CASE REPORT
Peter Andersen, MD, Section Editor
Dermatomyositis paraneoplastic syndrome before symptomatic tonsillar squamous cell carcinoma: A case report Ahmad H. Adi, MBBS,1 Hani Alturkmani, MBBS,1 Todd Spock, BS,1 Patrice Williams Yohannes, RN, MSN,2 Susannah Wargo, RN, PhD,1 Eva Szabo, MD,3 J. Silvio Gutkind, PhD,2 Carter Van Waes, MD, PhD1* 1
Head and Neck Surgery Branch, National Institute on Deafness and Other Communication Disorders, National Institutes of Health, Bethesda, Maryland, 2National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland, 3Division of Cancer Prevention, Lung and Upper Aerodigestive Cancer Research Group, National Institutes of Health, Bethesda, Maryland.
Accepted 3 April 2014 Published online 27 June 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/hed.23703
ABSTRACT: Background. Paraneoplastic syndromes are systemic or organ-related functional tumor-associated changes that arise distant to the tumor. Methods and Results. We present a rare case of a 63-year-old man with dermatomyositis as a paraneoplastic syndrome developing more than a year before clinical manifestations of tonsillar squamous cell carcinoma (SCC). He subsequently developed stage T1N2bM0 IVA tonsillar SCC. He was treated on a research protocol with 3 weeks of neoadjuvant rapamycin therapy before right transoral lateral pharyngectomy and modified radical neck dissection with preservation of CN XI. His symptoms of
INTRODUCTION Paraneoplastic syndromes are tumor-associated changes in the bodily structure, function, or both, that arise distant to the tumor. They show diverse clinical manifestations that are attributed to the systemic actions of the neoplasm.1It has been proposed that there is a common underlying mechanism to paraneoplastic syndromes, regardless of the tumor origins, involving complex interactions between different cytokines that affect immune reactions toward tumor cells. The balance between pro-inflammatory and anti-inflammatory cytokines may have an association with the clinical prognosis of various malignancies.2 Although rare in head and neck cancer, numerous paraneoplastic syndromes have been reported in the literature, including back pain, nondermatomal sensory changes, polymyalgia, proximal myopathy,3 hypercalcemia, syndrome of inappropriate antidiuretic hormone, and skin changes (such as pemphigus and Bazex syndrome).4–6 However, the cause of these paraneoplastic changes is poorly understood in most cases.4 Dermatomyositis is a myopathy characterized by muscle weakness and skin manifestations (including heliotrope rash and Gottron papules).7,8 The pathogenesis of
*Corresponding author: C. Van Waes, Head and Neck Surgery Branch, National Institute of Dental and Craniofacial Research, National Institutes of Health, Radiation Oncology Branch, NCI, CRC-4–2732, 10 Center Drive, Bethesda, MD 20892. E-mail: [email protected]
dermatomyositis subsequently improved and he was weaned off immunosuppressive therapy. Conclusion. To our knowledge, this is the first report of dermatomyositis as a paraneoplastic syndrome of tonsillar SCC in North America. We suggest that clinicians should monitor for signs of persistent or recurrent dermatomyositis symptoms as this may herald development or a return of the underlying C 2014 Wiley Periodicals, Inc. Head Neck 37: E1–E3, 2015 malignancy. V
KEY WORDS: dermatomyositis, paraneoplastic, tonsillar, carcinoma, squamous
dermatomyositis is not entirely understood, but has been linked to immune dysregulation.9 Dermatomyositis has been linked to neoplastic processes (with a frequency of 2.5% to 29%10); however, it has not been frequently reported to be associated with head and neck cancers.7,9 In this report, we present a case of dermatomyositis as a paraneoplastic syndrome developing more than 1 year before clinical manifestations of tonsillar squamous cell carcinoma (SCC).
