Skin manifestations of internal malignancy

A Case of Syringocystadenocarcinoma Papilliferum: Not Your Usual Suspect

Syringocystadenocarcinoma papilliferum (SCACP) is an exceptionally rare cutaneous adnexal tumor that is infrequently encountered by clinicians worldwide. The tumor typically appears in the older population, affecting patients in their fifth and sixth decades of life without male or female predominance. Patients frequently present with a variable-sized hyperpigmented ulcerative lesion containing an exudate that has a long-standing course of progression from its benign counterpart, Syringocystadenoma papilliferum (SCAP). Additionally, the clinical presentation and morphology of the neoplasm can be easily confused with a variety of other skin cancers, such as squamous cell carcinoma (SCC), basal cell carcinoma (BCC), cutaneous lymphoma, and cutaneous metastasis. Therefore, histopathology and tissue analysis play an essential role in establishing an accurate diagnosis. However, the lesion is so rare that no definitive diagnostic markers have been established yet. We present a case of SCACP localized to the scalp of the patient. Our case study highlights the presence of specific tumor markers that could potentially serve as objective criteria for diagnosis.

An important problem in an aging country: identifying the frailty via 9 Point Clinical Frailty Scale

OBJECTIVES

Frailty is a geriatric syndrome which develops as a result of cumulative decline in many physiological systems and results in an increased vulnerability and risk of adverse outcomes. The Clinical Frailty Scale (CFS) was validated as a predictor of adverse outcomes in community-dwelling older people and evaluates items such as comorbidity, cognitive impairment and disability. We aimed to study the concurrent and construct validity and reliability of the 9 point CFS in Turkish Population.Methods: This study was designed as a cross-sectional study. Participants, who were admitted to a geriatric medicine outpatient clinic, were included. Validity of 9 point CFS was tested by its correlation with the assessment and opinion of an experienced geriatric medicine specialist and Fried frailty phenotype. Test-retest and inter-rater reliability analyses were also performed.Results: Median age of the 118 patients was 74.5 years (min: 65 max: 88) and 64.4 % were female. The concordance of CFS and experienced geriatric medicine specialist's opinion was excellent (Cohen's K: 0.80, p < 0.001).The concordance of CFS and Fried Frailty phenotype was moderate (Cohen's K: 0.514, p < 0.001).CFS inter-rater reliability and test-retest reliability was very strong (Cohen's K: 0.811, p < 0.001 and Cohen's K: 1.0, p < 0.001, respectively).Conclusions: CFS appears to be a quick, reliable and valid frailty screening tool for community-dwelling older adults in the Turkish population.

Emergence of KRAS p.G13D mutation and acquired resistance to cetuximab in colorectal cancer with vulvar metastasis: A case report

RATIONALE

Vulvar metastasis of colorectal cancer (CRC) and acquired resistance to cetuximab is a very rare phenomenon. To our knowledge, few cases have been reported in the English literatures.

PATIENT CONCERNS

A 55-year-old woman was diagnosed as adenocarcinoma of the rectum and the primary tumor was detected to be Kirsten-RAS (KRAS) wild type.

DIAGNOSES

The patient was diagnosed with rectal adenocarcinoma by colonoscopy. Positron emission tomography/computed tomography (PET-CT) revealed multiple lymph node and bone metastases.

INTERVENTIONS

The patient received a first-line course of palliative chemotherapy with FOLFOX combined with cetuximab.

OUTCOMES

After an initial response, acquired resistance to cetuximab occurred and vulvar metastasis was established by a second biopsy. Further molecular analysis showed that the KRAS mutation was detected in plasma samples and tumor tissues.

LESSONS

Vulvar metastasis from CRC is relatively rare and indicates a poor prognosis. Routine physical examinations of cutaneous and subcutaneous may facilitate early detection of metastases and timely intervention of medical technology. Moreover, combining serial tumor biopsy, liquid biopsy, and radiologic imaging could help to define mechanisms of drug resistance and to guide selection of therapeutic strategies.

