Cutaneous Manifestations of Internal Malignancies: An Overview

Clinical value of [18F]F-FDG PET/CT in patients with suspected paraneoplastic dermatoses: Diagnostic performance and impact on clinical management

PURPOSE

We retrospectively evaluate the diagnostic performance of 2-deoxy-2[18F]fuoro-D-glucose([18F]F-FDG) PET/CT and its impact on clinical management in patients with suspected paraneoplastic dermatoses (PD).

MATERIALS AND METHODS

From an institutional PET/CT database (2014-2022), we retrospectively analyzed patients who were clinically suspected with PD and underwent [18F]F-FDG PET/CT for screening an underlying malignancy. For all scans, positive mucocutaneous lesions and PET-indicated malignancies were assessed, and the degree of FDG avidity among different dermatoses were quantified. The final diagnoses of dermatoses and neoplasms were based on pathologic results, international diagnostic standard and follow-up. We assessed the recommended and applied therapies before and after [18F]F-FDG PET/CT and noted whether the patient management changed on the basis of the [18F]F-FDG PET/CT results.

RESULTS

We analyzed 60 patients with 10 types of dermatoses in this study. Finally, 19 of the 60 patients who had both of specific dermatosis and contemporaneous neoplasm were diagnosed with PD. [18F]F-FDG PET could identify the underlying neoplasms in 18/19 (94.7%) PD patients, and led to a change of the management in 9/19 (47.4%) PD patients. In addition, the mucocutaneous manifestations of [18F]F-FDG PET/CT associated with several specific dermatoses were characteristic.

CONCLUSIONS

This study highlighted the value of [18F]F-FDG PET/CT as a useful tool for evaluation of patients with suspected PD to unveil the underlying culprit tumor, and profoundly supports the clinical management of PD patients.

Acrocyanosis and Progressive Skin Necrosis as Manifestation of Waldenstrom Macroglobulinemia Associated With Type I Cryoglobulinemia: A Case Report

Waldenstrom macroglobulinemia (WM), a rare malignant disorder, occurs as a result of abnormal proliferation of lymphocytes that produce immunoglobulin M. In rare cases, WM complicates by type I cryoglobulinemia. Type I cryoglobulinemia usually presents with cutaneous manifestations such as Raynaud's phenomenon, purpura, necrosis, and gangrene. Various medical conditions, including thrombotic events, rheumatologic disorders, and malignancies, may present with skin discoloration and necrosis. Patients suffering from malignant diseases who initially present with skin manifestations usually are misdiagnosed by physicians. Here, we describe a 72-year-old man presenting with a 6-month acrocyanosis and progressive skin necrosis who was misdiagnosed by physicians. Finally, he was diagnosed to have WM associated with type I cryoglobulinemia. Though uncommon, hematologic malignancies can present with cutaneous manifestations. In some cases, patients may manifest with skin disorders alone. Early and prompt treatment of these diseases may save the patient life, relieve patient symptoms, and increase life quality.

Mucocutaneous Findings in Hematolymphoid Neoplasms: An Observational Study

Background

Cutaneous manifestations of hematological neoplasms can be divided into three broad categories - direct infiltration, paraneoplastic conditions, and those due to the treatment of hematological cancers.

Objectives

To study the frequency and patterns of mucocutaneous manifestations in patients with hematolymphoid neoplasms and those due to chemotherapy.

Materials and Methods

This was an observational study done with 172 patients. Categorization of mucocutaneous manifestations was done into malignancy-associated and chemotherapeutic drugs-associated and data was analyzed.

Results

Out of a total of 172 patients, 15.6% (27/172) had malignancy-related mucocutaneous manifestations. Among these, 4.6% (8/172) had direct infiltration of malignant cells into the skin and 11% (19/172) had paraneoplastic manifestations. The most common chemotherapy-related mucocutaneous manifestations were nail changes - 47.1% (81/172), of which transverse melanonychia was the most common (20.9%). About 44.2% (76/172) had a cutaneous infection, the commonest of which was a fungal infection (15.1%). Chemotherapy-induced alopecia was noted in 46.5% (80/172) and found to be significantly associated with cytarabine, daunorubicin, doxorubicin, methotrexate, and vincristine. Cutaneous hyperpigmentation was found to be significantly associated with cytarabine, doxorubicin, and vincristine.

