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Sign of Leser-Trelat Clinical Presentation

  • Author: Robert A Schwartz, MD, MPH; Chief Editor: Dirk M Elston, MD  more...
 
Updated: Jun 10, 2016
 

History

A complete medical history should be obtained.

The sudden eruption of multiple seborrheic keratoses is diffusely evident on any body surface, most strikingly on the trunk. The face, the neck, the axillae, the groin, and the extremities may also be affected. The abruptness of the eruption is noteworthy; it should not be confused with generalized seborrheic keratoses of gradual onset. Nevertheless, for the purposes of diagnosis, precise quantification of the length of the eruptive period and the number of seborrheic keratoses is lacking. In the author's experience, many but not all elderly patients are able to provide a clear history.

Pruritus may be the only symptom of the sign of Leser-Trélat. Pruritus occurs in almost one half of patients, but it may also occur with eruptive seborrheic keratoses unassociated with malignancy.

Seborrheic keratoses are common findings. However, the early appearance of these keratoses in individuals aged 0-30 years and their eruptive nature are not common. In a few families, seborrheic keratoses were autosomal dominant, and the lesions were rarely present at birth or in individuals aged 10-30 years. Members of a family from India had multiple seborrheic keratoses since birth.[35] In another family, a mother and 3 daughters had generalized seborrheic keratoses that developed in their teens and 20s.[36] Seven families had multiple seborrheic keratoses. In 3, the investigators were able to trace the tumors through 3 generations.[37] In 3 generations of a family, multiple seborrheic keratoses appeared during or near puberty.[38]

Rarely, overlap may occur between the body areas involved by pulmonary adenocarcinoma and the seborrheic keratoses of the sign of Leser-Trélat.[39]

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Physical

A complete physical examination should include an examination of the lymph nodes; the liver; the spleen; the prostate in men; the rectum; the breasts; and the pelvic area, including the ovaries, in women.

Warty nodules that proliferate cutaneously are evident. Each nodule usually appears distinct, with its characteristic warty stuck-on morphologic features and brownish black or yellowish coloration. The author recommends that a biopsy specimen be obtained to confirm the diagnosis.

The eruption may appear in a Christmas tree or splash pattern, although these patterns are not specific for this sign and may occur with eruptive seborrheic keratoses unassociated with malignancy. Note the image below.

Middle-aged woman with a Christmas tree-like distr Middle-aged woman with a Christmas tree-like distribution of seborrheic keratoses on her back with no evidence of internal cancer.

Malignant acanthosis nigricans is frequently evident with the sign of Leser-Trélat. Malignant acanthosis nigricans occurs in about 35% of patients. Florid cutaneous papillomatosis is less common.[40]

Other rarely associated paraneoplastic entities include the following:

  • Acquired hypertrichosis lanuginosa [41]
  • Acquired ichthyosis [42]
  • Cowden disease [43]
  • Tylosis [13]
  • Acrokeratosis of Bazex [24]
  • Tripe palms [44]
  • Simultaneous paraneoplastic manifestations, including both ichthyosis acquisita and Bazex syndrome [45]

The sudden eruption and the rapid increase in the number and the size of freckles, along with seborrheic keratoses, may occur.

A proliferation of papillary angiomas may occur.

Eruptive capillary angiomas have been described as a paraneoplastic sign,[46] although this sign is not widely accepted. The author has observed 1 patient with eruptive capillary angiomas and a visceral malignancy in whom no eruptive seborrheic keratoses were present.

The sign of Leser-Trélat, malignant acanthosis nigricans, and florid cutaneous papillomatosis are 3 paraneoplastic entities that constitute a continuum. These conditions more commonly accompany each other than any other paraneoplastic disorder. Florid cutaneous papillomatosis is a sudden and widespread eruption of what appears to be common viral warts on clinical examination. Acanthosis nigricans is a widespread dermatosis with a verrucous tendency anywhere on the surface of the body, especially around the lips, the eyes, and the axillae.

Patients with erythroderma may develop a widespread eruption of multiple seborrheic keratoses without associated malignancies. In the author's experience, these patients usually have atopic dermatitis complicated by erythroderma.

The sudden eruption of hundreds of typical seborrheic keratoses confined to the skin of the breasts and a small area below them is described in association with pregnancy.

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Causes

The cause of the sign of Leser-Trélat is unknown. It may be due to the same unknown factors that induce malignant acanthosis nigricans. These paraneoplastic syndromes are probably directly caused by their underlying neoplasms, presumably from a tumor-secreted growth factor; however, evidence of this concept is lacking. The sign of Leser-Trélat is usually linked with visceral cancer, but it has also been described in metastasized malignant melanoma.[47] Insulin growth factor 2 secretion, presumably by a retroperitoneal malignant fibrous tumor, was described in a patient with the sign of Leser-Trélat.[48]

The sign of Leser-Trélat may be linked with cytokine alterations (see Pathophysiology).