Carcinoid Syndrome-Induced Scleroderma-Like Disease

Scleroderma is a rare complication of carcinoid syndrome and is usually encountered in the setting of a metastatic primary neuroendocrine tumour of the distal ileum. Associated endocardial fibrosis is a frequent finding and the condition carries a poor prognosis. We report a case of scleroderma occurring in a 72-year-old female with metastatic neuroendocrine carcinoma and associated pericardial fibrosis. The use of an alternative nomenclature such as “scleroderma-like” or “sclerodermoid” disease is proposed in order to emphasise its distinction from true idiopathic scleroderma, despite the histopathological similarities on skin biopsy.

Metastatic Dermatosis in Breast Carcinoma on Adjuvant Trastuzumab: Is Skin a Sanctuary Site in Human Epidermal Growth Factor Receptor-2-Amplified Disease?

Cutaneous metastasis (CM) from internal malignancies is commonly seen. Sometimes, skin metastases can be the first sign of advanced cancer or an indicator of cancer recurrence. Cases of breast cancer with cutaneous progression after or during trastuzumab therapy have been described in the past, frequently associated with systemic disease progression. However, CM during adjuvant trastuzumab therapy is very rare. It has been hypothesized that cancer cells located in the skin survive and take proliferative advantage by virtue of an immune-tolerance mechanism that hampers trastuzumab-mediated antibody-dependent cell-mediated cytotoxicity. We describe a case of human epidermal growth factor receptor-2-overexpressing breast cancer presenting with diffuse CM during adjuvant trastuzumab therapy.

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.

Subcutaneous metastases from early stage esophageal adenocarcinoma case report

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Subcutaneous metastases from esophageal adenocarcinoma are rare.

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Associated risk factors have not been clearly elucidated and prognosis is poor.

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We present three cases of subcutaneous metastases from esophageal adenocarcinoma.

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These metastases can occur even after resection of early stage disease.

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They can occur at various intervals of time and various locations.

The identification of subcutaneous metastatic lesions from primary visceral malignancies has increased over time, probably due to an increase in the awareness of their presentation and an increase in cancer survival times. Although the rate of subcutaneous metastases from breast,lung and colon cancer is more significant, the incidence of subcutaneous metastases from esophageal carcinomas is very low. These metastatic lesions usually present metachronously and may signify advanced disease and poor prognosis. We report three cases with early stage esophageal adenocarcinoma treated with surgery with curative intent presenting with subcutaneous metastases two months, two years and three years after their esophagectomy.

Cutaneous Metastasis from Signet-ring Gastric Adenocarcinoma in a Carcinoma En Cuirasse Pattern: An Unusual Clinical-diagnostic Sequence

Cutaneous metastasis (CM) of gastric adenocarcinoma (ADC) is rare and usually presents late in the course of the disease. We report a rare case of carcinoma en cuirasse (CEC) pattern of CM secondary to gastric malignancy in a 55-year-old male patient—the interesting part being that CM was the first-presenting sign, which on further histopathological and immunohistochemical evaluation led to the diagnosis of hidden gastric carcinoma. The finding of signet ring cells (SRCs) on cutaneous biopsy further added a differential of the rare possibility of primary cutaneous tumors.

The presentation, pathology, and current management strategies of cutaneous metastasis

Skin metastases are rare in the routine clinical practice of dermatology, but are of major clinical significance because they usually indicate advanced disease. We reviewed the literature on skin metastasis regarding recent trends in clinical presentation and diagnosis of the most common cutaneous lesions. An extensive literature review was conducted using PubMed from May 26, 2011 to July 16, 2013 relating cutaneous metastases. Articles chosen for reference were queried with the following prompts: “Cutaneous metastases”, “clinical presentation”, “histological features”, and “immunohistochemistry”. Further searches included “treatment” and “management” options for “metastatic breast”, “metastatic colorectal”, “metastatic melanoma”, “metastatic lung”, and “hematologic cancers.” We also reviewed the literature on the current management of melanoma as a model for all cutaneous metastatic disease. Our own clinical findings are presented and compared to the literature. Additionally, we highlight the most useful immunohistochemical studies that aid in diagnoses. Several novel therapies and combination therapies such as electrochemotherapy, vemurafenib, and imiquimod will be discussed for palliative treatment of cancers that have been found to improve cutaneous lesions. We review these notable findings and developments regarding skin metastases for the general dermatologist.

