Melanoma, growth factors, acanthosis nigricans, the sign of Leser-Trélat, and multiple acrochordons. A possible role for alpha-transforming growth factor in cutaneous paraneoplastic syndromes

Variability of Leser-Trélat Sign Secondary to Melanoma In Situ

Leser-Trélat sign (LTS) is characterized as an eruptive display of multiple seborrheic keratoses (SKs) in association with malignancy. This case highlights the variable presentation of LTS secondary to melanoma. To our knowledge, this LTS pattern is the first case where the sign manifests as a subtle pattern secondary to melanoma. This stands in contrast to the five documented cases in the literature of LTS-melanoma, which exhibited distinctive and eruptive patterns. A 64-year-old Caucasian female presented for a wellness examination. No personal history of skin cancer was noted. Patient displayed an onset proliferation of SKs with an irregular, sub-centimeter macular nevus over her right lateral mid back. A 6mm punch biopsy was significant for melanoma in situ, arising within a lentiginous compound dysplastic nevus, focally abutting one peripheral tissue edge. A re-excision with a minimum of 5mm margins was completed and the specimen was negative for residual in situ melanoma. Because of the rare occurrence of this delicate pattern at the site of the melanoma, this presentation adds to the knowledge surrounding this diagnosis. This case emphasizes the importance of maintaining vigilance regarding skin manifestations associated with disease and highlights the critical importance of observation and identification of subtle physical exam findings.

COVID-19 infection and Leser-Trelat sign: Is there an association?

Key Clinical Message

The etiology of the Leser-Trélat sign is still unknown, it is likely that viral infections like COVID-19 can be associated with eruptive seborrheic keratosis, although the exact pathogenesis is still not clear, but this phenomenon can be due to TNF-alpha and TGF-alpha and immunosuppression condition as well as in COVID-19 infection.

Abstract

Seborrheic keratosis is a typical benign skin lesion that is almost always seen in elderly populations. The sudden increase in size or an increase in the number of these lesions is called Leser-Trelat sign, this sign is suggesting as a paraneoplastic appearance of internal malignancy. But, Leser-Trelat sign is also described in some nonmalignant conditions, for example, human immunodeficiency virus infection and human papillomavirus infection. Herein, we describe a patient with Leser-Trelat sign after recovery from COVID-19 infection with no evidence of internal malignancy. This case was partially presented as a poster in the 102nd Annual Congress of British Association of Dermatologists in Glasgow, Scotland from July 5 2022 to July 7 2022. British Journal of Dermatology, 187, 2022 and 35. The patient signed written informed consent to permit the publication of the case report without identifying data and to use the photography for publication. The researchers committed to maintaining patient confidentiality. Institutional ethics committee approved the case report (ethics code: IR.sums.med.rec.1400.384).

The Pseudo-Sign of Leser-Trélat: A Rare Presentation

The true sign of Leser-Trélat is a rare cutaneous marker suggestive of an underlying malignancy. Its hallmark finding is the abrupt onset of multiple seborrheic keratoses (SKs) that increase rapidly in number and/or size within weeks to months. When the ominous finding is present, the associated tumor is usually aggressive and portends a poor prognosis. The "pseudo-sign" of Leser-Trélat also presents with the rapid onset of multiple SKs, but without any underlying disease. It is less well-known, and there are only a few reports documenting the phenomenon. This paper reports the case of an 89-year-old male who presented with multiple SKs that rapidly progressed over his scalp, neck, arms, back, trunk, and legs within two to three weeks. A clinical workup revealed elevated pancreatic tumor markers. His cancer antigen (CA) 19-9 levels were 52 U/mL (normal range 0-37 U/mL). Computed tomography (CT) of his abdomen/pelvis without intravenous (IV) and oral contrast showed no evidence of cancer. Bothersome SKs, such as those where his clothes were rubbed against, were destroyed via cryotherapy or shave removal under local anesthesia depending on their size. The patient has remained without any symptoms or findings of an underlying malignancy, confirming that his presentation was consistent with the pseudo-sign of Leser-Trélat. Because it can be concerning when a patient suddenly develops multiple large SKs, recognition of the pseudo-sign is important to determine the appropriate course of action.

