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Zhan SP. Necrolytic migratory erythema caused by pancreatic hyperglycemia with emphasis on therapeutic and prognosis: A case report. World J Clin Cases 2024; 12:5404-5409. [DOI: 10.12998/wjcc.v12.i23.5404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 05/10/2024] [Accepted: 06/13/2024] [Indexed: 07/05/2024] Open
Abstract
BACKGROUND With the incidence of pancreatic diseases increasing year by year, pancreatic hyperglycemia, as one of the common complications, is gradually gaining attention for its impact on the skin health of patients.
CASE SUMMARY This was the case of an elderly female with clinical manifestations of necrolytic migratory erythema, “three more and one less,” diabetes mellitus, hypertension, anemia, hypoproteinemia, and other syndromes, which had been misdiagnosed as eczema. Abdominal computed tomography showed a pancreatic caudal space-occupying lesion, and the magnetic resonance scanning of the epigastric region with dynamic enhancement and diffusion-weighted imaging suggested a tumor of the pancreatic tail, which was considered to be a neuroendocrine tumor or cystadenoma. The patient was referred to a more equipped hospital for laparoscopic pancreatic tail resection. Post-surgery diagnosis revealed a neuroendocrine tumor in the tail of the pancreas. To date, the patient’s general condition is good, and she is still under close follow-up.
CONCLUSION Necrolytic migratory erythema can be induced by endocrine system tumors or endocrine metabolic abnormalities, with complex clinical manifestations, difficult diagnosis, and easy misdiagnosis by dermatologists. The initial treatment principles in dermatology include symptomatic supportive therapy and effective drugs to relieve skin lesions. After clarifying the etiology of glucagonoma, comprehensive treatment in collaboration with endocrinologists, general surgeons, and oncologists can help provide individualized treatment for patients and improve their prognosis.
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Affiliation(s)
- Shi-Ping Zhan
- Department of Dermatology, General Hospital of the Yangtze River Shipping, Wuhan Brain Hospital, Wuhan 430000, Hubei Province, China
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2
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Yu S, Ge M, Zhang C, Chen L, Zhao L. Diagnosis and comprehensive treatment of a glucagonoma in a patient with residual intrahepatic metastases postoperatively: A case report and literature review. Oncol Lett 2024; 27:202. [PMID: 38516680 PMCID: PMC10955682 DOI: 10.3892/ol.2024.14336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 02/01/2024] [Indexed: 03/23/2024] Open
Abstract
Glucagonomas are rare neuroendocrine neoplasms of the pancreas with malignant potential. At present, their epidemiology is not entirely clear, so clinicians are not well versed, lacking any consensus on diagnosis or comprehensive treatment. The present study reports the case of a 32-year-old woman hospitalized for recurrent glossitis, perioral dermatitis and necrolytic migratory erythema (NME) of both lower limbs. Imaging studies revealed a low-density nodule (~2 cm) in the tail of the pancreas, as well as multiple space-occupying hepatic lesions. Surgical intervention was then selected, and distal pancreatectomy, splenectomy and palliative metastasectomies were performed. Tissue examination subsequently confirmed a primary pancreatic neuroendocrine tumor (grade 2), metastatic to the liver. The NME resolved postoperatively, aided by intramuscular injections of long-acting release octreotide (30 mg) every 28 days. A series of three percutaneous ablative treatments (microwave ablation) were also undertaken within a 2-year period, targeting the liver metastases. The present condition of the patient is good, with no cutaneous relapse to date. Palliative metastasectomies, in conjunction with ablative treatments and combination somatostatin analog (SSA) use, are unique aspects of this case that, to the best of our knowledge, have yet to be documented in the literature. Surgical palliation may benefit patients with liver involvement and prolong their survival time. Likewise, ablative treatments and SSA injections delivered together not only address hepatic spread, but also control hormone-related symptoms, having a positive impact on prognosis. As glucagonomas are so rare, there is no real agreement on their management. The present study aims to guide clinical practice by adding further to the available data.