Case series of different onset of skin metastasis according to the breast cancer subtypes

We report on five cases of skin metastasis according to the breast cancer (BC) subtype. Two cases of HER2 positive BC showed only skin metastasis after immediate postoperative period and rapid clinical response to targeted therapy. Another two cases of triple negative BC showed thyroid and lung metastasis in addition to skin metastasis, and their response of cytotoxic chemotherapy was not definite. The other hormone positive BC showed skin metastasis only, with a longer, slower, less progressive pattern than other subtypes. Most cases of skin metastasis were detected at terminal stage of malignancy and were considered to have a limited survival period. However, some BC patients can survive longer if the targeted agents are effective. Therefore, physicians should provide detailed follow up of BC after curative treatment and understand the metastatic pattern of BC according to the subtype.

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.

Cutaneous metastases of internal tumors

Cutaneous metastases are relatively rare in clinical practice and their diagnosis requires a high index of suspicion because clinical findings can be subtle. These metastases reveal the presence of disseminated malignant disease and can lead to the diagnosis of unsuspected internal tumors or the spread or recurrence of an already diagnosed tumor. Early recognition of cutaneous metastases can facilitate prompt and accurate diagnosis resulting in early treatment; however, they are generally indicative of a poor prognosis. Some tumors have a predilection to metastasize to specific areas. Recognition of these patterns provides essential information that can guide the search for the underlying tumor.

Cutaneous relapse of an ampullary carcinoma: an unusual presentation

This is the first ever reported case about a cutaneous relapse of small bowel adenocarcinoma. The ampulla of Vater is the area of the small bowel that presents more frequently malignant transformation, nevertheless ampullary adenocarcinomas are rare but aggressive diseases. However, distant metastases are infrequent. Cutaneous metastases constitute the 5.3% of skin tumours, and are usually found in the 12% of malignancies. Their management usually includes local treatment if they are unique and systemic treatment when they are multiple. Chemotherapy schemes used in ampullary adenocarcinoma are those used in cholangiocarcinomas, pancreas and tumours of the gallbladder; nevertheless, given the intestinal origin of these tumours combinations of capecitabine and oxaliplatin are commonly used.

Diagnosis and treatment of cutaneous paraneoplastic disorders

The skin plays a critical role in the detection of internal malignances. Cutaneous signs of these disorders afford clinicians opportunities for early diagnosis and treatment. We aim to succinctly review the recognition, diagnosis, and treatment of selected cutaneous paraneoplastic diseases. Skin disorders that may be associated with paraneoplastic syndromes include: cutaneous metastases, tripe palms, Sweet's syndrome, glucagonoma, Paget's disease and extramammary Paget's disease, acanthosis nigricans, Birt-Hogg-Dube syndrome, basal cell nevus syndrome, Bazex syndrome (acrokeratosis paraneoplastica), carcinoid syndrome, Cowden's disease(multiple hamartoma syndrome), dermatomyositis, erythema gyratum repens, ichthyosis aquisita, von Recklinghausen's disease, pityriasis rotunda, pyoderma gangrenosum, Quincke's edema (angioedema and paraneoplastic uricaria), paraneoplastic pemphigus, Degos' disease, superior vena cava syndrome, Werner's syndrome, diffuse normolipemic plane xanthomas, and yellow nail syndrome. Treatment for these disorders depends on the nature and anatomic distribution of the primary neoplastic process.

