27 - Paraneoplastic Syndromes Flashcards
Paraneoplasia: Definition
■ Symptoms that cannot be attributed to direct tumor invasion or compression .
■ May be the first sign of malignancy
■ Occurs in up to 15% of cancer patients
systems affected by Paraneoplastic Syndromes
■ Endocrine
■ Hematologic
■ Neurologic
■ Gastrointestinal
■ Rheumatologic
■ Dermatologic
■ Nephrologic
Pathophysiology of paraneoplastic syndromes
■ Immune mediated
– The body may produce antibodies aimed at destroying tumor cells, these antibodies may cross-react with normal causing damage.
■ Non Immune mediated
– Tumors may produce hormones, hormone precursors, a variety of enzymes, or cytokines.
Clinical Importance of paraneoplastic syndromes
■ Paraneoplastic syndromes may be the first or most prominent manifestation of a cancer
■ Course of paraneoplastic syndrome usually parallels disease
■ Metabolic or toxic effects of syndrome may constitute a more urgent hazard than underlying cancer
■ Complicates therapy of primary malignancy
Given the patient’s presentation with recurrent episodes of painful swelling and erythema of his arms and legs, along with the recent discovery of a pulmonary embolus and a mass in the pancreas, the most likely etiology for his recurrent episodes of swelling is:
■ B: Paraneoplastic hypercoagulable state
The presence of a pulmonary embolus and a pancreatic mass suggests an association with a hypercoagulable state related to the malignancy.
Hypercoagulable Syndrome in paraneoplastic syndromes
■ Migratory Superficial thrombophlebitis Trousseau syndrome
■ GI malignancies
– pancreas, stomach, colon
■ Procoagulant molecules released directly into bloodstream is one of many other factors involved
■ Platelets,neutrophil,monocyte, endothelial cells, tissue factor…
■ Patients develop DVT and arterial thrombosis
– manage as other DVT but usually prolonged anticoagulation
Microangiopathy in paraneoplastic syndromes
■ Microangiopathic hemolytic anemias (DIC, TTP)
■ TTP most commonly seen in mucin producing malignancies such as gastric cancer
– microangiopathic hemolytic anemia, thrombocytopenia, fever, renal dysfunction, neurologic changes
■ Chemotherapy : mitomycin C, Gemcitabine
■ Distinguish TTP from DIC
– TTP has normal PTT, INR
– DIC usually no or minimal renal impairment,
CNS findings
Hematologic paraneoplastic syndromes
■ Erythrocytosis : overproduction of Erytropoeitin
– RCC
– HCC
– Hemangioblatoma
– Uterine fibroids( absence of anemia with menorrhagia
– Pheochromocytoma
■ Granulocytosis
– Lung cancer, gastrointestinal , breast, renal ,
gynecological malignancies
■ Eosinophilia: Hodgkin disease
■ Pure red cell aplasia : thymoma
■ Thrombocytosis: majority of malignancies
B, sometimes A and C, but mostly B
Hyperkeratotic and proliferative dermatoses - Acanthosis Nigricans in paraneoplastic syndromes
Velvety, hyperpigmented skin lesion neck and axilla most commonly
Rarely associated with malignancies: most commonly gastric adenocarcinoma
Dermatologic paraneoplastic syndromes
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Hyperkeratotic and proliferative dermatoses
Acanthosis Nigricans
Palmoplantar keratoderma
Leser-Trelat sign -
Inflammatory dermatosis
Sweet syndrome or
Acute febrile neutrophilic dermatosis
Erythroderma -
Bullous dermatosis
Paraneoplastic pemphigus - Hyperpigmentation
Cushing syndrome
Generalized dermal melanosis
Hyperkeratotic and proliferative dermatoses - Lesar Trelat sign
*Rapid onset of multiple pruritic seborrheic keratoses
* can be associated with Gastrointestinal malignancies, and lymphoma.
Hyperkeratotic and proliferative dermatoses - Palmoplantar Keratoderma
thickening of the skin of palms and soles associated wth squamous cell carcinoma
also known as tylosis and howel-evans syndrome
45-year-old female presenting with dysphagia, she
reports thickening of the skin of her palms and soles.
Her father was diagnosed with metastatic
esophageal cancer last year.
■ Her skin lesion is most likely associated with, except:
■ A : squamous cell carcinoma
■ B :Autosomal recessive disease
■ C :Also known as Tylosis
■ D :Howel-Evans syndrome
B
Inflammatory dermatosis in dermatologic paraneoplastic syndromes - Erythroderma
*Diffuse erythema of the skin usually associated with induration and scaling
* cutaneous T-cell lymphoma
* Other less commonly associated malignancies: leukemia, lung ,prostate , liver, ovaries, rectum
Bullous dermatosis - dermatologic paraneoplastic syndromes - Paraneoplastic pemphigus
*Erosive painful mucositis with skin lesion resembling pemphigus or pemphigoid bullae or plaques resembling lichen planus
*NHL, CLL, Castleman disease, carcinoma
dermatologic paraneoplastic syndromes - Heliotrope erythema
dermatologic paraneoplastic syndromes - Gottron’s papules