cutaneous metastasis from an internal malignancy is rare and it indicates the later stage . malignancies which affect internal organs may display cutaneous manifestations , which may be the presenting symptoms and signs of the underlying malignancy . the aims of the study were to determine the frequency and significance of cutaneous manifestations of internal malignancies among the patients attending a cancer chemotherapy center . seven hundred and fifty patients with internal malignancies involving various organs , attending the cancer chemotherapy department of government general hospital , chennai , were recorded for a period of 3 years from 2005 to 2008 . in our institution , during the study period , it was not considered mandatory to obtain approval of ethical committee for conducting clinical study , and hence it was not obtained . data regarding history about the duration of the malignancy and the duration between the onset of malignancy and the skin changes , relapse of malignancy and the symptoms of cutaneous lesions were obtained . clinical examination including the cutaneous and systemic examination , hematological , radiological and cytological investigation was done to confirm the nature and site of malignancy . histopathology of the cutaneous lesions , suggestive of metastasis from an internal organ , was obtained . fine needle aspiration cytology ( fnac ) and t cell marker studies were done wherever necessary . out of the 750 patients studied , 52 ( 6.93% ) had cutaneous manifestations , 20 ( 2.66% ) had cutaneous metastases ( specific lesions ) and 32 ( 4.26% ) had nonspecific skin lesions . overall , the most common malignancies were leukemia and lymphomas ( 19.2% ) , followed by carcinoma breast ( 13.46% ) , carcinoma stomach ( 11.5% ) , carcinoma cervix ( 5.76% ) , carcinoma of the prostate ( 5.76% ) and carcinoma of the buccal mucosa ( 5.76% ) . the other malignancies encountered in our study in descending order of frequency were malignant melanoma , seminoma , carcinoma esophagus , carcinoma pharynx , hepatocellular carcinoma , astrocytoma , pheochromocytoma , secondaries in the neck with unknown primary . in males , non - hodgkin 's lymphoma ( nhl ) ( 26.47% ) [ figure 1 ] was the most common malignancy producing skin lesions , followed by leukemias ( 14.7% ) and carcinoma stomach ( 14.7% ) . a case of non - hodgkin 's lymphoma having inguinal nodes and skin - colored nodules over chest and abdomen in females , the most common malignancy was carcinoma breast ( 38.88% ) [ figures 2a , b ] , followed by leukemia ( 27.77% ) , carcinoma cervix ( 16.66% ) , nhl ( 5.55% ) , carcinoma stomach ( 5.55% ) and astrocytoma ( 5.55% ) . ( b ) ca breast ( right ) with ulcerative plaque eroding nipple and areola of the specific skin infiltrates , contiguous cutaneous metastases were seen in 6 ( 11.53% ) patients and non - contiguous metastases in 14 ( 26.92% ) patients [ tables 1 and 2 ] . skin - colored nodules were the most common , followed by erythematous and hyperpigmented papules and plaques . contiguous metastases non - contiguous metastases of the nonspecific lesions , herpes zoster was the most common ( 11 patients ) followed by generalized pruritus , multiple eruptive seborrheic keratoses , bullous disorders , erythroderma , flushing , purpura , systemic lupus erythematosus , pyoderma gangrenosum , insect bite allergy and lichenoid dermatitis . cutaneous metastasis can arise at any age . however , most cutaneous metastases occurred during or after the fifth decade as in the present study . the period of interval between the onset of symptoms of the primary malignancy and the onset of cutaneous metastases ranged from 2 months to 5 years . the shortest duration was 2 months in the case of acute myleoid leukemia and the longest was 5 years in the case of carcinoma breast . cutaneous metastatic lesions are usually multiple and may range from 1 to 100 . in our study , 5 out of 6 cases with contiguous metastases and 11 out of 14 cases of non - contiguous metastases had multiple lesions . skin - colored nodules at multiple sites were the most common clinical presentation of cutaneous metastases . the site of localization of metastasis depends upon mode of spread of the primary tumor , whether it is by lymphatics or hematogenous . the common malignancies that give rise to cutaneous metastases are carcinoma of the lung and colon in males and carcinoma of the colon and ovary in females . overall , melanomas are the most common , followed by carcinoma breast , carcinoma oral cavity , lungs , colon , and ovary . in this study , nhl was the most common neoplasm to produce cutaneous metastases , followed by carcinoma breast