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Affiliation(s)
- Shenghui Yu
- Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of China Medical University, Shenyang, Liaoning 110001, P.R. China
| | - Muxi Ge
- Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of China Medical University, Shenyang, Liaoning 110001, P.R. China
| | - Cheng Zhang
- Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of China Medical University, Shenyang, Liaoning 110001, P.R. China
| | - Lang Chen
- Department of Pancreatic and Biliary Surgery, The First Hospital of China Medical University, Shenyang, Liaoning 110001, P.R. China
| | - Lei Zhao
- Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of China Medical University, Shenyang, Liaoning 110001, P.R. China
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3
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Murina A, Allen A. Paraneoplastic Dermatoses and Cutaneous Metastases. Clin Geriatr Med 2024; 40:177-195. [PMID: 38000859 DOI: 10.1016/j.cger.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2023]
Abstract
Paraneoplastic syndromes include a variety of cutaneous presentations that have an associated internal malignancy. Some syndromes have a strong correlation to specific internal malignancies, whereas others are associated with a multitude of tumors. There are many cutaneous manifestations that suggest hematologic disorders, which will be reviewed in detail. Cutaneous metastases are commonly from breast and lung cancers and can present as nodules, vascular lesions, eczematous dermatitis, or inflammatory lesions. The most common histologic presentation of cutaneous metastasis is that of a dermal-based or subcutaneous-based nodule with sparing of the epidermis. Determination of origin of tumor requires immunohistochemistry and clinical correlation.
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Affiliation(s)
- Andrea Murina
- Department of Dermatology, Tulane University School of Medicine, 1430 Tulane Avenue #8036, New Orleans, LA 70112, USA.
| | - Ashley Allen
- Department of Dermatology, Tulane University School of Medicine, 1430 Tulane Avenue #8036, New Orleans, LA 70112, USA
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4
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Liu Z, Hu F, Guo S, Zhang P, Li G, Qin Y. Favorable response to surufatinib in a patient with necrolytic migratory erythema: A case report. Open Life Sci 2023; 18:20220672. [PMID: 38035045 PMCID: PMC10685408 DOI: 10.1515/biol-2022-0672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 10/05/2023] [Accepted: 10/05/2023] [Indexed: 12/02/2023] Open
Abstract
Necrolytic migratory erythema (NME) is usually associated with paraneoplastic syndrome caused by functional pancreatic neuroendocrine tumor (PNET). Accurate diagnosis and effective treatment of NET-related NME is challenging due to its rarity and lack of typical clinical symptoms and specific pathological manifestations. Here we report a rare case of PNET with NME as the initial manifestation. 68Ga-DOTA-TATE PET/MR was used to detect the primary pancreatic and metastatic liver tumors. Finally, the patient was diagnosed as PNET via liver biopsy. After four cycles of standard capecitabine plus temozolomide chemotherapy combined with long-acting octreotide, the patient's skin lesions on both lower extremities improved only slightly, while tumors remained stable and unchanged in size. Then the patient was treated with surufatinib. Two months later, the skin lesions healed completely, and tumors responded significantly. This rare case suggests that surufatinib may be a promising therapy for patients with PNET-associated NME.
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Affiliation(s)
- Zhongan Liu
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan430022, China
| | - Feng Hu
- Department of Dermatology, Wuhan No. 1 Hospital, Wuhan430022, China
| | - Shuang Guo
- Department of Pathology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan430022, China
| | - Peng Zhang
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan430022, China
| | - Guiling Li
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan430022, China
| | - You Qin
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan430022, China
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5
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Salaheldin Y, El Ansari W, Aljaloudi E, Elhag W. Third reported case of rare necrolytic migratory erythema associated with bacteraemia due to severe zinc deficiency after revisional Roux-En-Y gastric bypass: case report and literature review. Eat Weight Disord 2022; 27:1235-1241. [PMID: 34061321 PMCID: PMC8964611 DOI: 10.1007/s40519-021-01154-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 02/16/2021] [Indexed: 10/25/2022] Open
Abstract
INTRODUCTION Obesity is a risk factor for zinc deficiency. After bariatric surgery, non-compliance to diet/vitamin supplements, surgical complications leading to vomiting/diarrhea, poor follow-up and malabsorption can precipitate or exacerbate pre-existing zinc deficiency. CASE REPORT We report a patient with rare necrolytic migratory erythema associated with bacteraemia due to severe zinc deficiency after revisional Roux-en-Y gastric bypass (following primary laparoscopic sleeve gastrectomy). CONCLUSION Bariatric teams should screen patients before bariatric surgery for nutritional deficiencies and continue surveillance of their nutritional status after surgery. They should maintain a high index of suspicion for zinc deficiency in patients with skin rash after bariatric surgery. LEVEL OF EVIDENCE Level V, case report.