Cutaneous metastases from internal malignancies

Cutaneous metastases of internal malignancies still seem to occur infrequently, although medical publications report an incidence rate of up to 10.4%. Common sense, however, fosters suspicion that we might underdiagnose the problem distracted by harder striking facets of an advanced disease. With contemporary knowledge, morphology and behavior of cutaneous metastases resemble each other regardless of the site of origin. This article itemizes clinical presentations according to organ systems, specific features, and differential diagnoses. In general, the survival turned out to be less than 12 months. But incremental awareness of cutaneous metastases proclaims this paradigm insufficient. Although excision is the local treatment of choice, investigations attempt to propose tumor-specific chemotherapeutic/immunological approaches. This paper endeavors to critically review the state of the art concerning the clinic, prognosis, and therapeutic concepts.

Cutaneous metastases of visceral tumours: a review

BACKGROUND

Up to 10% of all visceral malignancies develop cutaneous metastases. As cutaneous metastases are underestimated and underdiagnosed they can be a clinical challenge. The clinical appearance and patterns of distribution of cutaneous metastases, the characterisation of clinical outcomes and available therapeutic options are compiled.

PATIENTS AND METHODS

Literature (over the last 6 years) MESH in terms of cutaneous metastases was comprehensively evaluated. Characteristics from 92 available cases are elaborated and adjusted with terms (time unlimited) of published epidemiological reviews to single organs.

RESULTS

The broad clinical spectrum with differential diagnoses is displayed. An allocation of cutaneous metastases and a particular organ is not reliable. In 22% of all cases cutaneous metastases can lead to the diagnosis of an internal malignoma. The majority of cases reveal cutaneous metastases to emerge in a tumour-free interval in about 36 months, after a successful treatment of the primary tumour, most commonly along with other organ metastases. Probable survival turned out to be less than 12 months. Consistently with this end-stage condition, treatment aligns with rules of palliation. Local treatment of choice is excision. Only a minority of investigators attempted to come up with tumour-specific treatment strategies, and almost no randomised therapy studies can be presented.

CONCLUSION

A reference guide of cutaneous metastases is given; the clinical spectrum is adjusted to an actual status; state of the art of the treatment is accomplished. An epidemiological, improved registration and diagnostic work-up for targeted therapies in conjunction with dermatologists are favoured.

Acral metastasis in a patient with ampullary carcinoma

Although skin metastasis from a malignant tumor of an internal organ usually occurs at an advanced disease stage, there has been no prior report of a cutaneous acral metastasis from ampullary carcinoma to date. We report a 71-year old male patient with cutaneous metastasis from an ampullary adenocarcinoma. The patient had a history of pylorus preserving pancreaticoduodenectomy for carcinoma of the ampulla of Vater two years prior to presentation. Physical examination revealed ill-defined, painful and hard erythematous nodules at the left thumb and distal phalanx of the right middle finger. The computed tomography scan showed low density masses in the retroperitoneum; the histological examination of a nodule from the right middle finger showed a metastatic adenocarcinoma. This case illustrates that cutaneous metastasis from ampullary carcinoma has a poor prognosis.

Acanthosis Nigricans in Patients with Nonalcoholic Steatohepatitis: An Uncommon Finding

OBJECTIVE

To determine the prevalence and the metabolic characteristics of acanthosis nigricans (AN) in a group of 28 study subjects with biopsy-proven nonalcoholic steatohepatitis (NASH).

METHODS

The study participants (15 female and 13 male patients, 20 of whom were white subjects; mean body mass index, 32.7 +/- 5.7 kg/m2; mean age, 45.7 +/- 11.3 years) underwent an oral glucose tolerance test (OGTT), frequently sampled intravenous glucose tolerance test (FSIGT), and fasting metabolic panels. AN status was clinically determined, and fat mass was measured by dual-energy x-ray absorptiometry.