Conclusion

Mucocutaneous manifestations cause additional discomfort to a patient undergoing chemotherapy. Early recognition and timely and appropriate management facilitate symptom control and prevent treatment-related morbidity. A multidisciplinary approach involving hemato-oncologists and dermatologists can help achieve this target.

Acanthosis Nigricans Manifesting as a Paraneoplastic Syndrome Associated With Cholangiocarcinoma

We present the case of a 64-year-old woman with type 2 diabetes who was diagnosed with early-stage intrahepatic cholangiocarcinoma and underwent partial hepatectomy followed by adjuvant chemotherapy. The patient simultaneously developed skin lesions compatible with acanthosis nigricans (AN). Thirty-seven months after completing chemotherapy, the patient had a recurrence of extensive skin and mucosal lesions compatible with AN. A thoracic-abdominal-pelvic (TAP) CT showed a relapse with hepatic hilar adenopathy. Currently, she is under evaluation to undergo radical treatment. Malignancy is a rare cause of AN and skin lesions can arise before, during, or after the diagnosis. As a paraneoplastic syndrome, it is usually related to gastric adenocarcinoma, with cholangiocarcinoma being a rare entity in this setting. Although an uncommon manifestation, the malignant etiology should be considered among other prevalent causes, such as metabolic disorders, and establishing an association can lead to an early diagnosis and initiation of curative treatment.

Subacute cutaneous lupus erythematosus: A facultative paraneoplastic dermatosis

Subacute cutaneous lupus erythematosus (SCLE) is a photosensitive dermatosis characterized by a nonscarring papulosquamous eruption and specific antibodies in the patient's serum. Genetic and environmental factors represent the leading causes of SCLE; however, several case reports in the literature link SCLE to various types of cancer. This review assesses the association between SCLE and neoplastic disorders. A PubMed search was performed for all relevant publications on cancer-associated SCLE from 1982 to 2022. This review supports the hypothesis that SCLE should be considered a facultative paraneoplastic phenomenon. It also emphasizes the importance of cancer screening in patients presenting SCLE manifestations.

Pharyngeal-Esophageal Malignancies with Dermatologic Paraneoplastic Syndrome

Systemic changes often send signals to the skin, and certain neoplastic diseases of the internal organs can also trigger skin manifestations. In this article, the authors make clinical photography presentations of the patients seen at our clinic with dermatologic paraneoplastic syndromes within pharyngeal–esophageal malignancies, describe several paraneoplastic dermatoses, and also review high-quality scientific literature in order to be able to highlight the dermatological signs of pharyngoesophageal malignant tumors. The majority of our patients with paraneoplastic dermatoses, filtering for pharyngoesophageal malignancies, had esophageal neoplasms, out of whom seven were female and two were male, making esophageal cancer more common within the paraneoplastic dermatoses within pharyngoesophageal malignancies. An early recognition of paraneoplastic dermatoses can diagnose neoplasms and sequentially contribute to a better prognosis for the patient. This matter is also useful for front-line medical personnel in order to improve early diagnosis of the underlying malignancy, curative interventions with prompt therapy administration and good prognosis.

Cutaneous metastases of internal malignancies: a single-institution experience

Aims

Cutaneous metastases of internal malignancies occur in 1–10% of cancer patients. The diagnosis can sometimes be challenging, especially in cases with an unknown primary cancer.

Materials and methods

A retrospective case review was performed including all cases of skin metastases from primary internal malignancies diagnosed at the Department of Pathology at the Maastricht University Medical Centre+ from 2007 to 2021. The clinicopathological data were collected and immunohistochemical and molecular diagnostic tests were performed to confirm the primary origin of the metastases.

Results

We identified 152 cases (71 female; 31 male patients) of cutaneous metastases of internal malignancies. 28 patients (20 women and 8 men) were diagnosed with multiple cutaneous metastases. Among the female patients, the most common primary tumour was breast cancer (50% of the cases), followed by lung (13.6%), gynaecological (7.3%), and gastrointestinal origin (7.3%). Among the male patients, the most common primary sites were gastrointestinal and lung origin (altogether, 50% of the cases). In 19 patients, the cutaneous metastasis was the first presentation of a clinically silent internal malignancy (18.6%), of which most (78.9%) represented metastatic lung carcinomas. Finally, metastasizing patterns were different across tumour types and gender.