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Affiliation(s)
- Yassmin Salaheldin
- Department of Bariatric Surgery/Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, State of Qatar
| | - Walid El Ansari
- Department of Surgery, Hamad General Hospital, Hamad Medical, Doha, State of Qatar. .,College of Medicine, Qatar University, Doha, State of Qatar. .,School of Health and Education, University of Skövde, Skövde, Sweden.
| | - Esraa Aljaloudi
- Department of Family Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, State of Qatar
| | - Wahiba Elhag
- Department of Bariatric Surgery/Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, State of Qatar
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6
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Li Y, Fu R, Jiang T, Duan D, Wu Y, Li C, Li Z, Ni R, Li L, Liu Y. Mechanism of Lethal Skin Toxicities Induced by Epidermal Growth Factor Receptor Inhibitors and Related Treatment Strategies. Front Oncol 2022; 12:804212. [PMID: 35223483 PMCID: PMC8866822 DOI: 10.3389/fonc.2022.804212] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 01/17/2022] [Indexed: 02/01/2023] Open
Abstract
Epidermal growth factor receptor (EGFR) inhibitors are widely used to treat various types of cancers such as non-small cell lung cancer, head and neck cancer, breast cancer, pancreatic cancer. Adverse reactions such as skin toxicity, interstitial lung disease, hepatotoxicity, ocular toxicity, hypomagnesemia, stomatitis, and diarrhea may occur during treatment. Because the EGFR signaling pathway is important for maintaining normal physiological skin function. Adverse skin reactions occurred in up to 90% of cancer patients treated with EGFR inhibitors, including common skin toxicities (such as papulopustular exanthemas, paronychia, hair changes) and rare fatal skin toxicities (e.g., Stevens–Johnson syndrome, toxic epidermal necrolysis, acute generalized exanthematous pustulosis). This has led to the dose reduction or discontinuation of EGFR inhibitors in the treatment of cancer. Recently, progress has been made about research on the skin toxicity of EGFR inhibitors. Here, we summarize the mechanism of skin toxicity caused by EGFR inhibitors, measures to prevent severe fatal skin toxicity, and provide reference for medical staff how to give care and treatment after adverse skin reactions.
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Affiliation(s)
- Yanping Li
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
| | - Ruoqiu Fu
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
| | - Tingting Jiang
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
| | - Dongyu Duan
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
| | - Yuanlin Wu
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
| | - Chen Li
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
| | - Ziwei Li
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
| | - Rui Ni
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
| | - Li Li
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
| | - Yao Liu
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
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7
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How Many Times Can One Go Back to the Drawing Board before the Accurate Diagnosis and Surgical Treatment of Glucagonoma? Diagnostics (Basel) 2022; 12:diagnostics12010216. [PMID: 35054383 PMCID: PMC8774529 DOI: 10.3390/diagnostics12010216] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 01/12/2022] [Accepted: 01/14/2022] [Indexed: 02/04/2023] Open
Abstract
Glucagonomas are neuroendocrine tumors (NETs) that arise from the alpha cells of the pancreatic islets. They are typically slow-growing tumors associated with abnormal glucagon secretion, resulting in one or more non-specific clinical features, such as necrolytic migratory erythema (NME), diabetes, diarrhea, deep vein thrombosis, weight loss, and depression. Here, we report the case of a 44-year-old male with a history of diabetes mellitus, presenting with a pruritic and painful disseminated cutaneous eruption of erythematous plaques, with scales and peripheral pustules, misdiagnosed as disseminated pustular psoriasis and treated for 2 years with oral retinoid and glucocorticoids. During this period, the patient complained of weight loss of 32 kg and diarrhea and developed deep vein thrombosis. These symptoms, together with an inadequate response to therapy of the skin lesions, led to the reassessment of the initial diagnosis. Laboratory tests confirmed elevated plasma glucagon levels (>1000 pg/mL) and computed tomography (CT) scans revealed a 35/44 mm tumor in the pancreatic tail. Due to considerable disease complications and the COVID-19 pandemic, the surgical removal of the tumor was delayed for nearly 2 years. During this time, somatostatin analogue therapy efficiently controlled the glucagonoma syndrome and likely prevented tumor progression. As in other functional pancreatic NETs, the early clinical recognition of hormonal hypersecretion syndrome and the multidisciplinary approach are the keys for best patient management.
