Clinical and pathologic findings of paraneoplastic dermatoses

F-18-FDG PET/CT findings of paraneoplastic dermatoses

Paraneoplastic dermatoses (PD) are defined as nonspecific skin disorders which are associated with internal neoplasms, but without direct association to primary tumors or metastases. Recognition of PD and the following surveillance may lead to the diagnosis of internal malignant neoplasms including early stage ones. Accurate imaging examinations in the following searching is essential in identifying the underlying neoplasms. Since whole-body 18-fluoro-2-deoxyglucose (F-18-FDG)-positron emission (PET)/computed tomography (CT) has been widely used in early diagnosis, staging of various malignant tumors, it may play a role for detection of underlying or occult malignant neoplasms in patients with PD. However, to date, only a few reports of FDG PET/CT findings of the associated neoplasms in PD patients have been cited in the literature. The present paper shows the cases of FDG-avid associated neoplasms in patients with PD in our 10-year experience in our institute, and reviews the well-known and/or relatively common PD and their associated neoplasms, and the previously reported cases of FDG-avid associated neoplasms in these patients.

Bullous pemphigoid associated with squamous cell lung carcinoma showing remarkable response to carboplatin-based chemotherapy: a case report

Background

Bullous pemphigoid is an uncommon dermatologic manifestation seen in squamous cell lung cancer, and evidence guiding optimal treatment, especially in the elderly population, is limited. We report herein a case of squamous cell lung cancer diagnosed after being investigated for refractory bullous pemphigoid showing marked response to carboplatin-based chemotherapy. This is the first case report that shows carboplatin can be used as an effective alternative in treatment of malignancy-associated bullous pemphigoid.

Case report

An 80-year-old caucasian man developed extensive vesiculobullous rashes on his trunk, chest, abdomen, and inguinal region associated with significant pruritus causing sleep disturbance. The diagnosis of bullous pemphigoid was confirmed on skin biopsy. The skin lesions continued to worsen even after use of oral and topical steroid in addition to oral doxycycline. Chest computed tomography revealed a spiculated left lung lesion along with mediastinal lymphadenopathy. Fine-needle aspiration from the mediastinal lymph node confirmed metastatic squamous cell lung carcinoma. Carboplatin with gemcitabine was initiated, and significant response was seen within 3 days of chemotherapy. The skin lesions continued to remain in remission even after stopping the chemotherapy.

Conclusion

Although there are still controversies regarding paraneoplastic etiology of bullous pemphigoid, this case presents a temporal association. It is the first case report showing a remarkable response with the use of a carboplatin-based regimen.

The protective role of etoricoxib against diethylnitrosamine/2-acetylaminofluorene-induced hepatocarcinogenesis in Wistar rats: The impact of NF-κB/COX-2/PGE2 signaling

BACKGROUND

Liver cancer ranks as the 7th and 5th leading cause of cancer morbidity worldwide in men and women, respectively. Hepatocellular carcinoma (HCC) is the most common type of liver cancer and is associated with an increasing global burden of nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH).

OBJECTIVE

The present study aimed to investigate the possible chemopreventive effect of etoricoxib on diethylnitrosamine (DENA) and 2-acetylaminofluorene (2AAF)-induced HCC in male Wistar rats.

METHODS

HCC was induced by DENA (150 mg/kg/week; i.p) for 2 weeks, then 2AAF (20 mg/kg; p.o) every other day for three successive weeks. Etoricoxib (0.6 mg/kg, p.o.) was given to DENA/2AAF-administered rats for 20 weeks.

RESULTS

Etoricoxib significantly suppressed alpha-fetoprotein (AFP) and carbohydrate antigen 19-9 (CA19.9) as liver tumor biomarkers. It also decreased serum aspartate aminotransferase (AST), alanine aminotransferase (ALT), and total bilirubin levels while increasing serum albumin levels. Besides, it alleviated DENA/2AAF-induced histopathological abrasions and inflammatory cell infiltration. Furthermore, etoricoxib showed a potent antioxidant effect, supported by a significant lipid peroxide reduction and elevation in superoxide dismutase and GSH content activity. In addition, Etoricoxib significantly down-regulated the protein expression of interleukin 1 beta (IL-1β), tumor necrosis factor α (TNFα), nuclear Factor-kappa B (NF-κB), phosphorylated nuclear Factor-kappa B (p-NF-κB), cyclooxygenase-2 (COX-2), and prostaglandin E2 (PGE2).