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Contributor Information and Disclosures
Author

Robert A Schwartz, MD, MPH Professor and Head of Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, Rutgers New Jersey Medical School; Visiting Professor, Rutgers University School of Public Affairs and Administration

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, New York Academy of Medicine, American Academy of Dermatology, American College of Physicians, Sigma Xi

Disclosure: Nothing to disclose.

Specialty Editor Board

David F Butler, MD Section Chief of Dermatology, Central Texas Veterans Healthcare System; Professor of Dermatology, Texas A&M University College of Medicine; Founding Chair, Department of Dermatology, Scott and White Clinic

David F Butler, MD is a member of the following medical societies: American Medical Association, Alpha Omega Alpha, Association of Military Dermatologists, American Academy of Dermatology, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Phi Beta Kappa

Disclosure: Nothing to disclose.

Warren R Heymann, MD Head, Division of Dermatology, Professor, Department of Internal Medicine, Rutgers New Jersey Medical School

Warren R Heymann, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Takeji Nishikawa, MD Emeritus Professor, Department of Dermatology, Keio University School of Medicine; Director, Samoncho Dermatology Clinic; Managing Director, The Waksman Foundation of Japan Inc

Disclosure: Nothing to disclose.

References
  1. Turan E, Yesilova Y, Yurt N, Koçarslan S. Leser-Trélat sign: does it really exist?. Acta Dermatovenerol Croat. 2013 Aug. 21(2):123-7. [Medline].

  2. Leser E. Ueber ein die Krebskrankheit beim Menschen haufig begleitendes, noch wenig gekanntes Symptom. Munchener Med Wochenschr. 1901. 51:2035-2036.

  3. De Bersaques J. Sign of Leser-Trelat. J Am Acad Dermatol. 1985. 12:724.

  4. Hollander E. V. Beitrage zur Fruhdiagnose des Darmcarcinomas (Hereditatsverhaltnisse und Hautveranderungen. Deutsche Medicinische Wochenschrift. 1900. 26:483-485.

  5. Dubreuilh W. Official Transactions. Des hyperkeratoses circonscrites. August 4-8, 1896.

  6. Freudenthal W. Verruca senilis und Keratoma senile. Arch F Dermat U Syph (Berlin). 1926. 152:505-528.

  7. Garcia RL, Bishop ME. The rapid onset of seborrheic keratoses of the breasts during pregnancy. J Assoc Mil Dermatol. 1977. 3 (2):13-4.

  8. Lindelöf B, Sigurgeirsson B, Melander S. Seborrheic keratoses and cancer. J Am Acad Dermatol. 1992 Jun. 26(6):947-50. [Medline].

  9. Kilmer SL, Berman B, Morhenn VB. Eruptive seborrheic keratoses in a young woman with acromegaly. J Am Acad Dermatol. 1990 Nov. 23(5 Pt 2):991-4. [Medline].

  10. Martin RW 3rd, Rady P, Arany I, Tyring SK. Benign Leydig cell tumor of the testis associated with human papillomavirus type 33 presenting with the sign of Leser-Trelat. J Urol. 1993 Oct. 150(4):1246-50. [Medline].

  11. Inamadar AC, Palit A. Eruptive seborrhoeic keratosis in human immunodeficiency virus infection: a coincidence or 'the sign of Leser-Trelat'?. Br J Dermatol. 2003 Aug. 149(2):435-6. [Medline].

  12. Eastman KL, Knezevich SR, Raugi GJ. Eruptive seborrheic keratoses associated with adalimumab use. J Dermatol Case Rep. 2013 Jun 30. 7(2):60-3. [Medline]. [Full Text].

  13. Millard LG, Gould DJ. Hyperkeratosis of the palms and soles associated with internal malignancy and elevated levels of immunoreactive human growth hormone. Clin Exp Dermatol. 1976 Dec. 1(4):363-8. [Medline].

  14. Ellis DL, Kafka SP, Chow JC, et al. Melanoma, growth factors, acanthosis nigricans, the sign of Leser-Trelat, and multiple acrochordons. A possible role for alpha-transforming growth factor in cutaneous paraneoplastic syndromes. N Engl J Med. 1987 Dec 17. 317(25):1582-7. [Medline].

  15. Horiuchi Y, Katsuoka K, Takezaki S, Nishiyama S. Study of epidermal growth activity in cultured human keratinocytes from peripheral-blood lymphocytes of a patient with Sezary syndrome associated with the Leser-Trelat sign. Arch Dermatol Res. 1985. 278(1):74-6. [Medline].