Conclusion

Breast, lung, gastrointestinal, and gynaecologic cancers are the most common primary tumours demonstrating skin metastases. Infrequently, cutaneous metastases can be the first clinically visual manifestation of an underlying not yet diagnosed internal malignancy; therefore, occasional broad immunohistochemical profiling, molecular clonal analysis, and a continuous high level of awareness are necessary for a precise diagnosis of cutaneous metastases of internal malignancies.

Paraneoplastic autoimmune hypophysitis: An emerging concept

Pituitary autoimmunity is one of the principal causes of hypopituitarism. Additionally, hypophysitis is one of the immune-related adverse events associated with immunotherapy. Recent case-oriented research has revealed a novel type of autoimmune hypophysitis, anti-PIT-1 hypophysitis, related to isolated adrenocorticotropic hormone (ACTH) deficiency and immune checkpoint inhibitor-related hypophysitis, as a form of paraneoplastic syndrome. Under these conditions, the ectopic expression of pituitary antigens present in tumors evokes a breakdown of immune tolerance, resulting in the production of autoantibodies and autoreactive cytotoxic T cells that specifically harm pituitary cells. Consequently, an innovative clinical entity of paraneoplastic autoimmune hypophysitis has been purported. This novel concept and its underlying mechanisms provide clues for understanding the pathogenesis of autoimmune pituitary diseases and can be applied to other autoimmune diseases. This review discusses the etiology of paraneoplastic autoimmune hypophysitis and its future.

Clinical, Pathological, and Molecular Features of Breast Carcinoma Cutaneous Metastasis

Cutaneous metastases (CMs) account for 2% of all skin malignancies, and nearly 70% of CMs in women originate from breast cancer (BC). CMs are usually associated with poor prognosis, are difficult to treat, and can pose diagnostic problems, such as in histopathological diagnosis when occurring long after development of the primary tumor. In addition, the molecular differences between the primary tumors and their CMs, and between CMs and metastases in other organs, are not well defined. Here, we review the main clinical, pathological, and molecular characteristics of breast cancer CMs. Identifying molecular markers in primary BC that predict CM and can be used to determine the molecular differences between primary tumors and their metastases is of great interest for the design of new therapeutic approaches.

[Hyperplasia-associated cutaneous paraneoplasia]

BACKGROUND

Hyperplasia-associated cutaneous paraneoplasia is an important differential diagnosis in everyday clinical practice. An early diagnosis of the underlying tumor disease can significantly improve the patient's prognosis.

PATHOGENESIS

Hyperplasia is probably mainly cytokine-mediated. The primary tumor and/or the metastases release growth factors and transcription factors which, via epidermal growth factors, lead to hyperproliferation of keratinocytes.

ACANTHOSIS NIGRICANS MALIGNA

Symmetrical mainly intertriginous hyperpigmentation with partially verrucous hyperplasia and lichenification mostly in association with gastric adenocarcinoma. Special forms are florid cutaneous papillomatosis and tripe palms. Pseudoacanthosis nigricans is to be distinguished (metabolic and hormonal disorders). LESER-TRéLAT SYNDROME: Eruptive occurrence of seborrheic keratosis associated with visceral tumors.

ACROKERATOSIS BAZEX

Erythema and scaling initially at the bridge of the nose, ear helix and acra with later spread, associated with tumors of the upper aerodigestive system. It should be clinically differentiated from psoriasis.

THERAPY

The treatment of the primary tumor is decisive, which also leads to a decrease of cutaneous symptoms. Reappreance suggests tumor recurrence.

Diagnosis of an occult gastric adenocarcinoma by oral manifestations (acanthosis nigricans): A case report

BACKGROUND

Acanthosis nigricans (AN) is a condition with an important characteristics of symmetrical areas of thickened skin with grayish brown hyperpigmentation. The mucosa may show a papillomatous surface, with or without hyperpigmentation. Lips and sites at risk of trauma may be affected and palmoplantar keratosis might also be present. In some rare cases, acanthosis nigricans presents as a sign of internal neoplasia, mostly a gastrointestinal cancer, and is called malignant acanthosis nigricans (MAN).

