Paraneoplastic syndrome: Difference between revisions

	Paraneoplastic syndrome Microchapters
Patient Information
Overview
Classification Endocrine Musculocutaneous Neurological Hematological Others
Causes
Differential diagnosis

VisualWikitext

Revision as of 19:44, 11 October 2019

PCFor patient information, click here

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Gertrude Djouka, M.D.[2] Synonyms and keywords: Paraneoplastic syndrome

Overview

Paraneoplastic syndromes are a rare type of disease that is caused by abnormal immune systems resulting from cancerous cells. Paraneoplastic syndromes are disorders due to the release of hormones, or peptides that cause immune cross-reactivity between cancerous cells and normal tissues. Sometimes the symptoms of paraneoplastic syndromes show even before the diagnosis of a malignancy. There is no screening for paraneoplastic syndromes. The stage and type of diagnosis of cancer determine the prognosis of a paraneoplastic syndrome. The causes are mostly related to the organ affected. The paraneoplastic syndromes are divided into four main categories such as musculocutaneous, neurological, hematological and endocrines. They are no cures for the paraneoplastic syndrome, but cancer treatment and some medications to reduce autoimmune responses are helpful.

Classification

Paraneoplastic syndromes may be classified into 5 main categories accordingly:


Type of paraneoplastic syndrome	Subtype	Associated Cancers
Endocrine metabolic syndromes^[1]^[2]^[3]	Hypercalcemia	breast cancer and lung cancer (typically squamous cell) due to the production of PTHrP (Parathyroid hormone-related protein)multiple myeloma, renal cell carcinoma, ovarian cancer, endometrial cancer, and lymphoma
	SIADH^[4]^[5]	small cell lung cancer, mesothelioma, breast, prostate, adrenal, urethral, thymoma, lymphoma, GI, CNS, and Ewing sarcoma
	Ectopic ACTH secretion	small-cell lung cancer, carcinoid tumor, thymoma and other cancers
	Tumor induced osteomalacia
	Hypoglycemia^[6]	GI cancers, mesothelioma, lung, and sarcomas
Musculocutaneous paraneoplastic syndromes ^[7]	Dermatomyositis
	Leser-Trélat sign	gastrointestinal adenocarcinomas (gastric, colon, rectal), breast cancer, and lymphoproliferative disorders/lymphoma, and melanoma.
	Acanthosis nigricans	gastric adenocarcinoma, endometrial cancer, and etc.
	Necrolytic migratory erythema
	Sweet's syndrome
	Pyoderma gangrenosum
Neurological paraneoplastic syndromes^[8]^[9]	Paraneoplastic cerebellar degeneration
	Encephalomyelitis
	Limbic encephalitis
	Brainstem encephalitis
	Opsoclonus (involving eye movement)
	Encephalitis^[10]	teratoma
	Polymyositis
	Autonomic neuropathy
	Lambert-Eaton myasthenic syndrome (LEMS)	small-cell lung cancer
	Myasthenia gravis
	Subacute (peripheral) sensory neuropathy
Hematological paraneoplastic syndromes ^[11]^[12]	Granulocytosis
	Thrombocytosis
	Pure red cell aplasia
	Eosinophilia
Others	Membranous glomerulonephritis

- Endocrine metabolic syndromes:
  - Hypercalcemia in breast cancer and lung cancer (typically squamous cell) due to the production of PTHrP (Parathyroid hormone-related protein)
    - Seen also in multiple myeloma, renal cell carcinoma, ovarian cancer, endometrial cancer, and lymphoma
  - SIADH
    - Associated cancers: small cell lung cancer, mesothelioma, breast, prostate, adrenal, urethral, thymoma, lymphoma, GI, CNS, and Ewing sarcoma
  - Ectopic ACTH secretion associated with small-cell lung cancer, carcinoid tumor, thymoma and other cancers
  - Tumor induced osteomalacia
  - Hypoglycemia
    - Associated cancers: GI, mesothelioma, lung, and sarcomas
- Musculocutaneous paraneoplastic syndromes
  - Dermatomyositis (25-50% of adult patients have an underlying malignancy)
  - Leser-Trélat sign, a sudden onset of many pigmented skin lesions.
    - Associated cancers: gastrointestinal adenocarcinomas (gastric, colon, rectal), breast cancer, and lymphoproliferative disorders/lymphoma, melanoma, and etc.
  - Acanthosis nigricans, seen in gastric adenocarcinoma, endometrial cancer, and etc.
  - Necrolytic migratory erythema which may be seen in pancreatic tumor.
  - Sweet's syndrome, most commonly associated with acute myeloid leukemia or another hematologic malignancy.
  - Pyoderma gangrenosum is associated with Squamous cell carcinoma, cutaneous lymphoma.
- Neurological paraneoplastic syndromes:
  - Paraneoplastic cerebellar degeneration associated with lung, ovarian, breast, lymphatic, and other cancers
  - Encephalomyelitis (inflammation of the brain and spinal cord)
  - Limbic encephalitis
  - Brainstem encephalitis
  - Opsoclonus (involving eye movement)
  - Encephalitis triggered by a teratoma
  - Polymyositis
  - Lambert-Eaton myasthenic syndrome (LEMS) in small-cell lung cancer
  - Myasthenia gravis
  - Subacute (peripheral) sensory neuropathy
  - Autonomic neuropathy
- Hematological paraneoplastic syndromes
  - Granulocytosis (increased granulocytes) due to the production of G-CSF
  - Eosinophilia
  - Pure red cell aplasia
  - Thrombocytosis
- Others:
  - Membranous glomerulonephritis

Causes

Common Causes

The major causes of paraneoplastic syndrome include:

Causes by Organ System

Paraneoplastic syndromes causes may be regrouped by organ system.^[13]^[14]

Dermatologic	Dermatomyositis Cutaneous T-cell lymphoma
Ear Nose Throat	Oropharyngeal cancer
Endocrine	Medullary thyroid cancer Adrenal cancer
Gastroenterologic	Pancreatic cancer Other GI cancers
Hematologic	Myeloproliferative disorders, Multiple myeloma, Melanoma Lymphoma HTLV-associated Lymphoma Hodgkin's lymphoma Chronic lymphocytic leukemia Cancers of the T-cells Adult T-cell leukemia Acute myeloid leukemia
Musculoskeletal/Orthopedic	Teratoma Sarcomas Ewing sarcoma
Neurologic	Brain Cancer
Obstetric/Gynecologic	Ovarian cancer Endometrial cancer
Oncologic	Breast cancer
Pulmonary	Small cell lung cancer Pancoast's tumour Oat cell carcinoma Non-small cell lung cancer Malignant Mesothelioma Bronchial carcinoid
Renal /Electrolyte	Renal cancer
Rheumatology /Immunology/Allergy	No underlying causes
Urologic	Ureteral cancer Prostate cancer Bladder cancer
Miscellaneous	Thymoma Testicular germ-cell tumors

Differential diagnosis

Paraneoplastic syndromes must be differentiated from others types of cancer depending on the location and type of organs.