CASE REPORT Patient presentation and clinical course A 63-year-old man presented in February/March of 2011 complaining of skin rashes (heliotrope rash, Gottron papules) and severe muscle weakness. He was diagnosed with dermatomyositis and treated with prednisone, methotrexate, and hydroxychloroquine. Symptoms improved but did not completely resolve, and he was referred to our institution in March 2012. Physical examination at the time showed erythroderma apparent on all sun-exposed areas, heliotrope facial rash, Gottron papules, and very mild proximal leg muscle weakness, all consistent with moderately to severely active dermatomyositis (Figure 1A and 1B). In addition, a large right cervical mass was noted. Ear, nose, and throat examination showed a right cervical level 3 lymph node measuring 4 cm and a 1.5-cm skin lesion on the left side of the nose. Nasopharyngolaryngoscopy was negative. Fine-needle aspiration of the node and skin HEAD & NECK—DOI 10.1002/HED
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FIGURE 1. Pretreatment (A) of the left elbow demonstrating violaceous rash. (B) Facial heliotrope rash and cutaneous basal cell carcinoma. Post-treatment (C) of the left elbow showing reduced rash. (D) Near complete resolution of the facial heliotrope rash. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
biopsy showed metastatic SCC and cutaneous basal cell carcinoma, respectively (details in pathology reports below). Positron emission tomography (PET)/CT scan demonstrated increased uptake in the right neck and tonsil (see Figure 2). A tonsillectomy revealed occult tonsillar SCC with deep positive margins. The patient was categorized as having stage IVA T1N2bM0 tonsillar SCC and was treated on a research protocol with 3 weeks of neoadjuvant rapamycin therapy before surgery (NCT01195922). A right transoral lateral pharyngectomy and modified radi-
cal neck dissection with preservation of CN XI was performed in May 2012. Postoperative complications included a pharyngocervical air leak and a left ulnar neuropathy on the side with greater dermatomyositis. The patient was subsequently treated with adjuvant chemoradiation, which ended in August 2012. Treatment was complicated by severe mucositis, dysphagia, neutropenic fever, and recurrent oral candidiasis. Symptoms of his dermatomyositis significantly improved (Figure 1C and 1D) and methotrexate and hydroxychloroquine were discontinued and
FIGURE 2. Preoperative (A) and postoperative (B) axial positron emission tomography (PET) views using F-18 fluorodeoxyglucose (FDG) at the level of the mandibular body. (A) Hypermetabolic foci are seen representing the right tonsil and a right level III lymph node. Postoperative (B) view demonstrates normal anatomy without residual disease.
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DERMATOMYOSITIS
prednisone administration was tapered off over the next year. Follow-up PET/CT (Figure 2B) demonstrated normal anatomy without disease recurrence in the head and neck. However, in July 2013, a repeat PET/CT scan showed 3 new areas of bone uptake, sternum, left acetabulum, and left iliac crest. These lesions were asymptomatic and physical examination only showed persistence of mild purple erythema involving the elbows and hands. Biopsy of the left iliac crest showed metastatic poorly differentiated carcinoma, consistent with the original SCC tonsillar primary lesion. He was then referred for systemic chemotherapy.
Pathology reports In April 2012, fine-needle aspiration of the right anterior cervical lymph node showed atypical epithelial cells with nuclear changes and dense occasionally keratinized cytoplasm, consistent with malignant metastatic SCC. Immunocytochemical studies showed positive expression of p63 and AE1/AE3. In May 2012, the postoperative pathology report showed the results of right modified radical neck dissection, measuring overall 25 3 11.5 3 3 cm. There were a 3.5- 3 2.8- 3 2.5-cm multiloculated cyst in level III and a 4- 3 2.7- 3 2.3-cm multinodular mass in level VA. A diagnosis of metastatic poorly differentiated SCC involving 15 lymph nodes was made, with microscopic extracapsular extension seen in 1 level IV and 1 level Va node. Malignant cells showed strong diffusely positive p16 immunostaining consistent with human papillomavirus (HPV). Epstein–Barr virus (EBV) was negative in the sample.
