A case of systemic sclerosis associated with gastric cancer

Recurrent metastatic breast cancer presenting with paraneoplastic scleroderma

A 44-year-old woman presented to the rheumatology clinic with a 5-month history of stiffness and tightness of the skin of the distal fingers, together with pruritus and skin changes throughout the limbs and chest. She had also developed Raynaud's phenomenon (during the summer months), fatigue and abdominal discomfort with early satiety. She had a history of adenocarcinoma of the left breast and had undergone a wide local excision and axillary node clearance 11 years earlier with adjuvant chemotherapy and hormone therapy to which she had responded well. She was found to have sclerodactyly with skin thickening over the knees, upper arms, face and chest wall together with nodularity at the scar site and distortion of the left breast. Subsequent investigations revealed recurrent metastatic breast cancer with paraneoplastic scleroderma. We explore this interesting case and review our current understanding of paraneoplastic scleroderma.

Rheumatic disorders as paraneoplastic syndromes

The long-established observation that some rheumatologic disorders (RDs) are associated with--or precede--the clinical manifestations of a variety of solid and hematological tumors represents an important clue for the early diagnosis and effective treatment of the cancers. Inflammatory myopathies, seronegative rheumatoid arthritis and some atypical vasculitides are the most frequently reported paraneoplastic RDs, although paraneoplastic scleroderma- and lupus-like syndromes, erythema nodosum, and Raynaud's syndrome have also been observed. Generally, the clinical course of a paraneoplastic RD parallels that of the cancer, and surgical removal of the tumor or its medical treatment usually results in a marked regression of the clinical manifestations of the RD. Most paraneoplastic RDs are difficultly distinguishable from idiopathic RDs. Even so, some atypical features of the clinical presentation raise the suspicion of an underlying tumor. This review summarizes current hypotheses for the pathogenesis that leads a tumor to present as an RD and discusses the clinical features that help distinguish paraneoplastic from idiopathic RDs.

[Systemic sclerosis (scleroderma) and malignancy]

The association of malignancy with collagen diseases has been a focus of interest. Especially, relation between dermatomyositis and malignancy is well-recognized. I reviewed here about the coexistence of SSc and malignancy in literature. I would like to raise four points as characteristics of the relationship. (1) Special attention should be paid to the patients who is late-onset, with advanced skin sclerosis (ex. Barnett III type) and male. (2) There are three generalized mechanisms of the association. The first is the predisposition of the malignancy on the basis of organ fibrosis, such as pulmonary fibrosis and lung cancer. The second is the nature of paraneoplastic syndrome. Lastly, immunological derangement inherent to SSc might cause carcinogenesis. (3) It has been documented that the interval of the onsets of SSc and breast cancer is extremely short. (4) Longstanding reflux esophagitis and Barrett's esophagus with SSc is suspected to predispose to esophageal carcinoma.