	Symptoms			Physical examination			Lab Findings			Imaging			Histopathology
Diseases	Clinical manifestations						Para-clinical findings							Gold standard	Additional findings
	Symptoms			Physical examination			Para-clinical findings
													Histopathology
Small cell lung cancer^[15]^[16]	Cough Weakness	Weight loss Fatigue	Dyspnea GI symptoms	Lymphadenopathy	Digital clubbing	Bone tenderness	↑ Ca++	Hyponatremia	_	Chest CT Scan: Necrotic and hemorrhagic hilar mass and lymphadenopathy	Chest X-ray: Hilar mass	_	Small, round and oval cells Necrosis	Biopsy	_
Squamous lung cancer^[17]	Asymptomatic at first	Chronic cough Dyspnea Weakness	Weight loss Fatigue Hemoptysis	Confusion Lymphadenopathy	Decreased breath sound in lung auscultation	Fingers clubbing	↑ Ca++	_	_	Chest Ct scan : Ground glass opacity	Chest X-ray: Spiculated Mass, bulky hilum	_	Intracellular bridges Central necrosis with cavitation	Biopsy	_
Hepatocellular carcinoma^[18]^[19]	Asymptomatic at first	Fatigue Abdominal pain Nausea Vomiting Fever	Loss of appetite Pruritus yellow discoloration of skin	Jaundice Cachexia	Splenomegaly	Abdominal swelling with fluid shift	Prolonged PT	↑ Alpha fetoprotein	_	_	_	U/S : Small hypoechoic lesion Irregular border with fibrosis, and calcification	Polygonal tumor cells Granular eosinophilic cytoplasm	Biopsy	_
Diseases	Symptom 1	Symptom 2	Symptom 3	Physical exam 1	Physical exam 2	Physical exam 3	Lab 1	Lab 2	Lab 3	Imaging 1	Imaging 2	Imaging 3	Histopathology	Gold standard	Additional findings
Breast cancer^[20]^[21]^[22]	Lump in the breast Nipple discharge	Bone pain Weight loss	Loss of appetite Shortness of breath	Enlarged Supraclavicular lymph nodes	Dimpling of skin Inverted nipples	Bloody nipple discharge Change in personality	_	_	_	Mammogram: Soft tissue mass Microcalcification	_	_	Numerous mitotic figures Pleomorphism	Biopsy	_
Renal cancer^[23]^[24]^[25]^[26]	Hematuria Flank pain	Weight loss Loss of appetite	Abdominal mass Fatigue	Cachexia Abdominal bruit Palpable abdominal mass	Supraclavicular lymphadenopathy	High blood pressure Pallor	↑ Ca++ Polycythemia ↑ Platelets	↑ ALP ↑ LFT ↑ LDH	↑ creatinine ↑ cancer cells in urine cytology	Abdominal CT scan: Thickened irregular walls neoplastic mass	_	_	Depends on the subtypes	Needle Biopsy	_
Pancreatic cancer^[27]^[28]^[29]^[30]	Epigastric pain Nausea Yellow discoloration of skin Dark urine	Weight loss Abdominal pain	Loss of appetite Greasy stools Lack of energy	Cachexia Migratory superficial thrombophlebitis on the skin	Abdominal distention and tenderness Left Supraclavicular lymphadenopathy	Palpable periumbilical mass	↑ Bilirubin	↑ ALP ↑ LFT	Low albumin and cholesterol	Abdominal CT scan: Pancreatic duct dilation Pancreatic atrophy Obstruction of common bile duct	_	U/S: hypoechoic mass	Small nuclei Pleomorphism Granular cytoplasm	Spiral CT scan with contrast	_
Gastric cancer^[31]^[32]^[33]^[34]	History of gastric ulcer Early satiety Hematemesis	Weight loss Loss of appetite	Difficulty swallowing Abdominal discomfort	Palpable abdominal mass	Left supraclavicular lymphadenopathy	_	↑ CA 19-9	Anemia	_	Abdominal CT scan: Thickened gastric wall Loss of rugal fold Mucosal irregularity Ulcerative lesion	_	Endoscopy: Ulcer	Irregular tubular structure Minimal stroma and cellular Pleomorphism Nucleus located at the periphery	Endoscopy and biopsy	Microangiopathic hemolytic anemia Hypercogulable state Menbranous nephropathy Polyarteritis nodosa Acanthosis nigricans
Lymphoma]^[35]^[36]	Weight loss Abdominal pain	Fever Fatigue	Night sweat	Lymphadenopathy	Hepatosplenomegaly	_	↑ ESR	↑ LDH	_	CT scan of abdomen, pelvic, and chest: for metastasis to distant organs	_	_	Depends on the type of lymphoma	Biopsy	_
Ovarian cancer^[37]^[38]	Asymptomatic at first	Abdominal pain Bloating	Early satiety Urinary frequency and urgency	Palpable adnexal mass Abdominal swelling with fluid shift	Leg swelling and tenderness	Diminished breath sound due to the effusion	↑ CA-125	↑ Ca++	_	Pelvic U/S: Solid irregular mass with irregular thick septation	Abdominal CT scan: findings depend on the subtypes	_	Nuclear pleomorphism Macronucleolus Eccentric nucleus Psammoma bodies Necrosis	Biopsy	Trousseau syndrome