  16. Ellis DL, Yates RA. Sign of Leser-Trelat. Clin Dermatol. 1993 Jan-Mar. 11(1):141-8. [Medline].

  17. Ponti G, Luppi G, Losi L, Giannetti A, Seidenari S. Leser-Trélat syndrome in patients affected by six multiple metachronous primitive cancers. J Hematol Oncol. 2010 Jan 11. 3:2. [Medline]. [Full Text].

  18. Barron LA, Prendiville JS. The sign of Leser-Trelat in a young woman with osteogenic sarcoma. J Am Acad Dermatol. 1992 Feb. 26(2 Pt 2):344-7. [Medline].

  19. Westrom DR, Berger TG. The sign of Leser-Trelat in a young man. Arch Dermatol. 1986 Dec. 122(12):1356-7. [Medline].

  20. Schwengle LE, Rampen FH, Wobbes T. Seborrhoeic keratoses and internal malignancies. A case control study. Clin Exp Dermatol. 1988 May. 13(3):177-9. [Medline].

  21. Grob JJ, Rava MC, Gouvernet J, et al. The relation between seborrheic keratoses and malignant solid tumours. A case-control study. Acta Derm Venereol. 1991. 71(2):166-9. [Medline].

  22. Kierland RR. Acanthosis nigricans: an analysis of data in twenty-two cases and a study of its frequency in necropsy material. J Invest Dermatol. 1947. 9:299-305.

  23. Li M, Yang LJ, Zhu XH, et al. The Leser-Trelat sign is associated with nasopharyngeal carcinoma: case report and review of cases reported in China. Clin Exp Dermatol. 2009 Jan. 34(1):52-4. [Medline].

  24. Rubisz-Brzezinska J, Zebracka T, Musialowicz D. [Coexistence of 2 paraneoplastic syndromes - acrokeratosis bazex and Leser-Trelat syndrome - in a case of squamous-cell laryngeal cancer]. Przegl Dermatol. 1983 Mar-Apr. 70(2):205-8. [Medline].

  25. Nyati A, Kalwaniya S, Jain S, Soni B. Sign of Leser-Trélat in association with laryngeal carcinoma. Indian J Dermatol Venereol Leprol. 2016 Jan-Feb. 82 (1):112. [Medline].

  26. Yavasoglu I, Kadikoylu G, Bolaman Z. The Leser-Trelat sign is a associated with acute myeloid leukemia. Ann Hematol. 2011 Mar. 90(3):363. [Medline].

  27. Fasoldt JJ, Brumwell ER, Lackey JN. Leser-Trélat sign presenting in a patient with recurrent pre-B-cell acute lymphocytic leukemia. Cutis. 2012 Jan. 89(1):33-5. [Medline].

  28. Li JH, Guo H, Li B, Gao XH. Leser-Trelat sign with primary hepatic carcinoma. Indian J Dermatol Venereol Leprol. 2015 May-Jun. 81 (3):320-1. [Medline].

  29. Onajin O, Comfere NI. Co-occurrence of malignant acanthosis nigricans and the Leser-Trélat sign in a patient with hepatocellular carcinoma. Int J Dermatol. 2015 May. 54 (5):e146-8. [Medline].

  30. Abakka S, Elhalouat H, Khoummane N, Achaaban M, ElAmrani S, Bargach S, et al. Uterine leiomyosarcoma and Leser-Trélat sign. Lancet. 2013 Jan 5. 381(9860):88. [Medline].

  31. Siedek V, Schuh T, Wollenberg A. Leser-Trelat sign in metastasized malignant melanoma. Eur Arch Otorhinolaryngol. 2009 Feb. 266(2):297-9. [Medline].

  32. Fink AM, Filz D, Krajnik G, Jurecka W, Ludwig H, Steiner A. Seborrhoeic keratoses in patients with internal malignancies: a case-control study with prospective accrual of patients. J Eur Acad Dermatol Venereol. 2009 Nov. 23(11):1316-9. [Medline].

  33. Stieler W, Plewig G. [Acanthosis nigricans maligna and Leser-Trélat sign in double malignancy of the breast and stomach]. Z Hautkr. 1987 Mar 1. 62(5):344-66. [Medline].

  34. Holdiness MR. A case of Leser-Trélat sign. J Am Acad Dermatol. 1987 Jan. 16(1 Pt 1):147-8. [Medline].

  35. Bedi TR. Familial congenital multiple seborrheic verrucae. Arch Dermatol. 1977 Oct. 113(10):1441-2. [Medline].

  36. Jadassohn J. Die benignen Epitheliome. Arch f Dermatol u Syph (Wien). 1913. 116:117.

  37. Reiches AJ. Seborrheic keratoses; are they delayed hereditary nevi?. AMA Arch Derm Syphilol. 1952 May. 65(5):596-600. [Medline].

  38. Rongioletti F, Corbella L, Rebora A. Multiple familial seborrheic keratoses. Dermatologica. 1988. 176(1):43-5. [Medline].