CASE PRESENTATION

In this study, a 55-year-old female Iranian patient with malignant acanthosis nigricans (MAN) is reported. She was seeking esthetic treatment for her oral and perioral regions. The peculiarity of this case is simultaneous skin manifestation consistent with MAN, "tripe palms" (TP) and Leser-Trélat (LT) sign and mucosal changes in the oral cavity such as papillomatosis and roughened surfaces of the lips, hard palate and buccal mucosa. These changes harbored gastric adenocarcinoma stage T3 N3, but the patient was asymptomatic except for pruritis.

CONCLUSION

There is an urgent need to suspect a correlation between oral and skin changes and the possibility of an internal neoplasia, therefore it is of utmost importance to refer these patients for early diagnosis of the underlying disease. This would improve the prognosis and lessen the consequences to a great extent.

A Rare Case of Erythema Gyratum Repens Associated With Esophageal Carcinoma

Rash is a common complaint in a primary care setting. Erythema gyratum repens (EGR) is a unique rash strongly associated with malignancy. Sometimes this rash can precede the clinical presentation of malignancy, most commonly lung carcinoma. Even though this is an uncommon rash, physicians need to be aware of this condition for the prompt evaluation of malignancy to start the therapy. In this report we present the case of a 61-year-old gentleman with stage IV squamous cell carcinoma of the esophagus who presented with EGR two months after the diagnosis of his malignancy. The diagnosis was made based on clinical exam and histological findings. The patient was reassured and the rash was managed conservatively. Chemotherapy was continued and the rash was resolved in two months.

Unremitting chronic skin lesions: a case of delayed diagnosis of glucagonoma

A 54-year-old Caucasian male with history of hypertension, hyperlipidemia, insulin-dependent diabetes mellitus, and chronic skin rash of 4 years presented to the emergency department with worsening rash and weight loss. Physical examination revealed diffuse erythematous rash, skin ulceration, bullae with associated paresthesia in the lower extremities, trunk, bilateral upper extremities, and palms and soles. A computed tomography (CT) scan with contrast showed a large, heterogenously enhancing pancreatic mass measuring 9.4 × 3.8 cm with surrounding low-attenuation soft tissue thickening. Blood tests showed hemoglobin A1C of 10.0%. Glucagon level was elevated to 2,178 (normal < 80 pg/dl). Endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) from the pancreatic mass was suggestive of pancreatic endocrine tumor. The tumor cells were positive for synaptophysin, chromogranin, CD56, and pan-cytokeratin with focal positivity for glucagon, suggestive of glucagonoma. The patient underwent distal pancreatectomy along with splenectomy and cholecystectomy. The glucagon level normalized to 25 pg/dl within a week of tumor resection, and during his 6-week outpatient follow up, skin rash had completely resolved.

Malignant acanthosis nigricans as a paraneoplastic manifestation of metastatic breast cancer

Malignant acanthosis nigricans is a rare paraneoplastic syndrome, usually associated with a gastric adenocarcinoma and less frequently with other neoplasms. In general, its appearance indicates a poor prognosis with a survival of < 2 years. We describe the case of a 40-year-old patient who presented with generalized cutaneous thickening that had a velvety appearance, was rapidly progressing, and involved right axillary adenopathy. Skin and nipple biopsy yielded results consistent with acanthosis nigricans, and palpable adenopathy biopsy results were compatible with mammary adenocarcinoma (human epidermal growth factor receptor 2 positive and estrogen and progesterone receptor negative) without a detectable primary tumor. This case of malignant acanthosis nigricans is presented because of the importance of its early recognition as a paraneoplastic syndrome and its relation with mammary adenocarcinoma, an association infrequently reported in the literature.

Obligate and facultative paraneoplastic dermatoses: an overview

Dermatological paraneoplastic syndromes are a group of cutaneous diseases associated with malignancy, but not directly related to the primary tumor itself or to its metastases. It is of utmost importance for the dermatologist to recognize the major cutaneous paraneoplastic syndromes to diagnose the underlying tumors that trigger them as early as possible. In this overview, skin conditions that are highly correlated with malignancy, whose recognition implies a mandatory investigation of internal cancer, are described.

Leser-Trélat Sign Presenting in a Patient with Relapsing Mycosis Fungoides

The Leser-Trélat sign is a rare sign of some malignant tumors and is characterized by the sudden appearance of seborrheic keratosis in association with an underlying malignancy. We describe a 60-year-old Saudi man with mycosis fungoides (MF) who developed numerous, rapidly growing, seborrheic keratoses on his face and back. To the best of our knowledge, this is the first reported case of MF with the Leser-Trélat sign from Saudi Arabia.