References

↑ Paraneoplastic+endocrine+syndromes at the US National Library of Medicine Medical Subject Headings (MeSH)
↑ Stewart AF (January 2005). "Clinical practice. Hypercalcemia associated with cancer". N. Engl. J. Med. 352 (4): 373–9. doi:10.1056/NEJMcp042806. PMID 15673803.
↑ Spinazzé S, Schrijvers D (April 2006). "Metabolic emergencies". Crit. Rev. Oncol. Hematol. 58 (1): 79–89. doi:10.1016/j.critrevonc.2005.04.004. PMID 16337807.
↑ Raftopoulos H (December 2007). "Diagnosis and management of hyponatremia in cancer patients". Support Care Cancer. 15 (12): 1341–7. doi:10.1007/s00520-007-0309-9. PMID 17701059.
↑ Ellison DH, Berl T (May 2007). "Clinical practice. The syndrome of inappropriate antidiuresis". N. Engl. J. Med. 356 (20): 2064–72. doi:10.1056/NEJMcp066837. PMID 17507705.
↑ Teale JD, Marks V (October 1998). "Glucocorticoid therapy suppresses abnormal secretion of big IGF-II by non-islet cell tumours inducing hypoglycaemia (NICTH)". Clin. Endocrinol. (Oxf). 49 (4): 491–8. PMID 9876347.
↑ Cohen PR, Kurzrock R (1997). "Mucocutaneous paraneoplastic syndromes". Semin. Oncol. 24 (3): 334–59. PMID 9208889.
↑ Nervous+system+paraneoplastic+syndromes at the US National Library of Medicine Medical Subject Headings (MeSH)
↑ Didelot A, Honnorat J (November 2009). "Update on paraneoplastic neurological syndromes". Curr Opin Oncol. 21 (6): 566–72. doi:10.1097/CCO.0b013e3283306647. PMID 19620862.
↑ Dalmau J, Tüzün E, Wu HY; et al. (2007). "Paraneoplastic anti-N-methyl-D-aspartate receptor encephalitis associated with ovarian teratoma". Ann. Neurol. 61 (1): 25–36. doi:10.1002/ana.21050. PMC 2430743. PMID 17262855. Unknown parameter |month= ignored (help)
↑ Staszewski H (1997). "Hematological paraneoplastic syndromes". Semin. Oncol. 24 (3): 329–33. PMID 9208888.
↑ Blay JY, Favrot M, Rossi JF, Wijdenes J (October 1993). "Role of interleukin-6 in paraneoplastic thrombocytosis". Blood. 82 (7): 2261–2. PMID 8400277.
↑ Pelosof LC, Gerber DE (2010). "Paraneoplastic syndromes: an approach to diagnosis and treatment". Mayo Clin Proc. 85 (9): 838–54. doi:10.4065/mcp.2010.0099. PMC 2931619. PMID 20810794.
↑ Henry K (July 2019). "Paraneoplastic syndromes: Definitions, classification, pathophysiology and principles of treatment". Semin Diagn Pathol. 36 (4): 204–210. doi:10.1053/j.semdp.2019.01.002. PMID 30876820.
↑ NCCN Clinical Practice Guidelines in Oncology. Small Cell Lung Cancer, version 2.2014
↑ Carter, Brett W.; Glisson, Bonnie S.; Truong, Mylene T.; Erasmus, Jeremy J. (2014). "Small Cell Lung Carcinoma: Staging, Imaging, and Treatment Considerations". RadioGraphics. 34 (6): 1707–1721. doi:10.1148/rg.346140178. ISSN 0271-5333.
↑ Rosado-de-Christenson, M L; Templeton, P A; Moran, C A (1994). "Bronchogenic carcinoma: radiologic-pathologic correlation". RadioGraphics. 14 (2): 429–446. doi:10.1148/radiographics.14.2.8190965. ISSN 0271-5333.
↑ Reynolds, Arich R.; Furlan, Alessandro; Fetzer, David T.; Sasatomi, Eizaburo; Borhani, Amir A.; Heller, Matthew T.; Tublin, Mitchell E. (2015). "Infiltrative Hepatocellular Carcinoma: What Radiologists Need to Know". RadioGraphics. 35 (2): 371–386. doi:10.1148/rg.352140114. ISSN 0271-5333.
↑ Flores, Yvonne N.; Lang, Cathy M.; Salmerón, Jorge; Bastani, Roshan (2011). "Risk Factors for Liver Disease and Associated Knowledge and Practices Among Mexican Adults in the US and Mexico". Journal of Community Health. 37 (2): 403–411. doi:10.1007/s10900-011-9457-4. ISSN 0094-5145.
↑ Mišković, Josip (2016). "DIAGNOSTIC VALUE OF FINE NEEDLE ASPIRATION CYTOLOGY FOR BREAST TUMORS". ACTA CLINICA CROATICA: 625–628. doi:10.20471/acc.2016.55.04.13. ISSN 0353-9466.
↑ Mišković J, Zorić A, Radić Mišković H, Šoljić V (2016). "Diagnostic Value of Fine Needle Aspiration Cytology for Breast Tumors". Acta Clin Croat. 55 (4): 625–628. doi:10.20471/acc.2016.55.04.13. PMID 29117654.
↑ McKenna RJ (1994). "The abnormal mammogram radiographic findings, diagnostic options, pathology, and stage of cancer diagnosis". Cancer. 74 (1 Suppl): 244–55. doi:10.1002/cncr.2820741308. PMID 8004594.
↑ Cairns, Paul; Srivastava, Sudhir; Grizzle, William E. (2011). "Renal cell carcinoma". Cancer Biomarkers. 9 (1–6): 461–473. doi:10.3233/CBM-2011-0176. ISSN 1875-8592.
↑ de la Mata J, Uy HL, Guise TA, Story B, Boyce BF, Mundy GR; et al. (1995). "Interleukin-6 enhances hypercalcemia and bone resorption mediated by parathyroid hormone-related protein in vivo". J Clin Invest. 95 (6): 2846–52. doi:10.1172/JCI117990. PMC 295971. PMID 7769125.
↑ Laski ME, Vugrin D (1987). "Paraneoplastic syndromes in hypernephroma". Semin Nephrol. 7 (2): 123–30. PMID 3306861.
↑ Leveridge MJ, Bostrom PJ, Koulouris G, Finelli A, Lawrentschuk N (2010). "Imaging renal cell carcinoma with ultrasonography, CT and MRI". Nat Rev Urol. 7 (6): 311–25. doi:10.1038/nrurol.2010.63. PMID 20479778.
↑ Horwhat JD, Gerke H, Acosta RD, Pavey DA, Jowell PS (2009). "Focal or diffuse "fullness" of the pancreas on CT. Usually benign, but EUS plus/minus FNA is warranted to identify malignancy". JOP. 10 (1): 37–42. PMID 19129613.
↑ Porta M, Fabregat X, Malats N, Guarner L, Carrato A, de Miguel A; et al. (2005). "Exocrine pancreatic cancer: symptoms at presentation and their relation to tumour site and stage". Clin Transl Oncol. 7 (5): 189–97. PMID 15960930.
↑ Holly, Elizabeth A.; Chaliha, Indranushi; Bracci, Paige M.; Gautam, Manjushree (2004). "Signs and symptoms of pancreatic cancer: a population-based case-control study in the San Francisco Bay area". Clinical Gastroenterology and Hepatology. 2 (6): 510–517. doi:10.1016/S1542-3565(04)00171-5. ISSN 1542-3565.
↑ Schmidt-Hansen M, Berendse S, Hamilton W (2016). "Symptoms of Pancreatic Cancer in Primary Care: A Systematic Review". Pancreas. 45 (6): 814–8. doi:10.1097/MPA.0000000000000527. PMID 26495795.
↑ Ajani JA, Bentrem DJ, Besh S, D'Amico TA, Das P, Denlinger C; et al. (2013). "Gastric cancer, version 2.2013: featured updates to the NCCN Guidelines". J Natl Compr Canc Netw. 11 (5): 531–46. PMID 23667204.
↑ Wanebo HJ, Kennedy BJ, Chmiel J, Steele G, Winchester D, Osteen R (1993). "Cancer of the stomach. A patient care study by the American College of Surgeons". Ann Surg. 218 (5): 583–92. doi:10.1097/00000658-199321850-00002. PMC 1243028. PMID 8239772.
↑ Sussman SK, Halvorsen RA, Illescas FF, Cohan RH, Saeed M, Silverman PM; et al. (1988). "Gastric adenocarcinoma: CT versus surgical staging". Radiology. 167 (2): 335–40. doi:10.1148/radiology.167.2.3357941. PMID 3357941.
↑ Karita M, Tada M (1994). "Endoscopic and histologic diagnosis of submucosal tumors of the gastrointestinal tract using combined strip biopsy and bite biopsy". Gastrointest Endosc. 40 (6): 749–53. PMID 7859977.
↑ Hagler KT, Lynch JW (2004). "Paraneoplastic manifestations of lymphoma". Clin Lymphoma. 5 (1): 29–36. PMID 15245605.
↑ Briani C, Vitaliani R, Grisold W, Honnorat J, Graus F, Antoine JC; et al. (2011). "Spectrum of paraneoplastic disease associated with lymphoma". Neurology. 76 (8): 705–10. doi:10.1212/WNL.0b013e31820d62eb. PMID 21339498.
↑ Hippisley-Cox J, Coupland C (2011). "Identifying women with suspected ovarian cancer in primary care: derivation and validation of algorithm". BMJ. 344: d8009. doi:10.1136/bmj.d8009. PMC 3251328. PMID 22217630.
↑ Li J, Fadare O, Xiang L, Kong B, Zheng W (2012). "Ovarian serous carcinoma: recent concepts on its origin and carcinogenesis". J Hematol Oncol. 5: 8. doi:10.1186/1756-8722-5-8. PMC 3328281. PMID 22405464.

