Tripe Palms: A Cutaneous Marker of Internal Malignancy

Tripe palms is a distinctive paraneoplastic cutaneous sign which is frequently associated with internal malignancy, specially carcinomas of the lung and stomach. We describe a patient with ovary carcinoma who showed a curious rugose thickening of the palms with accentuation of the normal dermatoglyphic ridges. The lesions were a specially prominent on the fingertips. The patient also showed classical acanthosis nigricans in the axillae and groin. The soles were spared. Histopathologic findings in palmar lesions consisted of an undulant epidermis, with hyperkeratosis, acanthosis, and papillomatosis. Excision of the ovary carcinoma was followed by complete regression of the cutaneous lesions. We review the literature about tripe palms and discuss the relationship between this striking cutaneous manifestation and internal malignancy.     

Acquired Pachydermatoglyphy A Cutaneous Sign of Internal Malignancy

A 70-year-old man with hypertrophic osteoartropathy secondary to a squamous cell carcinoma of the lung presented a distinctive pattern of late-onset bilateral palmar keratoderma. A yellowish rugose appearance with accentuation of normal ridges and sulci (pachydermatoglyphy) involving the palms was observed. The differential diagnosis and the clinical relevance of acquired pachydermatoglyphy as a cutaneous marker of internal malignancy are discussed.     

Malignant acanthosis nigricans and tripe palms associated with pancreatic adenocarcinoma

Malignant acanthosis nigricans is a disease that has an abrupt onset and is most commonly associated with gastric adenocarcinoma. It also has occurred as a paraneoplastic phenomenon in other carcinomas. Malignant acanthosis nigricans can occur simultaneously, before, or after the onset of internal malignancy. Malignant acanthosis on the palms is referred to as tripe palms. We describe a rare association of oral malignant acanthosis nigricans and tripe palms secondary to an underlying pancreatic adenocarcinoma.     

Punctate porokeratotic keratoderma—its occurrence with internal neoplasia

Punctate porokeratotic keratoderma (PPK) represents a diffuse involvement of palms and soles by multiple, acuminate keratotic papules and plugs, histologically identified by parakeratotic cornoid lamellae. A possible association between PPK and internal malignancy has been previously noted by Herman in 1973². A patient with a 3-month history of PPK is described in which a bronchial carcinoma was recently diagnosed. This association led us to speculate that PPK could be a sign of internal neoplasia, as already established for other forms of palmoplantar keratoderma. We suggest that the presence of an underlying malignancy must be screened for when a diagnosis of PPK is proposed.     

Pachyonychia Congenita: A Clinical Study of 12 Cases and Review of the Literature

Twelve cases of pachyonychia congenita were reviewed. The mode of inheritance was autosomal dominant. The clinical features of these patients included thickened nails, hyperkeratosis of the palms and soles, thinning of hair or alopecia, painful bullae or ulcerations of the palms and soles, leukokeratosis oris, verrucous lesions of the extremities, hyperhidrosis, premature eruption of teeth, paronychial infections, epidermal cysts with milia, and corneal dyskeratosis at times associated with cataracts. Biopsy from the plantar lesions usually revealed marked hyperkeratosis, acanthosis, moderate hypergranulosis, and minimal dermal inflammatory infiltration. Treatment with keratolytic agents and lubricants is indicated to areas of palmar and plantar hyperkeratosis but usually produces only transient benefit. Squamous cell carcinoma developed in one of the patients over the site of chronic plantar ulcerations. Areas of chronic bullous formation or ulceration should be observed for possible skin malignancy.     

Palmar filiform hyperkeratosis (FH) associated with underlying pathology?

We describe two patients with palmar filiform hyperkeratosis, characterized by multiple thin spiny keratotic projections on the palms. The condition has been associated with an underlying malignancy in some cases. One patient has myelofibrosis, an association not previously described. In addition we describe a further patient with filiform hyperkeratoses of both palms and soles with no associated underlying disorder. In view of the relatively high risk of underlying malignancy occurring in patients with filiform hyperkeratosis, these patients should always be investigated fully.     

Pulmonary nocardiosis with cutaneous involvement mimicking a metastasizing lung carcinoma in a patient with chronic myelogenous leukaemia

We report a unique case of a man suffering from chronic myelogenous leukaemia who presented with clinical symptoms, X-ray, and bronchoscopical findings consistant with a bronchopulmonary space-occupying process which was suspected to be a central lung carcinoma as a secondary de novo malignancy. In addition, the patient developed several subcutaneous nodular livid red lesions on the left forearm which were considered to be cutaneous metastases of the presumptive lung malignancy. Treatment was started with percutaneous radiation of the mediastinum over a period of ten days with a total dose of 25 Gray. The patient died from circulatory and respiratory failure. Only post mortem pathological examination was indicative of a nocardiosis of the lungs with haematological spread to eosophagus, pleura, and subcutaneous skin of the left forearm. Unfortunately, diagnosis of nocardiosis could not finally proven by culture or molecular biological methods. A lung carcinoma or an infiltrate of residual or relapsing chronic myelogenous leukemia in the lung could be definitely ruled out.     

