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  Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 9  |  Issue : 1  |  Page : 40-43  

Branch duct-type intraductal papillary mucinous neoplasm presenting as paraneoplastic small plaque para-psoriasis


1 Hepatology and Transplant Medicine, PVS Institute of Digestive Diseases, PVS Memorial Hospital, Cochin, Kerala, India
2 Department of Gastroenterology, PVS Institute of Digestive Diseases, PVS Memorial Hospital, Cochin, Kerala, India
3 Department of Diagnostic and Interventional Radiology, PVS Memorial Hospital, Cochin, Kerala, India
4 Department of Pathology, VPS Lakeshore Hospital, Cochin, Kerala, India

Date of Web Publication22-Jan-2018

Correspondence Address:
Cyriac A Philips
Philip Augustine Associates, PVS Memorial Hospital Campus, Kaloor, Cochin - 682 017, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/idoj.IDOJ_427_16

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   Abstract 


To present and discuss a novel association between branch duct-type intraductal papillary mucinous neoplasm and paraneoplastic parapsoriasis. We present the case of a middle-aged male presenting with skin lesions that were suggestive of parapsoriasis, resistant to treatment, and in whom a diagnosis of branch-type intraductal papillary mucinous neoplasm of the pancreas was eventually made. A curative Whipple's surgery led to complete resolution of the skin lesions within 3 weeks. Paraneoplastic parapsoriasis in association with intraductal papillary mucinous pancreatic neoplasm has never been reported before.

Keywords: Intraductal papillary mucinous neoplasia, obstructive jaundice, pancreatic tumor, paraneoplastic syndrome, parapsoriasis, pruritus psoriasis


How to cite this article:
Philips CA, Augustine P, Kumar L, Joseph G, Mahadevan P. Branch duct-type intraductal papillary mucinous neoplasm presenting as paraneoplastic small plaque para-psoriasis. Indian Dermatol Online J 2018;9:40-3

How to cite this URL:
Philips CA, Augustine P, Kumar L, Joseph G, Mahadevan P. Branch duct-type intraductal papillary mucinous neoplasm presenting as paraneoplastic small plaque para-psoriasis. Indian Dermatol Online J [serial online] 2018 [cited 2019 Dec 7];9:40-3. Available from: http://www.idoj.in/text.asp?2018/9/1/40/223722




   Introduction Top


Parapsoriasis (PP) are a heterogeneous group of rare dermatoses presenting, with erythematous and scaly patches of variable size and a chronic course, that are difficult to treat and mostly seen in the elderly. Small-plaque parapsoriasis (SPP) and large-plaque parapsoriasis (LPP) are the two broad categories within this group. Lesions are usually asymptomatic or associated with mild pruritus and are predominantly located on the trunk. SPP is generally considered a chronic benign condition whereas LPP is regarded as a premalignant condition with a high risk of progression to mycosis fungoides, a type of cutaneous T cell lymphoma.[1] Intraductal papillary mucinous neoplasia (IPMN) is considered precursors of pancreatic cancers with a slow growth rate that enables early diagnosis and curative surgical treatment. The World Health Organization classifies IPMN according to their malignant transformation into IPMN with low or intermediate dysplasia, high-grade dysplasia, or invasive cancer. Approximately 20% of the patients are asymptomatic whereas symptomatic patients present with nonspecific symptoms such as nausea, abdominal or back pain, and weight loss, and sometimes with recurrent pancreatitis. Patients with IPMN are most notably elderly females. Paraneoplastic syndromes are rarely described with IPMN.[2],[3] Here, we present a middle-aged male diagnosed to have treatment-resistant SPP in whom an eventual diagnosis of IPMN was made. Curative Whipple's surgery led to complete resolution of skin lesions within 3 weeks. This rare association has never been described before.