  39. Dasanu CA, Alexandrescu DT. Bilateral Leser-Trelat sign mirroring lung adenocarcinoma with early metastases to the contralateral lung. South Med J. 2009 Feb. 102(2):216-8. [Medline].

  40. Janniger EJ, Schwartz RA. Florid cutaneous papillomatosis. J Surg Oncol. 2010 Nov 1. 102(6):709-12. [Medline].

  41. Jemec GB. Hypertrichosis lanuginosa acquisita. Report of a case and review of the literature. Arch Dermatol. 1986 Jul. 122(7):805-8. [Medline].

  42. Hage E, Hage J. Malignant acanthosis nigricans--a para-endocrine syndrome?. Acta Derm Venereol. 1977. 57(2):169-72. [Medline].

  43. Aylesworth R, Vance JC. Multiple hamartoma syndrome with endometrial carcinoma and the sign of Leser-Trelat. Arch Dermatol. 1982 Feb. 118(2):136-8. [Medline].

  44. Kebria MM, Belinson J, Kim R, Mekhail TM. Malignant acanthosis nigricans, tripe palms and the sign of Leser-Trelat, a hint to the diagnosis of early stage ovarian cancer: a case report and review of the literature. Gynecol Oncol. 2006 May. 101(2):353-5. [Medline].

  45. da Rosa AC, Pinto GM, Bortoluzzi JS, Duquia RP, de Almeida HL Jr. Three simultaneous paraneoplastic manifestations (ichthyosis acquisita, Bazex syndrome, and Leser-Trélat sign) with prostate adenocarcinoma. J Am Acad Dermatol. 2009 Sep. 61(3):538-40. [Medline].

  46. Pembroke AC, Grice K, Levantine AV, Warin AP. Eruptive angiomata in malignant disease. Clin Exp Dermatol. 1978 Jun. 3(2):147-56. [Medline].

  47. Siedek V, Schuh T, Wollenberg A. Leser-Trelat sign in metastasized malignant melanoma. Eur Arch Otorhinolaryngol. 2009 Feb. 266(2):297-9. [Medline].

  48. Mathez AL, Moroto D, Dib SA, de Sa JR. Seborrheic keratoses and severe hypoinsulinemic hypoglycemia associated with insulin grow factor 2 secretion by a malignant solitary fibrous tumor. Diabetol Metab Syndr. 2016. 8:33. [Medline].

  49. Patton T, Zirwas M, Nieland-Fisher N, Jukic D. Inflammation of seborrheic keratoses caused by cytarabine: a pseudo sign of Leser-Trelat. J Drugs Dermatol. 2004 Sep-Oct. 3(5):565-6. [Medline].

  50. Peterson J, Shook BA, Wells MJ, Rodriguez M. Cupric keratosis: green seborrheic keratoses secondary to external copper exposure. Cutis. 2006 Jan. 77(1):39-41. [Medline].

  51. Pastar Z, Lipozencic J, Rados J, Stajminger G. Regressing seborrheic keratosis - clinically and dermoscopically mimicking a regressing melanoma. Acta Dermatovenerol Croat. 2007. 15(1):24-6. [Medline].

  52. Saraiya A, Al-Shoha A, Brodell RT. Hyperinsulinemia Associated with Acanthosis Nigricans, Finger Pebbles, Acrochordons, and the Sign of Leser-Trelat. Endocr Pract. 2013 Feb 20. 1-15. [Medline].

  53. Schwartz RA. Acanthosis nigricans, florid cutaneous papillomatosis and the sign of Leser-Trelat. Cutis. 1981 Sep. 28(3):319-22, 326-7, 330-1 passim. [Medline].

  54. Schwartz RA. Acanthosis nigricans. J Am Acad Dermatol. 1994 Jul. 31(1):1-19; quiz 20-2. [Medline].

  55. Schwartz RA. The sign of leser-trelat. Demis DJ, ed. Clinical Dermatology. 13th ed. Philadelphia, Pa: JB Lippincott; 1987. 26A: 1-3.

  56. Schwartz RA. Florid cutaneous papillomatosis. Clin Dermatol. 1993 Jan-Mar. 11(1):89-91. [Medline].

  57. Schwartz RA. Sign of Leser-Trelat. J Am Acad Dermatol. 1996 Jul. 35(1):88-95. [Medline].

  58. Schwartz RA, Burgess GH. Florid cutaneous papillomatosis. Arch Dermatol. 1978 Dec. 114(12):1803-6. [Medline].

  59. Schwartz RA, Helmold ME, Janniger CK, Gascon P. Sign of Leser-Trelat with a metastatic mucinous adenocarcinoma. Cutis. 1991 Apr. 47(4):258-60. [Medline].

 
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Middle-aged woman with a Christmas tree-like distribution of seborrheic keratoses on her back with no evidence of internal cancer.
 
 
 
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