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8
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Abdelli W, Alaoui F, Souissi A, Sassi W, Chelly I, Haouet S, Mokni M. Case of delayed diagnosis of necrolytic migratory erythema. Clin Case Rep 2021; 9:e05179. [PMID: 34938555 PMCID: PMC8665690 DOI: 10.1002/ccr3.5179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 11/20/2021] [Accepted: 11/23/2021] [Indexed: 11/22/2022] Open
Abstract
Necrolytic migratory erythema (NME) is a rare cutaneous paraneoplastic manifestation of glucagonoma. We report a case of a woman with a 6-year history of delayed diagnosis of glucagonoma. This case highlights the atypical clinical features of NME which makes the diagnosis difficult.
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Affiliation(s)
| | | | | | - Wiem Sassi
- Dermatology Department ‐ Rabta HospitalTunisTunisia
| | - Ines Chelly
- Anatomopathology Department – Rabta HospitalTunisTunisia
| | - Slim Haouet
- Anatomopathology Department – Rabta HospitalTunisTunisia
| | - Mourad Mokni
- Dermatology Department ‐ Rabta HospitalTunisTunisia
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9
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Mavi ME, Tuncel M. Treatment of Glucagonoma-Related Necrolytic Migratory Erythema With Peptide Receptor Radionuclide Therapy. Clin Nucl Med 2021; 46:1002-1003. [PMID: 34034327 DOI: 10.1097/rlu.0000000000003731] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Glucagonomas are rare types of pancreatic neuroendocrine tumors. They may present with a clinical entity called glucagonoma syndrome, which includes necrolytic migratory erythema as a skin component. Here we present a 26-year-old woman experiencing ongoing skin lesions, excessive weight loss, and nausea. She was diagnosed with metastatic glucagonoma. Her 68Ga-DOTATATE PET/CT showed increased uptake at the primary pancreatic lesion and hepatic metastases. She received 2 cycles of peptide receptor radionuclide therapy and had a partial response with a near-complete regression of her skin lesions.
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Affiliation(s)
- Mehmet Emin Mavi
- From the Department of Nuclear Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
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10
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Nosewicz J, Spaccarelli N, Roberts KM, Hart PA, Kaffenberger JA, Trinidad JC, Kaffenberger BH. The Epidemiology, Impact, and Diagnosis of Micronutrient Nutritional Dermatoses Part 1: Zinc, Selenium, Copper, Vitamin A, and Vitamin C. J Am Acad Dermatol 2021; 86:267-278. [PMID: 34748862 DOI: 10.1016/j.jaad.2021.07.079] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 07/16/2021] [Accepted: 07/23/2021] [Indexed: 11/27/2022]
Abstract
Dermatologists play a critical role in diagnosing and managing nutritional deficiencies as they often present with cutaneous findings. Traditionally, nutritional dermatoses are taught in the context of developing countries, famine, population displacement, and poor healthcare access; however, in the United States, common risk factors include chronic liver disease, alcoholism, psychiatric disease, bariatric surgery, inflammatory bowel disease, and hemodialysis. Additionally, nutritional dermatoses may be underdiagnosed in the United States and result in increased morbidity and utilization of hospital resources. There is a need for providers in developed nations to identify these deficiencies, and this review aims to meet that practice gap and provide relevant context to these diseases for dermatologists. This two-part review series will focus on the epidemiology, impact, appearance, and diagnostic modalities for micronutrient deficiencies, including zinc, selenium, copper, and vitamins A and C in part one. The companion review will focus on the B-complex vitamins.