DISCUSSION AND CONCLUSION Dermatomyositis has been reported as a paraneoplastic syndrome in epithelial cancers, including cervical,11 penile,10 esophageal,12 unknown primary site,13 and lung cancers.14 In the head and neck region, dermatomyositis has only rarely been reported in the tongue,15 and nasopharyngeal carcinoma.9 Our literature search revealed only 3 previous cases of dermatomyositis associated with tonsillar SCC, each presenting with dermatomyositis before the diagnosis of cancer. Botsios et al,8 from Italy, reported 1 case of a patient developing dermatomyositis 8 months before the diagnosis of SCC. A report from Korea described 2 separate cases of paraneoplastic dermatomyositis presenting 1 year and 2 years before diagnosis of SCC.7 To our knowledge, there have been no such case reports from North America. Consistent with previous reports, our patient’s paraneoplastic dermatomyositis showed clinical improvement following treatment of tonsillar SCC. It has been suggested that infection with EBV is linked to dermatomyositis and nasopharyngeal malignancy.16 Our patient’s tumor was negative for EBV, but strongly positive for p16, which is a surrogate marker for HPV infection. Prognosis of HPV-associated oropharyngeal cancer and p16-positive cancers is generally considered to be markedly better than prognosis of HPV-negative or p16-negative cancers.17 However, our patient developed metastatic disease within 11 months of finishing adjuvant chemoradiation postsurgery. One of the other 3 case
PARANEOPLASTIC SYNDROME
reports also described development of metastasis within 15 months of diagnosis, although long-term follow-up was not provided for the other 2 cases.7 Similarly, Sugiyama et al15 described a 19-year-old man who developed dermatomyositis 6 months before a rapidly progressive tongue carcinoma, which led to his death within 7 months. Whether the diagnosis of dermatomyositis portends a worse prognosis remains to be determined. In summary, as was demonstrated in this case and previous reports, dermatomyositis may be the initial presenting symptom of a patient with head and neck SCC. Therefore, it is prudent to consider the underlying workup for head and neck malignancy in patients presenting with dermatomyositis, especially those who fail to respond to standardof-care treatment options. PET/CT may show asymmetric uptake to guide evaluation and possible biopsy of tonsillar or base of tongue lesions even in patients without abnormality on oropharyngeal examination. Treatment of the underlying malignancy can contribute to the improvement of the dermatomyositis symptoms, including intractable rash and muscle weakness. In post-treatment follow-up, clinicians should monitor for signs of persistent or recurrent dermatomyositis symptoms as this may harken a return of the underlying malignancy.
REFERENCES 1. Bergman PJ. Paraneoplastic hypercalcemia. Top Companion Anim Med 2012;27:156–158. 2. Lippitz BE. Cytokine patterns in patients with cancer: a systematic review. Lancet Oncol 2013;14:e218–e228. 3. Saxby AJ, Chin M. Paraneoplastic syndrome in a case of sinonasal adenocarcinoma. Otolaryngol Head Neck Surg 2009;141:547–548. 4. Chapireau D, Adlam D, Cameron M, Thompson M. Paraneoplastic syndromes in patients with primary oral cancers: a systematic review. Br J Oral Maxillofac Surg 2010;48:338–344. 5. Ali M, Keir M, Dodd H, Cerio R. Flexural Bazex syndrome associated with tonsillar adenocarcinoma. J Drugs Dermatol 2004;3:557–559. 6. Mathew DG, Rooban T, Janani V, Joshua E, Rao U, Ranganathan K. Review of paraneoplastic syndromes associated with oropharyngeal squamous cell carcinoma. J Oral Maxillofac Pathol 2010;14:41–47. 7. Kim SW, Shim JS, Eun YG, Kwon KH. Tonsillar squamous cell carcinoma associated with dermatomyositis: the first 2 cases in Korea. Yonsei Med J 2010;51:605–608. 8. Botsios C, Ostuni P, Boscolo–Rizzo P, Da Mosto MC, Punzi L, Marchiori C. Dermatomyositis and malignancy of the pharynx in Caucasian patients: report of two observations. Rheumatol Int 2003;23:309–311. 