March/April 2014
Volume 12 • Issue 2
Editorial
The Sign of Leser-Trélat: Is It Really So?—For Your Eyes Only Michael Joseph Lavery, MB BCh BAO;1 Lawrence Charles Parish, MD, MD (Hon);2 Peter C. Lambert, MA;3 Robert E. Lee, MD;3 W. Clark Lambert, MD, PhD4,5
T
he Leser-Trélat sign, as a marker for internal malignancy, has been the subject of controversy since its inception. Even its very definition has been called into question.
The sign has been attributed to two professors of surgery: Edmund Leser (1853–1916), a German, and Ulysse Trélat (1795– 1879), a Frenchman, but they were describing angiomas in association with cancer.1 Eugen Hollander was actually the first to describe the association of seborrheic keratoses and cancer.2 The situation is even more muddled, however. Not until 1926 did Walter Freudenthal (1894–1952) clearly delineate seborrheic keratosis from actinic keratosis.3
eruption of these keratoses should be on unaffected skin—not on eczematous or erythrodermic skin.4 Making an Association Helen Olandorf Curth (1899–1982), in 1976, set forth 5 specific criteria for a causal relationship between dermatoses and internal malignancy.5 These are: 1. Similar time of onset. 2. A corresponding clinical course, with remission after treatment and recurrence with tumor growth. (One report revealed a reduction in the seborrheic keratoses after chemoradiotherapy for lung carcinoma and the recurrence of the seborrheic keratoses 1 year later, which coincided with an increase in size of the lung carcinoma.6)
Clinical Findings The definition of the sign of Leser-Trélat involves the sudden eruption of multiple seborrheic keratoses or the sudden increase in size or number of existing seborrheic keratoses (Figure), in association with an underlying malignancy. This paraneoplastic disease should be differentiated in patients who have gradual development of such widespread keratoses. Even the definition provokes debate, including the number of seborrheic keratoses needed to constitute this sign and the time frame required for a “sudden eruption.” Both seborrheic keratoses and malignancies, needless to say, are common in the elderly population and the mere presence of both during a workup could be a coincidence. The problem can be compounded further when a detailed history is attempted. The exact time frame of the development of these keratoses may be vague, as this patient subgroup often has difficulty in visualizing such lesions. Adding to the confusion is the observation that a sudden eruption of multiple seborrheic keratoses can occur in inflammatory dermatoses. At least one author notes that the
3. An association of the paraneoplastic sign with a specific tumor—seborrheic keratosis does not have this, although adenocarcinomas have the most common association. 4. The association between the dermatosis and malignancy should be high. 5. The paraneoplastic dermatoses are usually rare—seborrheic keratoses are common (but their rapid onset is not). Several authors have reported patients who have a sudden eruption of seborrheic keratosis and on investigation an underlying malignancy is identified. The most prevalent disease is adenocarcinoma, mainly of the stomach or colon (around 33%)7; however, other associations have been documented, including lymphoproliferative disorders (20%).7 Although it is generally accepted that members of the older population have keratoses, which has led some to feel that the legitimacy of the sign is spurious, the
From the Department of Dermatology, Antrim Area Hospital, Antrim, Northern Ireland;1 the Department of Dermatology and Cutaneous Biology and the Jefferson Center for International Dermatology, Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA;2 St. George’s University School of Medicine, St. Georges, Grenada, WI;3 and the Departments of Dermatology4 and Pathology,5 Rutgers University – New Jersey Medical School, Newark, NJ Address for Correspondence: Michael Lavery, MB BCh BAO, Antrim Area Hospital, Bush Road, Antrim, BT41 2RL, Northern Ireland • E-mail: mlavery88@yahoo.ie
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