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Affiliation(s)
- Jacob Nosewicz
- Division of Dermatology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Natalie Spaccarelli
- Division of Dermatology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Kristen M Roberts
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Phil A Hart
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Jessica A Kaffenberger
- Division of Dermatology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - John C Trinidad
- Division of Dermatology, The Ohio State University Wexner Medical Center, Columbus, Ohio
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11
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Fernandez CJ, Agarwal M, Pottakkat B, Haroon NN, George AS, Pappachan JM. Gastroenteropancreatic neuroendocrine neoplasms: A clinical snapshot. World J Gastrointest Surg 2021; 13:231-255. [PMID: 33796213 PMCID: PMC7993001 DOI: 10.4240/wjgs.v13.i3.231] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 01/17/2021] [Accepted: 03/02/2021] [Indexed: 02/06/2023] Open
Abstract
Our understanding about the epidemiological aspects, pathogenesis, molecular diagnosis, and targeted therapies of neuroendocrine neoplasms (NENs) have drastically advanced in the past decade. Gastroenteropancreatic (GEP) NENs originate from the enteroendocrine cells of the embryonic gut which share common endocrine and neural differentiation factors. Most NENs are well-differentiated, and slow growing. Specific neuroendocrine biomarkers that are used in the diagnosis of functional NENs include insulin, glucagon, vasoactive intestinal polypeptide, gastrin, somatostatin, adrenocorticotropin, growth hormone releasing hormone, parathyroid hormone-related peptide, serotonin, histamine, and 5-hydroxy indole acetic acid (5-HIAA). Biomarkers such as pancreatic polypeptide, human chorionic gonadotrophin subunits, neurotensin, ghrelin, and calcitonin are used in the diagnosis of non-functional NENs. 5-HIAA levels correlate with tumour burden, prognosis and development of carcinoid heart disease and mesenteric fibrosis, however several diseases, medications and edible products can falsely elevate the 5-HIAA levels. Organ-specific transcription factors are useful in the differential diagnosis of metastasis from an unknown primary of well-differentiated NENs. Emerging novel biomarkers include circulating tumour cells, circulating tumour DNA, circulating micro-RNAs, and neuroendocrine neoplasms test (NETest) (simultaneous measurement of 51 neuroendocrine-specific marker genes in the peripheral blood). NETest has high sensitivity (85%-98%) and specificity (93%-97%) for the detection of gastrointestinal NENs, and is useful for monitoring treatment response, recurrence, and prognosis. In terms of management, surgery, radiofrequency ablation, symptom control with medications, chemotherapy and molecular targeted therapies are all considered as options. Surgery is the mainstay of treatment, but depends on factors including age of the individual, location, stage, grade, functional status, and the heredity of the tumour (sporadic vs inherited). Medical management is helpful to alleviate the symptoms, manage inoperable lesions, suppress postoperative tumour growth, and manage recurrences. Several molecular-targeted therapies are considered second line to somatostatin analogues. This review is a clinical update on the pathophysiological aspects, diagnostic algorithm, and management of GEP NENs.
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Affiliation(s)
- Cornelius J Fernandez
- Department of Endocrinology and Metabolism, Pilgrim Hospital, United Lincolnshire Hospitals NHS Trust, Boston PE21 9QS, United Kingdom
| | - Mayuri Agarwal
- Department of Endocrinology and Metabolism, Pilgrim Hospital, United Lincolnshire Hospitals NHS Trust, Boston PE21 9QS, United Kingdom
| | - Biju Pottakkat
- Department of Surgical Gastroenterology, Jawaharlal Institute of Post Graduate Medical Education and Research (JIPMER), Puducherry 605006, India
| | - Nisha Nigil Haroon
- Department of Endocrinology and Internal Medicine, Northern Ontario School of Medicine, Sudbury P3E 2C6, Ontario, Canada
| | - Annu Susan George
- Department of Medical Oncology, VPS Lakeshore Hospital, Cochin 682040, Kerala, India
| | - Joseph M Pappachan
- Department of Endocrinology and Metabolism, Lancashire Teaching Hospitals NHS Trust, PR2 9HT, Preston, The University of Manchester, Oxford Road M13 9PL, Manchester Metropolitan University, All Saints Building M15 6BH, Manchester, United Kingdom
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12
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Böhm M, Gellner R. [Neuroendorine paraneoplastic syndromes]. Hautarzt 2021; 72:299-306. [PMID: 33661337 DOI: 10.1007/s00105-021-04778-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/03/2021] [Indexed: 10/22/2022]
Abstract
Skin is commonly affected by neuroendorine paraneoplastic syndromes (PNS). This is due to the expression of receptors in the skin by which abnormally secreted neuroendocrine hormones and mediators elicit directly, and indirectly, cutaneous key signs and thus facilitate early diagnosis of these diseases. In acromegaly, induction of the growth hormone-insulin-like growth factor‑1 axis results in trophic changes of the acral portions of the skin and mucosal membranes including cutis verticis gyrata. The skin signs of non-iatrogenic Cushing syndrome are identical with those of exogenous prolonged intake of glucocorticoids: centripetal accumulation of adipose tissue, plethora and striae distensae. Episodic flushing of the face and trunk (together with explosive diarrhea) is a key feature of carcinoid tumors. Fibrotic remodeling of the heart and retroperitoneal space, and less commonly of the skin, are important complications mediated by abnormally secreted 5‑hydroxytryptamine (serotonin, 5‑HT), the latter eliciting profibrotic responses on HT2B-receptor-expressing fibroblasts. Androgen-secreting tumors lead to well-established receptor-mediated cutaneous signs of peripheral hyperandrogenisms: seborrhea, acne, hirsutism, and androgenetic alopecia. In contrast, the pathogenesis of necrolytic migratory erythema as a key feature of glucagonoma remains incompletely understood and is thought to be related to hypoaminoacidemia. This review summarizes the clinical features of neuroendocrine PNS with skin involvement, elucidates its underlying pathophysiology, lists differential diagnoses, and explains key diagnostic steps and principal therapeutic options. An interdisciplinary approach is essential to provide the best care of all patients with neuroendocrine PNS.