9. Chakroun A, Guigay J, Lusinchi A, Marandas P, Janot F, Hartl DM. Paraneoplastic dermatomyositis accompanying nasopharyngeal carcinoma: diagnosis, treatment and prognosis. Eur Ann Otorhinolaryngol Head Neck Dis 2011;128:127–131. 10. Lalla SC, Aldridge RD, Tidman MJ. Carcinoma of the penis presenting with dermatomyositis. Clin Exp Dermatol 2001;26:558. 11. Jones G, Razdan D, Cracchiolo B, Houck K, Sharer L. Paraneoplastic SIADH and dermatomyositis in cervical cancer: a case report and literature review. Case Rep Oncol 2009;2:203–209. 12. Kikuchi K, Seto Y, Matsubara T, Yamada K, Tamaki K. Amyopathic dermatomyositis associated with esophageal cancer. Int J Dermatol 2008;47: 310–311. 13. Kim HI, Chung SH, Hwang JE, et al. Dermatomyositis associated with cancer of unknown primary site. J Korean Med Sci 2007;22 Suppl:S174–S177. 14. Przybylski G, Jarzemska A, Czerniak J, Siemiatkowska K, Gadzi nska A, Ciesli nski K. A case report of a patient with dermatomyositis as a prodromal sign of lung cancer. Pol Arch Med Wewn 2008;118:143–147. 15. Sugiyama T, Nakagawa T, Inui M, Tagawa T. Tongue carcinoma in a young patient with dermatomyositis: a case report and review of the literature. J Oral Maxillofac Surg 2001;59:925–928. 16. Chen DY, Chen YM, Lan JL, et al. Polymyositis/dermatomyositis and nasopharyngeal carcinoma: the Epstein–Barr virus connection? J Clin Virol 2010;49:290–295. 17. Lewis JS Jr. p16 Immunohistochemistry as a standalone test for risk stratification in oropharyngeal squamous cell carcinoma. Head Neck Pathol 2012;6 Suppl 1:S75–S82.
HEAD & NECK—DOI 10.1002/HED
JANUARY 2015
E3
Peter Andersen, MD, Section Editor
Dermatomyositis paraneoplastic syndrome before symptomatic tonsillar squamous cell carcinoma: A case report Ahmad H. Adi, MBBS,1 Hani Alturkmani, MBBS,1 Todd Spock, BS,1 Patrice Williams Yohannes, RN, MSN,2 Susannah Wargo, RN, PhD,1 Eva Szabo, MD,3 J. Silvio Gutkind, PhD,2 Carter Van Waes, MD, PhD1* 1
Head and Neck Surgery Branch, National Institute on Deafness and Other Communication Disorders, National Institutes of Health, Bethesda, Maryland, 2National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland, 3Division of Cancer Prevention, Lung and Upper Aerodigestive Cancer Research Group, National Institutes of Health, Bethesda, Maryland.
Accepted 3 April 2014 Published online 27 June 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/hed.23703
ABSTRACT: Background. Paraneoplastic syndromes are systemic or organ-related functional tumor-associated changes that arise distant to the tumor. Methods and Results. We present a rare case of a 63-year-old man with dermatomyositis as a paraneoplastic syndrome developing more than a year before clinical manifestations of tonsillar squamous cell carcinoma (SCC). He subsequently developed stage T1N2bM0 IVA tonsillar SCC. He was treated on a research protocol with 3 weeks of neoadjuvant rapamycin therapy before right transoral lateral pharyngectomy and modified radical neck dissection with preservation of CN XI. His symptoms of
INTRODUCTION Paraneoplastic syndromes are tumor-associated changes in the bodily structure, function, or both, that arise distant to the tumor. They show diverse clinical manifestations that are attributed to the systemic actions of the neoplasm.1It has been proposed that there is a common underlying mechanism to paraneoplastic syndromes, regardless of the tumor origins, involving complex interactions between different cytokines that affect immune reactions toward tumor cells. The balance between pro-inflammatory and anti-inflammatory cytokines may have an association with the clinical prognosis of various malignancies.2 Although rare in head and neck cancer, numerous paraneoplastic syndromes have been reported in the literature, including back pain, nondermatomal sensory changes, polymyalgia, proximal myopathy,3 hypercalcemia, syndrome of inappropriate antidiuretic hormone, and skin changes (such as pemphigus and Bazex syndrome).4–6 However, the cause of these paraneoplastic changes is poorly understood in most cases.4 Dermatomyositis is a myopathy characterized by muscle weakness and skin manifestations (including heliotrope rash and Gottron papules).7,8 The pathogenesis of
