Metastatic Tumors to the Skin

Metastatic Tumors to the Skin

Christine J. Ko, MD

David Cassarino, MD, PhD

This patient presented with a pink nodule on the anterior scalp. Certain tumors, like renal cell carcinoma (RCC), have the tendency to metastasize to the scalp.

This low-power image shows collections of clear cells with pools of extravasated erythrocytes, consistent with metastatic RCC. These tumors are typically positive with CD10, EMA, and RCC-Ma.


Mode of Metastasis

  • Hematogenous spread

  • Lymphatic spread

  • Direct extension from primary tumor

  • Accidental implantation during surgical procedure

    • Described with oral cavity, laryngeal, lung, mesothelioma, renal cell, colorectal cancers and others



  • Gender

    • Male: Primary tumor most often lung, colon

    • Female: Primary tumor most often breast, colon


  • Cutaneous metastases often located near primary tumor site

    • Breast carcinoma: Chest wall

    • Lung carcinoma: Chest wall

    • Genitourinary carcinoma: Abdominal wall, rarely genitalia

    • Oral cavity: Head and neck

  • Scalp

    • Tumors with a predilection to metastasize to scalp

      • Thyroid

      • Breast

      • Kidney

      • Lung

  • Umbilicus: Sister Mary Joseph nodule

    • Associated with adenocarcinoma of stomach, pancreas, ovary, and others


  • General points

    • Incidence rate of ˜ 2-10% in patients with internal malignancy

    • Rare among skin tumors (˜ 2% of all skin tumors)

    • Patients generally of age 60 or above, but exceptions occur

      • In neonates, neuroblastoma or other small round blue cell tumors may metastasize to skin

    • Skin metastases usually present within 2-3 years of diagnosis of primary

    • Breast cancer metastasizes to skin most frequently

    • Other internal cancers with not infrequent skin metastases include lung, colorectal, ovarian, head and neck, renal cell carcinoma, and gastrointestinal cancer

  • Signs/symptoms

    • Appearance

      • Generally red-pink, 1-3 cm firm nodule

      • Deeper purple or “vascular” appearance has been described for renal cell carcinoma metastasis

      • Multiple or solitary

      • Clustered or randomly distributed

      • May be movable or fixed, sometimes ulcerated

      • Uncommon bullous or inflammatory patterns of metastasis

    • Asymptomatic or painful

  • Special clinical variants

    • Inflammatory (erysipeloid) carcinoma

      • Lymphatic spread of carcinoma

      • Warm, red, tender plaque; resembles erysipelas

      • Most commonly associated with breast carcinoma, but also may be due to other carcinomas (i.e., colon, prostate) and melanoma

    • Carcinoma telangiectoides

      • Secondary to breast carcinoma

      • Plaque of coalescing telangiectasias and erythematous papules

    • Carcinoma en cuirasse

      • Secondary to breast carcinoma

      • Skin hardened and leathery

    • Superior vena cava syndrome

      • Can be secondary to lung carcinoma

      • Obstruction of superior vena cava leads to edema, cyanosis, plethora of head/neck; subcutaneous vessels may be prominent

    • Sister Mary Joseph nodule

      • Classically described as red nodule on umbilicus, most commonly due to gastric carcinoma

    • Alopecia neoplastica

      • Localized patches of alopecia on scalp secondary to metastatic disease in dermis

Laboratory Tests

  • Ovarian cancer

    • High CA-125 suggestive of advanced disease

    • CA 19-9 may be elevated

  • Colon cancer

    • CEA may be used to monitor disease

  • Hepatocellular and testicular cancer (and some others)

    • α-fetoprotein may be elevated

  • Pancreatic cancer

    • CA 19-9 may be elevated

  • Gastric cancer

    • CA 19-9 may be elevated

  • Prostate cancer

    • Prostate-specific antigen (PSA) often elevated

Natural History

  • Skin metastases are rarely presenting clue to internal malignancy

  • In most cases, skin metastases present after primary tumor has been diagnosed


  • In advanced disease, excision of metastases may be palliative

  • Other treatment options dependent on type of tumor and extent of disease (e.g., chemotherapy or radiation)

    • Chemotherapy

      • Traditional drugs (e.g., anthracyclines, taxanes)

      • Trend is to test tissue for molecular targets, and if positive, use targeted treatment (e.g., trastuzumab in Her2-neu positive breast cancer, tamoxifen in estrogen receptor positive cancers)


  • Poor overall survival

    • One study cites range of 1-34 months


Histologic Features

Jul 8, 2016 | Posted by in PATHOLOGY & LABORATORY MEDICINE | Comments Off on Metastatic Tumors to the Skin
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