Early diagnosis of internal malignancy is possible by carefully examining the cutaneous manifestation of internal malignancy

1. Presented by: Dr. Pravin Kumar
Moderator :Prof.N Biplab
CUTANEOUS MANIFESTATION OF
INTERNAL MALIGNANCY

2. Introduction:
• Internal malignancy can result in manifestation on
skin
• These signs can be malignant or non malignant
Malignant- Local spread
Non malignant- Paraneoplastic dermatosis
• Skin signs can also signify heritable conditions
associated with malignancy

3. Helen Ollendorff Curth proposed criteria for
diagnosis of a paraneoplastic dermatosis:
• The cutaneous manifestation and internal malignancy may
be diagnosed simultaneously or with in a short interval.
• The dermatoses may clear on treatment of malignancy and
relapse if the malignancy recurs.
• Specific type of neoplasms and the para neoplastic
conditions occur with specific dermatosis
• A statistically significant association is reported between
the cutaneous manifestation and the internal malignancy.
• A genetic association exists between the internal
maignancy and specific cutaneous disease

4. Cutaneous manifestations of internal
malignancies are grouped into 3 categories:
• Proliferative and inflammatory dermatoses
associated with internal malignancies.
• Genodermatoses with cutaneous tumors and internal
malignancies.
• Hormone secreting tumor with cutaneous
manifestations.

5. CUTANEOUS MANIFESTATION OF INTERNAL MALIGNANCY
PROLIFERATIVE AND
INFLAMATORY
GENODERMATOSIS HORMONE SECRETING
TUMOR
ACANTHOSIS NIGRICAN
SIGN OF LESER TRACT
TRIPE PALM
BAZEX SYNDROME
ACQUIRED
HYPERTRICHOSIS
DERMATOMYOSITIS
SWEET SYNDROME
PYODERMA GANGREOSUM
VASCULITIS
VASCULAR DISORDER
COAGULOPATHY
BULLOUS DISORDER
CLUBBING
PRIMARY SYSTEMIC
AMYLOIDOSIS
SCLEROMYXEDEMA
YELLOW NAIL SYNDROME
EXTRA MAMMARY PAGET
PTYRIASIS ROTUNDA
ACQUIRED ICTHYOSIS
COWDEN SYNDROME
MUIR TORRE
GARDNER SYNDROME
HOWEL EVAN
SYNDROME
BIRT HOGG DUBE
SYNDROME
RENAL CELL CANCER
SYNDROME
TUBEROUS SCLEROSIS
NEUROFIBROMATOSIS
PEUTZ JEGHER
SYNDROME
GORLIN SYNDROME
XERODERMA
PIGMETOSUM
ECTOPIC ACTH
CARCINOID
SYNDROME
GLUCAGONOMA
SYNDROME
MULTIPLE
ENDOCRINE
NEOPLASIA

7. • Velvety, verrucous,hyper pigmented plaques on flexures
and neck.
• Papillomatous changes in the oral cavity .
Associated malignancy:
• Adenocarcinoma of the stomach.(MC)
• Ca lung,ovary,endometrium,kidney, pancreas
Acanthosis Nigricans

8. Cutaneous manifestations :
• Sudden appearance and/or rapid
increase in size of multiple seborrheic
keratoses often pruritic.
Associated malignancy:
• carcinoma of the gastrointestinal
tract.
• Tumors of the female
reproductive system.
• lympho proliferative disorders.
Sign of leser tract

9. Cutaneous manifestation:
• Hyperkeratosis in a wrinkled or ridged
pattern on the palms(honey comb
appearance) and the dorsal surface of
the large joints.
Associated malignancy:
• Squamous cell carcinoma of the lung.
• Gastric carcinoma
Tripe palm

10. Cutaneous manifestations:
• Symmetrical, psoriasiform and erythematous to violaceous
plaques on nose, ears, and distal extremities.
• Dystrophic nails are pruritic.
• The malignancy and cutaneous findings are concurrent.
Associated malignancy:
• Carcinoma of the upper respiratory, and
Digestive tracts.(oralcavity,larynx,pharynx,esophagus)
Bazex syndrome(Akrokeratosis paraneoplastica)

12. Cutaneous manifestation:
• extensive, silky nonpigmented
lanugo hair on the face, neck, trunk,
and on the extremities.(previously
seen hair less by the patient).
• Painful glossitis,angular cheilitis,and
swollen red fungiform papillae on
the anterior half of the tongue.
• Hyper trichosis usually antedates
the malignancy.
Associated malignancy:
• Adeno carcinoma of the gastro
intestinal tract,lung cancer.
Acquired
Hypertrichosis
Lanuginosa

13. Cutaneous manifestation:
• Adult onset,
• - classical heliotrope rash
-gottrons papules.
-proximal myopathy.
• The risk of underlying
Associated malignancy:
• ovarian and breast cancers in F .
• Lung and prostate cancers in M.
Dermatomyositis
malignancy is highest in the
first year of diagnosis