*Corresponding author: C. Van Waes, Head and Neck Surgery Branch, National Institute of Dental and Craniofacial Research, National Institutes of Health, Radiation Oncology Branch, NCI, CRC-4–2732, 10 Center Drive, Bethesda, MD 20892. E-mail: [email protected]
dermatomyositis subsequently improved and he was weaned off immunosuppressive therapy. Conclusion. To our knowledge, this is the first report of dermatomyositis as a paraneoplastic syndrome of tonsillar SCC in North America. We suggest that clinicians should monitor for signs of persistent or recurrent dermatomyositis symptoms as this may herald development or a return of the underlying C 2014 Wiley Periodicals, Inc. Head Neck 37: E1–E3, 2015 malignancy. V
KEY WORDS: dermatomyositis, paraneoplastic, tonsillar, carcinoma, squamous
dermatomyositis is not entirely understood, but has been linked to immune dysregulation.9 Dermatomyositis has been linked to neoplastic processes (with a frequency of 2.5% to 29%10); however, it has not been frequently reported to be associated with head and neck cancers.7,9 In this report, we present a case of dermatomyositis as a paraneoplastic syndrome developing more than 1 year before clinical manifestations of tonsillar squamous cell carcinoma (SCC).
CASE REPORT Patient presentation and clinical course A 63-year-old man presented in February/March of 2011 complaining of skin rashes (heliotrope rash, Gottron papules) and severe muscle weakness. He was diagnosed with dermatomyositis and treated with prednisone, methotrexate, and hydroxychloroquine. Symptoms improved but did not completely resolve, and he was referred to our institution in March 2012. Physical examination at the time showed erythroderma apparent on all sun-exposed areas, heliotrope facial rash, Gottron papules, and very mild proximal leg muscle weakness, all consistent with moderately to severely active dermatomyositis (Figure 1A and 1B). In addition, a large right cervical mass was noted. Ear, nose, and throat examination showed a right cervical level 3 lymph node measuring 4 cm and a 1.5-cm skin lesion on the left side of the nose. Nasopharyngolaryngoscopy was negative. Fine-needle aspiration of the node and skin HEAD & NECK—DOI 10.1002/HED
JANUARY 2015
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ADI ET AL.
FIGURE 1. Pretreatment (A) of the left elbow demonstrating violaceous rash. (B) Facial heliotrope rash and cutaneous basal cell carcinoma. Post-treatment (C) of the left elbow showing reduced rash. (D) Near complete resolution of the facial heliotrope rash. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
biopsy showed metastatic SCC and cutaneous basal cell carcinoma, respectively (details in pathology reports below). Positron emission tomography (PET)/CT scan demonstrated increased uptake in the right neck and tonsil (see Figure 2). A tonsillectomy revealed occult tonsillar SCC with deep positive margins. The patient was categorized as having stage IVA T1N2bM0 tonsillar SCC and was treated on a research protocol with 3 weeks of neoadjuvant rapamycin therapy before surgery (NCT01195922). A right transoral lateral pharyngectomy and modified radi-
cal neck dissection with preservation of CN XI was performed in May 2012. Postoperative complications included a pharyngocervical air leak and a left ulnar neuropathy on the side with greater dermatomyositis. The patient was subsequently treated with adjuvant chemoradiation, which ended in August 2012. Treatment was complicated by severe mucositis, dysphagia, neutropenic fever, and recurrent oral candidiasis. Symptoms of his dermatomyositis significantly improved (Figure 1C and 1D) and methotrexate and hydroxychloroquine were discontinued and
FIGURE 2. Preoperative (A) and postoperative (B) axial positron emission tomography (PET) views using F-18 fluorodeoxyglucose (FDG) at the level of the mandibular body. (A) Hypermetabolic foci are seen representing the right tonsil and a right level III lymph node. Postoperative (B) view demonstrates normal anatomy without residual disease.
