Cutaneous Markers of Internal Malignancies - a presentation by Dr. Jerriton Brewin, DVL Post Graduate in SVMC, Pondicherry.

2. OVERVIEW
• Introduction
• Head to Toe Examination
-Site specific markers
-Site non-specific markers
• Classifying Markers & Associated Malignancies

3. INTRODUCTION
• Skin - a mirror for underlying malignancies.
• Skin manifestation - may be the only symptom
of underlying malignancy.
• A keen eye is, therefore, required to diagnose
them.

4. Cutaneous Markers
Secondaries Paraneoplastic
Syndromes

5. (a) Both conditions start at the same time,
(b) both conditions follow a parallel course,
(c) the condition is not recognized as a part of a
genetic syndrome,
(d) a specific tumor occurs with a certain
dermatosis,
(e) Genetic association is present, and
(f) a high percentage of the statistical association is
noted.
CURTH’S POSTULATES

6. HEAD TO TOE
EXAMINATION

7. SITE SPECIFIC
SKIN MARKERS

8. Silvery Hair- Chediak Higashi Syndrome
Alopecia Mucinosa - Metastasis to skin
Early Greying
Werner Syndrome

9. Angiofibromas
Collagenomas
- CowdenTrichilemmoma
1. TSC
2. MEN I
Telengiectatic rash - Bloom
LE-like / Eczema - Bazex

10. NF-1
Optic glioma
Lisch nodules
Everted, thick, bumpy eyelid - MEN – 2B
Cataract - Werner Syndrome

11. Pigmented macules - Peutz – Jeghers Syndrome
Soft, lumpy, protuberant lips - MEN 2B

12. Peutz – Jeghers Syndrome

13. 1. Mucosal neuroma
2. Cobblestone hyperplasia
MEN 2B
Cowden
Odontogenic Keratocyst - Gorlin Syndrome
Spotty Pigmentation
Carney Complex
Leukoplakia - DKC

15. CARNEY COMPLEX

16. Sun exposed parts;
Photosensitivity
Lentigenes
RTS, XP

17. XERODERMA PIGMENTOSUM

18. 1. Palmar Erythema
2. Acanthosis Palmaris
1. Acral Warty Keratosis
2. Punctate Keratosis
Cowden
PPK - Howel Evans
1. Dyskeratotic Pits
2. Calcification
Gorlin SyndromeBazex Syndrome

19. Acrokeratosis Paraneoplastica (Bazex Syndrome)

20. PALMOPLANTAR KERATODERMA

21. GORLIN SYNDROME

22. Dystrophy - Dyskeratosis Congenita
Clubbing
Reynaud’s phenomenon

23. Paget’s and Extra-mammary Paget’s

25. SITE NON SPECIFIC
SKIN MARKERS

26. 1. Scar infiltration
2. Morphea-like infiltration
3. Erysepelas-like infiltration
Metastasis to skin

27. Multiple atypical
melanocytic nevus
Familial Melanoma
Syndrome

28. Sebaceous Adenoma
Keratoacanthoma
MUIR - TORRE

29. Neurofibromas
Axillary Freckling
CALMs
NEUROFIBROMATOSIS

30. Angiofibroma
Periungual
fibroma
Frontal Fibrotic Plaque
Angiokeratoma
TSC

31. Lipomas
MEN 1 & 2B

32. Mucocutaneous Myxomas
Carney Complex

33. Glomeruloid Hemangioma
POEMS Syndrome

34. Cutaneous Leiomyoma - Hereditary Leiomyomatosis

35. Albinism
Chediak-Higashi Syndrome

36. Petechiae, purpura & bruises
Wiskott-Aldrich Syndrome

37. Reticular Hyperpigmentation
1. DKC
2. Fanconi’s anemia

40. Acanthosis Nigricans

41. Sign of Leser Trelat
Seborrheic Keratosis

42. Cutaneous Florid
Papillomatosis

43. Acquired Icthyosis

44. Pityriasis
Rotunda

45. Lanugo Hair
Hypertrichosis Lanuginosa Acquisita

46. Hyperhydrosis

47. Generalised Pruritis

48. Erythema
Gyratum
Repans
Necrolytic
Migratory
Erythema
MIGRATORY ERYTHEMAS

49. CLASSIFYING MARKERS
AND ASSOCIATED
MALIGNANCIES

50. DIRECT EXTENSION
1. Tumor spillage - FNAC, pleural biopsy, draining
malignant ascites, lap, sx
2. Carcinoma erysipeloides - Tumor cells in lymphatics;
erysipelas-like picture; CA breast.
3. Carcinoma en cuirasse – sclerotic infiltration of CA
breast
4. Carcinoma telangiectodes – telengiectatic
infiltration of CA breast
5. Paget’s disease – extension from underlying ductal
tumor of breast

51. Sclerotic and telangiectatic infiltration

52. Erysepelas-like infiltration

54. METASTASIS TO SKIN
1. M/C – Solitary nodule (dermal / SC)
2. Morphea-like sclerotic plaques
3. Scar infiltration
4. Erysepelas-like infiltration
5. Alopecia neoplastica – infiltrated areas of alopecia
6. Embolic mets to digits

59. GENODERMATOSIS

60. DISEASE FEATURES MALIGNANCY
Gardner’s syndrome multiple epidermoid
cysts, fibromas, and
pilomatrixomas
GI malignancy
Peutz–Jeghers
syndrome
mucocutaneous
pigmentation in peri-
and intra-oral
regions
GI malignancy
Howel–Evans
syndrome
PPK Oesophageal CA
Gorlin syndrome multiple basal cell
carcinomas,
mandibular
keratocysts,
dyskeratotic pits of
palms, and soles
medulloblastoma
and ovarian tumors