Eruptive Seborrheic Keratoses Are Associated With a Co-Occurring Malignancy in the Majority of Reported Cases: A Systematic Review

BACKGROUND

Eruptive seborrheic keratoses (ESK) is a benign skin condition that has been associated with malignant and nonmalignant diseases. We conducted a systematic review of reported cases of ESK to identify and summarize associated comorbidities.

METHODS

MEDLINE and Embase were searched from database inception (1946) to July 31, 2020 for original articles describing ESK with or without a co-occurring condition. Subject demographics, as well as details of ESK and associated diagnoses were extracted from 76 articles (70 case reports, 3 case series, 3 case control studies) representing 92 patients.

RESULTS

In total, 76.1% (n = 70/92) of patients with ESK had a co-occurring malignancy, 4.3% (n = 4/92) presented with a nonmalignant condition, 9.8% (n = 9/92) experienced ESK as an adverse drug reaction, and 9.8% (n = 9/92) did not report any underlying medical condition. ESK preceded a cancer diagnosis in 76.1% (n = 70/92) of patients with a mean latency period of 4.0 months (range: 0.25-9 months). The most common malignancies associated with ESK were cutaneous T-cell lymphoma (n = 10/70, 14.3%) and gastrointestinal adenocarcinoma (n = 9/70, 12.9%). ESK preceded nonmalignant conditions or no disease in 14.1% (n = 13/92) of patients with a mean latency period of 3.1 months (range: 0.75-6 months). Drug-induced ESK occurred in 9.8% (n = 9/92) of patients with a mean latency period of 7.1 weeks after changing medication.

CONCLUSION

Although the role of ESK as a paraneoplastic cutaneous marker is debated, healthcare providers should consider screening for underlying malignancy in patients presenting with ESK. Larger studies are needed to confirm its role as a marker for disease.

Laser-Trélat sign improved after the resection of a tiny ground-grass nodule: a case report

The Laser-Trélat sign refers to eruptive seborrheic keratoses accompanied by internal malignancies, mainly abdominal advanced ones. Detailed associations remain unclear, and the skin lesions do not improve with the treatment of internal malignancies in half of the patients. Herein, we report a rare case of Laser-Trélat sign that improved after resection of a 0.6-cm pulmonary ground-glass nodule: adenocarcinoma in situ. The patient requested the resection with the hopes of improving the skin lesions, though immediate resection was not indicated oncologically. With informed consent, despite possible failure in improving cutaneous diseases, thoracoscopic partial resection of the right lower lobe was performed. Fortunately, her seborrheic keratoses substantially improved after the resection, without exacerbation. To our knowledge, this is the first report describing such a clinical course. It is essential to inform patients regarding the indication of treatment for internal malignancy and its limitation in improving eruptive seborrheic keratoses.

[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.

Paraneoplastic syndromes in cholangiocarcinoma

Paraneoplastic syndromes are the symptoms or signs which result from damage to tissues that are distant from the site of malignancy, due to complex interactions between the body’s immune system and malignant neoplasm. Cholangiocarcinoma (CCA) is an aggressive epithelial malignancy of hepatobiliary tree and it is found to be associated with various paraneoplastic syndromes. These syndromes can present as dermatological, neurological, renal, hematological, or multi-systemic manifestations. Clinical suspicion and timely recognition of these syndromes can lead to early diagnosis of covert malignancies like CCA. The management plan remains the removal of the underlying cause which in this case is CCA.

Leser-Trélat sign as a rare manifestation of cutaneous melanoma

Leser-Trélat Sign (LTS) is a rare paraneoplastic syndrome characterized by the sudden eruption of multiple seborrheic keratoses in patients with internal malignancy, commonly localized in the gastrointestinal tract. We report an 80-year-old female patient showing a rapid increase in the number and size of seborrheic keratosis associated with the diagnosis of a cutaneous nodular melanoma (Breslow thickness: 4.5 mm) located on the right flank. After the excision of melanoma, subsequent staging procedures resulted negative, moreover no evidence of melanoma recurrence and no changes of the seborrheic keratoses was detected after a follow-up of 52 months. Although the association between melanoma and Leser Trelat sign is rare, an accurate skin examination with the aid of dermatoscopy searching for undiagnosed skin cancers, should be suggested in patient with sudden eruption of keratosis seborrheic to early diagnose and treat a possible melanoma.