and leukemia . however , this observation could not be taken as actual reflection of prevalence in south india , as our hospital is a tertiary referral center . contiguous spread was more common in females ( 66.6% ) than males ( 33.3% ) , while non - contiguous metastases were more common in males ( 85% ) than females ( 15% ) . this difference could be because the malignancy encountered in both sexes is different . in the present study , carcinoma breast was the most common ( 66% ) neoplasm causing direct extension to skin , followed by carcinoma buccal mucosa and amelanotic melanoma [ figures 3a , b ] . nhl was the most common neoplasm to produce non - contiguous metastases , followed by gastrointestinal malignancies ( 28.5% ) [ figure 4a , b ] and leukemia ( 21.4% ) , especially acute myeloid leukemia . the most common sites involved by cutaneous metastases in their order of occurrence were as follows : ( a , b ) amelanotic melanoma over right cheek with multiple nodules over neck ( a ) a case of carcinoma stomach showing a single nodule over neck . ( b ) histopathology of the nodule shows collection of atypical epithelial cells in upper dermis anterior chest wall , anterior abdominal wall , lower limb , neck , back , upper limb , face , pelvis , scalp . and tharakaram [ table 3 ] . comparison of sites of cutaneous metastases among the nonspecific skin manifestations with internal malignancy , herpes zoster ( 27% ) came first . carcinoma breast was the most common malignancy associated with herpes zoster , while carcinoma cervix ( 18% ) was the second . among 11 patients , 6 had single dermatomal involvement , 2 had disseminated and 3 had multidermatomal involvement . according to literature , disseminated herpes zoster is commonly associated with underlying malignant disease . one of them had nhl which was reported as the most common neoplasm associated with paraneoplastic pemphigus in a study by anhalt et al . the other patient had paraneoplastic pemphigus in association with secondaries in the neck . in this patient , skin manifestation as the first sign of internal malignancy was noted in another two patients . another was an elderly man who presented with erythroderma and was diagnosed to have szary syndrome on further systemic examination and investigations . one of our patients with carcinoma prostate developed bullous pemphigoid which is also reported in the literature . in the present study , generalized pruritus was noticed in three patients with hepatocellular carcinoma , polycythemia vera and carcinoma stomach . pruritus was observed as a common manifestation among patients with internal malignancy compared to controls in the study by rajagopal et al . three patients had multiple eruptive seborrheic keratoses and the most common malignancy associated was carcinoma stomach which corroborates with the literature reports . we encountered a patient with pronounced flushing involving the face and chest , associated with pheochromocytoma , and similar association is reported in literature . a known case of acute myeloid leukemia presented with purpura , which is a well - known association . survival period in patients with cutanenous metastasis is said to be around 3 months . early death in these patients could be due to undetected secondaries in visceral organs and high - grade malignant nature of the primary tumor . in our study , 23 out of 52 patients ( 44% ) , were lost to follow - up , and among the remaining 29 patients , 13 ( 44% ) succumbed to their illness during the study period . seven patients ( 54% ) showing specific cutaneous metastasis expired in the period of 26 months , whereas 6 patients ( 37% ) showing nonspecific cutaneous changes expired during the period of 14 days to 8 months [ table 4 ] . shortest survival period ( 2 months ) two patients with carcinoma breast , who developed recurrence of malignancy after surgery , expired in 4 months and 6 months , respectively . shortest survival period in patients showing nonspecific cutaneous metastases was 14 days in a patient with hepatocellular carcinoma . cutaneous metastases indicating a sign of recurrence and widespread metastases have poor prognosis and the survival period is reduced . though the skin is an infrequent site for metastasis and is only the 18th most common site , skin lesions offer easily accessible tissue for biopsy and histopathologic examination . systemic response to any particular chemotherapeutic agent can be assessed by the visible regression of skin metastasis . cutaneous metastases are important to recognize because they may precede internal visceral metastases and early recognition helps in prolonging the survival of the patient .