Cutaneous metastases are uncommon but clinically significant manifestations of internal or cutaneous malignancies, occurring in approximately 1–10 percent of patients with advanced cancer and generally indicating widespread disease and poor prognosis (1,2). They are most frequently associated with cancers of the breast, lung, gastrointestinal tract, genitourinary system and melanoma, and commonly affect the trunk, scalp and proximal limbs (1). The lesions show varied morphology, including papules, nodules, plaques and ulcerated or infiltrative growth, often resembling benign tumours, inflammatory dermatoses or primary cutaneous cancers, which can delay diagnosis and staging (2). Although histopathology is the diagnostic standard, repeated biopsies may be invasive, painful and difficult in frail oncology patients, creating a need for non-invasive imaging markers that help raise suspicion early (2). Dermoscopy plays an increasing role in identifying malignant skin lesions at the bedside. Early dermoscopic evaluation by Chernoff and colleagues demonstrated predominance of pink or skin-coloured nodules with irregular and polymorphous vascular patterns in most biopsy-proven metastatic lesions (3). Other studies reported recurrent vascular features such as arborising, linear-irregular, dotted, hairpin and polymorphous vessels on pink, red or skin-coloured structureless backgrounds, with occasional pigmented patterns especially in melanoma metastases (4). A more recent multicentre analysis found white structureless areas as a common feature across metastases, blue structureless areas particularly in melanoma metastases and irregular vascular patterns in metastases from non-melanoma skin cancers (5). However, most published data focus on dermoscopic appearances alone, are based on small heterogeneous case series and lack standardised terminology, limiting clinical application across diverse skin types (3-6). Evidence from darker phototypes remains particularly scarce, with only small series describing vascular patterns of breast-cancer–related metastases in Indian patients (6). Radiological imaging complements dermoscopy by assessing lesion depth, spread and systemic involvement. CT and MRI often show small intradermal or subcutaneous nodules that may be overlooked unless the skin is evaluated carefully (7). High-frequency ultrasound can delineate epidermal, dermal and subcutaneous planes, and metastatic lesions typically appear as solid hypoechoic nodules with irregular borders and increased vascularity on Doppler studies, distinguishing them from benign lesions like cysts and lipomas (7,8). PET-CT increases sensitivity by identifying metabolically active lesions that may not be clinically visible (7). Newer multimodal technologies such as combined reflectance confocal microscopy and optical coherence tomography show well-defined hyporeflective tumour nodules with dilated vessels and disturbed collagen, offering potential utility for depth assessment and treatment monitoring (9). Despite multiple imaging options, most studies evaluate dermoscopy or radiology separately, with radiological reports focusing more on subcutaneous disease rather than clinically visible cutaneous nodules (9). There is a clear research gap in combined multimodal assessment of cutaneous metastases, where dermoscopic and radiological features of the same lesions are studied together. Existing studies rarely correlate surface vascular and structural features with deeper imaging findings, and large cohorts from darker skin types are lacking (5,6). Without integrated imaging criteria, clinicians have limited guidance for selecting biopsy sites, differentiating metastases from benign nodules and optimising early diagnosis, particularly in oncology settings where rapid triage is needed. The present study aims to systematically describe dermoscopic findings of biopsy-proven cutaneous metastases from various primary malignancies and correlate these features with radiological characteristics, especially high-frequency ultrasound and available CT, MRI or PET-CT. By analysing associations with primary tumour origin, lesion morphology and depth, the study intends to develop combined imaging signatures that improve clinical suspicion, guide biopsy decisions and support earlier diagnosis in routine dermatology and oncology practice.