Cutaneous manifestations of internal malignancy

Skin lesions associated with internal malignancy may present as cutaneous metastases or as typical lesions occurring in the context of certain cancer-associated genetic syndromes. Paraneoplastic syndromes, on the other hand, are only indirectly associated with an underlying malignancy and are not malignant per se. Historically, a distinction has been made between "obligate" and "facultative" paraneoplastic disorders, depending on the likelihood with which they are potentially associated with malignancy. In addition, there are nonspecific cutaneous manifestations that are only rarely associated with an underlying malignancy. Another possible classification is based on the pathophysiological mechanisms underlying the cutaneous lesions. In everyday practice, it is essential that dermatologists recognize potentially cancer-associated dermatoses, as this will frequently contribute to the initial diagnosis of an underlying neoplasm.

[Malignant acanthosis nigricans associated with cholangiocarcinoma]

INTRODUCTION

Acanthosis nigricans is a dermatosis characterized by the presence of a hyperpigmented, velvety cutaneous thickening in the flexural areas, especially axillary and inguinal fossas, and lateral faces of the neck. AN is usually a benign condition but can sometimes reveal an internal malignancy corresponds to a cutaneous paraneoplasic syndrome. Literature shows a predominant association with gastric adenocarcinoma. Here, we report a rare association between AN and cholangiocarcinoma.

CASE REPORT

We report a 43-year-old woman who presented an extensive AN associated to a tripe palms syndrome and florid cutaneous papillomatosis. She consulted in dermatology because of the itchiness of the lesions as well as for esthetics reasons. Complementary investigations enabled to diagnose a cholangiocarcinoma without visceral metastasis and she was treated by tumor resection and chemotherapy. Consequently, a slight improvement of the skin condition and the disappearance of pruritus were observed.

CONCLUSION

AN should be considered as cutaneous sign either of malignancy or endocrinopathy and therefore requires further investigations. The existence of extensive lesions, pruritus, tripe palms syndrome, florid cutaneous papillomatosis or mucous lesions, associated to an AN is a sign of malignancy should be investigated urgently the early diagnosis of which can lead to a better prognosis.

Acanthosis Nigricans - A Two-Sided Coin: Consider Metabolic Syndrome and Malignancies!

BACKGROUND

Acanthosis nigricans (AN) is acquired hyperpigmentation of the intertriginous body regions. Histologically, AN is characterised by a thickened stratum corneum and a variable amount of acanthosis. Although benign and rarely symptomatic, AN may be a red flag for underlying pathologies.

CASE PRESENTATION

We analysed our patients with AN and could differentiate three different patterns, that are illustrated by one case report each. The is the benign AN associated with metabolic syndrome including obesity. The second type is the paraneoplastic AN malignancy which is associated with a wider range of malignancies. This type may occur before, after or with the clinical appearance of the malignancy. The third type is relapsing AN after complete remission. We present a patient who had a malignant AN and was treated successfully for his cancer. Years later, however, AN relapsed. In that case in association with the appearance of skin tags. Cancer restaging excluded a tumour relapse. His BMI was 31.2 kg/m², and the diagnosis of benign AN was confirmed.

CONCLUSIONS

The diagnosis of AN remains incomplete without screening for metabolic syndrome and/ or cancer. The combination of AN and skin tags is more often associated with metabolic syndrome. AN may be considered as a red flag for malignancies and the metabolic syndrome.

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.

Cutaneous paraneoplastic syndromes

A variety of cutaneous abnormalities can be seen in patients with malignant diseases, some of which are infectious, with others representing direct involvement of the skin by the underlying disorder. Yet another group of lesions can be regarded as associated markers of the malignant process, and, as such, are termed "paraneoplastic." This review considers the latter collection of conditions, grouping them by the generic type of malignancy that is usually linked to the paraneoplasia. Some of the processes show a predominant association with alimentary tract malignancies (acanthosis nigricans, acrodermatitis paraneoplastica, florid cutaneous papillomatosis, necrolytic migratory erythema, palmoplantar keratoderma, pancreatic fat necrosis, and pityriasis rotunda). Others are usually linked to a hematolymphoid malignancy (acquired ichthyosis, exfoliative erythroderma, necrobiotic xanthogranuloma, pemphigus paraneoplastica, plane xanthoma, pyoderma gangrenosum, scleromyxedema, Sweet syndrome, and leukocytoclastic vasculitis). Finally, yet another collection of paraneoplastic skin disorders can associate themselves with anatomically-diverse malignancies (Leser-Trelat syndrome, Trousseau syndrome, dermatomyositis, erythema gyratum repens, hypertrichosis lanuginosa acquisita, papuloerythroderma of Ofuji, tripe palms, and multicentric reticulohistiocytosis). Recognition of these processes by the pathologist can be a valuable step in the characterization of underlying malignant diseases.

