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slightly palpable&#44; well delimitated&#44; 2-5<span class="elsevierStyleHsp" style=""></span>mm in diameter&#44; many with collarettes of scale&#46; Lesions were located in both sun-exposed and non-sun-exposed sites&#44; predominantly in the back&#44; trunk and upper extremities &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46; The biopsy of a back lesion revealed a focal thinning of the epidermis&#44; with loss of the granular layer and a discrete column of parakeratosis &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#46; Symptomatic treatment with topical bethametason and salicyl acid was initiated with resolution of pruritus&#46; Patient did not accept the proposed systemic treatment with Acitretinon nor Tacalcitol oinment&#46; The patient is still receiving the combined therapy after achieving a complete disease remission and macules persist unchanged without dose reductions or lengthening of treatment intervals&#46; No new skin adverse reactions were observed&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Trastuzumab is a monoclonal antibody that binds to the extracellular domain of HER2 and exemestane is an aromatase inhibitor which suppresses plasma oestrogen levels by inhibition of the enzyme aromatase&#46; Acne vulgaris&#44; nail changes&#44; pruritus&#44; leukopenia and more rarely cellulitis&#44; dermal ulcer and erysipela have been described under trastuzumab treatment&#46; Alopecia&#44; dermatitis&#44; itching&#44; acute generalized exanthematous pustulosis&#44; pruritus and urticaria were reported for exemestane&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Porokeratosis is a heterogeneous group of hereditary or acquired disorders of keratinization believed to arise from an expansion of abnormal keratinocytes&#46; Multiple variants of porokeratosis have been described&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">2&#44;3</span></a> Recently&#44; a new entity named Eruptive porokeratosis has been reported to describe cases of acute&#44; disseminated eruptions&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a> Pathogenesis is not well understood&#46; Some proposed triggering factors include genetics&#44; ultraviolet light exposure&#44; infection&#44; and immunosuppression &#40;ie&#44;transplant recipients&#44; retroviral disease&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">2&#44;4&#8211;6</span></a> Some reports of drug-induced cases are also reported&#44; mainly due to immunosuppressing drugs &#40;ie&#44; prednisone&#44; antirheumatic drugs&#44; biologics&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">3&#8211;5</span></a> Some authors speculate that porokeratosis&#44; specially the eruptive form&#44; may represent a paraneoplastic manifestation since it has been described in association with hematopoietic malignancies orsolid organ tumors &#40;ie&#44; hepatocellular carcinoma&#44; cholangiocarcinoma&#44; ovarian cancer&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">3&#8211;7</span></a> The typical histological feature of porokeratosis is the cornoid lamella&#44; which corresponds to the border between normal epidermis and the clone of mutant keratinocytes&#46; Prognosis of porokeratosis is generally good but some cases of squamos cell carcinoma developed on porokeratosis have been described&#44; suggesting porokeratosis as a possible pre-cancer situation&#46; Proposed treatments are photodinamic therapy&#44; local tacalcitol or Acitretinoin for disseminated variants&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">2&#44;3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">No data have been reported so far about the link between porokeratosis and exemestane or trastuzumab&#46; As the patient is still receiving the same oncological treatment&#44; persistence of the lesions could be linked with either the immunotherapy or the antihormonal therapy&#46; Porokeratosis is a disorder of keratinization and antibodies targeting the HER-family receptors can cause disorders at this level The possibility that eruptive porokeratosis must be considered as a paraneoplastic phenomenon in our case cannot be completely ruled out&#46; Nevertheless&#44; the long period of time between both conditions&#44; the fact that skin eruption persists although tumor response to the treatment and a time association with the treatment starting supports a drug induced phenomenon in our opinion&#46;</p></span>"
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Case and Research Letters
A Case of Eruptive Disseminated Porokeratosis in a Cancer Patient after Trastuzumab and Exemestane Treatment: Cancer Related or Drug Induced Phenomenon?
Un caso de poroqueratosis diseminada eruptiva en un paciente oncológico tratado con trastuzumab y exemestano: ¿fenómeno asociado al cáncer o inducido por fármacos?
