated into primary and metastatic categories. Clinical details of the cases of cutaneous metastases were retrieved and analyzed. All the cases of cutaneous metastases were studied in detail for their clinical presentation, histomorphological features, and findings on IHC.

RESULTS

Out of a total of 484 skin biopsies in 3 years, 9.7% showed features of malignancy. Total ten cases of cutaneous metastases (2%) were found, out of which three were the primary presentation of silent visceral malignancy. The lung, breast, colon, and ovary were the common primary sites to manifest as cutaneous metastases with the abdominal wall being the commonest site. Histomorphological features aided by the IHC panel helped in diagnosing the cutaneous metastases and site of the primary malignancy.

CONCLUSION

Cutaneous metastasis as the primary presentation of visceral malignancy is rare and should not be missed as it indicates a poor prognosis. Clinico-pathological correlation and histomorphological features assisted by IHC markers help pathologists in diagnosing the site of primary malignancy in cases of cutaneous metastases.

Unique Skin Metastasis from Recurrent Cancer. Case Report

Introduction

Cutaneous metastasis is defined as the dissemination of malignant cells from a primary tumor to the skin. Skin may be affected by tumors, either through direct invasion from an adjacent organ or by cutaneous metastasis from an internal organ malignancy. We report a case of a 75-year-old female patient with skin metastasis 8 years after the initial treatment of primary breast cancer.

Patient Concern

The patient presented only with papules and nodular skin lesions in the left lateral abdominal area, without any other clinical manifestations.

Diagnosis

All laboratory tests were normal. Histological examinati revealed the infiltration of the dermis by tumor cells.

Interventions/Outcome

After the diagnosis of skin metastasis, she was treated with chemotherapy with complete remission of skin lesions.

Conclusion

Skin metastasis from internal organs is rarely the first sign. In this case, skin metastasis was the only clinical sign and the only diagnostic tool to drive to the correct diagnosis of a recurrent cancer after 8 years. Dermatologists might be the first doctors to facilitate the diagnosis of skin metastasis.

Cutaneous metastases from solid neoplasms in the 21st century: a retrospective study from a Portuguese tertiary care center

INTRODUCTION

Cutaneous metastases account for 2% of all skin cancers and are usually associated with widespread disease. The main of this retrospective study was to describe and illustrate clinicopathological features of cutaneous metastases diagnosed in our centre since the beginning of this century.

METHODS

All cases of cutaneous metastases from solid neoplasms diagnosed in our Dermatopathology Department from January 2000 to December 2018 were included. Statistical analysis was performed with SPSS.

RESULTS

A total of 164 patients were included, with a female to male ratio of 3:2. Malignancies that most commonly metastasized to the skin were melanoma (N = 58), breast cancer (N = 54) and lung cancer (N = 13). Immunohistochemical study was performed in 99 patients (60.4%). Time diagnosis of the primary tumour and appearance of cutaneous metastases was significantly higher in breast cancer, followed by melanoma and then by lung cancer (P < 0.05). Median survival after diagnosis of cutaneous metastases was 8 months. Survival after diagnosis of cutaneous metastases was also influenced by age of the patient, both at diagnosis of the primary tumour and at diagnosis of the cutaneous metastasis.

DISCUSSION

Clinical presentation of cutaneous metastases is highly variable and non-specific, being easily mistaken for other dermatological conditions. Histopathological examination is essential in this setting, and the judicious use of an immunohistochemistry panel considered the appropriate morphologic and clinical context. Survival after the diagnosis of cutaneous metastases is influenced not only by the location of the tumour but also by the age of the patient. Dermatologists should therefore be to these clinical pictures, and a high degree of suspicion is, along with a careful clinical history and physical examination. Although being limited by its retrospective nature, we describe one of the largest European series of cutaneous metastases, with findings with most of the available literature.

Carcinoma en cuirasse

Carcinoma en cuirasse (CeC) is an extremely rare form of cutaneous metastasis of breast cancer. Guidelines for diagnosis and treatment of CeC are limited due to the small number of reported cases. It can be difficult to distinguish CeC from benign etiologies on initial presentation, but CeC can be easily distinguished by histopathology. Treatment of CeC focuses on palliation with no consensus on therapy guidelines. Treatment modalities that have been explored include chemotherapy, radiotherapy (with or without local hyperthermia), and hormonal antagonists. Here we present a 62-year-old woman with recurrent triple-negative breast cancer manifesting as CeC to the chest wall.

Cutaneous metastases in a patient with no previous diagnosis of cancer: diagnostic challenge

On rare occasions, skin lesions are the first local of metastatic manifestation of internal malignancies. In case of no previous diagnosis of these tumors, the approach of suspicious skin lesions becomes a challenge, especially in differentiating cutaneous metastases and adnexal primary neoplasms. Currently, besides epidemiologic, dermoscopic and histopathologic aspects, the evaluation also integrates immunohistochemical exams and cell markers such as p40 and p63, highly specific for skin metastases. This article describes the case of cutaneous metastases as the sole obvious sign of breast cancer in a previously asymptomatic woman. The diagnosis was made by the finding of neoplastic cells in the dermis and immunohistochemistry compatible with ductal carcinoma.