Bazex syndrome in a patient with head and neck malignancy

Bazex syndrome (acrokeratosis paraneoplastica) is an uncommon dermatologic condition associated with an underlying malignancy, most commonly squamous cell carcinomas of the head and neck. This article describes Bazex syndrome in a 56-year-old woman who presented with bilateral cervical lymphadenopathy and a mass at the base of her tongue.

Features of seborrheic keratoses in patients with carbohydrate metabolism disorders

Multiple seborrheic keratosis (SK), especially when there is overexpression of the epidermal growth factor receptor (EGFR), is considered paraneoplastic dermatosis, but it is almost always associated with multiple fibroepithelial polyps (PF) and pseudoacanthosis, skin diseases in which the leading role is played by insulin resistance and type 2 diabetes mellitus. The study examines the possibility of the effect of disorders of carbohydrate metabolism on the clinical picture of multiple SK and the expression of EGFR.Aims. To study the clinical features of multiple SC and the expression of EGFR in patients, depending on the presence of concomitant type 2 diabetes mellitus.Materials and methods. There were 65 patients with multiple SK at the age from 55 to 77 years, including women (44) and men (21). All the patients were examined skin, consultation of the endocrinologist. For a histological and immunohis-tochemical study (IHC), a single SK was surgically excised in each patient. IHC-reactions were carried out with monoclonal antibodies to EGFR. The result was assessed by the number of stained cytoplasmic membranes of tumor cells.Results. In 81.5 % of cases, multiple SK was associated in patients with type 2 diabetes mellitus. The location of the SK was also characteristic mainly in large folds of the skin, in contrast to patients without disorders of carbohydrate metabolism, in which the SK were located mainly on the lateral surfaces of the trunk and abdomen, without affecting the large folds of the skin. Multiple PF were also characteristic of individuals with type 2 diabetes mellitus. In IHC studies EGFR expression was detected in 100 % of cases in individuals with multiple SC and type 2 diabetes mellitus in over 30 % of tumor cells, and only in 16.7 % of cases in individuals with multiple SK without violations of carbohydrate metabolism.Conclusions. The presence of multiple SK in patients, in combination with multiple PFs with characteristic tumor localization in large folds of the skin, serves as a diagnostic marker of carbohydrate metabolism disorders or predispositions to the development of type 2 diabetes. Increased expression of EGFR plays a leading role in the pathogenesis of multiple SK, stimulating the proliferation and growth of SK, in turn, as a consequence of impairment of insulin signaling pathways and insulin resistance.

Generalized Pustular Psoriasis in Association with Squamous Cell Carcinoma of the Hypopharynx

Pustular psoriasis is an uncommon form of psoriasis consisting of widespread pustules on an erythematous background. Very rarely pustular psoriasis represent a paraneoplastic dermatosis. In this report we describe a case of generalized pustular psoriasis (GPP) associated with advanced, inoperable, metastatic squamous cell carcinoma of the hypopharynx. We suggest that physicians should be alert for the worsening of existing psoriasis or formation of novel psoriasiform eruptions and should undertake clinical evaluation of possible neoplastic disease.

[Expression of epidermal growth factor receptor in patients with insulin resistance and seborrheic keratomas]

AIM

to study the expression of epidermal growth factor receptor (EGFR) in patients with seborrheic keratomas (SK) and insulin resistance (type 2 diabetes mellitus (DM2)) and in those without concomitant carbohydrate metabolic disturbances.

SUBJECTS AND METHODS

80 patients with SK were examined. According to the presence or absence of DM2, the patients were divided into 2 groups: 1) 40 patients with concomitant DM2; 2) 40 people without carbohydrate metabolic disturbances. DM2 was diagnosed on the basis of laboratory studies and an endocrinologist's consultation. Histological and immunohistochemical (IHC) examinations using anti-EGFR antibodies were performed; two intact skin sections from the patients with DM2 and two intact skin sections from those without carbohydrate metabolic disturbances were used as a control.

