Joshua Russell, MD, MSc, FCUCM, FACEP
Key words: paraneoplastic syndrome, gastric cancer, seborrheic keratosis, case report
ABSTRACT
Introduction: Lesar-Trélat sign (LTS) is an infrequent paraneoplastic phenomenon associated with an array of malignancies. Given that the primary manifestation is a seemingly benign dermatologic issue, such patients may choose urgent care as their initial site of clinical evaluation.
Clinical presentation: A 43-year-old man with no significant past medical history presented to UC with complaints of itching and “moles” appearing across his back for the past 2 months. He also had some vague upper abdominal pain and unintentional weight loss.
Physical exam: The patient’s skin exam revealed diffuse hyperpigmented ovoid lesions consistent with seborrheic keratoses (SK) restricted to his back. He was prescribed hydrocortisone 2.5% cream and referred to a dermatologist.
Case resolution: Several weeks later,the patient saw a dermatologist who prescribed a higher-potency steroid. His symptoms persisted, however. His increasing abdominal pain eventually led him to present for care in the emergency department. After computed tomography of his abdomen and esophagogastroduodenoscopy (EGD), he was diagnosed with metastatic gastric adenocarcinoma. Unfortunately, the patient died of complications of his cancer diagnosis several months after his UC presentation.
Conclusion: Awareness of the potential clinical significance of LTS and its association with occult malignancy may lead to earlier referral, cancer identification, and improved prognosis for afflicted patients.
INTRODUCTION
Lesar-Trélat Sign (LTS) is a paraneoplastic condition involving rapid appearance of multiple SK and is associated with a variety of solid organ malignancies, most commonly adenocarcinomas of the stomach, colon, and breast.1 LTS can also occur in cases of hematologic malignancy. It is nonspecific, however, and can also occur in benign conditions, such as pregnancy.2 Given the seemingly innocuous nature of multiple moles, patients and clinicians alike may initially underappreciate the potential gravity of the phenomenon.
CLINICAL PRESENTATION
A 43-year-old man with no significant past medical history sought care at his local UC center due to itching and associated “moles” that had appeared across his upper back over the prior two months.
His symptoms began with pruritus across the thoracic portion of his back, for which he had tried over-the-counter diphenhydramine with some initial relief. Several weeks later, however, the pruritus became more severe and he began noticing the dark spots appearing on his back. The moles were restricted to his back and he had had no prior instances of skin lesions. The patient had taken some photographs with his smartphone which confirmed there were no lesions present on the back just 3 months earlier. He denied any prominent family history of related conditions. He worked as a software engineer and denied alcohol and drug use. He was sexually monogamous with his wife.
On review of symptoms, he was otherwise asymptomatic except for occasional postprandial abdominal pain, for which he used famotidine with minimal relief.
Physical Exam Findings
The patient had normal vital signs when he presented to UC. He was well appearing and had an unremarkable cardiopulmonary and abdominal exam. His skin exam revealed numerous, diffuse SK distributed across his thoracic back (similar to the pattern seen in Figure 1). The SK were restricted to the posterior trunk and the remainder of his skin exam was within normal limits.
Urgent Care Management
The provider caring for the patient in UC realized this was an atypical presentation, with a larger number of SK presenting so rapidly and with an unusual degree of pruritus. Hence, in addition to prescribing a short course of 2.5% topical hydrocortisone cream, a dermatologist referral was made for follow-up.
Case Continuation and Timeline
The patient saw a dermatologist several weeks later. They prescribed a high-potency steroid, but the patient’s itching continued to progress as did his upper abdominal pain. Additionally, he began to develop progressive fatigue and had 5 kg unintentional weight loss.
Diagnostic Assessment and Case Conclusion
Approximately 1 month after the dermatologist visit, the patient presented to the emergency department for severe abdominal pain and vomiting. He underwent computed tomography of the abdomen and pelvis, which demonstrated severe gastric thickening with gastric outlet obstruction and multiple heterogeneous lesions in the liver. He was admitted to the hospital and had an upper endoscopy with biopsies that revealed gastric adenocarcinoma; this was confirmed to be stage IV given the presence of liver metastases.
Before he began chemotherapy, he suffered a massive gastrointestinal hemorrhage, which required intensive care unit admission. Unfortunately, due to multiple subsequent complications, the patient died just 2 weeks after his initial cancer diagnoses.
DISCUSSION
Lesar-Trélat Sign (LTS) is a paraneoplastic condition involving rapid appearance of multiple SK and is associated with a variety of malignancies, most commonly adenocarcinomas of the stomach, colon, and breast.1 LTS can be seen in cases of hematologic malignancy, as well, but also in benign conditions, such as pregnancy.2 In the 1800s, Lesar and Trélat described angiomas associated with underlying malignancy.
A century later, Hollander noted that the rapid appearance of SK occasionally preceded the diagnosis of certain cancers, most commonly gastric cancer.3
Lesions can occur anywhere on the body, but most commonly occur on the trunk (~20% of cases). Patients usually become aware of the lesions because of associated pruritus, which occurs in approximately half of cases.2 The etiology of LTS is uncertain, but it is thought to be most likely that the SK appear due to high levels of circulating growth factors secreted by the associated neoplasm.3 LTS precedes the diagnosis of the underlying malignancy in 68% of cases,4 as occurred in the case presented. When identified, LTS warrants rapid referral to a primary care provider who can coordinate a work-up, which generally includes comprehensive bloodwork (eg, complete blood count, metabolic panel, etc.) as well as screening upper and lower endoscopy.3
Key Take Away for Urgent Care Providers
LTS represents one of many paraneoplastic syndromes that can initially present in urgent care, often with mild symptoms that may seem innocuous. Early identification of paraneoplastic conditions is a crucial clinical skill to allow for the most rapid referral, diagnosis, and treatment of the underlying malignancy. With rare exceptions, metastatic cancer is incurable.5 Therefore, an urgent care assessment which leads to an earlier diagnosis of malignancy can dramatically influence a patient’s treatment options and, thus, prognosis.
Ethics Statement and Patient Perspective
Informed consent for publication was obtained from the deceased patient’s wife. She stated that she was hopeful that sharing her husband’s story may increase clinician awareness for this condition.
Manuscript submitted 7/29/22; accepted 8/3/22.
References
- Sardon C, Dempsey T. The Leser-Trélat sign. Cleve Clin J Med. 2017;84(12):918.
- Husain Z, Ho JK, Hantash BM. Sign and pseudo-sign of Leser-Trélat: case reports and a review of the literature. J Drugs Dermatol. 2013;12(5):e79-e87.
- Kirchberger MC. Gastrointestinal: eruptive seborrheic keratoses: sign of Leser-Trélat in gastric adenocarcinoma. J Gastroenterol Hepatol. 2019;34(12):2058.
- Bernett CN, Schmieder GJ. Leser Trelat Sign. [Updated 2021 Sep 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan.
- American Society of Clinical Oncology. What is metastasis? Available at: https://www.cancer.net/navigating-cancer-care/cancer-basics/what-metastasis#:~:text=Metastasis%20means%20that%20cancer%20has,the%20cancer%20has%20%E2%80%9Cmetastasized.%E2%80%9D. Accessed July 29, 2022
Author disclosures: Joshua Russell, MD, MSc, FCUCM, FACEP, North Shore University Health System; University of Chicago Medical Center Affiliate; Legacy/GoHealth Urgent Care; Journal of Urgent Care Medicine. The author has no relevant final relationships with any commercial interests.