Study Design and Setting This was a hospital-based, cross-sectional observational study conducted in collaboration between the Department of Dermatology, Venereology and Leprosy (DVL) and the Department of Radiology at a tertiary care teaching hospital. The study was carried out over a period of 2 years (2022-2024), during which patients clinically suspected to have cutaneous metastases were evaluated using dermoscopy and radiological imaging before histopathological confirmation. Study Population and Sample Size A total of 50 patients with clinically suspected cutaneous metastatic lesions were included. All patients presented with new skin or subcutaneous nodules suspected to be secondary to an underlying malignancy or recurrence in known cancer cases. Only patients whose diagnosis was confirmed with histopathology were considered for final analysis. Inclusion Criteria Patients of any age and gender presenting with skin nodules suspected to be metastatic, either as the first clinical manifestation or in known cases of internal or cutaneous malignancy, who consented to dermoscopic examination, radiological evaluation and biopsy. Exclusion Criteria Patients with primary cutaneous malignancies, benign tumours, infectious or inflammatory dermatoses mimicking metastasis, patients who declined biopsy or imaging, and lesions with inadequate tissue samples for diagnosis were excluded. Clinical Examination All patients underwent detailed clinical assessment including history of primary malignancy, duration of skin lesions, number, site, morphology, symptoms, treatment status and systemic spread. Photographic documentation of lesions was performed for records. Dermoscopy Dermoscopy was performed using a polarized handheld dermoscope at ×10 magnification with or without immersion fluid. Each lesion was evaluated for colour, background patterns, vascular structures, pigmented areas, white, blue or red structureless zones and other morphological features using standard dermoscopic terminology. Multiple lesions were examined in patients with more than one nodule, and dominant patterns were recorded. Radiological Imaging High-frequency ultrasonography was performed using a linear probe of 10–18 MHz to assess lesion depth, echotexture, margins, vascularity and involvement of subcutis or deeper tissues. Colour Doppler imaging was used to evaluate vascular patterns. Additional imaging such as CT, MRI was reviewed wherever available to assess systemic involvement, deeper extension and metabolic activity. Radiological findings were documented using descriptive imaging criteria and correlated with dermoscopic findings for the same lesion. Histopathological Confirmation All lesions underwent skin biopsy (incisional or excisional depending on size and accessibility). Haematoxylin-eosin staining was performed, and immunohistochemistry was done when necessary to confirm secondary deposits and determine the primary tumour origin. Histopathology served as the reference standard to confirm cutaneous metastasis. Data Collection and Variables Data were recorded using a structured proforma. Variables included demographic details, primary malignancy, lesion characteristics, dermoscopic features (vascular pattern, background colour, structureless areas, pigment), radiological findings (echogenicity, borders, vascularity, depth), and histopathological diagnosis. Statistical Analysis Data were analysed using standard statistical software (SPSS 24.0 version). Descriptive statistics were expressed as mean ± standard deviation for continuous variables and proportions for categorical variables. Association between dermoscopic and radiological features was assessed using chi-square or Fisher’s exact test, and p-values < 0.05 were considered statistically significant. Ethical Considerations Institutional Ethics Committee approval was obtained prior to study initiation, and written informed consent was taken from all participants for clinical photography, dermoscopic evaluation, imaging and biopsy procedures.