61. DISEASE FEATURES MALIGNANCY
Dysplastic nevus
syndrome
multiple atypical
melanocytic nevi
pancreatic,
gastrointestinal,
lung, breast, and
laryngeal carcinoma
Xeroderma
pigmentosum
Photosensitivity,
myriads of lentigines
ocular, and
cutaneous
malignancy
Von Hippel-Landau
syndrome
hemangiomas and
cafe-au-lait spots
hemangioblastoma
of CNS,
pheochromocytoma,
renal and pancreatic
cancers
Neurofibromatosis
type 1 and 2
multiple peripheral
neurofibromas, cafe-
au-lait macules,
axillary freckles
CNS tumors

62. DISEASE FEATURES MALIGNANCY
Carney’s syndrome lentigines, atrial
myxomas,
mucocutaneous
myxomas, blue nevi
gonadal hormone
secreting tumors,
malignant thyroid
tumors
Cowden’s disease warty “cobblestone”
hyperplasia of the
mucosal surfaces,
acral warty keratosis,
and punctuate
keratosis
GI polyposis and cysts
and breast
adenocarcinoma
Muir–Torre syndrome sebaceous lesions
and keratoacanthoma
HNPCC
Bloom syndrome sun sensitive
telangiectasia, cafe-
au-lait macules
lymphoproliferative
neoplasia

63. PIGMENTARY
DISORDERS

64. PATTERN EXAMPLES
Diffuse, or diffuse with localized
accentuation (addisonian
pattern of pigmentation)
Pheochromocytoma, Ectopic
ACTH syndrome, POEMS
syndrome
Patchy or reticulated Fanconi’s anemia
Dyskeratosis congenita
Photo distributed Carcinoid syndrome
Lentigines and freckles Carney complex, XP, NF,
Cowden, Gardner
HYPERPIGMENTATION

65. PATTERN EXAMPLES
Generalized Chediak–Higashi syndrome
Localized, multiple TSC (Ash-leaf macules), MF
(hypopigmented variant)
HYPOPIGMENTATION

66. PATTERN EXAMPLES
Poikiloderma Dermatomyositis, RTS
(photodistributed)
MIXED PIGMENTATION

67. DEPOSITION DISORDERS

70. BULLOUS DISORDERS
• Paraneoplastic pemphigus - NHL, Castleman tumor,
thymoma
• Pemphigus - Thymoma, Hodgkin’s disease.
• Herpes gestationis - hydatidiform mole and germ
cell tumor.
• EBA - CA of bronchus and multiple myeloma
• LAD - Lymphoma, CLL, carcinoma bladder and
esophagus, and hydatidiform mole
• Cicatricial pemphigoid - CA lung, stomach, colon,
and endometrium

71. KERATINIZATION DISORDERS
• Acanthosis nigricans - Gastric and intra-abdominal
adenocarcinoma.
• Acquired ichthyosis - Hodgkin’s lymphoma,
carcinoma lung, breast, and cervix.
• Palmer hyperkeratosis - Esophageal carcinoma.
• Palmoplantar keratoderma - Breast or ovarian
carcinoma.
• Tripe palms - Gastric and lung carcinoma.
• Erythroderma - Leukemia, lymphoma, MF.

72. • Bazex - SCC of oropharynx, larynx, lung, esophagus,
and thymus.
• Florid cutaneous papillomatosis - CA stomach,
breast, lungs, and ovary.
• Sign of Leser–Trelat - Adenocarcinoma of stomach
or colon.
• Multiple cherry angiomas are associated with solid
tumors.
• Multiple skin tags are associated with colonic
polyps.
• P. Rotunda – HCC

73. COLLAGEN VASCULAR DISORDERS
• Dermatomyositis - CA ovary, lung, pancreas,
stomach, colorectal, and lymphoma.
• Lupus erythematosus - Lymphoma, thymoma.
• Scleroderma - CA lung, esophagus.
• Systemic lupus erythematosus - Lymphoreticular
malignancies, myeloma, and paraproteinemias.

74. VASCULAR DISORDERS
• Raynaud’s phenomenon – Solid tumors, RE
neoplasms.
• Erythromelalgia – Myeloproliferative disorders (eg.
PCV).
• Palmar erythema – Cerebral malignancies.
• Vasculitis – Myeloproliferative disorders (esp. hairy
cell leukemia).
• Chilblain-like lesions – Leukemia and
myeloproliferative disorders.
• Flushing – Carcinoid syndrome, mastocytosis.

75. PRURITIS
• Generalized - Hodgkin’s, non-Hodgkin’s disease,
Sézary syndrome, mycosis fungoides, myelomatosis
and leukemia, PRV.
• Localized (nerve damage by tumor) - Brachioradial
pruritus and localized facial or nasal pruritus.

76. OTHER DERMATOSES
• Necrolytic migratory erythema - Glucagonoma
syndrome
• Erythema gyratum repens - CA breast, lung,
bladder, prostate, cervix, stomach, esophagus, and
multiple myeloma.
• PCT - Liver CA
• Sweet's - AML, myelodysplastic syndrome, multiple
myeloma, and lymphoma.

77. • Pyoderma gangrenosum - AML, CML, acute
lymphoblastic leukemia, multiple myeloma, and
PRV.
• Paraneoplastic sweating - Hodgkin’s lymphoma,
liver metastasis
• Urticaria - Myeloma, Lymphoma.
• Granuloma Annulare - Lymphomas, other
hematological malignancies

78. REFERENCES
1. Rook’s Textbook of Dermatology
2. Bolognia’s Dermatology
3. Fitzpatrick’s Dermatology
4. Vora RV, Kota RS, Diwan NG, Jivani NB, Gandhi SS.
Skin: A mirror of internal malignancy. Indian J Med
Paediatr Oncol 2016;37:214-22.