Management of Cutaneous Carcinosis (Skin Metastases)
The management of cutaneous carcinosis requires a multidisciplinary approach with surgical resection as the primary treatment for resectable lesions, followed by consideration of adjuvant radiation therapy and systemic treatments based on the primary tumor origin and extent of disease. 1
Diagnosis and Assessment
- Cutaneous metastases represent approximately 2% of all skin malignancies and are often associated with poor prognosis 2
- The most common primary tumors that metastasize to the skin are:
- Cutaneous metastases may be the first sign of internal malignancy, particularly with lung, kidney, and ovarian cancers 3
- Thorough evaluation including imaging studies (MRI or CT) is necessary to assess tumor extent and identify potential metastases in other organs 1
Surgical Management
- Wide local excision is the treatment of choice for isolated cutaneous metastases when feasible 1
- For extensive lesions or those in anatomically challenging locations, surgical consultation with specialists (surgical oncology, plastic surgery) is recommended 1
- When complete excision is not possible, amputation of the affected digit or limb may be necessary in cases of extensive involvement 1
- Regional lymph node dissection should be performed if nodal metastases are identified 1
Radiation Therapy
- Radiation therapy is recommended as an adjuvant treatment following surgical excision for high-risk lesions 1
- For inoperable lesions, radiation therapy can be used as primary treatment, though cure rates may be lower than with surgery 1
- Radiation therapy is particularly valuable for palliative treatment of symptomatic cutaneous metastases 1
- Smaller and thinner tumors tend to be more responsive to radiation therapy 1
Systemic Therapy Options
- For patients with widespread cutaneous metastases, systemic therapy should be considered based on the primary tumor type 1
- Chemotherapy options include:
- Cisplatin as a single agent or combined with 5-fluorouracil (5-FU) has shown some activity 1
- Targeted therapies:
- Epidermal growth factor receptor (EGFR) inhibitors such as cetuximab and panitumumab have demonstrated efficacy in advanced cutaneous squamous cell carcinoma 1
- Immune checkpoint inhibitors:
- Pembrolizumab and other immune checkpoint inhibitors are being evaluated in clinical trials for metastatic cutaneous carcinomas 1
Special Considerations for Immunosuppressed Patients
- Immunosuppressed patients, particularly solid organ transplant recipients (SOTRs), have a higher risk of aggressive disease and poor prognosis 1
- Consider modification of immunosuppressive regimens when possible:
Palliative Care
- For patients with advanced disease, best supportive and palliative care should be provided to optimize symptom management and maximize quality of life 1
- Management of pain with appropriate analgesia, including opioids when necessary 1
- Special dressings designed for high exudate levels or odor control may be helpful in managing wounds from cutaneous metastases 1
- Psychological support for patients and families is essential, particularly after diagnosis and as end-of-life care approaches 1
Follow-up Recommendations
- Regular follow-up examinations should be performed to monitor for recurrence or new metastatic lesions 1
- Annual skin examination is recommended for patients with a history of cutaneous metastases 1
- Patient education regarding skin self-examination and sun protection is important 1
Common Pitfalls to Avoid
- Delaying diagnosis - cutaneous metastases can mimic benign dermatological conditions such as cysts, dermatofibroma, or inflammatory lesions 2
- Failure to consider multidisciplinary consultation, which is strongly recommended given the complexity and rarity of cutaneous metastases 1
- Underestimating the importance of palliative care in patients with advanced disease 1
- Inadequate follow-up to monitor for disease progression or new metastatic sites 1