RESULTS

The ICH examination using anti-EGFR monoclonal antibodies revealed that Group 1 showed intense diffuse membrane staining of more than 50% of the cells in 32 (80%) patients, moderate (30-50% cells) and weak (10-30% cells) staining in 6 (15%) and 2 (5%) patients, respectively. Marked EGFR expression was also noted in two intact skin biopsy specimens taken from patients with DM2. In Group 2, the staining intensity was weak in more than 10% but less than 30% of the SK cells in 28 (70%) patients; moderate EGFR expression was observed in 9 (22.5%) and diffuse, pronounced, staining in more than 50% of the SK cells was in 3 (7.5%) patients. The intact skin biopsy specimens taken from 2 patients without carbohydrate metabolic disturbances displayed a weak EGFR expression in the basal cell layer of the epidermis.

CONCLUSION

EGFR overexpression in SK may be a result of metabolic disorders rather than a diagnostic sign of malignant neoplasms of the internal organs. The increased EGFR expression revealed in patients with SK and concomitant DM2 is caused by insulin resistance and hyperinsulinemia, in which the dysregulation of insulin signal transmission into the cell leads to changes in EGF synthesis and signaling pathway that regulates cell proliferation and growth.

Cutaneous paraneoplastic disorders in stomach cancer: Collaboration between oncologically active dermatologists and clinical oncologists

To our knowledge this is the first systemic review that provides an overview of the cutaneous paraneoplastic syndromes (CPS) (i.e., clinical manifestations, pathomechanisms, and treatment modalities) occurring in stomach cancer. CPS are caused by substances produced by stomach cancer and may precede, coincide with, or follow the diagnosis of this malignancy. More than 20 possible CPS in association with stomach cancer have been identified. CPS mostly compromises the patient's quality of life by skin impairment plus discomfort and are often associated with a dismal prognosis on survival. Studies of these CPS not only in stomach cancer have partially contributed to the understanding of pathomechanism and since CPS may be the presenting sign of an occult cancer, cognizance of their features and clinical implications are of considerable importance. Patients with these syndromes should have an appropriate work-up for a possibly occult malignancy with consecutive successful early treatment.

A Case of Leser-Trélat Syndrome Associated with a Renal Cell Carcinoma

Seborrheic keratoses can often be found in elderly people. In general, they appear gradually. In cases of a sudden eruption with itching it might be paraneoplastic. Although some authors doubt the existence of the paraneoplastic Leser-Trélat syndrome, we present a case of sudden eruption of seborrheic keratoses connected with a newly diagnosed renal cell carcinoma. As far as we know, this is the first case report of a Leser-Trélat syndrome with a malignancy of the kidney.

Seborrheic keratosis and insulin resistans

Regardless of multiple studies performed, aetiology and pathogenesis of seborrheic keratosis (SK) remain unknown. Insulin resistance may play the leading role. For instance, hyperinsulinemia is responsible for development of fibroepithelial polyps and acanthosis nigricans, diseases frequently associated with seborrheic keratosis. The purpose of the investigation is to study clinical factors and carbohydrate metabolism of patients with SK. Material and methods. The results of examination of 130 patients divided in two groups, were presented: 1st group with a single instance of SK (n = 60) and 2nd group with multiple SK (n = 70). All patients underwent histologic examination, analysis of carbohydrate metabolism: blood glucose, plasma insulin, level of glycated hemoglobin, glucose tolerance test; based on the results, advice from an endocrinologist was provided. Results and conclusions. Link between multiple SK and carbohydrate dysbolism was revealed: insulin resistance was found in 85.7% of patients from the 2nd group (16.6% in the 1st group). In our study, the association of multiple SK with fibroepithelial polyps and adiposity has evidenced that the patient suffered from type 2 diabetes mellitus.

Malignant acanthosis nigricans associated with prostate cancer: a case report

Background

Acanthosis nigricans is characterized by hyperpigmentation and hyperkeratosis of the skin or mucous membranes. Its malignant form is associated with internal neoplasms, especially gastric adenocarcinoma (55–61%). Coexistence with prostate cancer is uncommon. In the paraneoplastic type of this dermatosis, the skin and mucous lesions are characteristically of more sudden onset and more severe than those in the benign form. The efficacy of various treatment strategies remains disappointing.

Case presentation

We here report a case of 66-year-old Caucasian patient with metastatic prostate cancer and a mild form of acanthosis nigricans that preceded the diagnosis of malignancy and resolved with chemotherapy in parallel with the prostate cancer. The dermatosis recurred when the prostate cancer progressed.