Branch Duct-type Intraductal Papillary Mucinous Neoplasm Presenting as Paraneoplastic Small Plaque Para-psoriasis

To present and discuss a novel association between branch duct-type intraductal papillary mucinous neoplasm and paraneoplastic parapsoriasis. We present the case of a middle-aged male presenting with skin lesions that were suggestive of parapsoriasis, resistant to treatment, and in whom a diagnosis of branch-type intraductal papillary mucinous neoplasm of the pancreas was eventually made. A curative Whipple's surgery led to complete resolution of the skin lesions within 3 weeks. Paraneoplastic parapsoriasis in association with intraductal papillary mucinous pancreatic neoplasm has never been reported before.

Skin: A mirror of internal malignancy

Skin manifestations are a reflection of many of the internal diseases. Sometimes, skin disease may be the only manifestation of the internal disease. Internal malignancies may give rise to a number of cutaneous manifestations through their immunological, metabolic, and metastatic consequences. Curth proposed criteria to establish a causal relationship between a dermatosis and a malignant internal disease. Malignancy can present with a plethora of cutaneous manifestations. Here, we describe in brief about various skin manifestations of internal malignancies.

Seborrheic Keratoses as the First Sign of Bladder Carcinoma: Case Report of Leser-Trélat Sign in a Rare Association with Urinary Tract Cancer

Introduction. Skin disorders can be the first manifestation of occult diseases. The recognition of typical paraneoplastic dermatoses may anticipate the cancer diagnosis and improve its prognosis. Although rarely observed, the sudden appearance and/or rapid increase in number and size of seborrheic keratoses can be associated with malignant neoplasms, known as the sign of Leser-Trélat. The aim of this report is to unveil a case of a patient whose recently erupted seborrheic keratoses led to investigation and consequent diagnosis of bladder cancer. Case Presentation. A 67-year-old man was admitted to the intensive care unit due to an exacerbation of chronic obstructive pulmonary disease (COPD). On physical examination, multiple seborrheic keratoses on the back of the hands, elbows, and trunk were observed; the patient had a 4-month history of these lesions yet was asymptomatic. The possibility of Leser-Trélat syndrome justified the investigation for neoplasia, and a bladder carcinoma was detected by CT-scan. The patient denied previous hematuria or any other related symptoms. Many of the lesions regressed during oncologic treatment. Conclusion. Despite the critics on the validity of the sign of Leser-Trélat, our patient fulfills the description of the disease, though urinary malignancy is a rare association. That corroborates the need of further investigation when there is a possibility of paraneoplastic manifestation.

Unusual Paraneoplastic Presentation of Cholangiocarcinoma

Introduction. Cutaneous paraneoplastic syndromes are a heterogeneous group of skin manifestations that occur in relation to many known malignancies. Paraneoplastic occurrence of SCLE has been noted but is not commonly reported. SCLE association with cholangiocarcinoma is rare. Case Presentation. A 72-year-old man with a history of extrahepatic stage IV cholangiocarcinoma presented with a pruritic rash. Cholangiocarcinoma had been diagnosed three years earlier and was treated. Five months after interruption of his chemotherapy due to a semiurgent surgery, he presented with explosive onset of a new pruritic rash, arthralgias, and lower extremity edema. Physical exam revealed a scaly erythematous rash on his arms, hands, face, neck, legs, and trunk. It was thick and scaly on sun exposed areas. Skin biopsy revealed vacuolar interface dermatitis. Immunofluorescence revealed IgM positive cytoid bodies scattered along the epidermal basement membrane zone. PET-CT scanning revealed metabolically active recurrent disease in peripancreatic and periportal region with hypermetabolic lymph nodes. Oral steroids and new regimen of chemotherapy were started. Rash improved and steroids were tapered off. Discussion. Paraneoplastic syndromes demonstrate the complex interaction between the immune system and cancer. Treatment resistant SCLE should raise a suspicion for paraneoplastic etiology.

Acanthosis nigricans: A fold (intertriginous) dermatosis

Acanthosis nigricans (AN) is a mucocutaneous disorder that is characterized by focal or diffuse hyperkeratotic, surfaces, which are symmetrically distributed hyperpigmented lesions of the skin. It rarely affects mucosal surfaces like oral cavities. Although it is commonly seen in adolescents, AN is also increasingly seen in children who are obese. Recent studies have found that AN can be a cutaneous indicator of insulin resistance and malignancy. Acanthosis nigricans has been associated with type 2 diabetes mellitus, obesity, endocrinopathies, drugs, and malignancies.