Case Report

A 42-year-old male without chronic comorbid illnesses and a teetotaler presented with fluctuating jaundice for 2 weeks. His past history was significant for multiple crops of pruritic flat red and scaly skin lesions affecting mostly the trunk and upper thighs that were waxing and waning for 3 months. He was told to have psoriasis, even though a skin biopsy was not done, and was given short courses of steroids and topical retinoids without relief. He denied gastrointestinal bleeds, altered sensorium, abdominal distension, abdominal pain, or fevers. A significant weight loss of >10% had occurred during the last month with loss of well-being and appetite. Clinical examination revealed mild icterus without pallor, lymphadenopathy, or peripheral edema. Abdominal examination was essentially normal. General skin examination revealed multiple erythematous, round-to-oval, scaly lesions with distinct borders scattered mostly over the trunk [Figure 1]a, arrow] and upper chest that were provisionally thought to be SPP, cutaneous T cell lymphoma, or tinea incognito. Hemogram was normal, liver function tests showed total bilirubin of 9.4 mg/dL with direct fraction 5.8 mg/dL, alanine transaminase 76 IU/L, aspartate transaminase 98 IU/L, alkaline phosphatase 88 IU/L, and gamma glutamyl trans peptidase 228 IU/L. Tumor markers including CA19-9, carcinoembryonic antigen, alfa fetoprotein, and prostate specific antigen were within normal limits. The dermatologist ordered a skin biopsy which revealed, focal keratosis, parakeratosis, and acanthosis with upper papillary dermal fibrosis with perivascular lymphocytic infiltrates [Figure 1]b, along with few areas showing spongiotic changes and neutrophilic exocytosis, consistent with PP with focal spongiotic dermopathy [Figure 1]c. A contrast-enhanced computed tomography imaging of the abdomen revealed bilateral intrahepatic biliary radicle dilatation [Figure 2]a, black arrow], cystic dilatation of the branches of pancreatic duct near the head and uncinate process [Figure 2]b, white arrow], with a soft tissue mass at the distal end of the common bile duct (CBD) and extending into the distal pancreatic duct causing dilatation of both ducts, which was confirmed by a magnetic resonance cholangiopancreatogram (MRCP) [Figure 2]c, white circle], as well as a normal appearing liver and absence of lymphadenopathy or ascites. A subsequent endoscopic ultrasound and fine-needle aspiration cytology from the mass lesion near the CBD revealed only benign cholangiocytes. After discussion with the hepatobiliary surgical team, Whipple's resection was performed and the resected specimens were sent for histopathological evaluation. Sections from the pancreas showed dilated main pancreatic duct showing intermediate-grade IPMN arranged in papillae, lined by pancreaticobiliary type epithelium focally showing mucinous appearance with lining cells showing focal crowding, and stratification [Figure 3]a and [Figure 3]b, arrows]. Occasional foci showed areas of microinvasion [Figure 3]c, arrow] and surrounding stroma showing mild inflammatory infiltrates [Figure 3]d. A final diagnosis of paraneoplastic SPP secondary to IPMN was made. One month after the surgery on follow-up, the patient is doing well, with complete resolution of the skin lesions [Figure 4] and increased appetite and weight gain.
Figure 1: (a) Multiple erythematous, round to oval, scaly lesions with distinct borders scattered mostly over the trunk (arrows); (b) Skin biopsy showing focal keratosis, parakeratosis and acanthosis with upper papillary dermal fibrosis with perivascular lymphocytic infiltrates (Hematoxylin and Eosin stain, ×10); (c) Spongiotic changes and neutrophilic exocytosis, consistent with parapsoriasis with focal spongiotic dermopathy (Hematoxylin and Eosin stain ×40)

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Figure 2: (a) Contrast CT imaging of abdomen showing bilateral intrahepatic biliary radicle dilatation (black arrow); (b) Soft tissue mass at the distal end of CBD and extending into the distal pancreatic duct (white arrow); (c) MRCP showing soft tissue mass at the lower end of CBD and distal pancreatic duct showing duct cut off signs (white circle)

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Figure 3: (a) Pancreatic histology showing dilated main pancreatic duct with intermediate grade intraductal papillary mucinous neoplasm (IPMN) arranged in papillae, lined by pancreaticobiliary type epithelium (arrows, Hematoxylin and Eosin stain ×20); (b) Focal mucinous appearance with lining cells showing focal crowding and stratification (arrows, Hematoxylin and Eosin stain, ×40); (c) Occasional foci showing areas of microinvasion (arrow, Hematoxylin and Eosin stain, ×40) and (d) Surrounding stroma showing mild inflammatory infiltrates (Hematoxylin and Eosin stain, ×40)

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Figure 4: Post Whipples surgery, the skin lesions resolved completely

