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 Table of Contents  
ONLINE ONLY ARTICLES - CASE REPORT
Year : 2022  |  Volume : 6  |  Issue : 2  |  Page : 151

An unusual paraneoplastic manifestation of adenocarcinoma lung: Tripe palm


1 Junior Resident, Department of Dermatology, Sri Lakshmi Narayana Institute of Medical Sciences, Pondicherry, India
2 Senior Resident, MD Dermatology, Sri Lakshmi Narayana Institute of Medical Sciences, Pondicherry, India

Date of Submission24-Nov-2020
Date of Decision26-Jan-2021
Date of Acceptance28-Jan-2021
Date of Web Publication26-Aug-2022

Correspondence Address:
C Kanmani Indra
Senior Resident, Dermatology Department, Sri Lakshmi Narayana, Institute of Medical Sciences, Pondicherry
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cdr.cdr_130_20

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  Abstract 


Tripe palms (TP) are the rare paraneoplastic manifestation with the thickened palms and pronounced dermatoglyphics. In cancer patients with mere TP, the most occurring malignancy is pulmonary carcinoma. Although it precedes a malignancy, it may arise at any point in the course of the disease. Here, we present a patient who came with complaints of thickened blackish discoloration of palms and soles for 3 weeks and a clinical diagnosis of TP was made. He had concomitant adenocarcinoma lung TNM stage IB diagnosed 5 months back. Thus, he was diagnosed with TP secondary to adenocarcinoma lung. Although TP precede internal malignancy we report this case as TP occurred after the diagnosis of adenocarcinoma of the lung was made.

Keywords: Acanthosis palmaris, adenocarcinoma lung, paraneoplastic syndrome, tripe palms


How to cite this article:
Jacob NS, Indra C K, Nasrin M I, Raj P A. An unusual paraneoplastic manifestation of adenocarcinoma lung: Tripe palm. Clin Dermatol Rev 2022;6:151

How to cite this URL:
Jacob NS, Indra C K, Nasrin M I, Raj P A. An unusual paraneoplastic manifestation of adenocarcinoma lung: Tripe palm. Clin Dermatol Rev [serial online] 2022 [cited 2022 Sep 26];6:151. Available from: https://www.cdriadvlkn.org/text.asp?2022/6/2/151/354738




  Introduction Top


Tripe palms (TP) is a very rare skin disorder characterized by accentuated dermatoglyphic ridges and velvety white thickening of the palms like the rugosities of a bovine gut.[1] This was first described by the London dermatologist Dr. Jacqueline Clarke in 1977.[2] The Association of TP with internal malignancy is very high about 90% as well as with other paraneoplastic syndromes like acanthosis nigricans. TP often precedes a new or a recurrent tumor. It may also arise during any point in the course of the malignancy.[3] The usual types of cancers associated with TP are gastrointestinal or bronchial tumors.[4]


  Case Report Top


A 57-year-old male came to our Dermatology Department for blackish discoloration with thickening of both his palms and soles for 3 weeks not associated with itching, pain sweating, or burning sensation. He had a history of dyspnea, hemoptysis, loss of appetite, and weight 5 months back for which he got checked up. His lung biopsy reports showed infiltrating neoplasm composed of neoplastic cells and were diagnosed with primary lung adenocarcinoma. He was a chronic smoker with 35 pack-year cigarette smoking. There was no history of hypertension, diabetes, Malena, or hematemesis. The patient was nonalcoholic. On general examination, there was mild pallor and clubbing. No lymphadenopathy was noted. Cutaneous examination showed diffuse hyperpigmentation and thickening of the palms and soles suggestive of TP [Figure 1] and [Figure 2]. Oral cavity, hair, scalp, and other cutaneous findings were normal.
Figure 1: Thickening and hyperpigmentation of both palms noted

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Figure 2: Thickening of the soles

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Respiratory system examination showed decreased breath sounds in the left lower lung fields. Other systemic examinations revealed no abnormality. Skin biopsy from the left palm displayed hyperkeratosis with acanthosis and no dysplasia noted. Routine blood investigations detected mild anemia. Chest X-ray showed diffuse homogenous opacity in left lower lung fields. Computed tomography thorax revealed large well defined heterogeneous enhancing soft tissue lesion with irregular lobulated margins, the surrounding fibrotic strands, and ground glassing in the posterobasal segment of the lower lobe with segmental bronchial cut off [Figure 3]. The viral markers of human immune deficiency virus, hepatitis B and C were negative. Thus, a clinical diagnosis of adenocarcinoma lung TNM stage IB with TP was made.
Figure 3: Enhancing soft-tissue lesion present over the left lower lobe of the lung is noted

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  Discussion Top


In the present case, the patient has TP with adenocarcinoma lung. TP also known as acanthosis palmaris or acquired pachydermatoglyphia are rare paraneoplastic dermatoses (PD). It is characterized by thickened velvety palms that look like tripe. The honeycombed and corrugated thickening of the palms may be seen with periungual tenderness. Normal dermatoglyphic ridges are accentuated.[5]

PD is a group of diverse, acquired, and rare dermatologic clinical presentations in presence of underlying cancer. After endocrine syndromes, these are the second-most common paraneoplastic syndromes. PDs can be classified into obligate or facultative based on the percentage by which they are associated with neoplasia. If the neoplasm is present in 90%–100% of the cases, it is obligate and if 25%–30%, it is facultative, TP being obligate.[6] It was Curth in 1976, who proposed six criteria for the diagnosis of cutaneous paraneoplastic syndromes [Table 1].[7]
Table 1: Curth's criteria for the diagnosis of paraneoplastic syndromes