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Affiliation(s)
- M Böhm
- Klinik für Hautkrankheiten, Universitätsklinikum Münster, Von-Esmarch-Str. 58, 48149, Münster, Deutschland.
| | - R Gellner
- Medizinische Klinik B, Universitätsklinikum Münster, Münster, Deutschland
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13
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He S, Zeng W, Geng S, Jia J. Glucagonoma syndrome with atypical necrolytic migratory erythema. Indian J Dermatol Venereol Leprol 2021; 87:49-53. [PMID: 31368453 DOI: 10.4103/ijdvl.ijdvl_588_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Accepted: 03/01/2019] [Indexed: 11/04/2022]
Abstract
Necrolytic migratory erythema is most commonly associated with glucagonoma syndrome. We report a rare case of glucagonoma syndrome with necrolytic migratory erythema presenting as pruritic papules and follicular pustules in a 57-year-old woman; showing eosinophilic infiltration on histology. However, the final diagnosis was confirmed by demonstrating neuroendocrine tumour on histopathological examination of the liver metastases. Nutrition therapy was administered as a palliative treatment. This case also highlights the atypical clinical features and nonspecific histology of necrolytic migratory erythema which makes the diagnosis difficult.
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Affiliation(s)
- Shujuan He
- Department of Dermatology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Weihui Zeng
- Department of Dermatology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Songmei Geng
- Department of Dermatology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Jinjing Jia
- Department of Dermatology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
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14
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Glucagonoma-related necrolytic migratory erythema. Med Clin (Barc) 2020; 155:418-419. [PMID: 31515063 DOI: 10.1016/j.medcli.2019.06.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 06/27/2019] [Indexed: 11/20/2022]
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15
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Sandru F, Carsote M, Albu SE, Valea A, Petca A, Dumitrascu MC. Glucagonoma: From skin lesions to the neuroendocrine component (Review). Exp Ther Med 2020; 20:3389-3393. [PMID: 32905095 PMCID: PMC7465236 DOI: 10.3892/etm.2020.8966] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 05/15/2020] [Indexed: 02/06/2023] Open
Abstract
Glucagonoma is a hormonally active rare pancreatic neuroendocrine tumour causing an excess of glucagon. This is a narrative review based on a multidisciplinary approach of the tumour. Typically associated dermatosis is necrolytic migratory erythema (NME) which is most frequently seen at disease onset. Insulin-dependent diabetes mellitus, depression, diarrhoea, deep vein thrombosis are also identified, as parts of so-called 'D' syndrome. Early diagnosis is life saving due to potential aggressive profile and high risk of liver metastasis. NME as paraneoplastic syndrome may be present for months and even years until adequate recognition and therapy; it is remitted after successful pancreatic surgery. Thus the level of practitioners' awareness is essential. If surgery is not curative, debulking techniques may improve the clinical aspects and even the outcome in association with other procedures such as embolization of hepatic metastasis; ablation of radiofrequency type; medical therapy including chemotherapy, targeted therapy with mTOR inhibitors such as everolimus, PRRT (peptide receptor radiotherapy), and somatostatin analogues (including combinations of medical treatments). Increased awareness of the condition involves multidisciplinary practitioners.