Hyperkeratosis of the palms and soles associated with internal malignancy and elevated levels of immunoreactive human growth hormone

Three cases are described of late onset hyperkeratosis of the palms and soles which was associated with internal carcinoma. In two cases high levels of immunoreactive human growth hormone (IRHGH) were present. Surface microscopy showed a cobbled appearance replacing the normal dermatoglyphics. The prognosis in each case was poor after the development of the palmar-plantar hyperkeratosis and the relationship to the high levels of IRHGH is discussed. Comparisons are made with other palmar-plantar hyperkeratoses associated with malignancy.     

Urticaria and large cell undifferentiated carcinoma of lung

The association of urticaria with internal cancer is known mostly with lymphoreticular system malignancies. Rarely, it occurs with cancer of lung, mostly with adenocarcinoma or small cell carcinoma. We report a unique occurrence of urticaria on a patient who suffered from large cell undifferentiated carcinoma of lung. Only the treatment for malignancy relieved the patient from his long standing cutaneous manifestation.     

DERMATOMYOSITIS: A CLINICAL OF TWENTY-THREE CASES IN HONG KONG

SUMMARY.— Twenty-three cases of dermatomyositis are reported of which 12 (52%) were associated with internal malignancy. In the patients over 40 years of age, malignant diseases were encountered in 69%, while only one of 7 cases under 40 had associated malignancy. Nasopharyngeal carcinoma accounted for 75% of the malignant disease.
A distinctive skin eruption, consisting of hyperkeratotic, follicular, erythematous papules, is described. On the face, trunk and limbs, the papules tended to become confluent. Along the tendons and over the bony prominences on the backs of the hands and feet, the eruption was usually arranged in a linear fashion. There was alopecia of the scalp. On the palms and soles were hyperkeratotic papules or plaques. The occurrence of this form of eruption in dermatomyositis may be influenced by racial factors.     

Clinical characteristics of pigmented macules on palms and/or soles appearing after middle age in Japan

We have examined the clinical characteristics of pigmented macules on palms and/or soles. A total of 238 inpatients and 111 healthy persons over 40 years old in Japan were included in our analysis. We found: (a) that such pigmented macules may occur not only on healthy persons but also on patients who suffer from various internal disorders, (b) that, in both males and females, the incidence of pigmented macules is relatively high in malignancy patients in comparison with non-malignancy and control individuals, (c) that the incidence is higher in males than in females, (d) that, in both males and females, there was a tendency toward distribution on both palms and soles in malignancy patients in comparison with the non-malignancy and control individuals (p<0.01), and (e) that, among cases with pigmented macules, the number of pigmented macules is empirically greater in inpatients (the malignancy and non-malignancy groups) than in the controls.     

Pigmented macules on the palms and/or soles of Japanese subjects: influences of clinical severity and duration of illness.

We have suggested that pigmented macules on the palms and/or soles occur in response to various systemic diseases. In the present paper, we evaluated the influences of clinical severity and duration of illness in Japanese subjects. In males, cases who suffered from cerebral vascular accident (CVA) for long periods and/or severely tended to have numerous pigmented macules. In females, cases with CVA did not show any similar tendency. As the result of our prior and present studies, we conclude that underlying systemic disease itself can play a pivotal role in the development of pigmented macules on the palms and/or soles of Japanese subjects. We emphasize that such a pigmented macular eruption with characteristic clinical features is an important sign of internal disorders, including malignancy.     

Oral acanthosis nigricans, tripe palms and sign of leser-trélat in a patient with gastric adenocarcinoma

Acanthosis nigricans (AN), tripe palms (TP) and the sign of Leser-Trélat (LT) may be seen with the presence of malignancy. Acanthosis nigricans may have a mucocutaneous localization involving the oral mucosa with papillomatous and verrucous lesions usually on the lips and buccal mucosa. These paraneoplastic dermatoses are generally linked with intra-abdominal malignancy, most often gastric adenocarcinoma. Improvement of the associated dermatoses after the treatment of the malignancy has been frequently observed. We report the case of a 53-year-old man suffering from advanced gastric adenocarcinoma, in which metastases seemed to sustain all three paraneoplastic dermatoses. To the best of our knowledge this is the first case of a patient showing manifestations of all three paraneoplastic dermatoses. Patients presenting with this set of dermatoses should be suspected to harbor an occult malignancy, or have persistence of a known malignancy.     