[1] Paraneoplastic+endocrine+syndromes at the US National Library of Medicine Medical Subject Headings (MeSH)

[pmid15673803-2] Stewart AF (January 2005). "Clinical practice. Hypercalcemia associated with cancer". N. Engl. J. Med. 352 (4): 373–9. doi:10.1056/NEJMcp042806. PMID 15673803.

[pmid16337807-3] Spinazzé S, Schrijvers D (April 2006). "Metabolic emergencies". Crit. Rev. Oncol. Hematol. 58 (1): 79–89. doi:10.1016/j.critrevonc.2005.04.004. PMID 16337807.

[pmid17701059-4] Raftopoulos H (December 2007). "Diagnosis and management of hyponatremia in cancer patients". Support Care Cancer. 15 (12): 1341–7. doi:10.1007/s00520-007-0309-9. PMID 17701059.

[pmid17507705-5] Ellison DH, Berl T (May 2007). "Clinical practice. The syndrome of inappropriate antidiuresis". N. Engl. J. Med. 356 (20): 2064–72. doi:10.1056/NEJMcp066837. PMID 17507705.

[pmid9876347-6] Teale JD, Marks V (October 1998). "Glucocorticoid therapy suppresses abnormal secretion of big IGF-II by non-islet cell tumours inducing hypoglycaemia (NICTH)". Clin. Endocrinol. (Oxf). 49 (4): 491–8. PMID 9876347.

[pmid9208889-7] Cohen PR, Kurzrock R (1997). "Mucocutaneous paraneoplastic syndromes". Semin. Oncol. 24 (3): 334–59. PMID 9208889.

[8] Nervous+system+paraneoplastic+syndromes at the US National Library of Medicine Medical Subject Headings (MeSH)

[pmid19620862-9] Didelot A, Honnorat J (November 2009). "Update on paraneoplastic neurological syndromes". Curr Opin Oncol. 21 (6): 566–72. doi:10.1097/CCO.0b013e3283306647. PMID 19620862.

[pmid17262855-10] Dalmau J, Tüzün E, Wu HY; et al. (2007). "Paraneoplastic anti-N-methyl-D-aspartate receptor encephalitis associated with ovarian teratoma". Ann. Neurol. 61 (1): 25–36. doi:10.1002/ana.21050. PMC 2430743. PMID 17262855. Unknown parameter |month= ignored (help)

[pmid9208888-11] Staszewski H (1997). "Hematological paraneoplastic syndromes". Semin. Oncol. 24 (3): 329–33. PMID 9208888.

[pmid8400277-12] Blay JY, Favrot M, Rossi JF, Wijdenes J (October 1993). "Role of interleukin-6 in paraneoplastic thrombocytosis". Blood. 82 (7): 2261–2. PMID 8400277.