Conclusion

Concurrent acanthosis nigricans and prostate cancer is rare, and few such cases have been reported. Anti-tumor therapy occasionally results in regression of this dermatosis. Underlying malignant disease should be suspected in individuals with elderly-onset of acanthosis nigricans.

Seborrheic keratosis: current concepts of pathogenesis

The article covers problems of seborrheic keratosis. The authors discuss current concepts of the etiology and pathogenesis of the disease paying special attention to the histology and immunohistochemistry of different forms and diverse clinical presentations. They describe Leser - Trelat syndrome as well as potential neoplastic transformation of seborrheic keratomas and their association with malignant skin neoplasms.

Molecular and bioenergetic differences between cells with African versus European inherited mitochondrial DNA haplogroups: implications for population susceptibility to diseases

The geographic origins of populations can be identified by their maternally inherited mitochondrial DNA (mtDNA) haplogroups. This study compared human cybrids (cytoplasmic hybrids), which are cell lines with identical nuclei but mitochondria from different individuals with mtDNA from either the H haplogroup or L haplogroup backgrounds. The most common European haplogroup is H while individuals of maternal African origin are of the L haplogroup. Despite lower mtDNA copy numbers, L cybrids had higher expression levels for nine mtDNA-encoded respiratory complex genes, decreased ATP (adenosine triphosphate) turnover rates and lower levels of reactive oxygen species production, parameters which are consistent with more efficient oxidative phosphorylation. Surprisingly, GeneChip arrays showed that the L and H cybrids had major differences in expression of genes of the canonical complement system (5 genes), dermatan/chondroitin sulfate biosynthesis (5 genes) and CCR3 (chemokine, CC motif, receptor 3) signaling (9 genes). Quantitative nuclear gene expression studies confirmed that L cybrids had (a) lower expression levels of complement pathway and innate immunity genes and (b) increased levels of inflammation-related signaling genes, which are critical in human diseases. Our data support the hypothesis that mtDNA haplogroups representing populations from different geographic origins may play a role in differential susceptibilities to diseases.

Leser–Trélat syndrome in malignant mesothelioma and pulmonary adenocarcinoma: is the EGFR pathway part of the syndrome?

The syndrome of Leser–Trélat (LT) is characterized by the sudden appearance of multiple seborrhoeic keratoses (SKs) in association with internal occult malignancy. Usually, the syndrome has been associated with adenocarcinoma, most frequently of the gastrointestinal tract and breast. The pathogenesis is unclear but might be explained by circulating tumor-associated growth factors. We present two thoracic malignancies associated with LT: adenocarcinoma of the lung (ACL) and pleural malignant mesothelioma (MM). Both malignant tumors expressed high levels of epidermal growth factor receptors (EGFR) detected by immunohistochemistry (IHC), with membranous staining on the majority of malignant cells corresponding to maximum IHC scores of 290 and 300, respectively, for the MM and the ACL. SKs revealed a universal membranous staining throughout the entire epithelium with no difference in EGFR expression between the two cases and two controls with no malignant history. By fluorescence in situ hybridization, no amplification of the EGFR gene in malignant tumors as well as in SK lesions was observed. Further investigations are needed to see whether tumor-associated EGFR ligands/EGFR autocrine loops in malignant cells expressing high levels of EGFR protein on the surface might play a role for the development of SKs, as well as for the growth of malignant tumors in LT.

Acanthosis nigricans associated with an adrenocortical tumor in a pediatric patient

Malignant acanthosis nigricans (AN) is a rare paraneoplastic syndrome seen primarily in adults with an underlying diagnosis of gastrointestinal adenocarcinoma. Malignant AN is characterized by hyperpigmentation and velvety hyperplasia of the epidermis. This condition is generally not associated with tumors in pediatric populations or in the adrenal gland. We present a case of malignant AN in a pediatric patient with a nonmalignant, functional adrenocortical tumor.

Seborrheic keratoses of florid eruption

We report the case of a 79-year-old Caucasian man, who developed numerous pruritic seborrheic keratoses on his chest and back within one year. An underlying malignant disease was suspected. Upper and lower endoscopies were performed and the patient was diagnosed with adenocarcinoma of the ascending colon. We discuss the clinical significance of his cutaneous symptoms/signs, and review the medical literature on the paraneoplastic sign of Leser-Trélat.