CONCLUSION

In conclusion, the current results proved that etoricoxib possesses an anticarcinogenic effect via its antioxidant, anti-inflammatory, and modulation of NF-κB/COX-2/PGE2 signaling.

Cutaneous toxicities occurring during palbociclib (CDK4/6 inhibitor) and endocrine therapy in patients with advanced breast cancer: a single-centre experience

PURPOSE

Treatment with Palbociclib, a cyclin-dependent kinase 4/6 inhibitor, has demonstrated significantly improved progression-free survival in patients with hormone receptor-positive, HER2-negative, advanced breast cancer, when used in combination with letrozole or fulvestrant endocrine therapies. However, limited information exists on its cutaneous adverse effects (AE). Hence, we conducted a retrospective cohort study to investigate the prevalence and management of cutaneous AE during palbociclib and endocrine therapy.

METHOD

We included 324 adult patients with advanced breast cancer who received palbociclib between March 2016 and August 2020 within a tertiary comprehensive cancer centre. Patient demographics, details of previous and concurrent treatments, as well as treatment-related cutaneous AE were recorded from electronic records.

RESULTS

The incidence of treatment-related cutaneous AE was 14.2% (46 from a total of 324 patients). The most frequent cutaneous reactions included maculopapular rash (41%), asteatosis (37%), pruritus and urticaria (20%), and bullous dermatitis reactions (9%). We identified two patients with treatment-induced subacute cutaneous lupus erythematosus, one case of bullous pemphigoid, and a single erythema multiforme. Patients received an average of 9 cycles of treatment, completing an average of 6 cycles before developing cutaneous AE, which persisted for a median of 43 days. Only 15% (n = 7) of affected patients required temporary suspension, and 4% (n = 2) required discontinuation. The majority were managed with potent topical steroids, with oral corticosteroids being required in 3 patients, and one patient required hydroxychloroquine.

CONCLUSION

Our study describes both the spectrum of cutaneous AE of palbociclib and endocrine therapy, and approaches to management. Prompt management may limit the negative impact on patients, facilitating beneficial continuation of palbociclib and endocrine therapy.

Sweet syndrome as a paraneoplastic manifestation of cholangiocarcinoma: A case report

BACKGROUND

Sweet’s syndrome, also known as acute febrile neutrophilic dermatosis, is a rare skin disorder that may be associated with cancer.

CASE SUMMARY

A 58-year-old female presented with a cholestatic syndrome and significant weight loss three months before admission. Five months earlier, she had abruptly developed skin lesions with erythematous papules that evolved to erythematous blisters. Clinical evaluation and laboratory tests confirmed hepatic cholangiocarcinoma. Skin lesions histopathological findings showed neutrophilic dermatosis, massive edema, fibrin, necrosis, and elastosis. These results, in association with the macroscopic aspects of the findings, led to the diagnosis of paraneoplastic Sweet’s syndrome due to cholangiocarcinoma. As staging was consistent with an advanced tumor without a cure perspective, we opted to perform percutaneous biliary drainage, and subsequently, palliative care. Eventually, after a few weeks, the patient died.

CONCLUSION

In conclusion, the diagnosis of the underlying disease-causing Sweet’s syndrome must be accurate, and patients need to be followed-up, as neoplasia such as cholangiocarcinoma may be a later manifestation.

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.

Erythroderma as first manifestation of squamous cell lung cancer: rare case report

Erythroderma as the first manifestation of a solid organ malignancy is rare. The underlying cancer is a challenging condition to diagnose. There are a few cases of erythroderma in cancer patients reported in the literature. We here describe the case of a 70-year-old man who presented with asthenia, weight loss, dry cough and total body erythema with desquamation over the past month. A chest computed tomography scan showed a nodular lesion, which was finally diagnosed as a squamous cell lung carcinoma. To our knowledge, as an erythroderma presentation, only 13 cases have been reported in the literature. This case report demonstrates the need to search for a neoplasm in patients presenting with erythroderma, particularly in the presence of accompanying debilitating symptoms.

Synchronous Occurrence of Bazex Syndrome and Remitting Seronegative Symmetrical Synovitis with Pitting Edema Syndrome in a Patient with Lung Cancer

A 69-year-old man developed bilateral polyarthritis, edematous extremities, and skin desquamation on the fingers and ears. He did not meet the criteria for any connective tissue disease, including rheumatoid arthritis. An examination revealed advanced lung cancer. His systemic manifestations were attributed to paraneoplastic Bazex syndrome and remitting seronegative symmetrical synovitis with pitting edema (RS3PE) syndrome. Treatment with pembrolizumab (an anti-programmed death-1 antibody) for lung cancer relieved his symptoms and shrank the lung tumor. Bazex and RS3PE syndromes are rare paraneoplastic diseases. We herein report this unique case of synchronous development of these two paraneoplastic syndromes in the presence of advanced lung cancer.