[pmid20810794-13] Pelosof LC, Gerber DE (2010). "Paraneoplastic syndromes: an approach to diagnosis and treatment". Mayo Clin Proc. 85 (9): 838–54. doi:10.4065/mcp.2010.0099. PMC 2931619. PMID 20810794.

[pmid30876820-14] Henry K (July 2019). "Paraneoplastic syndromes: Definitions, classification, pathophysiology and principles of treatment". Semin Diagn Pathol. 36 (4): 204–210. doi:10.1053/j.semdp.2019.01.002. PMID 30876820.

[NCCN-15] NCCN Clinical Practice Guidelines in Oncology. Small Cell Lung Cancer, version 2.2014

[CarterGlisson2014-16] Carter, Brett W.; Glisson, Bonnie S.; Truong, Mylene T.; Erasmus, Jeremy J. (2014). "Small Cell Lung Carcinoma: Staging, Imaging, and Treatment Considerations". RadioGraphics. 34 (6): 1707–1721. doi:10.1148/rg.346140178. ISSN 0271-5333.

[Rosado-de-ChristensonTempleton1994-17] Rosado-de-Christenson, M L; Templeton, P A; Moran, C A (1994). "Bronchogenic carcinoma: radiologic-pathologic correlation". RadioGraphics. 14 (2): 429–446. doi:10.1148/radiographics.14.2.8190965. ISSN 0271-5333.

[ReynoldsFurlan2015-18] Reynolds, Arich R.; Furlan, Alessandro; Fetzer, David T.; Sasatomi, Eizaburo; Borhani, Amir A.; Heller, Matthew T.; Tublin, Mitchell E. (2015). "Infiltrative Hepatocellular Carcinoma: What Radiologists Need to Know". RadioGraphics. 35 (2): 371–386. doi:10.1148/rg.352140114. ISSN 0271-5333.

[FloresLang2011-19] Flores, Yvonne N.; Lang, Cathy M.; Salmerón, Jorge; Bastani, Roshan (2011). "Risk Factors for Liver Disease and Associated Knowledge and Practices Among Mexican Adults in the US and Mexico". Journal of Community Health. 37 (2): 403–411. doi:10.1007/s10900-011-9457-4. ISSN 0094-5145.

[Mišković2016-20] Mišković, Josip (2016). "DIAGNOSTIC VALUE OF FINE NEEDLE ASPIRATION CYTOLOGY FOR BREAST TUMORS". ACTA CLINICA CROATICA: 625–628. doi:10.20471/acc.2016.55.04.13. ISSN 0353-9466.

[pmid29117654-21] Mišković J, Zorić A, Radić Mišković H, Šoljić V (2016). "Diagnostic Value of Fine Needle Aspiration Cytology for Breast Tumors". Acta Clin Croat. 55 (4): 625–628. doi:10.20471/acc.2016.55.04.13. PMID 29117654.

[pmid8004594-22] McKenna RJ (1994). "The abnormal mammogram radiographic findings, diagnostic options, pathology, and stage of cancer diagnosis". Cancer. 74 (1 Suppl): 244–55. doi:10.1002/cncr.2820741308. PMID 8004594.

[CairnsSrivastava2011-23] Cairns, Paul; Srivastava, Sudhir; Grizzle, William E. (2011). "Renal cell carcinoma". Cancer Biomarkers. 9 (1–6): 461–473. doi:10.3233/CBM-2011-0176. ISSN 1875-8592.

[pmid7769125-24] Mata J, Uy HL, Guise TA, Story B, Boyce BF, Mundy GR; et al. (1995). "Interleukin-6 enhances hypercalcemia and bone resorption mediated by parathyroid hormone-related protein in vivo". J Clin Invest. 95 (6): 2846–52. doi:10.1172/JCI117990. PMC 295971. PMID 7769125.

[pmid3306861-25] Laski ME, Vugrin D (1987). "Paraneoplastic syndromes in hypernephroma". Semin Nephrol. 7 (2): 123–30. PMID 3306861.

[pmid20479778-26] Leveridge MJ, Bostrom PJ, Koulouris G, Finelli A, Lawrentschuk N (2010). "Imaging renal cell carcinoma with ultrasonography, CT and MRI". Nat Rev Urol. 7 (6): 311–25. doi:10.1038/nrurol.2010.63. PMID 20479778.

[pmid19129613-27] Horwhat JD, Gerke H, Acosta RD, Pavey DA, Jowell PS (2009). "Focal or diffuse "fullness" of the pancreas on CT. Usually benign, but EUS plus/minus FNA is warranted to identify malignancy". JOP. 10 (1): 37–42. PMID 19129613.

[pmid15960930-28] Porta M, Fabregat X, Malats N, Guarner L, Carrato A, de Miguel A; et al. (2005). "Exocrine pancreatic cancer: symptoms at presentation and their relation to tumour site and stage". Clin Transl Oncol. 7 (5): 189–97. PMID 15960930.

[HollyChaliha2004-29] Holly, Elizabeth A.; Chaliha, Indranushi; Bracci, Paige M.; Gautam, Manjushree (2004). "Signs and symptoms of pancreatic cancer: a population-based case-control study in the San Francisco Bay area". Clinical Gastroenterology and Hepatology. 2 (6): 510–517. doi:10.1016/S1542-3565(04)00171-5. ISSN 1542-3565.

[pmid26495795-30] Schmidt-Hansen M, Berendse S, Hamilton W (2016). "Symptoms of Pancreatic Cancer in Primary Care: A Systematic Review". Pancreas. 45 (6): 814–8. doi:10.1097/MPA.0000000000000527. PMID 26495795.

[pmid23667204-31] Ajani JA, Bentrem DJ, Besh S, D'Amico TA, Das P, Denlinger C; et al. (2013). "Gastric cancer, version 2.2013: featured updates to the NCCN Guidelines". J Natl Compr Canc Netw. 11 (5): 531–46. PMID 23667204.

[pmid8239772-32] Wanebo HJ, Kennedy BJ, Chmiel J, Steele G, Winchester D, Osteen R (1993). "Cancer of the stomach. A patient care study by the American College of Surgeons". Ann Surg. 218 (5): 583–92. doi:10.1097/00000658-199321850-00002. PMC 1243028. PMID 8239772.