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DERMATOMYOSITIS
prednisone administration was tapered off over the next year. Follow-up PET/CT (Figure 2B) demonstrated normal anatomy without disease recurrence in the head and neck. However, in July 2013, a repeat PET/CT scan showed 3 new areas of bone uptake, sternum, left acetabulum, and left iliac crest. These lesions were asymptomatic and physical examination only showed persistence of mild purple erythema involving the elbows and hands. Biopsy of the left iliac crest showed metastatic poorly differentiated carcinoma, consistent with the original SCC tonsillar primary lesion. He was then referred for systemic chemotherapy.
Pathology reports In April 2012, fine-needle aspiration of the right anterior cervical lymph node showed atypical epithelial cells with nuclear changes and dense occasionally keratinized cytoplasm, consistent with malignant metastatic SCC. Immunocytochemical studies showed positive expression of p63 and AE1/AE3. In May 2012, the postoperative pathology report showed the results of right modified radical neck dissection, measuring overall 25 3 11.5 3 3 cm. There were a 3.5- 3 2.8- 3 2.5-cm multiloculated cyst in level III and a 4- 3 2.7- 3 2.3-cm multinodular mass in level VA. A diagnosis of metastatic poorly differentiated SCC involving 15 lymph nodes was made, with microscopic extracapsular extension seen in 1 level IV and 1 level Va node. Malignant cells showed strong diffusely positive p16 immunostaining consistent with human papillomavirus (HPV). Epstein–Barr virus (EBV) was negative in the sample.
DISCUSSION AND CONCLUSION Dermatomyositis has been reported as a paraneoplastic syndrome in epithelial cancers, including cervical,11 penile,10 esophageal,12 unknown primary site,13 and lung cancers.14 In the head and neck region, dermatomyositis has only rarely been reported in the tongue,15 and nasopharyngeal carcinoma.9 Our literature search revealed only 3 previous cases of dermatomyositis associated with tonsillar SCC, each presenting with dermatomyositis before the diagnosis of cancer. Botsios et al,8 from Italy, reported 1 case of a patient developing dermatomyositis 8 months before the diagnosis of SCC. A report from Korea described 2 separate cases of paraneoplastic dermatomyositis presenting 1 year and 2 years before diagnosis of SCC.7 To our knowledge, there have been no such case reports from North America. Consistent with previous reports, our patient’s paraneoplastic dermatomyositis showed clinical improvement following treatment of tonsillar SCC. It has been suggested that infection with EBV is linked to dermatomyositis and nasopharyngeal malignancy.16 Our patient’s tumor was negative for EBV, but strongly positive for p16, which is a surrogate marker for HPV infection. Prognosis of HPV-associated oropharyngeal cancer and p16-positive cancers is generally considered to be markedly better than prognosis of HPV-negative or p16-negative cancers.17 However, our patient developed metastatic disease within 11 months of finishing adjuvant chemoradiation postsurgery. One of the other 3 case
PARANEOPLASTIC SYNDROME
reports also described development of metastasis within 15 months of diagnosis, although long-term follow-up was not provided for the other 2 cases.7 Similarly, Sugiyama et al15 described a 19-year-old man who developed dermatomyositis 6 months before a rapidly progressive tongue carcinoma, which led to his death within 7 months. Whether the diagnosis of dermatomyositis portends a worse prognosis remains to be determined. In summary, as was demonstrated in this case and previous reports, dermatomyositis may be the initial presenting symptom of a patient with head and neck SCC. Therefore, it is prudent to consider the underlying workup for head and neck malignancy in patients presenting with dermatomyositis, especially those who fail to respond to standardof-care treatment options. PET/CT may show asymmetric uptake to guide evaluation and possible biopsy of tonsillar or base of tongue lesions even in patients without abnormality on oropharyngeal examination. Treatment of the underlying malignancy can contribute to the improvement of the dermatomyositis symptoms, including intractable rash and muscle weakness. In post-treatment follow-up, clinicians should monitor for signs of persistent or recurrent dermatomyositis symptoms as this may harken a return of the underlying malignancy.