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.

Erythema gyratum repens: a rare paraneoplastic rash

Erythema gyratum repens (EGR) is a rare and characteristic, paraneoplastic rash associated with a variety of malignancies, most notably lung, esophageal, and breast cancers. This case report details the appearance, epidemiology, diagnosis, and treatment of EGR. Prompt identification of EGR is essential, as the rash often precedes the diagnosis of malignancy by several months. Urgent patient referral to evaluate for malignancy is crucial, as this may lead to decreased morbidity and mortality.

Neoplastic/paraneoplastic dermatitis, fasciitis, and panniculitis

The skin changes outlined in this article can be important clues to an underlying malignancy. Paraneoplastic dermatoses are skin disorders associated with an underlying neoplasm and whose course parallels that of the neoplasm. Recognizing these skin presentations leads to early diagnosis and management of the underlying malignancy. Effective treatment of the associated neoplasm often leads to improvement of the cutaneous manifestations and should be the primary focus of each patient's management.

Erythroderma as a paraneoplastic cutaneous disorder in systemic anaplastic large cell lymphoma

BACKGROUND

  Paraneoplastic cutaneous disorders (PCDs) or dermadromes are skin conditions that have an association with internal malignancies but are not themselves malignant. We report the first two cases of systemic anaplastic large cell lymphoma (s-ALCL) accompanied by erythroderma and multiple leg ulcers as PCDs. CASE 1:  A 52-year-old Japanese man presented with disseminated itchy papular erythemas which he had over his entire body for the preceding 5 years that later exacerbated to erythroderma. Multiple punched-out ulcers also developed on his lower legs. Superficial lymph nodes (LNs) were swollen, and a left axillary LN biopsy demonstrated dense CD30(+) atypical large cell (ALC) infiltration. By contrast, lymphocytes infiltrating into the erythroderma and leg ulcers were CD30(-) , and T-cell receptor β (TCRβ) chain gene rearrangement was negative in skin biopsy specimens. Thus, he was diagnosed with s-ALCL. Not only his s-ALCL but also his erythroderma and leg ulcers responded well to chemotherapy. CASE 2:  A 71-year-old Japanese woman presented with erythroderma that persisted for approximately 20 years after mastectomy. At her initial hospital visit, she was diagnosed with s-ALCL by biopsy of swollen left inguinal LNs. Similar to Case 1, CD30(+) ALCs were negative in skin samples with normal TCRβ chain gene rearrangement. As the erythrodermic skin lesion responded well to chemotherapy for s-ALCL, it was considered a PCD.

CONCLUSION

  s-ALCL development may be predicted by the precedence and concurrence of intractable paraneoplastic erythrodermic and ulcerative skin lesions, as reported in our two cases.

Cutaneous manifestations of internal malignancies in a tertiary health care hospital of a developing country

In a public hospital in Lima, Peru, 24 patients with 16 types of paraneoplastic dermatoses were identified by data collection. The most frequent dermatosis was dermatomyositis (four patients). The other dermatoses were malignant acanthosis nigricans, palmoplantar keratoderma, bullous dermatoses, lymphomatoid papulosis, edematous scarring vasculitic panniculitis, Norwegian scabies, primary systemic amyloidosis, necrolytic migratory erythema, infective dermatitis, pancreatic panniculitis, generalized pruritus, Lesser-Trelat syndrome, and acquired ichthyosis. Most of these paraneoplastic dermatoses were diagnosed before (45.8%) or at the time of (38.5%) the diagnosis of the underlying malignancy. The most frequent underlying malignancies were lymphoma, adenocarcinomas of the upper digestive tract, and malignant neoplasms of the pancreas. The average age of the patients was 47.0 ± 16.9 years and the length of the disease since diagnosis was 13.7 months. The mortality rate was 75%. Paraneoplastic dermatoses are rare dermatologic entities that are difficult to diagnose. Surveillance is also hampered when patients do not have easy access to health care centers due to financial and geographical issues. However, when identified, they might facilitate the early diagnosis of an associated tumor and contribute to increase the surveillance of patients.

