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A 30-year-old woman presented with a 4-month history of widespread thickened, verrucous, hyperpigmented plaques distributed symmetrically on her body, especially on the axillae (Figure 1A), anogenital region, inguinal skin, and both palms, with slight itching. The verrucous plaques also involved the conjunctiva, lips, and gingiva (Figure 1B). The patient had experienced a weight loss of 6 kg during the last 3 months. Within the last month, the patient’s thyroid became enlarged, and she developed anorexia and abdominal discomfort. Laboratory test results revealed remarkably elevated levels of carcinoembryonic antigen, carbohydrate antigen 19-9, carbohydrate antigen 125, tissue polypeptide antigen and carbohydrate antigen 242. Biopsy specimens of lesions on the axillae and lips both revealed a papillary structure with hyperkeratosis. An endoscopic examination and computed tomographic scan of the abdomen were performed.
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C. Malignant acanthosis nigricans
The keys to the correct diagnosis are the verrucous, hyperpigmented plaques in atypical sites (mucous membranes, palms and anogenital region), the additional paraneoplastic findings (tripe palms), and recent obvious weight loss. Most cases of acanthosis nigricans (AN) are benign and are associated with obesity and insulin resistance in which blood glucose and insulin levels are important for diagnosis. The disease is less commonly associated with a malignant neoplasm. Malignant AN is predominantly associated with gastrointestinal tract tumors, especially carcinoma of the stomach.1
The gastroscopy findings revealed esophageal papillomatous polyposis and a submucosal mass involving the gastric angle. Biopsy results revealed that the mass was a mix of adenocarcinoma and signet-ring cell carcinoma (Figure 2). A computed tomographic scan of the abdomen showed a thickening of the gastric wall and multiple organ metastases. The results of biopsies of the thyroid and pancreas suggested metastases of gastric cancer. The patient was then transferred for further chemotherapy without any dermatological treatment and died 4 months later due to cancer progression.
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Corresponding Author: Mingyue Wang, MD, PhD, Department of Dermatology, Peking University First Hospital, 8 Xishiku St, Xicheng District, Beijing 100034, China (email@example.com).
Published Online: March 14, 2019. doi:10.1001/jamaoncol.2018.7153
Conflict of Interest Disclosures: None reported.
Additional Contributions: We thank Ping Tu, MD and Qianxi Li, MD for the discussion of the patient’s diagnosis and treatment plan. They were not compensated for their contributions.
Additional Contributions: We thank the patient for granting permission to publish this information.
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