[pmid3357941-33] Sussman SK, Halvorsen RA, Illescas FF, Cohan RH, Saeed M, Silverman PM; et al. (1988). "Gastric adenocarcinoma: CT versus surgical staging". Radiology. 167 (2): 335–40. doi:10.1148/radiology.167.2.3357941. PMID 3357941.

[pmid7859977-34] Karita M, Tada M (1994). "Endoscopic and histologic diagnosis of submucosal tumors of the gastrointestinal tract using combined strip biopsy and bite biopsy". Gastrointest Endosc. 40 (6): 749–53. PMID 7859977.

[pmid15245605-35] Hagler KT, Lynch JW (2004). "Paraneoplastic manifestations of lymphoma". Clin Lymphoma. 5 (1): 29–36. PMID 15245605.

[pmid21339498-36] Briani C, Vitaliani R, Grisold W, Honnorat J, Graus F, Antoine JC; et al. (2011). "Spectrum of paraneoplastic disease associated with lymphoma". Neurology. 76 (8): 705–10. doi:10.1212/WNL.0b013e31820d62eb. PMID 21339498.

[pmid22217630-37] Hippisley-Cox J, Coupland C (2011). "Identifying women with suspected ovarian cancer in primary care: derivation and validation of algorithm". BMJ. 344: d8009. doi:10.1136/bmj.d8009. PMC 3251328. PMID 22217630.

[pmid22405464-38] Li J, Fadare O, Xiang L, Kong B, Zheng W (2012). "Ovarian serous carcinoma: recent concepts on its origin and carcinogenesis". J Hematol Oncol. 5: 8. doi:10.1186/1756-8722-5-8. PMC 3328281. PMID 22405464.

[1]

[2]

[3]

[4]

[5]

[6]

[7]

[8]

[9]

[10]

[11]

[12]

[13]

[14]

[15]

[16]

[17]

[18]

[19]

[20]

[21]

[22]

[23]

[24]

[25]

[26]

[27]

[28]

[29]

[30]

[31]

[32]

[33]

[34]

[35]

[36]

[37]

[38]