Table 1: Demographic Profile of Patients with Cutaneous Metastases (n = 50) Parameter Category Mean ± SD / n (%) Age (years) — 54.8 ± 11.6 Gender Male 22 (44%) Female 28 (56%) Duration of Skin Lesions (months) — 4.2 ± 2.8 Mean Number of Lesions — 3.6 ± 2.1 The study included 50 patients diagnosed with cutaneous metastases, with a mean age of 54.8 ± 11.6 years. Females constituted a slightly higher proportion of the cohort (56%) compared to males (44%). The average duration of skin lesions before presentation was 4.2 ± 2.8 months, indicating a relatively short clinical history in most patients. On examination, patients had an average of 3.6 ± 2.1 metastatic skin lesions, reflecting variable but generally multiple lesion involvement (Table 1). Table 2: Clinical Characteristics of Cutaneous Lesions (n = 50) Parameter Category n (%) Number of Lesions Solitary 18 (36%) Multiple (≥2) 32 (64%) Site of Lesions Trunk 26 (52%) Scalp / Head & Neck 9 (18%) Upper limbs 7 (14%) Lower limbs 6 (12%) Multiple body regions 2 (4%) Morphology Firm nodules 31 (62%) Plaques 9 (18%) Ulcerated nodules 7 (14%) Subcutaneous indurated swellings 3 (6%) Symptoms Asymptomatic 29 (58%) Pain/Tenderness 14 (28%) Ulceration/Discharge 5 (10%) Pruritus 2 (4%) Among the 50 patients, multiple lesions were more common, with 64% presenting with two or more lesions, whereas 36% had solitary lesions. The trunk was the most frequent anatomical site (52%), followed by the scalp/head and neck region (18%), upper limbs (14%), lower limbs (12%), and multiple body regions (4%). Firm nodules were the predominant morphological pattern, observed in 62% of cases, while plaques (18%), ulcerated nodules (14%), and subcutaneous indurated swellings (6%) were less common presentations. Most patients were asymptomatic (58%), whereas 28% reported pain or tenderness, 10% had ulceration or discharge, and 4% experienced pruritus (Table 2). Breast carcinoma was the most common primary malignancy leading to cutaneous metastases (42%), followed by lung carcinoma (20%), gastrointestinal cancers (14%), genitourinary cancers (10%), melanoma (8%), and a small proportion from other malignancies (6%). A majority of patients (78%) developed skin lesions after a known diagnosis of primary cancer, whereas 22% presented with skin lesions as the initial indicator of malignancy. Systemic metastases were present in most patients (76%) at the time of skin involvement, while 24% had disease limited to the skin. Regarding treatment status, 54% were receiving active chemotherapy, 28% were under post-treatment surveillance, and 18% were treatment-naïve at presentation (Table 3). Table 3: Oncology and Systemic Profile (n = 50) Parameter Category n (%) Primary Malignancy Breast carcinoma 21 (42%) Lung carcinoma 10 (20%) Gastrointestinal cancers 7 (14%) Genitourinary cancers 5 (10%) Melanoma 4 (8%) Others 3 (6%) Presentation Type Known primary malignancy 39 (78%) First presentation via skin lesions 11 (22%) Systemic Metastasis at Presentation Present 38 (76%) Absent / confined to skin 12 (24%) Treatment Status Under active chemotherapy 27 (54%) Post-treatment surveillance 14 (28%) Treatment-naïve 9 (18%) Figure 1: Dermoscopic Background and Colour Patterns (n = 50) Most lesions showed a pink or skin-coloured background (56%), while erythematous-red tones were seen in 28% of cases. Less frequently, lesions displayed a white structureless background (12%), and a blue-black background suggestive of melanoma-type pigmentation was noted in 4%. Secondary colour components showed notable variability, with milky-white areas present in 22%, hemorrhagic or red blotches in 18%, and blue structureless areas in 14%, reflecting differing tumour morphology, vascularity, and depth across lesions (Figure 1). Figure 2: Vascular Patterns Seen on Dermoscopy (n = 50) Most lesions demonstrated linear-irregular vessels (44%), which formed the predominant vascular pattern. Polymorphous or mixed vessel patterns were also relatively common, occurring in 30% of cases, indicating heterogeneous tumour vasculature. Arborising vessels were identified in 14% and dotted vessels in 12%, while less frequent patterns included hairpin or looped vessels (8%). A small subset (6%) appeared avascular or showed minimal visible vascular structures on dermoscopy, suggesting deeper or less vascular surface involvement (Figure 2). Figure 3: Structural and Surface Features (n = 50) Nearly half of the lesions appeared as homogeneous pink nodules (48%), making this the most frequent additional dermoscopic feature. White structureless areas were observed in 28%, while shiny white streaks were present in 22%, both indicating stromal or fibrotic changes. Ulceration or crusting was seen in 