A unique presentation of renal cell transformation into renal cell carcinoma in subcutaneous fatty tissue post twenty year old healing gun-shot wound: A case report

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An RCC presenting as a result of malignant transformation of remnant renal cells.

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At a site where twenty years ago the patient had sustained a gunshot wound.

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He underwent several surgeries, including a nephrectomy for that gunshot trauma.

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The case is unique in its time course, the preceding events, & no primary lesions.

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Its unheard-of malignant transformation of seemingly non-functional cells.

Introduction

Renal cell carcinoma (RCC) is the most common malignancy in the genitourinary tract, and is among the 10 most common cancers in both males and females.

Presentation of case

We report a case of a 61-year-old male who presented with a cutaneous lesion on his left back side at a site where he had undergone several surgeries – including Left nephrectomy – twenty years ago for a gun-shot wound he sustained which penetrated his abdomen.

Discussion

At that time pathology reports turned out to be normal, specially left kidney pathology report which was negative for any malignancy. Twenty years later, patient presented with a clear fluctuating painless cutaneous mass of 1–2 cm on his left back side, which grew gradually over time. Histopathologically, the incisional biopsy showed trabecular & papillary clear cells with prominent vascularity and hemosiderin deposition in the stroma, consistent with a malignant Renal cell Carcinoma (RCC). Immunohistochemically, it stained positive for Vimentin, CD10, PAX-8. Labs revealed positive renal cell carcinoma antibody. CT scans, urine tests, and bone scans failed to reveal the site of the primary lesion. Furthermore, the patient reports minimal constitutional symptoms and is grossly well.

Conclusion

The authors have reported an interesting case of an RCC presenting in a healed gun-shot wound in a previously nephrectomized patient. To the best of authors’ knowledge, such a case hasn’t been reported in the literature before, with it being unique in its time course, preceding events, and absence of primary lesions.

Image-guided intensity-modulated radiotherapy for refractory bilateral breast cancer in a patient with extensive cutaneous metastasis in the chest and abdominal walls

Treatment for bilateral breast cancer with chest wall and abdominal skin invasion normally involves conventional radiotherapy (RT); however, conventional RT provides inadequate target volume coverage and excessive treatment of large volumes of normal tissue. Helical tomotherapy (HT) has the ability to deliver continuous craniocaudal irradiation that suppresses junction problems and provides good conformity of dose distribution. A 47-year-old female with stage IV bilateral breast cancer with chest wall and pectoralis major muscle invasion, lymphadenopathy, bilateral pleural effusion, and multiple bone metastases received chemotherapy and target therapy beginning in January 2014; 4 months after the initiation of chemotherapy, computed tomography revealed progression of chest and abdominal wall invasion. A total dose of 70.2 Gy was delivered to both breasts, the chest wall, the abdominal wall, and the bilateral supraclavicular nodal areas in 39 fractions via HT. The total planning target volume was 4,533.29 cm³. The percent of lung volume receiving at least 20 Gy (V20) was 28%, 22%, and 25% for the right lung, left lung, and whole lung, respectively. The mean dose to the heart was 8.6 Gy. Follow-up computed tomography revealed complete response after the RT course. Grade 1 dysphagia, weight loss, grade 2 neutropenia, and grade 3 dermatitis were noted during the RT course. Pain score decreased from 6 to 1. No cardiac, pulmonary, liver, or intestinal toxicity developed during treatment or follow-up. Concurrent HT with or without systemic treatment could be a safe salvage therapy for chemorefractory locally advanced breast cancer patients with extensive cutaneous metastasis.

Cutaneous metastasis of a breast cancer diagnosed 13 years before

Metastasis is defined as a neoplastic lesion originating from another primary tumor, with which it is no longer in contact. Cutaneous metastases result from lymphatic embolization, hematogenous or contiguous dissemination or also direct implantation during surgical procedures. In women, the tumor most likely to metastasize to skin is breast cancer, which may manifest as papulonodular neoplastic lesions. We report the case of a 66 years old female patient, presenting papulonodular lesions13 years after the initial treatment with surgery and chemotherapy for a cancer of the left breast.

Metastatic transitional cell carcinoma of the skin presenting as painful zosteriform eruptions

Metastatic skin disease is an uncommon manifestation of visceral malignancies and failure to diagnose this early may result in incorrect treatment. Here, we report a 65-year-old man with bilateral painful eruptions on the abdominal skin and a past history of transitional cell carcinoma of urinary bladder.