Occult cause of paraneoplastic acanthosis nigricans in a patient with known breast dcis: case and review

Paraneoplastic acanthosis nigricans (pan) is an infrequently encountered cutaneous manifestation of internal malignancy. Here, we describe a case of pan in the setting of a known breast ductal carcinoma in situ, which, to our knowledge, had not been described in association with pan. As a result, thorough investigation was undertaken to search for another concurrent neoplasm that would better explain the development of pan. In so doing, we identified a coexisting metastatic cholangiocarcinoma. We thus conclude that when pan is observed in an uncommon association with a known malignancy, further investigation should be undertaken to explore whether a more likely occult culprit exists.

The possible role of trauma in skin tags through the release of mast cell mediators

Background:

Skin tags (ST) are common benign tumors of the skin but their etiopathogenesis is not well understood. STs arise in sites subjected to trauma. It was proved that mast cells are recruited to sites of skin trauma and increase their tumor necrosis factor-α (TNF-α) content.

Aim:

STs are linked to obesity and frictional sites, but this has not been studied at the molecular level. We hypothesized that mast cells, TNF-α and its family member, TNF-related apoptosis-inducing ligand (TRAIL) might play a role in the pathogenesis of STs as a response to trauma.

Materials and Methods:

A study was done on 15 patients with STs. Two STs and a snip of normal skin were obtained in each subject. We counted the mast cells after Toluidine blue staining. Enzyme-linked immunosorbant assay was used to measure TNF-α level while reverse transcriptase polymerase chain reaction was used to evaluate the level of TRAIL mRNA expression.

Results:

Mast cell count in all STs was significantly higher than that in control (P=0.0355). There was a highly significant increase in the level of TNF-α in all STs as compared to its level in controls (P<0.0001). Expression of TRAIL mRNA was significantly higher in STs as compared to its expression in controls (P<0.0001).

Conclusion:

Our study suggests that mast cells, TNF-α and TRAIL may play a role in the pathogenesis of STs.

Acral-type Malignant Acanthosis Nigricans Associated with Gastric Adenocarcinoma

Acanthosis nigricans is a symmetric eruption characterized by the presence of a hyperpigmented, velvety cutaneous thickening, that can develop on any part of the body, but characteristically affects the flexural areas of the body. The velvety hyperkeratotic lesions can be located on the dorsum of the hands and feet in dark-skinned people in the form of a variant of acanthosis nigricans called as acral acanthotic anomaly or acral type acanthosis nigricans. Although acanthosis nigricans is associated with malignant tumors, particularly gastric carcinoma, acral type acanthosis nigricans has never been reported to be associated with gastric adenocarcinoma. In our present study, we describe a case of 58-year-old man with acral type acanthosis nigricans and its association with carcinoma of the stomach; a marked improvement was seen in the skin condition of the patient with chemotherapy.

Oral acanthosis nigricans in chronic hepatitis B with a 21-year follow up

Acanthosis nigricans is a rare mucocutaneous disorder of unknown etiology that manifests as hyperpigmented velvety plaques, most often on intertriginous areas such as the neck and axillae as well as on mucosal sites such as the oral cavity. The disorder presents either as a paraneoplastic manifestation of an underlying malignancy, especially gastrointestinal adenocarcinomas or in association with obesity, administration of drugs or endocrinopathies, most commonly insulin-resistant diabetes mellitus. In the present article, a case of acanthosis nigricans with oral and cutaneous manifestations in a male patient with chronic hepatitis B infection is described. To the best of our knowledge, this is the first case of benign oral acanthosis nigricans associated with chronic hepatitis B.

Genetic syndromes of severe insulin resistance

Insulin resistance is among the most prevalent endocrine derangements in the world, and it is closely associated with major diseases of global reach including diabetes mellitus, atherosclerosis, nonalcoholic fatty liver disease, and ovulatory dysfunction. It is most commonly found in those with obesity but may also occur in an unusually severe form in rare patients with monogenic defects. Such patients may loosely be grouped into those with primary disorders of insulin signaling and those with defects in adipose tissue development or function (lipodystrophy). The severe insulin resistance of both subgroups puts patients at risk of accelerated complications and poses severe challenges in clinical management. However, the clinical disorders produced by different genetic defects are often biochemically and clinically distinct and are associated with distinct risks of complications. This means that optimal management of affected patients should take into account the specific natural history of each condition. In clinical practice, they are often underdiagnosed, however, with low rates of identification of the underlying genetic defect, a problem compounded by confusing and overlapping nomenclature and classification. We now review recent developments in understanding of genetic forms of severe insulin resistance and/or lipodystrophy and suggest a revised classification based on growing knowledge of the underlying pathophysiology.