@@ Line 15: / Line 15: @@
 | align="center" style="background:#4479BA; color: #FFFFFF;" |'''Associated Cancers'''
 |-
-| rowspan="5"  align="center" style="background:#f0f0f0;" |[[Endocrine|Endocrine metabolic]] [[Syndrome|syndromes]]</ref><ref name="pmid15673803">{{cite journal |vauthors=Stewart AF |title=Clinical practice. Hypercalcemia associated with cancer |journal=N. Engl. J. Med. |volume=352 |issue=4 |pages=373–9 |date=January 2005 |pmid=15673803 |doi=10.1056/NEJMcp042806 |url=}}</ref><ref name="pmid16337807">{{cite journal |vauthors=Spinazzé S, Schrijvers D |title=Metabolic emergencies |journal=Crit. Rev. Oncol. Hematol. |volume=58 |issue=1 |pages=79–89 |date=April 2006 |pmid=16337807 |doi=10.1016/j.critrevonc.2005.04.004 |url=}}</ref>
+| rowspan="5"  align="center" style="background:#f0f0f0;" |[[Endocrine|Endocrine metabolic]] [[Syndrome|syndromes]]<ref>{{MeshName|Paraneoplastic+endocrine+syndromes}}</ref><ref name="pmid15673803">{{cite journal |vauthors=Stewart AF |title=Clinical practice. Hypercalcemia associated with cancer |journal=N. Engl. J. Med. |volume=352 |issue=4 |pages=373–9 |date=January 2005 |pmid=15673803 |doi=10.1056/NEJMcp042806 |url=}}</ref><ref name="pmid16337807">{{cite journal |vauthors=Spinazzé S, Schrijvers D |title=Metabolic emergencies |journal=Crit. Rev. Oncol. Hematol. |volume=58 |issue=1 |pages=79–89 |date=April 2006 |pmid=16337807 |doi=10.1016/j.critrevonc.2005.04.004 |url=}}</ref>
 |[[Hypercalcemia]]
 |[[breast cancer]] and [[lung cancer]] (typically [[Squamous cell carcinoma|squamous cell]]) due to the production of [[Parathyroid hormone-related protein|PTHrP]] ([[Parathyroid hormone]]-related [[protein]])[[multiple myeloma]], [[renal cell carcinoma]], [[ovarian cancer]], [[endometrial cancer]], and [[lymphoma]]
@@ Line 169: / Line 169: @@
 ** [[Renal carcinoma]]
 ===Causes by Organ System===
-*Paraneoplastic syndromes [[causes]] may be regrouped by organ system.
+*Paraneoplastic syndromes [[causes]] may be regrouped by organ system.<ref name="pmid20810794">{{cite journal| author=Pelosof LC, Gerber DE| title=Paraneoplastic syndromes: an approach to diagnosis and treatment. | journal=Mayo Clin Proc | year= 2010 | volume= 85 | issue= 9 | pages= 838-54 | pmid=20810794 | doi=10.4065/mcp.2010.0099 | pmc=2931619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20810794  }} </ref><ref name="pmid30876820">{{cite journal |vauthors=Henry K |title=Paraneoplastic syndromes: Definitions, classification, pathophysiology and principles of treatment |journal=Semin Diagn Pathol |volume=36 |issue=4 |pages=204–210 |date=July 2019 |pmid=30876820 |doi=10.1053/j.semdp.2019.01.002 |url=}}</ref>
 {| style="width:82%; height:100px" border="1"
 |-
@@ Line 352: / Line 352: @@
 ! style="background: #4479BA; color: #FFFFFF; text-align: center;" |
 |-
-| style="background: #DCDCDC; padding: 5px; text-align: center;" |'''[[Small cell lung cancer]]'''
+| style="background: #DCDCDC; padding: 5px; text-align: center;" |'''[[Small cell lung cancer]]<ref name="NCCN">[http://www.nccn.org/professionals/physician_gls/f_guidelines_nojava.asp NCCN Clinical Practice Guidelines in Oncology. Small Cell Lung Cancer, version 2.2014]</ref><ref name="CarterGlisson2014">{{cite journal|last1=Carter|first1=Brett W.|last2=Glisson|first2=Bonnie S.|last3=Truong|first3=Mylene T.|last4=Erasmus|first4=Jeremy J.|title=Small Cell Lung Carcinoma: Staging, Imaging, and Treatment Considerations|journal=RadioGraphics|volume=34|issue=6|year=2014|pages=1707–1721|issn=0271-5333|doi=10.1148/rg.346140178}}</ref>'''
 | style="background: #F5F5F5; padding: 5px;" |
 * [[Cough]]
@@ Line 387: / Line 387: @@
 | style="background: #F5F5F5; padding: 5px;" |_
 |-
-| style="background: #DCDCDC; padding: 5px; text-align: center;" |'''[[Squamous cell carcinoma of the lung|Squamous lung cancer]]'''
+| style="background: #DCDCDC; padding: 5px; text-align: center;" |'''[[Squamous cell carcinoma of the lung|Squamous lung cancer]]<ref name="Rosado-de-ChristensonTempleton1994">{{cite journal|last1=Rosado-de-Christenson|first1=M L|last2=Templeton|first2=P A|last3=Moran|first3=C A|title=Bronchogenic carcinoma: radiologic-pathologic correlation.|journal=RadioGraphics|volume=14|issue=2|year=1994|pages=429–446|issn=0271-5333|doi=10.1148/radiographics.14.2.8190965}}</ref>'''
 | style="background: #F5F5F5; padding: 5px;" |
 * [[Asymptomatic]]  at first
@@ Line 425: / Line 425: @@
 | style="background: #F5F5F5; padding: 5px;" |_
 |-
-| style="background: #DCDCDC; padding: 5px; text-align: center;" |'''[[Hepatocellular carcinoma]]'''
+| style="background: #DCDCDC; padding: 5px; text-align: center;" |'''[[Hepatocellular carcinoma]]<ref name="ReynoldsFurlan2015">{{cite journal|last1=Reynolds|first1=Arich R.|last2=Furlan|first2=Alessandro|last3=Fetzer|first3=David T.|last4=Sasatomi|first4=Eizaburo|last5=Borhani|first5=Amir A.|last6=Heller|first6=Matthew T.|last7=Tublin|first7=Mitchell E.|title=Infiltrative Hepatocellular Carcinoma: What Radiologists Need to Know|journal=RadioGraphics|volume=35|issue=2|year=2015|pages=371–386|issn=0271-5333|doi=10.1148/rg.352140114}}</ref><ref name="FloresLang2011">{{cite journal|last1=Flores|first1=Yvonne N.|last2=Lang|first2=Cathy M.|last3=Salmerón|first3=Jorge|last4=Bastani|first4=Roshan|title=Risk Factors for Liver Disease and Associated Knowledge and Practices Among Mexican Adults in the US and Mexico|journal=Journal of Community Health|volume=37|issue=2|year=2011|pages=403–411|issn=0094-5145|doi=10.1007/s10900-011-9457-4}}</ref>'''
 | style="background: #F5F5F5; padding: 5px;" |
 * [[Asymptomatic]] at first
@@ Line 479: / Line 479: @@
 !Additional findings
 |-
-| style="background: #DCDCDC; padding: 5px; text-align: center;" |'''[[Breast cancer]]'''
+| style="background: #DCDCDC; padding: 5px; text-align: center;" |'''[[Breast cancer]]<ref name="Mišković2016">{{cite journal|last1=Mišković|first1=Josip|title=DIAGNOSTIC VALUE OF FINE NEEDLE ASPIRATION CYTOLOGY FOR BREAST TUMORS|journal=ACTA CLINICA CROATICA|year=2016|pages=625–628|issn=03539466|doi=10.20471/acc.2016.55.04.13}}</ref><ref name="pmid29117654">{{cite journal| author=Mišković J, Zorić A, Radić Mišković H, Šoljić V| title=Diagnostic Value of Fine Needle Aspiration Cytology for Breast Tumors | journal=Acta Clin Croat | year= 2016 | volume= 55 | issue= 4 | pages= 625-628 | pmid=29117654 | doi=10.20471/acc.2016.55.04.13 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29117654  }}</ref><ref name="pmid8004594">{{cite journal| author=McKenna RJ| title=The abnormal mammogram radiographic findings, diagnostic options, pathology, and stage of cancer diagnosis. | journal=Cancer | year= 1994 | volume= 74 | issue= 1 Suppl | pages= 244-55 | pmid=8004594 | doi=10.1002/cncr.2820741308 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8004594  }}</ref>'''
 | style="background: #F5F5F5; padding: 5px;" |
 * [[Lump]] in the [[breast]]
@@ Line 512: / Line 512: @@
 | style="background: #F5F5F5; padding: 5px;" |_