18%, and non-melanoma pigmented areas in 16%, suggesting variable surface changes and pigment deposition. Blue structureless areas, seen in 12%, were less common and may reflect deeper tumour infiltration or melanocytic components in selected cases (Figure 3). Table 4: Lesion-wise Assessment Patterns Parameter Mean ± SD Number of lesions assessed dermoscopically per patient 2.4 ± 1.2 Percentage of patients with multiple dermoscopically evaluated lesions 34 (68%) On average, 2.4 ± 1.2 lesions per patient were evaluated dermoscopically, indicating that most individuals had more than one lesion suitable for detailed examination. A majority of patients (68%) underwent assessment of multiple lesions rather than a single representative lesion, reflecting the multifocal nature of cutaneous metastases in this cohort (Table 4). Table 5: Ultrasound Characteristics of Cutaneous Metastases (n = 50) Ultrasound Feature Category n (%) Echotexture Hypoechoic solid nodules 34 (68%) Heterogeneous solid lesions 10 (20%) Mixed echogenicity 6 (12%) Margins Irregular / infiltrative 29 (58%) Well-defined 21 (42%) Lesion Depth Confined to dermis 14 (28%) Dermis + subcutis 26 (52%) Extending into deeper planes 10 (20%) Shape / Contour Lobulated 18 (36%) Ovoid 22 (44%) Nodular with tail-like extension 10 (20%) Most lesions appeared as hypoechoic solid nodules on ultrasonography (68%), while heterogeneous solid lesions (20%) and mixed echogenicity patterns (12%) were less common. Over half of the lesions showed irregular or infiltrative margins (58%), reflecting invasive growth, whereas 42% were well-defined. In terms of depth, the majority extended from the dermis into the subcutis (52%), while 28% were confined to the dermis and 20% penetrated deeper planes. Regarding contour, ovoid shapes predominated (44%), followed by lobulated lesions (36%) and nodular lesions with tail-like extensions (20%), indicating varied growth patterns across metastatic deposits (Table 5). Figure 4: Vascularity on Colour Doppler (n = 50) More than half of the lesions demonstrated increased internal vascularity (56%) on Doppler evaluation, suggesting active intralesional blood flow. Peripheral vascularity was noted in 24% of cases, while 12% exhibited a mixed pattern with both internal and peripheral vessels. A smaller proportion (8%) showed poor or absent Doppler flow, indicating relatively low vascular activity or deeper, less perfused tumour components (Figure 4). Table 6: Cross-sectional Imaging (CT / MRI) Findings (n = 50) Parameter Category n (%) Presence of deeper extension Subcutaneous extension 22 (44%) Fascial involvement 11 (22%) Muscle invasion 6 (12%) No deep extension 11 (22%) Systemic Metastatic Burden Present 38 (76%) Absent / isolated skin involvement 12 (24%) Associated Lymphadenopathy Present 19 (38%) Absent 31 (62%) Enhancement Pattern (Post-contrast) Heterogeneous enhancement 24 (48%) Mild peripheral enhancement 17 (34%) No significant enhancement 9 (18%) Deep extension beyond the skin was common, with 44% of lesions extending into the subcutaneous tissue, 22% involving the fascia, and 12% showing muscle invasion, while 22% had no deep extension. Most patients had systemic metastatic disease at presentation (76%), and only 24% had lesions confined to the skin. Associated lymphadenopathy was present in 38% of cases. Post-contrast imaging most frequently revealed heterogeneous enhancement (48%), followed by mild peripheral enhancement (34%), while 18% showed no significant enhancement, indicating varied vascular and structural characteristics across metastatic lesions (Table 6). Table 7: Radiology–Dermoscopy Correlation Summary Radiology Feature Corresponding Dermoscopic Pattern Observed Correlation n (%) Increased vascularity on Doppler Polymorphous / linear-irregular vessels 26 (52%) White structureless areas (US fibrosis) Shiny white streaks / white background 14 (28%) Subcutaneous infiltration Multiple nodules / erythematous background 18 (36%) Poor vascular flow (necrotic) Ulceration / crust 7 (14%) A majority of lesions showing increased vascularity on Doppler corresponded to polymorphous or linear-irregular vascular patterns on dermoscopy (52%), indicating alignment between radiologic and surface vascular signals. White structureless areas suggestive of fibrosis on ultrasound matched with shiny white streaks or white backgrounds on