squamous cell carcinoma ( scc ) is a common malignancy , and cutaneous scc accounts for up to 20% of non - melanoma skin cancers in the united states , making it the second most common skin cancer . other primary sites of scc are locations where squamous epithelium is normally found , including the lung , oropharynx , cervix , esophagus , and anal canal . metastatic scc without a known primary site constitutes about 5% of all cancers of unknown primary site . gastrointestinal involvement as a manifestation of metastatic scc is relatively uncommon , yet has been reported in the literature , including several cases identifying colonic involvement from known primary locations including the esophagus , lung [ 5 , 6 ] , and cervix . however , this is the first report that identifies a gastrointestinal metastasis manifesting as recurrent disease from a cutaneous primary source without evidence of active disease elsewhere on multiple imaging studies . the patient was a 65-year - old male with a history of cutaneous scc involving the right upper chest diagnosed in 2009 and initially treated with resection followed by mohs surgery . two years later he had a cutaneous recurrence confirmed to be carcinoma in situ . in october 2014 ct of the chest , abdomen , and pelvis showed bulky right axillary and retropectoral lymphadenopathy . lymph node dissection in november 2014 confirmed 7 of 22 positive nodes for metastatic disease . postoperative pet scan demonstrated mildly fdg - avid right pectoral lymph nodes believed to be reactive and a small area of increased uptake in the transverse colon of uncertain significance . colonoscopy was recommended based on the pet scan but deferred by the patient as he began chemoradiation using radiosensitizing doses of carboplatin and paclitaxel , including the right subpectoral lymph node in the treatment field . this therapy was completed in february 2015 , and subsequent imagining including pet / ct scans in august 2015 and february 2016 demonstrated low - grade metabolic uptake in the region of the right shoulder and axilla , consistent with posttreatment changes without any evidence of active disease , including no evidence of increased colonic uptake . on february 22 , 2016 the patient underwent a routine screening colonoscopy , which did not demonstrate any lesion in the transverse colon , but a small area of nodular polypoid tissue within a diverticulum of the sigmoid colon was identified ( fig 1 ) . these findings were confirmed on histology and immunohistochemical stains ( pancytokeratin aw1/ae3 and p63 positive , ck20 negative ) . the subsequent management decisions were discussed at several specialized cancer centers , and it was ultimately recommended that the patient undergo local resection of the colonic metastasis , as this was the only identified site of recurrent neoplasm . preoperative marking of the site was accomplished on repeat endoscopic evaluation with repeat biopsy confirmation of the site . in june 2016 , laparoscopy with a robotically assisted low anterior resection was performed and a previously unidentified small bowel metastatic lesion was noted in the jejunum . the sigmoid resection confirmed metastatic scc at the base of a deep diverticulum with 3 of 4 positive lymph nodes and clear margins of resection . postsurgically in july 2016 the patient was enrolled in a trial with pembrolizumab and is currently undergoing systemic immunotherapy . repeat ct / pet imaging in october 2016 demonstrated unremarkable colocolonic and small bowel anastomotic sites without evidence of any new metastatic disease . scc is a common malignancy with several potential primary locations , including the oropharynx , nasopharynx , lung , esophagus , cervix , and anus , with metastasis typically involving regional lymph nodes . cutaneous scc constitutes up to 20% of non - melanoma skin cancers , with principal epidemiologic risk factors that include uv exposure , age , and phenotypic variations ( including fair skin , blue eyes , and northern european origin ) . other less common but significant risk factors include prior therapy with immunosuppressive agents and immunosuppressed populations such as transplant recipients . in general , the spread of metastatic cutaneous scc occurs via lymphatics , with occasional distant metastases to organs . primary colonic scc has been described in case reports [ 12 , 13 ] and several small series   and has been estimated to constitute up to 0.2% of primary colon cancers . however metastatic colonic involvement , though reported to rarely occur with lung [ 5 , 6 ] , esophageal , and cervical primary cancers , has not been reported from a cutaneous scc . a single case of a synchronous metastatic scc to the colon was reported by ito et al . in 2016 . however , their patient presented with concurrent cervical lymph node involvement , no identifiable primary site , and a colonic submucosal mass . the diagnosis was established based only on surgical resection and not mucosal biopsies , in contrast to the currently reported patient in whom a very subtle mucosal abnormality was identified arising within a diverticular orifice . in addition , this is the first reported case to date of a previously treated cutaneous scc to manifest solely as a colonic metastasis . the secondary metastatic findings in this case are also noteworthy . discovering the colonic lesion prompted laparoscopic surgical resection , which revealed a second gastrointestinal lesion in the small bowel . though uncommon , the presence of a gastrointestinal metastatic lesion in this setting should prompt consideration to exclude other synchronous lesions and the need for possible additional systemic therapy . the authors declare that there are no conflicts of interest or conflicts of financial support .