REFERENCES 1. Bergman PJ. Paraneoplastic hypercalcemia. Top Companion Anim Med 2012;27:156–158. 2. Lippitz BE. Cytokine patterns in patients with cancer: a systematic review. Lancet Oncol 2013;14:e218–e228. 3. Saxby AJ, Chin M. Paraneoplastic syndrome in a case of sinonasal adenocarcinoma. Otolaryngol Head Neck Surg 2009;141:547–548. 4. Chapireau D, Adlam D, Cameron M, Thompson M. Paraneoplastic syndromes in patients with primary oral cancers: a systematic review. Br J Oral Maxillofac Surg 2010;48:338–344. 5. Ali M, Keir M, Dodd H, Cerio R. Flexural Bazex syndrome associated with tonsillar adenocarcinoma. J Drugs Dermatol 2004;3:557–559. 6. Mathew DG, Rooban T, Janani V, Joshua E, Rao U, Ranganathan K. Review of paraneoplastic syndromes associated with oropharyngeal squamous cell carcinoma. J Oral Maxillofac Pathol 2010;14:41–47. 7. Kim SW, Shim JS, Eun YG, Kwon KH. Tonsillar squamous cell carcinoma associated with dermatomyositis: the first 2 cases in Korea. Yonsei Med J 2010;51:605–608. 8. Botsios C, Ostuni P, Boscolo–Rizzo P, Da Mosto MC, Punzi L, Marchiori C. Dermatomyositis and malignancy of the pharynx in Caucasian patients: report of two observations. Rheumatol Int 2003;23:309–311. 9. Chakroun A, Guigay J, Lusinchi A, Marandas P, Janot F, Hartl DM. Paraneoplastic dermatomyositis accompanying nasopharyngeal carcinoma: diagnosis, treatment and prognosis. Eur Ann Otorhinolaryngol Head Neck Dis 2011;128:127–131. 10. Lalla SC, Aldridge RD, Tidman MJ. Carcinoma of the penis presenting with dermatomyositis. Clin Exp Dermatol 2001;26:558. 11. Jones G, Razdan D, Cracchiolo B, Houck K, Sharer L. Paraneoplastic SIADH and dermatomyositis in cervical cancer: a case report and literature review. Case Rep Oncol 2009;2:203–209. 12. Kikuchi K, Seto Y, Matsubara T, Yamada K, Tamaki K. Amyopathic dermatomyositis associated with esophageal cancer. Int J Dermatol 2008;47: 310–311. 13. Kim HI, Chung SH, Hwang JE, et al. Dermatomyositis associated with cancer of unknown primary site. J Korean Med Sci 2007;22 Suppl:S174–S177. 14. Przybylski G, Jarzemska A, Czerniak J, Siemiatkowska K, Gadzi nska A, Ciesli nski K. A case report of a patient with dermatomyositis as a prodromal sign of lung cancer. Pol Arch Med Wewn 2008;118:143–147. 15. Sugiyama T, Nakagawa T, Inui M, Tagawa T. Tongue carcinoma in a young patient with dermatomyositis: a case report and review of the literature. J Oral Maxillofac Surg 2001;59:925–928. 16. Chen DY, Chen YM, Lan JL, et al. Polymyositis/dermatomyositis and nasopharyngeal carcinoma: the Epstein–Barr virus connection? J Clin Virol 2010;49:290–295. 17. Lewis JS Jr. p16 Immunohistochemistry as a standalone test for risk stratification in oropharyngeal squamous cell carcinoma. Head Neck Pathol 2012;6 Suppl 1:S75–S82.
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JANUARY 2015
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![[Paraneoplastic dermatomyositis revealing an undifferentiated nasopharyngeal carcinoma: about a case].](/assets/img/hold.png)