14. Cutaneous manifestation:
• Acute onset of erythematous,tender
papules,plaques,or nodules on the face,
extremities and upper trunk with
vesiculation or pustules on the surface.
Associated malignancy:
• Myeloproliferative disorders
commmonly acute myelogenous
leukemia.
Neutrophillic Dermatoses /Sweet’s syndrome

15. Cutaneous manifestation:
• large spreading purulent ulcers,with
cyanotic over hanging borders .
• Cutaneous disease and malignancy
often present concurrently and run a
parallel course
Associated malignancy:
• Hematological malignancy,
• Monoclonal gammmopathies,
• Myeloma solid tumors,Non
hodgkins lymphoma,
Pyoderma gangrenosum

16. Cutaneous manifestation:
•palpable purpura
Associated malignancy:
• Myelo proliferative disorders.
Vasculitis

17. Figurate erythema
Cutaneous manifestation:
• Erythema gyratum repens (multiple
wavy urticarial bands with fine
scales,migratory with wood grain like
pattern)
Associated malignancy:
•lung, esophageal,breast,cancers
Vascular disorder:

18. • Extensive areas of purpura non
palpable,may be associated with
DIC.
• Trousseau syndrome:migratory
superficial thrombophlebitis and
multiple DVT on the neck ,chest
abdominal wall and limbs.
Associated malignacy:
• Hematological malignancies,tumors
arising in the pancreas,lung, prostate
Coagulopathy

19. Cutaneous manifestation:
• Paraneoplstic pemphigus,
• Cicatricial pemphigoid,
• Dermatitis herpetiformis,
• Epidermolysis acquisita.
Associated malignacy:
• Castleman tumor
• Non hodgkins lymphoma,thymoma
• Follicular dendritc cell sarcoma and chronic
lymphocytic leukemia
• Adenocarcinomas,intestinal lymphomas,lympho
reticular tumors.
Bullous disorders

20. Cutaneous manifestation:
• Genaralised waxy papules,nodules,
purpura,macroglossia,
Associated malignancy:
• Myelomas

21. Cutaneous manifestation:
• Linear waxy,lichenoid papules,
aka pseudo scleroderma
Associated malignancy:
• Myelomas, plasma cell dyscrasias
Scleromyxedema

22. cutaneous manifestation:
• Erythematous plaques at site other
than the breast ,most often on the
axillary ,inguinal fold,vulva or
scrotum.
Associated malignancy:
• Adenoca of the rectum or anal
canal,underlying sweat
gland,sebaceous and apocrine
carcinomas.
Extramammary paget disease

23. Cutaneous manifestation:
• Hypertrophic osteoarthropathy a manifestation of sub
periosteal new bone formation occurs along the shaft of the
phalanges.
Pachydermoperiostosis:
• clubbing associated with acromegaloid features.
Associated malignancy:
• Lung cancer and metastatic tumors to the lung.
• Pitutory tumor in case of Acromegaly

24. cutaneous manifestation:
• Yellow discoloration of
nails,thickened nails with slow
growth,some times nails present
with edema of the proximal nail
folds.
Associated malignancy:
• Mycosis fungoides,laryngeal
carcinoma
• Ca GB,,bronchiogenic
carcinoma, Ca breast,NHL
• Endometrial carcinoma
Yellow Nail Syndrome

25. Acquired icthyosis
• Cutaneous manifestation--
genaralised xerosis and ichthyotic
scaling.
• Associated malignancy--hodgkins
lymphoma,lympho proliferative
disorders.
Pityriasis Rotunda
• Cutaneous manifestation-
Symmetrical circular scaly lesions on
the trunk described in japanese.
• Associated malignancy-HCC,cancers of
GIT ,prostate, myeloproliferative
disorders.

26. .

27. • COWDEN SYNDROME(MHS, AD)
Hamartomas of skin and mucosa
At least one of the four types of skin
lesions
• Facial trichillemmomas
• Oral lesions –cobblestone appearance
known as papillomatosis.
• Acral keratosis- Dorsal surface of hands
and feet
• Palmoplantar keratoses – scaly spots on
the palms and soles

28. Associated malignancy
 Breast cancer
 Genitourinary tumours
 Thyroid cancer,especially follicular thyroid
carcinoma
 Skeletal abnormalities such as bone cysts.
 Gastrointestinal polyps

29. Cutaneous features:
• Sebaceous adenomas
• keratoacanthomas. (firm, rounded,
flesh- coloured or reddish papule--
central part of the face,the dorsum of
the hand,wrist and forearm
commonly affected.)
Associated malignancy:
• Colorectal, genito urinary cancers.
Muir Torre syndrome

30. Gardner syndrome
-Benign lipomas, frontal
& maxillary osteomas.
(often get exophthalmos)
-Related to
familial adenomatous
polyposis(FAP). Colon polyps
become malignant and
extracolonic tumours of
thyroid, craniofacial skeleton
& cysts of the epidermis.