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Affiliation(s)
- Florica Sandru
- Department of Dermatology, ‘Elias’ Emergency University Hospital, 125100 Bucharest, Romania
- Department of Dermatology, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Mara Carsote
- Department of Endocrinology,‘C.I. Parhon’ National Institute of Endocrinology, 011863 Bucharest, Romania
- Department of Endocrinology, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Simona Elena Albu
- Department of Gynecology, Emergency University Hospital, 050098 Bucharest, Romania
- Department of Gynecology, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Ana Valea
- Department of Endocrinology, Clinical County Hospital, 400000 Cluj-Napoca, Romania
- Department of Endocrinology, ‘Iuliu Hatieganu’ University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Aida Petca
- Department of Dermatology, ‘Elias’ Emergency University Hospital, 125100 Bucharest, Romania
| | - Mihai Cristian Dumitrascu
- Department of Gynecology, Emergency University Hospital, 050098 Bucharest, Romania
- Department of Gynecology, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania
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Gracia-Darder I, Ramos D, Boix-Vilanova J, Bauzá-Alonso AF. Necrolytic migratory erythema associated with painful plantar keratoderma. A new diagnostic clue for this paraneoplastic syndrome? An Bras Dermatol 2020; 95:666-668. [PMID: 32723612 PMCID: PMC7563007 DOI: 10.1016/j.abd.2020.02.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 02/29/2020] [Indexed: 12/02/2022] Open
Affiliation(s)
- Inés Gracia-Darder
- Department of Dermatology, Son Espases University Hospital, Palma de Mallorca, Baleares, Spain.
| | - Daniel Ramos
- Department of Dermatology, Son Espases University Hospital, Palma de Mallorca, Baleares, Spain
| | - Julián Boix-Vilanova
- Department of Dermatology, Son Espases University Hospital, Palma de Mallorca, Baleares, Spain
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17
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Shen C, He J, Le X, Zheng L, Cao D. Application of Somatostatin, Chemotherapy Combined with TAE in Heterogeneous Glucagonoma Presented with Necrolytic Migratory Erythema. Onco Targets Ther 2019; 12:11339-11344. [PMID: 31920326 PMCID: PMC6929939 DOI: 10.2147/ott.s237634] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 12/07/2019] [Indexed: 02/05/2023] Open
Abstract
Glucagonoma, a rare neuroendocrine tumor of the pancreas, which is often misdiagnosed because of non-characteristic clinical manifestations. In addition, the treatment has not been well established for this disease so far. We here report a case of glucagonoma previous misdiagnosed as recurrent erythema. In this case, necrolytic migratory erythema was the main clinical manifestation, and he received surgical resection after admission although with liver metastasis. Postoperative pathological results showed that the heterogeneity of proliferative index in primary (Ki-67: 5~10%) and metastatic (Ki-67: 25~30%) tumors were obviously observed. One month postoperatively, abdominal CT and MRI showed multiple liver metastasis (type III) again. Interestingly, the skin rash was obviously improved after treatment with somatostatin combined with chemotherapy (octreotide, temozolomide and capecitabine). Subsequently, the patient received transarterial embolization (TAE). Up to now, no progression was noted for liver metastasis. Due to its rarity, clinical diagnosis is challenging; thus, further understanding of the disease by clinicians is helpful for early diagnosis and treatment, so as to improve the prognosis of patients.
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Affiliation(s)
- Chaoyong Shen
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, People's Republic of China
| | - Jiaoxue He
- Department of Oncology, Wenjiang District People's Hospital, Chengdu, Sichuan, People's Republic of China
| | - Xiaoyan Le
- Department of Oncology, Wenjiang District People's Hospital, Chengdu, Sichuan, People's Republic of China
| | - Linmao Zheng
- Department of Pathology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, People's Republic of China
| | - Dan Cao
- Department of Abdominal Oncology, Cancer Center of West China Hospital, Sichuan University, Chengdu 610041, Sichuan, People's Republic of China
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Cunha-Silva M, da Costa JG, Faria GAS, Massuda JY, Cintra ML, da Costa LBE, Assad VM, de Ataíde EC, Mazo DFDC, Sevá-Pereira T. Diarrhea: a missed D in the 4D glucagonoma syndrome. AUTOPSY AND CASE REPORTS 2019; 9:e2019129. [PMID: 31807436 PMCID: PMC6880768 DOI: 10.4322/acr.2019.129] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Accepted: 09/26/2019] [Indexed: 12/11/2022] Open
Abstract
Glucagonoma is a rare and slow-growing pancreatic tumor that usually manifests as glucagonoma syndrome. It is mainly characterized by a typical Dermatosis named necrolytic migratory erythema (NME), Diabetes and glucagon oversecretion. Deep vein thrombosis and Depression complete this set. We report the case of an advanced glucagonoma with liver spread, where all these 4D symptoms occurred but a chronic secretory Diarrhea was the most relevant feature. A 65-year-old man was referred to our center to investigate multiple hepatic nodules evidenced by abdominal tomography. He had a recent diagnosis of diabetes and complained of significant weight loss (25 kg), crusted skin lesions and episodes of a large amount of liquid diarrhea during the past 6 months. On admission, there were erythematous plaques and crusted erosions on his face, back and limbs, plus angular cheilitis and atrophic glossitis. The typical skin manifestation promptly led dermatologists to suspect glucagonoma as the source of our patient’s symptoms. A contrast-enhanced abdominal computed tomography showed a hypervascularized pancreatic lesion and multiple hepatic nodules also hypervascularized in the arterial phase. Despite initial improvement of diarrhea after subcutaneous octreotide, the patient’s impaired nutritional status limited other therapeutic approaches and he died of respiratory failure due to sepsis. His high levels of serum glucagon were not yet available so we performed an autopsy, confirming the diagnosis of metastatic glucagonoma with NME on histology. Chronic diarrhea is not a common feature in glucagonoma syndrome; however, its severity can lead to serious nutritional impairment and set a poor outcome.
