Quick viewing(Text Mode)

Spot the Diagnosis Cutaneous Lesions on the Legs

Spot the Diagnosis Cutaneous Lesions on the Legs

Qureshi et al: Breast metastasis of gastric carcinoma 

References carcinoma to the breast from stomach. Yonsei Med J 2000;41:669-72. 6. Park JM, Kwon JS, Gong G. Metastatic breast carcinoma from gastric can- cer: A case report. J Korean Radiol Soc 1998;38:1139-41. 1. Di Cosimo S, Ferretti G, Fazio N, Mandala M, Curigliano G, Bosari S, et al. 7. Briest S, Horn LC, Haupt R, Schneider JP, Schneider U, Hockel M. Breast and ovarian metastatic localization of signet ring cell gastric carci- Metastasizing signet ring cell carcinoma of the stomach-mimicking bilateral noma. Ann Oncol 2003;14:803-4. inflammatory breast cancer. Gynecol Oncol 1999;74:491-4. 2. Hamby LS, McGrath PC, Cilbull ML, Schwartz RW. Gastric carcinoma meta- 8. Friedrich T, Kellermann S, Leinung S. Atypical metastasis of stomach carci- static to the breast. J Surg Oncol 1991;48:117-21. noma. Zentralbl Chir 1997;122:117-21. 3. Alexander HR, Turnbull AD, Rosen PP. Isolated breast metastases from 9. Raju U, Ma CK, Shaw A. Signet ring variant of lobular carcinoma of the breast: gastrointestinal carcinomas: Report of two cases. J Surg Oncol 1989;42:264- A clinicopathologic and immunohistochemical study. Mod Pathol 1993;6:516- 6. 20. 4. Cavazzini G, Colpani F, Cantore M, Aitini E, Rabbi C, Taffurelli M, et al. Breast 10. Tot T. The role of cytokeratins 20 and 7 and estrogen receptor analysis in metastasis from gastric signet ring cell carcinoma, mimicking inflammatory separation of metastatic lobular carcinoma of the breast and metastatic sig- carcinoma. A case report. Tumori 1993;79:450-3. net ring cell carcinoma of the gastrointestinal tract. APMIS 2000;108:467- 5. Kwak JY, Kim EK, Oh KK. Radiologic findings of metastatic signet ring cell 72.

Spot the Diagnosis www.jpgmonline.com

Cutaneous on the legs

A 34-year-old woman had several symmetrically located, well- circumscribed, non-ulcerating, waxy, red-brown plaques on her lower limbs [Figure 1]. The first appeared 13 years ago. She was concerned about the cosmetic appearance.

Questions 1. What is the diagnosis? 2. What is the systemic association with this dermatosis? 3. How are these lesions managed?

Figure 1: The first of these multiple, symmetrically located lesions appeared as a small macule 13 years previously. Inset: Close-up view of the oldest For the answer check page number 130 lesion shows waxy appearance and telangiectasias

J Postgrad Med June 2005 Vol 51 Issue 2 127   Alymlahi et al: Bilateral facial squamous cell carcinoma

20. veloping two different types of malignancies simultaneously. Pediatr Surg 6. Goyal JL, Rao VA, Srinivasan R, Argomal K. Oculocutaneous manifestations Int 1998;13:299-300. in xeroderma pigmentosum. Br J Ophthalmol 1994;78:295-7. 9. Leal-Khouri S, Hruza GJ, Hruza LL, Martin AG. Management of a young pa- 7. Hertle Rw, Durso F, Metzler JP, Varsa EW. Epibulbar squamous cell carci- tient with xeroderma pigmentosum. Pediatr Dermatol 1994;11:72-5. noma in brothers with xeroderma pigmentosum. J Pediatr Ophthalmol Stra- 10. Ahmed H, Hassan RY, Pindiga UH. Xeroderma pigmentosum in three con- bismus 1991;28:350-3. secutive siblings of a Nigerian family: Observations on oculocutaneous mani- 8. Masinjila H, Arnbjornsson E. Two children with xeroderma pigmentosum de- festations in black African children. Br J Ophthalmol 2001;85:110-1.