dermoscopy in 28% of cases. Subcutaneous infiltration demonstrated radiologically was associated with multiple nodules and erythematous backgrounds in 36% of lesions. Poor vascular flow suggestive of necrosis showed dermoscopic features such as ulceration or crust in 14%, reflecting surface breakdown in poorly perfused lesions (Table 7). Figure 5: Histopathological Findings of Cutaneous Metastases (n = 50) Dermal nodular infiltrates were the most frequent growth pattern on histopathology (42%), followed by diffuse sheets of tumour cells (30%). Infiltrative cords or strands were noted in 18%, while pagetoid or epidermotropic spread was relatively uncommon (10%). Adenocarcinoma cells constituted the predominant cellular morphology (52%), with squamous carcinoma cells observed in 16% and melanocytic atypical cells in 8%. Poorly differentiated or undifferentiated tumour cells accounted for 14%, and other less common morphologies, including sarcoma or hematologic origins, comprised 10% of cases (Figure 5). Table 8: Immunohistochemistry Profile (n = 50) IHC Marker Positive Cases n (%) Suggestive of Primary Tumour CK7 positive 28 (56%) Breast, lung adenocarcinoma CK20 positive 6 (12%) GI / colorectal origin ER/PR positive 17 (34%) Breast carcinoma HER2 positive 6 (12%) HER2-enriched breast cancer TTF-1 positive 8 (16%) Lung adenocarcinoma S100 / HMB-45 positive 4 (8%) Melanoma metastases PSA positive 3 (6%) Prostate carcinoma CD45 / hematologic markers 3 (6%) Lymphoma/leukemia Undifferentiated / no specific lineage 5 (10%) Poorly differentiated tumours Most lesions showed CK7 positivity (56%), supporting origins from breast or lung adenocarcinoma. Hormone-receptor expression was also notable, with ER/PR positivity in 34% and HER2 positivity in 12%, reinforcing breast carcinoma as a major source. TTF-1 positivity was seen in 16% of cases, further linking several lesions to lung adenocarcinoma. CK20 positivity (12%) suggested gastrointestinal or colorectal origin, while melanocytic markers such as S100/HMB-45 were positive in 8%, indicating metastatic melanoma. PSA positivity was identified in 6% and hematologic markers (CD45 and related panels) in another 6%, confirming prostate- and lymphoma-related metastases, respectively. A subset (10%) showed no definitive lineage and remained poorly differentiated on immunohistochemistry (Table 8). Table 9: Diagnostic Confirmation and Biopsy Type Parameter Category n (%) Biopsy Type Incisional biopsy 34 (68%) Excisional biopsy 16 (32%) Final Diagnostic Confirmation Histopathology alone sufficient 35 (70%) Histopathology + IHC required 15 (30%) Primary Tumour Traceability via IHC Successfully matched to known primary 37 (74%) Helped detect primary in unknown cases 8 (16%) Inconclusive lineage 5 (10%) Most cases were diagnosed using incisional biopsy (68%), while one-third underwent excisional biopsy (32%). Histopathology alone was adequate for diagnostic confirmation in 70% of cases, whereas 30% required additional immunohistochemistry for definitive classification. IHC successfully matched lesions to an already known primary tumour in 74% of patients, and in 16% it aided in identifying the primary in cases where malignancy first manifested through skin lesions. In 10% of cases, lineage remained inconclusive despite evaluation (Table 9). Table 10: Overall Combined Correlation Scores Correlation Type Strong Concordance Moderate Concordance Poor Concordance Dermoscopy ↔ Doppler 42 (84%) 6 (12%) 2 (4%) Dermoscopy ↔ Histopathology 39 (78%) 8 (16%) 3 (6%) Radiology ↔ Histopathology 40 (80%) 7 (14%) 3 (6%) Three-way correlation confirmed (all modalities align) 36 (72%) — — Most lesions demonstrated strong concordance between the different diagnostic modalities. Dermoscopy correlated strongly with Doppler findings in 84% of cases, with only a small proportion showing moderate (12%) or poor agreement (4%). Likewise, dermoscopic patterns aligned well with histopathological features, showing strong correlation in 78%, moderate in 16%, and poor in 6%. Radiological findings showed similarly high alignment with histopathology, with strong correlation in 80% and poor correlation in only 6%. Notably, a full three-way correlation across dermoscopy, radiology, and histopathology was achieved in 72% of cases, indicating consistent multimodal diagnostic agreement in the majority of patients (Table 10).