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Affiliation(s)
- Marlone Cunha-Silva
- University of Campinas, Department of Gastroenterology (Gastrocentro). Campinas, SP, Brazil
| | | | | | | | | | | | | | | | | | - Tiago Sevá-Pereira
- University of Campinas, Department of Gastroenterology (Gastrocentro). Campinas, SP, Brazil
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19
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Saavedra C, Lamarca A, Hubner RA. Resolution of necrolytic migratory erythema with somatostatin analogue in a patient diagnosed with pancreatic glucagonoma. BMJ Case Rep 2019; 12:12/8/e229115. [PMID: 31401568 DOI: 10.1136/bcr-2018-229115] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 70-year-old man reported progressive weight loss, fatigue and a generalised rash. The rash was consistent with necrolytic migratory erythema, further investigations were performed and the patient was diagnosed with a mass in the tail of the pancreas, in keeping with a localised glucagonoma. Somatostatin analogue therapy was started for symptom control, leading to complete resolution of the skin rash and an improvement in constitutional symptoms. Subsequently, the pancreatic lesion was excised, and pathology assessment confirmed the diagnosis of well-differentiated neuroendocrine tumour with high expression of glucagon compatible with glucagonoma.
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Affiliation(s)
- Cristina Saavedra
- Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK.,Medical Oncology, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Angela Lamarca
- Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK.,Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - Richard A Hubner
- Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK.,Division of Cancer Sciences, University of Manchester, Manchester, UK
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Guilmette J, Nosé V. Paraneoplastic syndromes and other systemic disorders associated with neuroendocrine neoplasms. Semin Diagn Pathol 2019; 36:229-239. [PMID: 30910348 DOI: 10.1053/j.semdp.2019.03.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Neuroendocrine paraneoplastic syndromes (PNS) consist of metabolic disorders that accompany benign and malignant neoplasms but remain unrelated to mass effects or invasion by the primary tumor or its metastases. The underlying pathogenesis responsible for PNS usual clinical presentation relies on aberrant production of protein hormones, proteins and other substances by the tumor. Prompt recognition of characteristic signs and symptoms combined with serological identification of key substances may result in early diagnosis of PNS and its underlying malignancy. For these reasons, healthcare professionals should familiarize themselves with tumor-induced hypercalcemia, syndrome of inappropriate antidiuretic hormone, carcinoid syndrome, virilisation syndrome, gynecomastia, acromegaly, Cushing syndrome, osteogenic osteomalacia, tumor-induced hypoglycemia, necrolytic migratory erythema, and watery diarrhea, hypokalemia and achlorydria syndrome. Medical awareness for PNS can improve patient outcomes through earlier administration of cancer therapy and treatment, better symptomatic relief and prolong overall survival.
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Affiliation(s)
- Julie Guilmette
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114-2696, United States; Department of Pathology, Charles-Lemoyne Hospital, Greenfield Park, Quebec, Canada
| | - Vânia Nosé
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114-2696, United States.
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Abstract
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.
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Affiliation(s)
- Mark R Wick
- PRW Laboratories, Charlottesville, VA, United State.
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