Leser-Trélat Sign without Internal Malignancy

Leser-Trélat sign is characterized by the abrupt appearance of multiple seborrheic keratoses in association with underlying malignant disease. A case of Leser-Trélat sign in a 66-year-old healthy woman is presented. Evaluation and follow-up for the development of malignancy over a 2-year period failed to reveal any evidence of malignancy. To date, almost all cases of Leser-Trélat sign have been reported in association with an underlying malignancy. It is less known that Leser-Trélat sign can also occur in healthy individuals in the absence of internal malignancy.

Malignant Acanthosis Nigricans Associated with Ovarian Cancer

Malignant acanthosis nigricans is a cutaneous eruption characterized by symmetric hyperpigmented hyperkeratosis, dermal papillomatosis, and mucosal involvement associated with internal malignancies. Tripe palms refers to a characteristic velvety thickening of the palms, with exaggeration of normal skin markings. We present the second case of ovarian cancer in association with two coexisting paraneoplastic dermatoses occurring in a 57-year-old Korean female. The presence of acanthosis nigricans in conjunction with tripe palms in a female patient is highly suggestive of an internal malignancy including an ovarian cancer and demands an extensive search for the hidden ovarian cancer.

Associação entre acrocórdons e resistência à insulina

FUNDAMENTOS: Acrocórdons são lesões dermatológicas comuns na população e estão associados ao diabetes mellitus, à obesidade, à resistência insulínica e à aterosclerose. A identificação precoce de pacientes com resistência insulínica pode ter papel preventivo primário. OBJETIVO: Avaliar a associação entre presença de acrocórdons cervicais ou axilares e resistência insulínica. MÉTODOS: Estudo transversal com pacientes dermatológicos adultos atendidos em hospital universitário. Casos foram definidos como portadores de mais de cinco acrocórdons cervicais e/ou axilares. A resistência insulínica foi estimada pelo índice HOMA-IR. Resultados foram ajustados pelas demais covariáveis de risco para resistência insulínica conhecidos, a partir de regressão logística múltipla. RESULTADOS: Avaliaram-se 98 casos e 103 controles, que não diferiram entre si quanto à idade ou ao gênero. Acrocórdons se associaram diretamente aos valores de HOMA-IR (Odds Ratio = 1,4), hipertrigliceridemia e índice de massa corpórea, independentemente do ajuste por diabetes mellitus, idade, fototipo, gênero, história de diabetes mellitus familiar e relação cintura/quadril. Níveis qualitativamente elevados de HOMA-IR (> 3,8) também evidenciaram associação significativa (Índice de probabilidade = 7,5). CONCLUSÕES: Presença de múltiplos acrocórdons se associou à resistência insulínica, independentemente dos demais fatores de risco.

Leser-Trélat syndrome in patients affected by six multiple metachronous primitive cancers

Leser-Trélat syndrome is characterized by the eruptive appearance of multiple seborrheic keratoses in association with underlying malignant disease. Usually, the sign of Leser-Trélat is associated with adenocarcinoma, most frequently of the colon, breast, or stomach, but also of the lung, kidney, liver, and pancreas. Herein, we present a case that we believe is the first report of the sign of Leser-Trélat in association with occult gastric adenocarcinoma and the anamnestic oncologic history of five other multiple primitive cancers. Epidermal growth factor receptor (EGFR) immunohistochemical expression analysis of multiple seborrheic keratoses revealed an intense membranous staining in the basal keratinocytes and in all the upper epidermal layers. Patients with the sign of Leser-Trélat should undergo a diagnostic screening programme for malignant disease along with patients with known Leser-Trélat syndrome who present with a recent acute and florid eruption of their seborrheic keratoses. We propose the importance of combining the molecular features of multiple seborrheic keratoses with EGFR immunohistochemistry analyses to determine the likelihood of Leser-Trélat syndrome and the consequent high risk of underlying multiple visceral malignancies.