Immunohistochemical distinction of primary sweat gland carcinoma and metastatic breast carcinoma: can it always be accomplished reliably?

OBJECTIVES

Even with adequate history, the distinction of cutaneous metastatic breast carcinoma from primary sweat gland carcinoma can be difficult. Although previous studies have attempted to separate these tumors with various immunohistochemical panels, those series have been limited by small numbers of patients as well as the inclusion of benign sweat gland tumors.

METHODS

In this analysis, stains for p63, CK5/6, and D2-40 were included, as well as GATA3 and mammaglobin, in an evaluation of 21 primary sweat gland carcinomas and 33 examples of cutaneous metastatic breast carcinoma.

RESULTS

Immunoreactivity for p63, CK5/6, D2-40, GATA3, and mammaglobin was respectively observed in 81%, 71%, 52%, 71%, and 5% of sweat gland carcinomas compared with 6%, 6%, 6%, 91%, and 45% of metastatic breast carcinomas. These differences were statistically significant for p63, CK5/6, and D2-40. For the diagnosis of metastatic breast carcinoma, GATA3 was the most sensitive marker (91%), but its sensitivity was substantially lower. Mammaglobin was 95% specific for breast carcinoma but again suffered from limited sensitivity (45%) in this context.

CONCLUSIONS

These data suggest that p63 and CK5/6 are specific determinants for sweat gland carcinoma in the stated setting. In the absence of those analytes, metastatic breast carcinoma cannot always be identified to the exclusion of a primary tumor. This diagnostic scenario continues to require the procurement of a detailed clinical history regarding the number and duration of skin lesions in any given case.

Bazex syndrome revealing a gastric cancer

We herein report the case of a 73-year-old woman who developed skin and nail disorders 2 months before her digestive symptoms started, which lead to the diagnosis of gastric adenocarcinoma. The lesions were diagnosed as Bazex syndrome, usually seen in squamous cell carcinoma. Under systemic chemotherapy, the cutaneous signs improved for some months before worsening when the disease progressed.

Acquired ichthyosis triggered by an osseous hemangiopericytoma: a case report and review of the literature

Ichthyoses are a heterogeneous group of cutaneous keratinization disorders that can be congenital or acquired. Apart from neoplastic disorders, the acquired form of ichthyosis (AI) has been associated with a variety of diseases including infections, autoimmune/inflammatory and endocrine/metabolic diseases as well as nutritional conditions, medications and others. However, malignancy accounts for half of the reported cases, most commonly including lymphoproliferative disorders. We present a case of AI as a paraneoplastic skin manifestation of a primary, osseous hemangiopericytoma (HP) accompanied by multiple liver metastases. We also review the literature and discuss the necessity of investigating underlying diseases, especially malignancy, when adult-onset ichthyosis arises.

Paraneoplastic cutaneous manifestations: concepts and updates

The skin often signals systemic changes. Some neoplastic diseases that affect internal organs may trigger several cutaneous manifestations. Although these dermatoses are relatively unusual, the recognition of some typical paraneoplastic dermatoses may lead to the early diagnosis of a neoplasm and determine a better prognosis. In this review article, we discuss the paraneoplastic cutaneous manifestations strongly associated with neoplasms, which include acanthosis nigricans maligna, tripe palms, erythema gyratum repens, Bazex syndrome, acquired hypertrichosis lanuginosa, necrolytic migratory erythema, Leser-Trélat sign and paraneoplastic pemphigus. We also review the clinical manifestations of each condition and include updated knowledge on disease pathogenesis.

Cutaneous manifestations of systemic malignancies: part 2

The skin can be key to early diagnosis of systemic malignancies. In the second part of this review, we present various skin conditions that can, in certain contexts, reveal the presence of malignancy. The skin conditions are presented in groups based on a diverse range of morphological characteristics. Specifically, the following groups are analyzed: erosive and blistering lesions; inflammatory papules and nodules; xerosis, ichthyosis, and generalized exfoliative dermatitis; symptoms such as pruritus; abnormal hair distribution patterns; sweating disorders; benign tumors that can form part of hereditary syndromes associated with a risk of visceral cancer; and finally, oral and nail abnormalities. This review highlights the importance of the skin in the study of systemic malignancies.

