The association of skin with visceral cancer was first described by Hebra in 1868.[1] More than 50 dermatological conditions have been reported as markers of malignancy.
Paraneoplastic dermatoses are heterogeneous group of clinical manifestations that
often appears benign, and they are the third most common paraneoplastic site very
next to neurologic and endocrine syndromes.[2] There is no relationship between the severity of symptoms and the size of the primary
tumor. It commonly precedes or follows visceral cancer[3] and early recognition may result in earlier diagnosis and management of visceral
cancer. At other times, the syndromes may occur late in the course of disease or may
appear as the first sign of recurrence.[3]
We report a 60-year-old male chronic smoker who presented with complaints of peeling
of the skin all over the body sparing the face for the last 2 weeks. He also had a
loss of appetite and weight that was not quantified. His past history was unremarkable.
On examination, vitals were stable with a body mass index of 17.8 kg/m. He had pallor
and bilateral digital clubbing. General physical examination showed prominent dermatoglyphics
with exaggeration of the ridges and furrows and thickening and darkening of both palm
and sole with a velvety appearance ([Fig. 1]). Systemic examination and routine blood investigations were normal expect for mild
anemia. Skin biopsy of palm showed marked hyperkeratosis, irregular acanthosis, and
mild papillomatosis ([Fig. 2A]) collectively termed as tripe palms, which can be the first sign of an undiagnosed
cancer particularly gastric and lung cancer. Hence, the patient underwent a full diagnostic
workup for an associated malignancy. Imaging of thorax showed necrotic lung mass with
cavitation and necrotic mediastinal lymphadenopathy ([Fig. 3]). Computed tomography-guided biopsy of lung mass was suggestive of small cell carcinoma
of the lung ([Fig. 2B]). Upper gastrointestinal (GI) endoscopy and ultrasonographic abdomen, done to rule
out GI malignancies, were normal. A diagnosis of tripe palms secondary to small cell
carcinoma of the lung was made and the patient was referred to medical oncologist
and started on intravenous etoposide and cisplatin in cycles. However, the patient
succumbed to cancer after 1 month.
Fig. 1 Prominent dermatoglyphics with exaggeration of the ridges and furrows of palm (A) and sole (B) with a velvety appearance.
Fig. 2 (A) Skin biopsy showing epidermal hyperkeratosis, mild papillomatosis, and irregular
acanthosis with unremarkable dermis. (B) Lung biopsy showing atypical cells arranged in clusters with high nucleus cytoplasm
ratio, moderate amount of cytoplasm, vesicular nucleus, and prominent nucleoli.
Fig. 3 Computed tomography thorax showing the right upper lobe necrotic mass with mediastinal
lymph nodes.
Paraneoplastic syndromes are a group of clinical disorders that are associated with
malignant diseases and are not directly related to direct invasion, obstruction, or
metastasis.[3] Although paraneoplastic syndromes can be associated with many types of malignancies,
they are most frequently associated with lung cancer occurring in 10% of these patients,[3] especially small cell lung cancer (SCLC). Humoral hypercalcemia of malignancy in
squamous cell carcinoma and syndrome of inappropriate antidiuretic hormone in SCLC
are the two common paraneoplastic syndromes in lung cancer patients. Some of the common
paraneoplastic dermatoses are listed in [Table 1]. SCLC is most commonly associated with neurologic, endocrine, and rheumatic paraneoplastic
syndromes. Clubbing and hypertrophic osteoarthropathy occur in 1 to 5% of all patients
with SCLC and it is the most reported paraneoplastic dermatoses,[4] but it is not specific to SCLC. Other paraneoplastic dermatoses reported in literature
in SCLC patients include dermatomyositis, Bazex syndrome, and acquired ichthyosis.
Table 1
Common paraneoplastic dermatologic syndromes associated with lung cancer
|
Paraneoplastic dermatologic syndromes associated with lung cancer
|
|
Acrokeratosis paraneoplastica (Bazex syndrome)
|
|
Acanthosis nigricans
|
|
Tripe palms
|
|
The sign of Leser-Trélat
|
|
Erythema gyratum repens
|
|
Pityriasis rubra pilaris
|
|
Pyoderma gangrenosum
|
|
Eosinophilic cellulitis
|
|
Pemphigus herpetiformis
|
|
Hypertrichosis lanuginosa acquisita
|
|
Erythema elevatum diutinum
|
|
Polymyositis/dermatomyositis
|
|
Hypertrophic pulmonary osteoarthropathy
|
We report a first case of SCLC that presented with tripe palms. Tripe palms consist
of acanthosis palmaris, pachydermatoglyphy, and palmar hyperkeratosis where there
is yellowish rugose hypertrophy of the palms, and sometimes the soles, leading to
an exaggeration of the skin lines and the skin, resemble the edible lining of bovine
foregut and is usually associated with paraneoplastic acanthosis nigricans. Tripe
palms are usually associated with malignancy in 90% of cases, gastric and lung cancers
accounting for more than 50% of cases.[5] In the absence of an association with paraneoplastic acanthosis nigricans, lung
cancer becomes more prevalent, accounting for more than 50% of cases.[5] Pulmonary tumors are usually nonsmall cell, with squamous cell and adenocarcinoma
described most frequently in the literature. Other neoplasms that are correlated with
tripe palms include liver, gallbladder and bile duct breast, and genitourinary tract
cancers.
The exact pathogenesis of acanthosis palmaris is poorly understood. Several cytokines
such as transforming growth factor α, insulin growth factor-1-like, fibroblast growth
factor, and melanocyte-stimulating hormone-β produced by neoplastic cells could be
responsible for an increased proliferation of keratinocytes and the development of
paraneoplastic acanthosis palmaris.[1] In general, paraneoplastic dermatologic syndromes improve in response to the treatment
of the underlying neoplasm; the efficacy of ectopic local treatments is partial or
insufficient. Furthermore, the responsiveness to the therapy is generally weaker compared
with the nonparaneoplastic equivalents.
Good understanding of paraneoplastic syndromes associated with lung cancer is necessary
for their early recognition that may result in earlier diagnosis and management of
lung cancer. Currently, the treatment of these syndromes consists of direct therapies
aimed at the underlying lung cancer.