31. Association between tylosis
(thickened skin of the palms and
soles) and esophageal cancer.
• The keratoderma usually develops
during childhood and is
accentuated over pressure sites
• Oral leukoplakia
• chromosome 17q25, now referred
to as the tylosis (o)esophageal
cancer (TOC) gene, appears to be
associated with this syndrome
Howel-Evan Syndrome

32. Autosomal dominant syndrome.
Skin tags and benign hair follicle tumors
(fibrofolliculomas and trichodiscomas) that most
often occur on the head and neck.
Associated malignancy
• Chromophobe and oncocytic types of RCC,
Medullary carcinoma of the thyroid is also
associated
• A mutation in the 17p11.2 gene, which
encodes folliculin
Birt-Hogg-Dube Syndrome

33.  An autosomal dominant condition
 The cutaneous leiomyomas may be
segmental or band-like rather than
diffuse and symmetric . They are
firm, flesh- colored, red or brown,
and may be painful
 Appear by age 25 years
 Multiple leiomyomas of the uterus
 Papillary renal cell carcinoma.
Heriditary leiomyomatosis/ Renal cell carcinoma
syndrome

34. Tuberous sclerosis
Cutaneous feature:-
• Adenoma sebaceum
• shagreen patch
• ash leaf macule
• koenens tumors
Associated malignancy
• Renal cancers,CNS tumors(usually benign)

35. Neurofibromatosis
Type 1: Cutaneous features:
• CALMS, axillary
freckling,neurofibromas.
Associated malignancy:
• Malignant peripheral nerve
sheeth tumor,leukemias,breast
cancers.
Type2: Cutaneous features:
schwanomas,neurofibroma
Associated malignancy:
• Acoustic neuromas,meningiomas

36. Peutz-Jegher syndrome
• Autosomal dominant
• Freckle-like pigmented macules
that in lips, nose, buccal mucosa,
fingertips, and under the nails
• mutations in the STK11/LKB1
gene on chromosome 19p13.3.
Associated malignancy :
• extensive hamartomatous polyps
and carcinomas throughout the GI
tract, mainly the small intestine

37. Gorlin syndrome
• Also known as naevoid basal cell
carcinoma.
• Associated malignancy:
medulloblastoma & benign tumours
of the ovaries.

38. Xeroderma pigmentosum(AR)
cutaneous features:
• Freckles,lentigenes, Poikiloderma
• Xeroderma,corneal ulceration
Associated malignancy:
• leukemia
• cancers of
breast,lung,pancreas,stomach,testes

39. Hormone Secreting Tumor And
Cutaneous Manifestation

40. Glucagonoma Syndrome
Cutaneous manifestation:
Necrolytic migatory
erythema,affects the perioral
region and the distal extremities
Associated malignancy:
Neoplastic proliferation of the
glucagon secreting alpha cells of
the pancreas

41. Ectopic ACTH
Cutaneous manifestations:
• Intense hyper pigmentation.
• systemic feature :↓ K, ↑pH,
↑BP,↓Weight,↑RBS
Associated malignancy:
• Small cell carcinoma of the lung,
• carcinoid tumors
• pancreatic islet cell tumors
• pheochromocytoma.

42. Carcinoid syndrome
Cutaneous manifestations:
• Flushing,Permanent facial cyanotic flush and
telangiectasia,resembling rosacea.
• Leonine facies due to persistant facial
erythema and edema,
Pellagroid rash.
Associated malignancy:
• Carcinoid tumors are most often found in the
appendix or small intestine.
• Extra intestinal carcinoids may arise in
the bile ducts, pancreas, stomach,
ovaries or bronchi.

43. Multiple endocrine neoplasia
Cutaneous manifestation:
• Carcinoid like syndrome in MEN 2A
• Mucocutaneous lesions occur only in
MEN 2B (multiple mucosal
neuromas ).
• Skin lesions do not characterize
MEN 1
Associated malignancy:
• Medullary thyroid cancers

44. Cutaneous manifestation
• Flesh colored to violaceous
nodules,commonly located close
to the primary neoplasm.
• Common in malignancy
spreading the lymphatics, such
as cancers of the
breast,oropharynx,and urinary
bladder

45. CONCLUSION
• The skin examination can reveal signs of a
predisposition toward malignancy
• It can yield valuable early clues suggesting an
underlying neoplastic process.
• Although the skin changes doesn’t guarantee a
100% acurate diagnosis of internal cancer ,
recognition of these cutaneous signs and
symptoms should alert the clinician to initiate
appropriate diagnostic measures for a early
diagnosis of malignancy