Cutaneous alerts in systemic malignancy: part I

The aim of this review is to familiarize dermatologists and clinicians in general with cutaneous signs and symptoms that can help lead to an early diagnosis of an underlying malignancy. Because the skin is one of the most accessible organs, it should never be overlooked in systemic disease. Examination of the skin has the advantage of revealing important information about the patient's condition without requiring the use of invasive techniques. In the literature, most discussions of cutaneous manifestations of internal malignancy refer to classic paraneoplastic syndromes, but a wide variety of skin conditions, while not strictly paraneoplastic, can, in certain contexts, indicate the presence of malignancy or an increased risk of developing cancer later in life. In this review, various skin conditions that can signal malignancy or increased cancer risk are presented in randomly ordered groups based on clinical morphology. Conditions with multiple signs and symptoms have been classified on the basis of their most characteristic feature.

Acanthosis nigricans and "tripe palm" as paraneoplastic manifestations of metastatic tumor

Acanthosis nigricans is a common dermatosis and is most often associated with benign conditions, such as insulin resistance. It is rare as a paraneoplastic marker. As such, it is characterized by sudden onset and rapid dissemination of velvety and hyperchromic skin lesions. The term "tripe palm" refers to exaggeration of the palmar ridge pattern, which resembles the internal surface of the bovine intestinal tract. This is a paraneoplastic marker of high specificity, with 90% of the cases being associated with malignancy. We report the case of a patient with stage IV ovarian adenocarcinoma presenting acanthosis nigricans and tripe palm. Both findings are closely correlated to the neoplasm course.

Cutaneous metastases from internal malignancies: a clinicopathologic and immunohistochemical review

Skin metastases occur in 0.6%-10.4% of all patients with cancer and represent 2% of all skin tumors. Skin metastases from visceral malignancies are important for dermatologists and dermatopathologists because of their variable clinical appearance and presentation, frequent delay and failure in their diagnosis, relative proportion of different internal malignancies metastasizing to the skin, and impact on morbidity, prognosis, and treatment. Another factor to take into account is that cutaneous metastasis may be the first sign of clinically silent visceral cancer. The relative frequencies of metastatic skin disease tend to correlate with the frequency of the different types of primary cancer in each sex. Thus, women with skin metastases have the following distribution in decreasing order of frequency of primary malignancies: breast, ovary, oral cavity, lung, and large intestine. In men, the distribution is as follows: lung, large intestine, oral cavity, kidney, breast, esophagus, pancreas, stomach, and liver. A wide morphologic spectrum of clinical appearances has been described in cutaneous metastases. This variable clinical morphology included nodules, papules, plaques, tumors, and ulcers. From a histopathologic point of view, there are 4 main morphologic patterns of cutaneous metastases involving the dermis, namely, nodular, infiltrative, diffuse, and intravascular. Generally, cutaneous metastases herald a poor prognosis. The average survival time of patients with skin metastases is a few months. In this article, we review the clinicopathologic and immunohistochemical characteristics of cutaneous metastases from internal malignancies, classify the most common cutaneous metastases, and identify studies that may assist in diagnosing the origin of a cutaneous metastasis.

Cutaneous manifestations of breast carcinoma

The incidence of breast carcinoma cutaneous manifestation in patients with breast carcinoma is 23.9%. The most common sites of breast carcinoma cutaneous manifestation are the chest wall and abdomen, but they can occur at the extremities and in the head/neck region. Due the high incidence of breast carcinoma, these cutaneous manifestations are the most common metastases seen by dermatologists. In clinical practice, cutaneous metastases show a wide range of clinical manifestations. Nodules are the most common presentation, but several other patterns are described below.

Pigmented lesions of the vulva

Approximately one of every 10 women has a pigmented vulvar lesion. Given the risk of melanomas and pigmented vulvar intraepithelial neoplasia (squamous cell carcinoma in situ), proper evaluation of vulvar pigmented lesions is critical. Most vulvar lesions are benign; however, vulvar lesions grossly, dermoscopically, and histologically can appear atypical compared with pigmented lesions on the rest of the body. Thus, it is imperative to use not only a keen eye but also a low threshold for biopsy.