Medical and surgical management of paraneoplastic pyoderma gangrenosum--a case report and review of the literature

We present a case of a 44-year-old male with pyoderma gangrenosum (PG) presenting simultaneously with diagnosis of acute leukemia. His skin disease was stabilized with corticosteroids and most lesions cleared after chemotherapy-induced remission of the malignancy, but the largest lesion remained necrotic. Surgical treatment of the large necrotic ulcer included debridement followed by split-thickness skin graft while maintaining corticoid therapy. Unfortunately, relapse of the pyoderma gangrenosum with bullous lesions heralded relapse of the ultimately fatal malignancy. This case illustrates: (1) PG presenting simultaneously with a haematologic malignancy (2) Relapse with atypical bullous lesions with return of the malignancy and (3) The use of surgical modalities in managing patients with PG, a disease notorious for surgical complications.

Seborrhoeic keratoses in patients with internal malignancies: a case-control study with prospective accrual of patients

BACKGROUND

The association between the eruption of numerous seborrhoeic keratoses as a result of an underlying malignancy is controversially discussed. The aim of this case-control study with prospective accrual of patients was to determine whether a direct association exists between the number seborrhoeic keratoses and internal malignancies.

METHODS

The numbers and sites of seborrhoeic keratoses were counted in 150 oncological patients and 150 matched controls. Additionally, the presence or absence of pruritus, acanthosis nigricans, and the sudden appearance of seborrhoeic keratoses were assessed.

RESULTS

Seborrhoeic keratoses did not differ significantly between patients with internal malignancies and controls. Only two patients fulfilled the criteria of the Leser-Trélat sign, defined as the eruption of numerous seborrhoeic keratoses as a cutaneous marker of an underlying internal malignancy.

CONCLUSION

No association was found between seborrhoeic keratoses and cancer. Furthermore, our data did not provide support to the validity of the Leser-Trélat sign in patients with internal malignancies.

Synchronous orofacial granulomatosis and mucoepidermoid carcinoma: paraneoplastic syndrome or coincidence?

Some malignant neoplasias induce the appearance of local or systemic manifestations at distant sites, which can act as indicators of their presence in a process named paraneoplastic syndrome. Granulomatous reactions have already been described related to malignancies. This report describes a case of synchronous orofacial granulomatosis and mucoepidermoid carcinoma and discusses the significance of this association.

[Sézary syndrome and Leser-Trélat sign: a chance association?]

BACKGROUND

Leser-Trélat sign involves the combined sudden onset of seborrheic keratosis and cancer. However, some doubt surrounds the existence of this syndrome. We report a case of Leser-Trélat sign that led to the discovery of Sézary syndrome.

PATIENTS AND METHODS

A 59-year-old woman presented generalized pruritus with secondary appearance of multiple seborrheic keratosis. Leser-Trélat sign was diagnosed and 20 months later, Sézary syndrome was discovered. Extracorporeal photopheresis was initiated, after which there was a marked reduction in the patient's pruritus, erythroderma and numbers of seborrheic keratoses and Sézary cells.

DISCUSSION

Leser-Trélat sign is often associated with gastric carcinoma or lymphoproliferative tumours. Rampen and Schwengle [J Am Acad Dermatol 21 (1989) 50-5] have thrown doubt on this entity because of the "subjective" definition, the frequent dissociation between the course of the tumour and that of the seborrheic keratosis, the disparity between the frequency with which rapid onset seborrheic keratosis is seen and the rarity of cases in which this phenomenon reveals a tumour and the absence of association with any specific type of malignancy. The time between diagnosis of Sézary syndrome and cutaneous symptoms of Leser-Trélat sign appears very long in the present case. In the absence of any established physiopathology, it is impossible to prove any direct link between these two syndromes. Leser-Trélat sign remains controversial. Knowledge of its pathogenesis could help determine whether Leser-Trélat sign should or should not be considered a paraneoplastic syndrome.

Caso para diagnóstico

Relata-se caso de erythema gyratum repens em paciente do sexo masculino, de 40 anos, com eritema disseminado, pruriginoso, bizarro, figurado, com fina descamação nas bordas. Na primeira consulta, os exames laboratoriais e a radiografia do tórax foram normais. Durante acompanhamento clínico foi diagnosticado câncer de pulmão por tomografia computadorizada de tórax, tendo a imuno-histoquímica da biópsia da linfonodomegalia inguinal confirmado o pulmão como sítio primário.