We report a 59-year-old patient with malignant acanthosis nigricans associated with metastasis of endometrial carcinoma. The patient presented papillomatosis lesions that appeared to be benign on multiple skins of body folds, particularly on lips. The lesions in lips and axilla had histological characteristic appearances of acanthosis nigricans, while the masses in abdomen and pelvis were metastasis endometrial adenocarcinoma. The article highlights the importance of biopsy and histopathological diagnosis in presumed benign lesions and the role of doctors in screening for body internal tumors.
A 59-year-old woman was evaluated due to a 3-month history of oral papillomatosis on the lips. The patient had sialorrhea on account of the eversion of her tumefaction lips. The epichil was easy to bleed with a scab formation (Figure 1). Hyperkeratotic and hyperpigmented skin on the face, elbows, pudendum, groins, especially in the axilla area with some warty thickening of nipples, was followed by the appearance of velvety patchy lesions in these areas (Figure 2). In the patient’s history, endometrial adenocarcinoma was diagnosed and treated with surgery of hysterectomy and bilateral salpingectomy nine years prior. The follow-up computed tomography scan of the chest detected an enlargement of the mediastinal lymph nodes. Both the computed tomography scan and ultrasounds of the abdomen and pelvis showed several vesicle and mixed-type masses, with the largest one being 5.0 cm×4.3 cm, which was proven to be metastases carcinoma in pathological biopsy. Biopsy of lips and axilla tissue showed hyperkeratosis, acanthosis, increased dermal pigmentation and papillomatous hyperplasia of the epidermis (Figure 3). Human papillomavirus DNA was not detected in the fluorescent quantitation analysis.
Based on the diagnostic results, the patient was diagnosed with malignant acanthosis nigricans related to metastasis of endometrial adenocarcinoma with clinical stage-IVB according to the International Federation of Gynecology and Obstetrics (2009).1 Due to the progress of the advanced disease, the patient was discharged home for palliative treatment and died 4 months later due to cancer progression.
Our differential diagnosis included oral squamous cell carcinoma, metastatic carcinoma, premalignant lesions, lymphoma, deep fungal infections, chronic traumatic ulcer and benign acanthosis nigricans. Oral squamous cell carcinoma presents with nuclear hyperchromatism, pleomorphism, increased nuclear cytoplasmic ratio, premature keratinzation and formation of keratin pearls. Metastatic carcinoma can be diagnosed when it is inscribed within the properties of the primitive tumor, as shown by the comparative molecular analysis or histopathological evaluation of the primitive tumor and its own metastases. The premalignant lesions and lymphoma can be ruled out histopathologically. Deep fungal infections are characterized by primary involvement of lungs and microscopic examination, which was ruled out in our case. Chronic traumatic ulcer is more frequently seen on tongue and show chronic cell infiltration on histopathological evaluation. The primary pathological manifestations of benign and malignant acanthosis nigricans are identical, characterized by hyperkeratosis, acanthosis, increased dermal pigmentation and papillomatous hyperplasia of the epidermis. The difference between these two types is the cause of the lesion, with the benign related to benign conditions, common in insulin-resistant patients, including type 2 diabetes mellitus, obesity, polycystic ovary syndrome and Donohue syndrome, whereas the malignant are associated with internal carcinoma. Thus, the diagnosis of malignant acanthosis nigricans can be made only when there is pathological manifestation and a definite diagnosis of internal carcinoma.
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Image Gallery: Generalized mucosal and cutaneous papillomatosis, a unique sign of malignant acanthosis nigricans
British Journal of Dermatology (2017)