Spot the Diagnosis www.jpgmonline.com

Check page number 127 for the question gen bundles with a hyalinized appearance, surrounded by fi- brosis, a diffuse infiltrate of histiocytes and a giant-cell granu- These cutaneous lesions are characteristic of lomatous reaction. Capillary wall thickening and microvascu- lipoidica (NL). They are typically multiple, bilateral, and lo- lar occlusion are often present. cated on the lower legs, most commonly pretibially[1] and oc- casionally on the thighs, ankles and feet, but rarely on the trunk, Treatment of NL is unsatisfactory with cosmetic camouflage upper limbs and . Early lesions appear as rounded, dull the preferred option. Regression of lesions does not correlate red, symptom-less or plaques that progress slowly and with improved glycaemic control. Topical or intralesional indurate with central . The lesions have a shiny surface corticosteriods may improve early NL.[3] Psolarens and ultra- and a waxy, yellowish central area with prominent telangiecta- violet A (PUVA) therapy can improve patients not responsive sias. The margins may carry comedone-like plugs. Koebner’s to steriods.[4] Antiplatelet therapy with aspirin and dipyrida- phenomenon occurs in some patients. The clinical and his- mole has shown no benefit[5] but anecdotal reports with topathological differential diagnoses include rheumatoid nod- pentoxyfilline, tretinoin, nicotinic acid, topical , ules, annulare, necrobiotic xanthogranuloma, sar- cyclosporine, and infliximab have all documented benefits. coidosis, , , subacute nodular migra- Excision and skin grafting may help some. Other complica- tory panniculitis, nodosum, erythema induratum, tions include ulceration following trauma, occasionally infec- et atrophicus, tertiary , radiodermati- tions and rarely squamous cell carcinoma. tis, sclerosing lipogranuloma, and Hansen’s disease.[2] Putta-Manohar S, Syed AA, Parr JH An association with diabetes mellitus has been recognized for Department of Diabetes and Endocrinology, South Tyneside a long time. NL was originally termed dermatitis atrophicans District Hospital, Harton Lane, South Shields, Tyne and Wear lipoidica diabeatica (Oppenheim 1929) and later renamed NE34 OPL, United Kingdom diabeticorum (Urbach 1932). In one large series, 111 of 171 patients (65%) with NL had diabetes mellitus Correspondence: at presentation;[3] it preceded the onset of diabetes in 15% of Dr. Akheel A. Syed, E-mail: [email protected] patients. Its prevalence is 0.3% in people with diabetes, is three References times commoner in women, and occurs usually before 30 years of age. In our patient, Type 1 diabetes occurred two years prior 1. Lynch JM, Barrett TL. Collagenolytic (necrobiotic) : part II—the to the first lesion. Her glycaemic control was poor and she had ‘red’ granulomas. J Cutan Pathol 2004;31:409-18. 2. Lowitt MH, Dover JS. Necrobiosis lipoidica. J Am Acad Dermatol diabetic retinopathy as well. 1991;25:735-48. 3. Muller SA, Winkelmann RK. Necrobiosis lipoidica diabeticorum. A clinical and pathological investigation of 171 cases. Arch Dermatol 1966;93:272-81. The aetiology remains obscure, but is not a microangiopathy 4. De Rie MA, Sommer A, Hoekzema R, Neumann HA. Treatment of necrobio- and not associated with glycaemic control or chronic diabetic sis lipoidica with topical psoralen plus ultraviolet A. Br J Dermatol 2002;147:743-7. complications. Antibody-mediated and abnormali- 5. Statham BN, Finlay AY, Marks R. Aspirin and dipyridamole ineffective in treat- ties of collagen are the other chief putative mechanisms. ment of necrobiosis lipoidica. N Engl J Med 1980;303:1419. Histologically, NL occurs as palisading or pseudotuberculoid granulomatous lesions[1] consisting of foci of degenerate colla- PubMed ID : 16006707

 130 J Postgrad Med June 2005 Vol 51 Issue 2

Top View