RESULTS

All study subjects had insulin resistance (IR), and 15 (54%) had the metabolic syndrome (by Adult Treatment Panel III criteria). Of the 28 patients, 4 (14%) had AN (AN+) and 24 did not (AN-). AN+ subjects had a higher body mass index (37.7 +/- 5.6 versus 31.5 +/- 4.3 kg/m2), fat mass (38.9 +/- 4.0 versus 29.2 +/- 2.3 kg), and leptin levels (17.2 +/- 3.9 versus 9.3 +/- 1.6 ng/mL) (P<0.05). They also had significantly higher indices of insulin secretion: fasting and stimulated insulin and C-peptide levels from OGTT and FSIGT. Metabolic syndrome prevalence was 40% in AN- versus 75% in AN+ subjects (not significantly different). Although the AN+ group had significantly lower fasting and OGTT-derived indices of insulin sensitivity in comparison with the AN- group, their FSIGT indices were similar. Waist circumference (a surrogate of visceral adiposity) and cytokine profiles were similar in the AN+ and AN- groups.

CONCLUSION

AN was not highly prevalent in our study cohort with NASH, despite the high prevalence of IR. Hyperinsulinemia and total adiposity, rather than visceral adiposity and IR, were the indices most predictive of AN. The use of AN as an index of IR in patients with NASH appears to have limited diagnostic value.

Clinical and pathologic findings of paraneoplastic dermatoses

Paraneoplastic dermatoses comprise a heterogeneous group of noninherited skin conditions that manifest internal malignancy. Familiarity with paraneoplastic dermatoses is important to both clinician and pathologist alike, as recognition of such a condition offers opportunity for early diagnosis and treatment of internal malignancy; monitoring for tumor recurrence; and insight into pathophysiology which may yield possible clues to treatment. Herein are reviewed 16 of the best established paraneoplastic dermatoses that display distinctive clinical and pathologic findings.

LEARNING OBJECTIVE

At the conclusion of this leaning activity, participants should be able to recognize, diagnose, and describe the clinical and pathologic findings of paraneoplastic dermatoses.

Current status of gastrointestinal carcinoids

Gastrointestinal (GI) carcinoids are ill-understood, enigmatic malignancies, which, although slow growing compared with adenocarcinomas, can behave aggressively. Carcinoids are classified based on organ site and cell of origin and occur most frequently in the GI (67%) where they are most common in small intestine (25%), appendix (12%), and rectum (14%). Local manifestations--mass, bleeding, obstruction, or perforation--reflect invasion or tumor-induced fibrosis and often result in incidental detection at emergency surgery. Symptoms are protean (flushing, sweating, diarrhea, bronchospasm), usually misdiagnosed, and reflect secretion of diverse amines and peptides. Biochemical diagnosis is established by elevation of plasma chromogranin A (CgA), serotonin, or urinary 5-hydroxyindoleacetic acid (5-HIAA), while topographic localization is by Octreoscan, computerized axial tomography (CAT) scan, or endoscopy/ultrasound. Histological identification is confirmed by CgA and synaptophysin immunohistochemistry. Primary therapy is surgical excision to avert local manifestations and decrease hormone secretion. Hepatic metastases may be amenable to cytoreduction, radiofrequency ablation, embolization alone, or with cytotoxics. Hepatic transplantation may rarely be beneficial. Chemotherapy and radiotherapy have minimal efficacy and substantially decrease quality of life. Intravenously administered receptor-targeted radiolabeled somatostatin analogs are of use in disseminated disease. Local endoscopic excision for gastric (type I and II) and rectal carcinoids may be adequate. Somatostatin analogues provide the most effective symptomatic therapy, although interferon has some utility. Overall 5-year survival for carcinoids of the appendix is 98%, gastric (types I/II) is 81%, rectum is 87%, small intestinal is 60%, colonic carcinoids is 62%, and gastric type III/IV is 33%.

Cutaneous signs and syndromes associated with internal malignancies

Cutaneous changes may indicate the presence of or herald the incipient development of internal malignancies. The authors review 24 cutaneous signs, symptoms, diseases, and syndromes associated with internal malignancies. Early recognition of these cutaneous changes may allow for vigilance for, and prompt detection and management of, the underlying neoplasm.