C. Mangasa,
Autor para correspondencia
, V. Espelib, R. Blumc
a Unidad de Dermatología, Hospital Regional de Bellinzona e Valli, Bellinzona, Suiza
b Oncology Institute of Italian Switzerland (IOSI), Bellinzona, Suiza
c Unidad de Dermatología, Inselspital, Hospital Universitario de Berna, Berna, Suiza
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    "titulo" => "A Case of Eruptive Disseminated Porokeratosis in a Cancer Patient after Trastuzumab and Exemestane Treatment&#58; Cancer Related or Drug Induced Phenomenon&#63;"
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        "titulo" => "Un caso de poroqueratosis diseminada eruptiva en un paciente oncol&#243;gico tratado con trastuzumab y exemestano&#58; &#191;fen&#243;meno asociado al c&#225;ncer o inducido por f&#225;rmacos&#63;"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Histopathology &#40;hematoxylin and eosin&#59; magnification 10x&#41; shows the typical pattern of porokeratosis with central column of parakeratosis &#40;cornoid lamella&#41; and dyskeratotic keratinocytes&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We report a rare skin toxicity in a 62-years-old white female with a history of an estrogen receptor- and progesterone receptor&#8211;positive &#40;95&#37; and 50&#37; of tumor cells&#44; respectively&#41; human epidermal growth factor receptor 2 &#40;HER2&#41;&#8211;positive invasive ductal carcinoma of the left breast &#40;initial stage pT2 pN1a M0&#41;&#46; She underwent radical modified mastectomy plus axillary node dissection followed by adjuvant treatment with 1 year of trastuzumab and 5 years of the aromatase inhibitor letrozole&#46; Six years after the diagnosis&#44; the patient developed bone and internal mammary lymph node metastases treated with exemestane and trastuzumab&#46; Two months after starting treatment&#44; she developed non-painful but slightly itching diffuse skin lesions&#46; She showed multiple&#44; disseminated&#44; brown-grey oval macules&#44; slightly palpable&#44; well delimitated&#44; 2-5<span class="elsevierStyleHsp" style=""></span>mm in diameter&#44; many with collarettes of scale&#46; Lesions were located in both sun-exposed and non-sun-exposed sites&#44; predominantly in the back&#44; trunk and upper extremities &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46; The biopsy of a back lesion revealed a focal thinning of the epidermis&#44; with loss of the granular layer and a discrete column of parakeratosis &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#46; Symptomatic treatment with topical bethametason and salicyl acid was initiated with resolution of pruritus&#46; Patient did not accept the proposed systemic treatment with Acitretinon nor Tacalcitol oinment&#46; The patient is still receiving the combined therapy after achieving a complete disease remission and macules persist unchanged without dose reductions or lengthening of treatment intervals&#46; No new skin adverse reactions were observed&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Trastuzumab is a monoclonal antibody that binds to the extracellular domain of HER2 and exemestane is an aromatase inhibitor which suppresses plasma oestrogen levels by inhibition of the enzyme aromatase&#46; Acne vulgaris&#44; nail changes&#44; pruritus&#44; leukopenia and more rarely cellulitis&#44; dermal ulcer and erysipela have been described under trastuzumab treatment&#46; Alopecia&#44; dermatitis&#44; itching&#44; acute generalized exanthematous pustulosis&#44; pruritus and urticaria were reported for exemestane&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Porokeratosis is a heterogeneous group of hereditary or acquired disorders of keratinization believed to arise from an expansion of abnormal keratinocytes&#46; Multiple variants of porokeratosis have been described&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">2&#44;3</span></a> Recently&#44; a new entity named Eruptive porokeratosis has been reported to describe cases of acute&#44; disseminated eruptions&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a> Pathogenesis is not well understood&#46; Some proposed triggering factors include genetics&#44; ultraviolet light exposure&#44; infection&#44; and immunosuppression &#40;ie&#44;transplant recipients&#44; retroviral disease&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">2&#44;4&#8211;6</span></a> Some reports of drug-induced cases are also reported&#44; mainly due to immunosuppressing drugs &#40;ie&#44; prednisone&#44; antirheumatic drugs&#44; biologics&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">3&#8211;5</span></a> Some authors speculate that porokeratosis&#44; specially the eruptive form&#44; may represent a paraneoplastic manifestation since it has been described in association with hematopoietic malignancies orsolid organ tumors &#40;ie&#44; hepatocellular carcinoma&#44; cholangiocarcinoma&#44; ovarian cancer&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">3&#8211;7</span></a> The typical histological feature of porokeratosis is the cornoid lamella&#44; which corresponds to the border between normal epidermis and the clone of mutant keratinocytes&#46; Prognosis of porokeratosis is generally good but some cases of squamos cell carcinoma developed on porokeratosis have been described&#44; suggesting porokeratosis as a possible pre-cancer situation&#46; Proposed treatments are photodinamic therapy&#44; local tacalcitol or Acitretinoin for disseminated variants&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">2&#44;3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">No data have been reported so far about the link between porokeratosis and exemestane or trastuzumab&#46; As the patient is still receiving the same oncological treatment&#44; persistence of the lesions could be linked with either the immunotherapy or the antihormonal therapy&#46; Porokeratosis is a disorder of keratinization and antibodies targeting the HER-family receptors can cause disorders at this level The possibility that eruptive porokeratosis must be considered as a paraneoplastic phenomenon in our case cannot be completely ruled out&#46; Nevertheless&#44; the long period of time between both conditions&#44; the fact that skin eruption persists although tumor response to the treatment and a time association with the treatment starting supports a drug induced phenomenon in our opinion&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Mangas C&#44; Espeli V&#44; Blum R&#46; Un caso de poroqueratosis diseminada eruptiva en un paciente oncol&#243;gico tratado con trastuzumab y exemestano&#58; &#191;fen&#243;meno asociado al c&#225;ncer o inducido por f&#225;rmacos&#63;&#46; Actas Dermosifiliogr&#46; 2018&#59;109&#58;559&#8211;560&#46;</p>"
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