Generalized lichenoid dermatosis as a tumor-associated dermadrome in a patient with inoperable esophageal cancer

ARTICLE

ejd.2011.1333

Auteur(s) : Shiori Kato shioris@dermatol.med.kyushu-u.ac.jp, Masakazu Takahara, Asuka Shono, Yoichi Moroi, Masutaka Furue

Dermatology Department, Kyushu University Medical Sciences, Maidashi 3-1-1, Higashi-ku Fukuoka, Japan

Dermadromes or paraneoplastic syndromes are skin disorders that appear in association with internal malignancies. We report an unusual case in which lichenoid dermatosis preceded the diagnosis of esophageal cancer. Radiation therapy for esophageal cancer led to regression of both the cancer and the dermatosis.

An 84-year-old man with hypertension and alcoholic liver disease visited our hospital in April 2010 because of an itching eruption that had not disappeared after about 8 months. Generalized red papules and edematous erythema were observed on the trunk and extremities (figure 1A). He did not have heliotrope rash, Gottron's papules, or oral lesions. A drug-induced eruption was initially suspected but this eruption did not improve after discontinuation of antihypertensive medication. A routine endoscopic examination to detect complications of the alcoholic liver disease revealed an esophageal cancer in March 2010. The pathological diagnosis was a moderately differentiated submucosal squamous cell carcinoma (SCC) with lymphoid infiltration.

No metastasis was found. Routine laboratory examinations at the first visit showed unremarkable findings, with normal levels of creatine kinase and absence of antinuclear antibodies; however, mild eosinophilia [WBC, 4,970/μL; eosinophils (Eo), 5.2%] and a slight elevation of the serum SCC antigen levels (3.8 ng/mL; normal range: <1.5) were observed. A biopsy specimen taken from the abdominal eruption showed lichenoid tissue reaction, including a dense, band-like, lymphocytic, and eosinophilic infiltrate in the superficial dermis, focal parakeratosis of the epidermis, and scattered necrotic keratinocytes and vacuolar degeneration in the dermo-epidermal junction (figure 1B). The infiltrating lymphocytes comprised CD4⁺ and CD8⁺ T cells. The eruption was unresponsive to treatment with oral antihistamine drugs and topical steroid ointment. Because of the patient's age and past history, only radiation therapy (65.4 Gy in 35 fractions) was administered for the esophageal cancer. The eruption initially worsened slightly, but it gradually and spontaneously improved and almost cleared after completion of the radiation therapy (figure 1C), which also led to regression of the cancer. The patient's eosinophil levels also temporarily increased (WBC, 4,340/μL; Eo, 27%) during the first month of irradiation therapy and then returned to normal, parallel with the course of the eruption.Therefore, we made a diagnosis of a dermadrome associated with esophageal cancer.

Dermadromes or paraneoplastic syndromes are reported as skin changes associated with internal malignancies [1-3]. Paraneoplastic pemphigus is known to be associated with hematological malignancies. Dermatomyositis can also present as a lichenoid tissue reaction and may be associated with solid cancers. Multiple cases of lichen planus with thymoma have been reported [4]. Our case revealed different clinical features from these disorders, and the association with esophageal cancer is supported by the clinical course of the eruption, which was parallel with the development and disappearance of the cancer. Only one case of lichen planus-like lesions with malignant lymphoma has been reported as a manifestation of malignancy [5]. A lichenoid tissue reaction is characterized by basal cell damage and band-like lymphocytic infiltration. This reaction is considered to be induced by cytotoxic T-cell injury to the epidermal basal-cell compartment and aggravated by the inflammatory signaling pathway, involving plasmacytoid dendritic cell-derived interferon (IFN)-α activity [6]. Thus, the eruption in the present case was possibly induced by a cytotoxic T cell-mediated immune reaction to common autoantigens between the esophageal cancer cells and skin cells. The transient exacerbation of the eruption during the initial radiation treatment may be explained by the extensive release of autoantigens from the esophageal cancer cells damaged by irradiation.

The findings in this case suggest that clinicians should recognize unusual lichenoid dermatoses as paraneoplastic dermatosis, and efforts should be made to detect internal malignancies, especially when it is refractory to treatment.

Disclosure

Financial support: none. Conflict of interest: none.

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