velvet palm as a paraneoplastic sign

A 54-year-old woman who had a 34-pack-year smoking history presented with a 5-month history of changes in palmar skin texture associated with a 15-kg weight loss and left hip pain waking her at night.

On physical examination, cachexia was noted, along with a rugated, velvety appearance of the palms (Panel A), acanthosis nigricans, and left hip pain on rotation.

Laboratory evaluation revealed neutrophil leukocytosis (white-cell count, 42,300 per cubic millimeter), thrombocytosis (platelet count, 1.17 million per cubic millimeter), and hypercalcemia (calcium corrected for albumin, 4.5 mmol per liter [18 mg per deciliter]).

Chest computed tomography (CT) revealed nodules (Panel B, arrow), and bone scintigraphy showed increased uptake in the left hip. Both these radiographic findings suggest metastasis. CT-guided fine-needle aspiration of a lung nodule revealed cells consistent with non–small-cell carcinoma of the lung.

The palmar changes represent a cutaneous paraneoplastic sign known as tripe or velvet palm. It is highly associated with cancer (94% in some reports), most frequently with gastric adenocarcinoma or bronchogenic carcinoma. The patient was referred to oncology for chemotherapy but died a few weeks later of metastatic lung cancer.