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   Discussion Top


Paraneoplastic dermatoses are the second most common paraneoplastic syndrome after endocrine syndromes. Curth et al., in his studies of acanthosis nigricans maligna, provided criteria to assess the causal relationship between dermopathy and potential underlying malignancy (Curth's Criteria). Various dermatological manifestations are described in the literature that have shown strong associations with internal malignancies [Table 1].[4],[5],[6],[7] IPMN are potentially malignant epithelial neoplasms consisting of cystic dilatations of the main pancreatic duct (MD type), side branches (BD type), or a combination of both. The BD type is mostly seen in the head and uncinate process is more localized and mass-like, but maybe multifocal with macro or microcystic in appearance.[5],[7] IPMNs are classified into low-grade, intermediate-grade, and high-grade dysplasia based on cytological atypia. Based on histological features and mucin immune-phenotype, IPMN are classified into gastric, intestinal, pancreatobiliary, and oncocytic types. Fukuoka guidelines state that pancreatic cysts more than 5 mm in diameter and communicating with the main pancreatic duct, in the absence of pancreatitis and/or diffuse dilation of the main pancreatic duct more than 5 mm diameter without other causes of obstruction are sufficient radiological criteria for IPMN, which were noted in our patient and proven thereafter with histopathology.[8],[9] IPMN has been rarely shown to present with paraneoplastic features. Grigorescu et al. reported the association of IPMN with paraneoplastic rheumatoid arthritis.[10] Roch et al. described 220 extrapancreatic malignancies in 185 patients of IPMN compared with expected 5% in the general population. One hundred ten synchronous autoimmune diseases were found in 96 patients (11%). Systemic lupus erythematosus, rheumatoid arthritis, and inflammatory bowel disease showed statistically significant observed/expected ratios (P < 0.0001., 01, and <0.0001, respectively) without impact of immunosuppressive treatment on the IPMN subtype and malignancy rate. They concluded that IPMNs are associated with surprisingly high rates of autoimmune diseases suggesting that IPMN might be one manifestation of a more systemic disease.[11]
Table 1: Curth's criteria for paraneoplastic dermatoses and commonly described paraneoplastic dermatosis and the associated internal malignancies

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Our case demonstrates two novel associations. One, the description of a paraneoplastic dermopathy in association with IPMN, following Curth's criteria and one that improved after curative resection of the primary and two, the first description of SPP as a paraneoplasm in association with internal malignancy, especially pancreatobiliary cancers.


   Conclusion Top


IPMNs are rare tumors that can present with rare autoimmune systemic symptoms and with paraneoplasms, especially dermopathies. Early identification and evaluation for pancreatobiliary malignancies are warranted in patients presenting with dermatological symptoms that are atypical and refractory to conventional treatment.

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.
Belousova IE, Vanecek T, Samtsov AV, Michal M, Kazakov DV. A patient with clinicopathologic features of small plaque parapsoriasis presenting later with plaque-stage mycosis fungoides: Report of a case and comparative retrospective study of 27 cases of “nonprogressive” small plaque parapsoriasis. J Am Acad Dermatol 2008;59:474.  Back to cited text no. 1
    
2.
Bassi C, Sarr MG, Lillemoe KD, Reber HA. Natural history of intraductal papillary mucinous neoplasms (IPMN): Current evidence and implications for management. J Gastrointest Surg 2008;12:645-50.  Back to cited text no. 2
    
3.
Grützmann R, Post S, Saeger HD, Niedergethmann M. Intraductal papillary mucinous neoplasia (IPMN) of the pancreas: Its diagnosis, treatment, and prognosis. Dtsch črztebl Int 2011;108:788-94.  Back to cited text no. 3
    
4.
Pipkin CA, Lio PA. Cutaneous manifestations of internal malignancies: An overview. Dermatol Clin 2008;26:1-15.  Back to cited text no. 4
    
5.
Thiers BH, Sahn RE, Callen JP. Cutaneous manifestations of internal malignancy. CA Cancer J Clin 2009;59:73-98.  Back to cited text no. 5
    
6.
Ehst BD, Minzer-Conzetti K, Swerdlin A, Devere TS. Cutaneous manifestations of internal malignancy. Curr Probl Surg 2010;47:384-445.  Back to cited text no. 6
    
7.
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. 7
    
8.
Castellano-Megías VM, Andrés CI, López-Alonso G, Colina-Ruizdelgado F. Pathological features and diagnosis of intraductal papillary mucinous neoplasm of the pancreas. World J Gastrointest Oncol 2014;6:311-24.  Back to cited text no. 8
    
9.
Hsiao CY, Yang CY, Wu JM, Kuo TC, Tien YW. Utility of the 2006 Sendai and 2012 Fukuoka guidelines for the management of intraductal papillary mucinous neoplasm of the pancreas: A single-center experience with 138 surgically treated patients. Medicine 2016;95:e4922.  Back to cited text no. 9
    
10.
Grigorescu I, Cismaru A, Chira R, Catinean A, Dumitrascu DL. Intraductal papillary mucinous neoplasia-a challenging diagnosis in a patient with paraneoplastic rheumatoid arthritis. Case report. Med Ultrason 2015;17:129-32.  Back to cited text no. 10
    
11.
Roch AM, Rosati CM, Cioffi JL, Ceppa EP, DeWitt JM, Al-Haddad MA, et al. Intraductal papillary mucinous neoplasm of the pancreas, one manifestation of a more systemic disease? Am J Surg 2016;211:512-8.  Back to cited text no. 11
    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
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