Cutaneous metastases represent a clinically significant marker of advanced malignancy and often indicate widespread disease. In the present study involving 50 biopsy-proven cases, breast carcinoma was the most frequent primary tumour (42 percent), followed by lung carcinoma (20 percent), gastrointestinal cancers (14 percent), genitourinary cancers (10 percent), and melanoma (8 percent). This pattern is comparable to earlier large series where breast cancer remained the predominant source of cutaneous metastases, particularly in women, while lung and gastrointestinal primaries accounted for a substantial proportion in men (10). The commonest anatomical site in this study was the trunk (52 percent), which aligns with previous findings that metastases tend to occur over the chest wall, abdomen, and back due to proximity to underlying primaries and rich vascular networks (11). Multiple nodules were noted in 64 percent of patients, a trend consistent with reports that metastatic skin lesions frequently appear as multiple firm nodules rather than solitary plaques (12). Most patients in the present series were asymptomatic (58 percent), similar to earlier observations where metastatic lesions present as painless nodules that may be overlooked (12). Twelve percent of patients presented with lesions as the first manifestation of malignancy, which is within the range of 7–15 percent reported in previous literature (11). Systemic metastasis was present in 76 percent of patients, reinforcing the association between cutaneous deposits and disseminated disease. Dermoscopy in this study revealed a predominance of linear-irregular vascular patterns (44 percent) and polymorphous vessels (30 percent) over pink or skin-coloured structureless backgrounds. These findings resemble the observations of Chernoff et al., who described predominant serpentine and polymorphous vessels in metastatic nodules (13). The presence of white structureless areas (28 percent) and shiny streaks (22 percent) in our series correlates with stromal fibrosis and tumour matrix, similar to patterns reported in recent multicentric studies (14). Blue structureless areas were seen in lesions from melanoma primaries (12 percent), matching earlier dermoscopic descriptions of melanoma metastasis showing blue-black homogeneous zones due to deeper melanin deposition (15). Radiologically, most lesions were hypoechoic solid nodules with irregular margins (68 and 58 percent respectively), findings consistent with ultrasound descriptions by Cuenca-Barrales et al., who reported hypoechoic lesions infiltrating the dermis and subcutis with variable vascularity (16). Increased internal vascularity was observed on Doppler in 56 percent of lesions in our study, correlating well with polymorphous vascular patterns on dermoscopy. Similar relationships between vascular dermoscopic patterns and Doppler flow have been suggested but not extensively quantified previously (17). CT and MRI identified deeper extension into subcutis in 52 percent and muscle involvement in 12 percent, reflecting aggressive behaviour comparable to reports in oncology imaging literature where cutaneous metastases are frequently under-recognised unless actively evaluated (14). Histopathologically, adenocarcinoma was the most frequent subtype (52 percent), which is consistent with global profiles where adenocarcinomas from breast and lung primaries predominate (11). IHC was required in 30 percent of cases and successfully identified the primary in previously unknown cases, supporting its diagnostic utility. Melanoma metastases showed S100 and HMB-45 positivity and corresponded to blue structureless dermoscopic areas and deeper invasion, similar to prior studies on pigmented metastatic nodules (15). A key contribution of this study is the integrated correlation across three diagnostic modalities. A strong dermoscopy-Doppler correlation was seen in 84 percent of cases, and three-way agreement among dermoscopy, radiology and histopathology occurred in 72 percent. Earlier studies have generally examined each modality in isolation; combined assessments are limited to case reports and small series with no large Indian cohort (14). The present work therefore adds new insight by demonstrating that consistent multimodal imaging patterns can provide reliable non-invasive diagnostic clues, especially in patients where biopsy is delayed or limited by clinical condition.

Cutaneous metastases in this study most commonly originated from breast and lung carcinomas and presented predominantly as multiple firm nodules over the trunk. Dermoscopy revealed linear-irregular and polymorphous vascular patterns with white structureless zones, while ultrasonography showed hypoechoic lesions with internal vascularity and subcutaneous spread. Histopathology confirmed adenocarcinoma as the leading subtype, and immunohistochemistry aided diagnosis in poorly differentiated tumours and cases with unknown primaries. Strong correlation was observed between vascular dermoscopic patterns, Doppler flow and invasive histologic features, suggesting that combined dermoscopic and radiological evaluation can improve diagnostic precision and help guide biopsy decisions. The study supports the role of multimodal imaging as an adjunct to histopathology, particularly in advanced malignancy and in settings requiring rapid non-invasive assessment.

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