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Gyrate erythema associated with metastatic tumor of gastrointestinal tract

  • Author(s): Ravić-Nikolić, Ana
  • Miličić, Vesna
  • Jovović-Dagović, Bojana
  • Ristić, Gordana
  • et al.
Main Content

Gyrate erythema associated with metastatic tumor of gastrointestinal tract
Ana Ravić-Nikolić, Vesna Miličić, Bojana Jovović-Dagović, Gordana Ristić
Dermatology Online Journal 12 (6): 11

Department of Dermatology, Clinical Center Kragujevac, Kragujevac, Serbia and Montenegro.anabravic@ptt.yu

Abstract

Figurate or gyrate erythemas are group of skin conditions that present as annular or figurate erythematous papules and plaques with peripheral spreading. Several diseases are included in this group but only two of them are associated with underlying malignancy, erythema annulare centrifugum and erythema gyratum repens. We present a 58-year-old woman with simultaneous presentation of gyrate erythema and skin metastasis from a gastrointestinal tumor that was diagnosed by histopathology and immunohistochemistry as a leiomyogenic gastrointestinal stromal tumor.



Clinical synopsis


Figure 1Figure 2
Figure 1. Serpiginous erythematous bands with a fine marginal scale on the right side of trunk
Figure 2. A 2-cm, erythematous, dome-shaped, smooth-surfaced skin metastasis associated with the clinical manifestation of gyrate erythema

A 58-year-old woman presented with a 1-month history of a serpiginous eruption with a thin trailing scale, on the right flank (Fig. 1). Erythematous, 0.5-2.0-cm dome-shaped nodules appeared on the right side of the trunk at about the same time (Fig. 2). According to the patient, erythematous bands with a similar serpiginous appearance had presented several months before, at about the time of diagnosis of a gastrointestinal stromal tumor. Once the tumor was surgically removed, the cutaneous eruption disappeared, but 3 months after surgery (1 month prior to presentation to dermatology) a figurate eruption re-appeared along with the new erythematous nodules. Rapid movement of the erythematous band to create a bizarre pattern was observed upon re-examination after 2 days.

Pathohistological and immunohistochemical studies of the primary tumor showed a malignant, leiomyogenic gastrointestinal stromal tumor, nodular macro type, with high cellularity and malignancy. Histological findings revealed a mesenchymal tumor of spindle-shaped cells with a high proliferative potential. The origin of this tumor is unclear, it is postulated that the precursor cells are Cajal interstitial cells with partial differentiation to smooth muscle cells.

The biopsy of the figurate skin lesion was non-specific. Histology of the nodules revealed metastasis of skin and subcutaneous tissue consistent with diffuse carcinoma of gastrointestinal tract.

Additional evidence of metastasis was not detected. Laboratory studies (complete and differential blood count, biochemical analysis and urine tests) were all within normal limits. Chest X-ray and ultrasound of abdomen were normal.

The patient was transferred to Oncology unit where she refused to receive planned combination chemotherapy.


Comments

Tumors that commonly metastasize to skin include cancer of the breast, lung, stomach, kidney and ovary. Clinically, skin metastases are not unique and they are usually localized near the primary tumor. Their presence is a poor prognostic sign.

Figurate erythemas are a group of skin eruptions presenting as annular or figurate erythematous skin lesions that spread peripherally. Various entities in this group include urticarial reactions, erythema marginatum, erythema migrans, erythema annulare centrifugum (EAC), and erythema gyratum repens (EGR). Psoriasis, dermatophyte infection, erythema multiforme and several forms of cutaneous lupus erythematosus may present as annular-serpiginous eruptions but are not generally categorized with the figurate erythemas. Only erythema annulare centrifugum (EAC) and erythema gyratum repens (EGR) are associated with malignancy.

Erythema gyratum repens is a rare paraneoplastic dermatosis commonly associated with underlying malignancy [1, 2]. It is classically characterized by a concentric appearance creating wood-grain-like erythema with a thin covering of scale. The eruption is localized on the trunk, axillae, and groins [3]. This scaly erythema rapidly spreads centrifugally and usually runs a parallel course with the underlying malignancy [4]. Erythema gyratum repens is most commonly associated with bronchial, esophageal, and breast cancer [5, 6], but has been reported rarely in patients without evidence of malignancy [7].

Erythema annulare centrifugum is described in association with dermatophyte infections, infestations, and malignancy, but often the etiology of EAC remains unclear [8,9]. Clinical findings are similar to EGR. Erythematous lesions show slow centrifugal spreading with central clearing, forming different shapes on the affected skin. It is usually localized on the trunk, but any part can be affected. Distinction between these diseases is very difficult, even controversial; some authors consider them to be the same entity.

The histolopathologic pictures of EAC and EGR are non-specific. Both can be associated with malignancy (EGR more often). Typically, the eruption disappears after tumor excision in EGR as well in EAC. One of the differences between them is in the rapidity of movement. Erythema gyratum repens exhibits characteristic rapid movement over minutes and hours; erythema annulare centrifugum moves slowly over days and months.

The gyrate erythema presented in this case had clinical features similar to both EGR and EAC but the rapidity of movement was more consistent with EGR.

References

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3. Boyd AS, Neldner KH, Menter A. Erythema gyratum repens: a paraneoplastic eruption. J Am Acad Dermatol 1992; 26: 757-62.

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8. Mahood JM. Erythema annulare centrifugum: a review of 24 cases with special refrence to its association with underlying disease. Clin Exp Dermatol 1983; 8: 383.

9. Diaz-Cascajo C, Weyers I. Erythema annulare centrifugum: results of a clinicopathologic study of 73 patients. Am J Dermatopathology 2003; 25: 451-62.

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