A complex pattern of melanonychia and onycholysis after treatment with pemetrexed for lung cancer.

A 53-year-old black man was diagnosed with poorly differentiated adenocarcinoma of the lung and treated initially with 4 cycles of paclitaxel in combination with carboplatin and external-beam radiation therapy with a good clinicoradiologic response. The patient tolerated the chemotherapy well and did not develop any skin or nail changes during that period of time. His lung cancer recurred 10 months later, when he was found to have bone metastases. Second-line chemotherapy with pemetrexed 500 mg/m2 intravenously every 3 weeks was commenced. A week prior, the patient was started on folic acid 1 mg orally daily and given an injection of vitamin B12 1000 microg intramuscularly that was continued every 3 cycles thereafter. Dexamethasone 4 mg orally twice daily was given around the time of chemotherapy administration to prevent the dermatitis associated with the drug. The patient denied taking other drugs. Two months into his second-line chemotherapy, he developed multiple, concomitant, transverse and longitudinal black lines in all of his fingernails and toenails. After an interval of 3 months, he presented a complex pattern of nail hyperpigmentation, from combined dense horizontal and longitudinal streaks in some nails to diffuse black discoloration in others (Figure). Other associated changes included koilonychia, dystrophy, and friability of nail plates. Along with normal results of a hepatorenal panel and normal serum vitamin B12 and folate levels, no metabolic or endocrinologic alterations were present to explain the nail pigmentation and dystrophic changes. Results of his mycologic examination and cultures came back negative. When questioned, he denied taking any other drugs including other alternative medicine approaches or vitamin supplements, particularly retinoids, well known for causing severe nail dystrophy.

Distinct patterns of chromonychia, Beau's lines, and melanoderma seen with vincristine, adriamycin, dexamethasone therapy for multiple myeloma.

Nail and skin alterations associated with the use of chemotherapy have been described in the last decade involving various combinations of two different types of nail changes. They are entirely reversible within a few months after withdrawal of the offending agent. We describe a 52-year-old male diagnosed with stage III multiple myeloma, who was treated with 5-monthly cycles of VAD (vincristine, adriamycin and dexamathasone). During administration of chemotherapy, the patient progressively developed a complex association of Beau's lines, transverse melanonychia, Muehrcke's lines, and diffuse hyperpigmentation of the skin. No metabolic or endocrine changes were present to explain the observed pigmentation and structural alterations. This complex pattern of nail and skin changes is accounted by synergy or an additive effect of chemotherapy agents on cellular proliferation of nail compartments. All changes disappeared 4 months after the discontinuation of VAD chemotherapy, which further pointed out towards adriamycin and vincristine as possible etiologic agents.

Unusually large colon cancer cutaneous and subcutaneous metastases occurring in resection scars.

Development of cutaneous metastases from colon cancer is a rare event, usually occurring in the setting of diffusely-disseminated disease and commonly carrying a dismal prognosis. Cutaneous and subcutaneous metastases in surgical scars occur extremely rarely, with only a few cases reported. We describe two cases of cutaneous metastases from colon cancer. A 62-year-old woman developed an 11-cm midline abdominal mass that slowly grew on the skin surface. The mass occurred at the scar site of her previous surgery performed 5 years prior for resection of a colon adenocarcinoma. A 46-year-old male presented with a subcutaneous 4.5-cm nodule in midline-abdominal scar, 3 years after resection of the primary colon cancer. These cases illustrate the pathological features and natural history of cutaneous metastases observed until the tumors have reached a very large size. Particular features of cutaneous scar metastases from colon cancer observed in our cases are a superficial pattern of spread, strong positivity for EGFR, low serum carcinoembrionic antigen, and long survival of the patients, possibly contributed to by the use of chemotherapy.