Carcinoid tumors and fibrosis: an association with no explanation

Carcinoid tumors are slow-growing neuroendocrine neoplasms most commonly associated with the gut and broncho-pulmonary system. In many instances, they are identified at surgery for unexplained bowel obstruction or during exploration of the small bowel in search of a primary tumor once distant metastases have been detected. Carcinoid tumors of the small bowel often present with pronounced fibrosis in the peri-tumoral tissues, distant in the heart or lungs, and locally in the peritoneal cavity. Despite medical and therapeutic advances that have alleviated symptoms and prolonged life, a substantial subset of patients develops mesenteric and small bowel carcinoid fibrosis and/or carcinoid heart disease. Fibrosis, and increasingly cardiac heart disease, are important components of intestinal carcinoid disease and are of considerable clinical concern, as both of these conditions reflect a connective tissue disorder whose etiology, biology, and therapy are unknown. In the past, individuals with carcinoid disease died of metastasis and uncontrollable symptomatology. Currently, there exists no clinical method to determine the development of fibrosis and little is understood about the biological basis of fibrosis. The elucidation of the biology and management of fibrosis is thus an issue of paramount clinical and scientific importance in determining appropriate diagnostic and therapeutic strategy. Therefore, the unraveling of the molecular events indicative of fibrosis in these cells and the identification of appropriate therapeutic targets is of considerable patient-care relevance. We have surveyed the world literature over the past 40 yr to evaluate both the incidence of carcinoid processes and track the evolving understanding of this process. In addition, we have provided more current mechanistic information in regard to the biological basis of fibrosis associated with small bowel carcinoid tumors.

Cutaneous paraneoplastic syndromes in dogs and cats: a review of the literature

Cutaneous paraneoplastic syndromes are a group of noncancerous dermatoses associated with internal malignancy. Their recognition can facilitate detection and timely treatment of underlying cancer. More than 30 such disorders have been identified in the human scientific literature, whereas only a few are described in veterinary medicine. This may reflect a lower incidence in animals than in people or may be the result of failure to recognize an association between certain skin lesions and neoplasia. Establishing a relationship between a cutaneous disorder and neoplasia can be difficult unless the skin lesions are rare and almost always associated with a particular tumour type, as is the case for most recognized veterinary paraneoplastic dermatoses. Among these are feline paraneoplastic alopecia, feline thymoma-associated exfoliative dermatitis, nodular dermatofibrosis, feminization syndrome associated with testicular tumours, superficial necrolytic dermatitis and paraneoplastic pemphigus. The aetiology of most cutaneous paraneoplastic syndromes has remained elusive in both people and animals.

Eruptive melanotic macules and papules associated with adenocarcinoma

BACKGROUND

Malignancies may be associated with paraneoplastic cutaneous manifestations, including pigmentary disorders.

METHODS

The clinical findings were reviewed. Skin and tumor tissue samples were examined by routine histology, immunohistochemistry, and in one case also by electron microscopy.

RESULTS

Two patients developed diffuse melanotic macules and papules associated with visceral adenocarcinoma. One patient was a 64-year-old man with advanced carcinoma of the distal esophagus. The other was a 62-year-old man with metastatic pulmonary adenocarcinoma. The detection of the primary tumor in both patients was preceded by the rapid onset of melanotic macules and papules in the anogenital region and in one patient also around both nipples. The pigmented lesions were histologically characterized by a lentiginous melanocytic proliferation of large and heavily pigmented melanocytes associated with hyperpigmentation of adjacent keratinocytes. Both patients had been misdiagnosed as having epidermotropic metastatic malignant melanoma. None of them had prior, concurrent, or subsequent cutaneous or extracutaneous invasive melanoma. Both patients died of metastatic adenocarcinoma.

CONCLUSION

Eruptive melanotic macules and papules represent an under-recognized paraneoplastic syndrome. The cases illustrate a diagnostic pitfall for clinicians and pathologists unaware of this phenomenon.