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The exact mechanism of TP is not well understood but is thought to be by some substances that stimulate the cellular proliferation of the palms and soles. Elevated TGF-α was considered as the culprit in a patient who had carcinoma bronchus with tripe palm.[8] EGFs are upregulated in malignancy-associated tripe palms. EGF, TGF-α released from the neoplastic cells are believed to cause TP.[8] Epidermal growth factors (EGFs) are upregulated in malignancy-associated TP. EGF-α, TGF-alpha released from the neoplastic cells are believed to cause TP. Histopathology of TP shows hyperkeratosis, acanthosis, and papillomatosis.[9] It resembles pathologic findings in acanthosis nigricans and seborrheic keratosis. Perivascular deposition of dermal mucin may be also seen.[10]

As per many of the published literature, TP secondary to an internal malignancy alone is 23% and in conjunction with other paraneoplastic syndromes like acanthosis nigricans is 77%.[4] Sometimes, the sign of Leser-Trelat with multiple seborrheic keratoses can also be found with TP.[5] The most common associated carcinomas are gastric, and pulmonary followed by rectum, esophagus, bronchus, urinary tract, ovary, bile duct, thyroid, uterus, liver, kidneys, and breast. Less commonly associated cancers include melanoma, tongue, gallbladder, sarcomas, and prostate tumors.[11]

The patients with TP alone had lung carcinomas in 53% of cases.[4] The onset of TP precedes malignancy in >40%, follows malignancy in 19%, or can be concurrent within 1 month of diagnosis of malignancy in 37% of cases.[12] Clinically, TP involves the palmar skin, occasionally the soles. TP is usually asymptomatic, but can also present with palmar hyperhidrosis. No specific treatment for TP is needed as it usually resolves after the correction of the underlying tumor.[5]

Adenocarcinoma is a type of cancer that forms in the glandular cells in different body sites such as the colon, pancreas, lung, breast, and prostate. It is a type of nonsmall cell lung cancer and accounts for about 40% of all lung cancers.[13]

It is to be noted that this rare disorder TP is serious and extensive investigations should be done to discover an expected underlying malignancy. A thickened palm or sole should never be considered trivial; a life-threatening cancerous growth must be evaluated for rather. Even though TP predominantly precedes a tumor, it is to be kept in mind that it can also occur after a tumor as is evident from this case.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Barman B, Devi LP, Thakur BK, Raphael V. Tripe palms and acanthosis nigricans: A clue for diagnosis of advanced pancreatic adenocarcinoma. Indian Dermatol Online J 2019;10:453-5.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Clarke J. Malignant acanthosis nigricans. Clin Exp Dermatol 1977;2:167-70.  Back to cited text no. 2
    
3.
Cohen PR, Grossman ME, Silvers DN, Kurzrock R. Tripe palms and cancer. Clin Dermatol 1993;11:165-73.  Back to cited text no. 3
    
4.
Cohen PR, Grossman ME, Almeida L, Kurzrock R. Tripe palms and malignancy. J Clin Oncol 1989;7:669-78.  Back to cited text no. 4
    
5.
Fabroni C, Gimma A, Cadinali C, Scocco GL. Trip palms associated with malignant acanthosis nigricans in a patient wth gastric adenocarcinoma: A case report and review of the literature. Dermatol Online J 2012;18:15.  Back to cited text no. 5
    
6.
Didona D, Fania L, Didona B, Eming R, Hertl M, Di Zenzo G. Paraneoplastic Dermatoses: A brief general review and an extensive analysis of paraneoplastic pemphigus and paraneoplastic dermatomyositis. Int J Mol Sci 2020;21:2178.  Back to cited text no. 6
    
7.
Curth HO. Skin lesions and internal carcinoma. In: Andrade R, Gumport SL, Popkin GL, Rees TD, editors. Cancer of the Skin. Philadelphia: WB Saunders; 1976. p. 1308-9.  Back to cited text no. 7
    
8.
Douglas F, McHenry PM, Dagg JH, MacBeth FM, Morley WN. Elevated levels of epidermal growth factor in a patient with tripe palms. Br J Dermatol 1994;130:686-7.  Back to cited text no. 8
    
9.
Lo WL, Wong CK. Tripe palms: A significant cutaneous sign of internal malignancy. Dermatology 1992;185:151-3.  Back to cited text no. 9
    
10.
Silva JA, Mesquita Kde C, Igreja AC, Lucas IC, Freitas AF, Oliveira SM, et al. Paraneoplastic cutaneous manifestations: Concepts and updates. An Bras Dermatol 2013;88:9-22.  Back to cited text no. 10
    
11.
Pentenero M, Carrozzo M, Pagano M, Gandolfo S. Oral acanthosis nigricans, tripe palms and sign of Leser-Trélat in a patient with gastric adenocarcinoma. Int J Dermatol 2004;43:530-2.  Back to cited text no. 11
    
12.
Abreu Velez AM, Howard MS. Diagnosis and treatment of cutaneous paraneoplastic disorders. Dermatol Ther 2010;23:662-75.  Back to cited text no. 12
    
13.
Zappa C, Mousa SA. Non-small cell lung cancer: Current treatment and future advances. Transl Lung Cancer Res 2016;5:288-300.  Back to cited text no. 13
    


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