ABSTRACT
We present a case in which a patient presented with widespread cutaneous warty lesions misdiagnosed as warts 3 months before the diagnosis of his advanced gastric adenocarcinoma. Florid cutaneous and mucosal papillomatosis is a paraneoplastic dermatosis, following a parallel course with the underlying malignancy, which is most often gastric adenocarcinoma.
Case presentation
A 58-year-old man presented with sudden onset of massive tarry stool and dyspnea on exertion for 5 days and was sent to hospital. Laboratory examination showed severe anemia (6.6 g/dL; reference range 13.5–17.5 g/dL) and panendoscopy demonstrated circumferential ulcerative mass with edematous surrounding mucosa on the gastric body and cardia. Histology of the ulcerative mass revealed adenocarcinoma and whole-body tumour scan showed gastric cancer with multiple liver, bone and lung metastases; stage 4 gastric adenocarcinoma was diagnosed.
Dermatologists were consulted for widespread cutaneous warty lesions that had developed exuberantly 3 months before admission and had been treated as warts. Dermatologic examination revealed confluent verrucous lesions across the lip vermilions and hyperkeratotic papules diffusely affecting the dorsa of the hands, axillae, nipples, scrotum and perianal area (Fig 1a, b, c). The patient reported mild dysphagia in the following 3 months and panendoscopy disclosed papillomatosis in the esophageal mucosa (Fig 1d). Histopathological examination from the lesions on the lip, perianal area (Fig 2a, b), and esophageal mucosa showed papillomatosis, hyperkeratosis, and acanthosis, in the absence of classic koilocytosis and viral inclusions. Florid cutaneous and mucosal papillomatosis was diagnosed based on the characterised clinical presentation and the consistency with histopathology.
A 58-year-old man with advanced gastric adenocarcinoma showing confluent papillomatosis across the (a) lip vermillions, (b) hyperkeratosis of the nipple and mammary areola, and (c) warty papules on the perianal area with (d) esophageal papillomatosis in upper gastrointestinal endoscopy.
Histopathological examination from skin biopsy on the perianal lesion showing hyperkeratosis, marked acanthosis, papillomatosis, and scattered melanophages in the dermis [haematoxylin–eosin stain, (a) original magnification ×100 and (b) original magnification ×200].
The cutaneous papillomas had a poor response to five courses of cryotherapy; however, the patient hesitated to receive oral retinoid as an add-on therapy. The XELOX regimen (oxaliplatin and capecitabine) of palliative chemotherapy was initiated since the diagnosis of gastric adenocarcinoma. The latest tumour scan, after 6 months, showed increased liver metastases. Meanwhile, the verrucous lesions also got more severe and prominent along with his adenocarcinoma progression.
Discussion
Florid cutaneous and mucosal papillomatosis is a paraneoplastic syndrome characterised by the sudden and widespread eruption of multiple verrucous, papillomatosis lesions affecting the whole body, particularly the dorsal hands, mucosa, and nipples/areola, which should be differentiated with viral warts and epidermodysplasia verruciformis.1,2 Florid cutaneous and mucosal papillomatosis can manifest before or concomitantly with malignancies, including cancers of stomach (most often), hepatobiliary tract, lung, and breast.1,2 Tripe palms, malignant acanthosis nigricans, and Leser-Trélat sign are other well-known paraneoplastic syndromes that may coexist with florid cutaneous and mucosal papillomatosis.1–3 Florid cutaneous and mucosal papillomatosis often follows a parallel course with the underlying malignancy; the persistence, recurrence or exacerbation of skin lesions can reflect treatment failure, tumour recurrence or progression, respectively.2,4 Therapy of skin lesions is only for a palliative intention, including oral retinoid, cryotherapy, and topical therapy (fluorouracil, retinoic acid, keratolytics, and podophyllotoxin).5
Florid cutaneous and mucosal papillomatosis is a paraneoplastic dermatosis, following a parallel course with the underlying malignancy and most often associated with gastric adenocarcinoma. A sudden and widespread eruption of cutaneous and mucosal papillomas should not be treated just as viral warts but prompts early identification of potential responsible neoplasms.
- © Royal College of Physicians 2023. All rights reserved.
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