"I forgot to shave my hands": A case of spiny keratoderma

A 57-year-old Caucasian man presented with multiple asymptomatic spiny papules on the palms and soles that he had been shaving off with a razor for many years. He was otherwise healthy with no personal or family history of skin disease or malignancy. A diagnosis of spiny keratoderma of the palms and soles or "music box spine dermatosis" was made. The clinical, histologic, and electron-microscopic features of spiny keratoderma are distinct. This entity previously had multiple classifications and it is important to distinguish it from other keratodermas as some keratodermas can be linked to cutaneous and internal malignancies and conditions: polycystic kidney disease, liver cysts, Darier's disease, and hyperlipoproteinemia among others. Spiny keratodermas can have systemic associations and do not resolve spontaneously. Treatment is generally ineffective.     

Generalized Acanthosis Nigricans in Early Childhood

Acanthosis nigricans (AN) is a disorder often accompanied by internal malignancy in adult patients, but in children it is usually benign. Generalized forms of AN, especially in childhood, are extremely rare. We report a 5-year-old boy with a 3-year history of AN who had generalized roughness and hyperpigmentation, numerous skin wrinkles, disseminated skin tags, tripe palms, and intensive pruritus. No clinical evidence of internal disorders, notably of an endocrinologic or neoplastic nature, have been detected thus far.     

Acanthosis palmaris: tripe palms

We describe five patients who showed a distinctive pattern of late onset hyperkeratosis and acanthosis of palms and fingers. The epidermal thickening gave rise to a rugose appearance with broadened rete ridges bounded by deep sulci (tripe palms). One of these patients had malignant acanthosis nigricans, two also had carcinomata with the palmar changes as a forme fruste of acanthosis nigricans and two patients had pruriginous dcrmatoses with palmar changes of diffuse lichenification which were reversible. The relationship between palmar-plantar keratoderma and malignancy is discussed.     

Erythema gyratum repens with associated squamous cell carcinoma of the lung

A 63-year-old man with erythema gyratum repens (EGR) was found to have an underlying squamous cell carcinoma of the lung. Neither radiation nor chemotherapy had any effect on the extensive eruption. EGR is the most distinctive of the figurate erythemas, and continues to be one of the most consistent cutaneous signs of an associated visceral malignancy.     

Cutaneous metastasis of lung carcinoma: a retrospective study of 12 cases

Background The skin is a rare site of metastasis of the internal malignancies. On the contrary, lung cancer is a common primary malignancy of skin metastasis. The latter is either synchronous with the primary lung tumour or can reveal it. Objective To analyse the clinical findings and the outcome of cutaneous metastasis in patients with primary lung cancer. Methods Retrospective study including 12 cases of cutaneous metastasis of lung cancer diagnosed in our institution during 6 years. Results Our patients included three women and nine men with a median age of 59.83 years. The cutaneous metastases were unique in seven cases. They revealed the primary tumour in two cases, were discovered synchronously with the primary tumour in six cases and after the primary tumour in four cases. They appeared in patients presenting multiple metastases in 10 cases. Clinical appearance consisted on a firm nodule, sometimes ulcerated with a diameter ranging from 0.5 to 5.5 cm. The tumour was sited in the thorax, the back, the abdomen; or the upper or lower limbs. Pathological examination of bronchial biopsy revealed an adenocarcinoma in eight cases, a squamous cell carcinoma in two cases and a small cell carcinoma in two cases. In spite of lung cancer therapies, the patients with metastasis to other organs with a median follow‐up time of 4 months died. Conclusion Cutaneous metastases of lung cancer are of poor prognosis. They are most of the time associated with an advanced neoplastic process with metastasis to other organs. Median survival after skin involvement does not exceed months.     

PALMAR AND PLANTAR SEED KEEATOSES AND INTEENAL MALIGNANCY

Summary— In a survey of 500 patients over the age of 40 years attending the skin clinic, 62% were found to have "seed" keratoses on their palms or their soles. No statistically significant association was found between the presence of these keratoses and internal malignancy.
The proportion of patients with keratoses was higher in those with basal cell epitheliomata but the excess was not statistically significant.     

Cancer and scleroderma.

Of 2,141 patients with scleroderma who were seen at the Mayo Clinic, Rochester, Minn, between 1959 and 1975, 78 had 87 internal malignancies. The relative frequency of the types of cancers was similar to that for the general population. The increased numbers of patients with breast and uterine carcinomas were consistent with the female preponderance in scleroderma. Contrary to previous reports, carcinoma of the lung was not the most frequent malignancy associated with scleroderma. The lymphoma-leukemia malignancies were second only to breast carcinoma in frequency, comprising about 17% of the malignancies. Both conditions developed within a three-year period in 68% (45/66) of our patients affected with systemic scleroderma, and this subgroup comprised a high mortality group. This study is not an epidemiologic one in the strictest sense, but it is a review of the experience of the Mayo Clinic with patients who have had both scleroderma and an internal malignancy.