 |-
-| style="background: #DCDCDC; padding: 5px; text-align: center;" |'''[[Renal cell carcinoma|Renal cancer]]'''
+| style="background: #DCDCDC; padding: 5px; text-align: center;" |'''[[Renal cell carcinoma|Renal cancer]]<ref name="CairnsSrivastava2011">{{cite journal|last1=Cairns|first1=Paul|last2=Srivastava|first2=Sudhir|last3=Grizzle|first3=William E.|title=Renal cell carcinoma|journal=Cancer Biomarkers|volume=9|issue=1-6|year=2011|pages=461–473|issn=18758592|doi=10.3233/CBM-2011-0176}}</ref><ref name="pmid7769125">{{cite journal| author=de la Mata J, Uy HL, Guise TA, Story B, Boyce BF, Mundy GR et al.| title=Interleukin-6 enhances hypercalcemia and bone resorption mediated by parathyroid hormone-related protein in vivo. | journal=J Clin Invest | year= 1995 | volume= 95 | issue= 6 | pages= 2846-52 | pmid=7769125 | doi=10.1172/JCI117990 | pmc=295971 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7769125  }}</ref><ref name="pmid3306861">{{cite journal| author=Laski ME, Vugrin D| title=Paraneoplastic syndromes in hypernephroma. | journal=Semin Nephrol | year= 1987 | volume= 7 | issue= 2 | pages= 123-30 | pmid=3306861 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3306861  }}</ref><ref name="pmid20479778">{{cite journal| author=Leveridge MJ, Bostrom PJ, Koulouris G, Finelli A, Lawrentschuk N| title=Imaging renal cell carcinoma with ultrasonography, CT and MRI. | journal=Nat Rev Urol | year= 2010 | volume= 7 | issue= 6 | pages= 311-25 | pmid=20479778 | doi=10.1038/nrurol.2010.63 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20479778  }}</ref>'''
 | style="background: #F5F5F5; padding: 5px;" |
 * [[Hematuria]]
@@ Line 554: / Line 554: @@
 | style="background: #F5F5F5; padding: 5px;" |_
 |-
-| style="background: #DCDCDC; padding: 5px; text-align: center;" |'''[[Pancreatic cancer]]'''
+| style="background: #DCDCDC; padding: 5px; text-align: center;" |'''[[Pancreatic cancer]]<ref name="pmid19129613">{{cite journal| author=Horwhat JD, Gerke H, Acosta RD, Pavey DA, Jowell PS| title=Focal or diffuse "fullness" of the pancreas on CT. Usually benign, but EUS plus/minus FNA is warranted to identify malignancy. | journal=JOP | year= 2009 | volume= 10 | issue= 1 | pages= 37-42 | pmid=19129613 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19129613  }}</ref><ref name="pmid15960930">{{cite journal| author=Porta M, Fabregat X, Malats N, Guarner L, Carrato A, de Miguel A et al.| title=Exocrine pancreatic cancer: symptoms at presentation and their relation to tumour site and stage. | journal=Clin Transl Oncol | year= 2005 | volume= 7 | issue= 5 | pages= 189-97 | pmid=15960930 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15960930  }}</ref><ref name="HollyChaliha2004">{{cite journal|last1=Holly|first1=Elizabeth A.|last2=Chaliha|first2=Indranushi|last3=Bracci|first3=Paige M.|last4=Gautam|first4=Manjushree|title=Signs and symptoms of pancreatic cancer: a population-based case-control study in the San Francisco Bay area|journal=Clinical Gastroenterology and Hepatology|volume=2|issue=6|year=2004|pages=510–517|issn=15423565|doi=10.1016/S1542-3565(04)00171-5}}</ref><ref name="pmid26495795">{{cite journal| author=Schmidt-Hansen M, Berendse S, Hamilton W| title=Symptoms of Pancreatic Cancer in Primary Care: A Systematic Review. | journal=Pancreas | year= 2016 | volume= 45 | issue= 6 | pages= 814-8 | pmid=26495795 | doi=10.1097/MPA.0000000000000527 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26495795  }}</ref>'''
 | style="background: #F5F5F5; padding: 5px;" |
 * [[Epigastric]] [[pain]]
@@ Line 598: / Line 598: @@
 | style="background: #F5F5F5; padding: 5px;" |_
 |-
-| style="background: #DCDCDC; padding: 5px; text-align: center;" |'''[[Gastric cancer]]'''
+| style="background: #DCDCDC; padding: 5px; text-align: center;" |'''[[Gastric cancer]]<ref name="pmid23667204">{{cite journal| author=Ajani JA, Bentrem DJ, Besh S, D'Amico TA, Das P, Denlinger C et al.| title=Gastric cancer, version 2.2013: featured updates to the NCCN Guidelines. | journal=J Natl Compr Canc Netw | year= 2013 | volume= 11 | issue= 5 | pages= 531-46 | pmid=23667204 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23667204  }}</ref><ref name="pmid8239772">{{cite journal| author=Wanebo HJ, Kennedy BJ, Chmiel J, Steele G, Winchester D, Osteen R| title=Cancer of the stomach. A patient care study by the American College of Surgeons. | journal=Ann Surg | year= 1993 | volume= 218 | issue= 5 | pages= 583-92 | pmid=8239772 | doi=10.1097/00000658-199321850-00002 | pmc=1243028 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8239772  }}</ref><ref name="pmid3357941">{{cite journal| author=Sussman SK, Halvorsen RA, Illescas FF, Cohan RH, Saeed M, Silverman PM et al.| title=Gastric adenocarcinoma: CT versus surgical staging. | journal=Radiology | year= 1988 | volume= 167 | issue= 2 | pages= 335-40 | pmid=3357941 | doi=10.1148/radiology.167.2.3357941 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3357941  }}</ref><ref name="pmid7859977">{{cite journal| author=Karita M, Tada M| title=Endoscopic and histologic diagnosis of submucosal tumors of the gastrointestinal tract using combined strip biopsy and bite biopsy. | journal=Gastrointest Endosc | year= 1994 | volume= 40 | issue= 6 | pages= 749-53 | pmid=7859977 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7859977  }}</ref>'''
 | style="background: #F5F5F5; padding: 5px;" |
 * History of [[gastric ulcer]]
@@ Line 644: / Line 644: @@
 * [[Acanthosis nigricans]]
 |-
-| style="background: #DCDCDC; padding: 5px; text-align: center;" |'''[[Lymphoma]]'''
+| style="background: #DCDCDC; padding: 5px; text-align: center;" |'''[[Lymphoma]]]<ref name="pmid15245605">{{cite journal| author=Hagler KT, Lynch JW| title=Paraneoplastic manifestations of lymphoma. | journal=Clin Lymphoma | year= 2004 | volume= 5 | issue= 1 | pages= 29-36 | pmid=15245605 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15245605  }}</ref><ref name="pmid21339498">{{cite journal| author=Briani C, Vitaliani R, Grisold W, Honnorat J, Graus F, Antoine JC et al.| title=Spectrum of paraneoplastic disease associated with lymphoma. | journal=Neurology | year= 2011 | volume= 76 | issue= 8 | pages= 705-10 | pmid=21339498 | doi=10.1212/WNL.0b013e31820d62eb | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21339498  }}</ref>'''
 | style="background: #F5F5F5; padding: 5px;" |
 * [[Weight loss]]
@@ Line 673: / Line 673: @@
 | style="background: #F5F5F5; padding: 5px;" |_
 |-
-| style="background: #DCDCDC; padding: 5px; text-align: center;" |'''[[Ovarian cancer]]'''
+| style="background: #DCDCDC; padding: 5px; text-align: center;" |'''[[Ovarian cancer]]<ref name="pmid22217630">{{cite journal| author=Hippisley-Cox J, Coupland C| title=Identifying women with suspected ovarian cancer in primary care: derivation and validation of algorithm. | journal=BMJ | year= 2011 | volume= 344 | issue=  | pages= d8009 | pmid=22217630 | doi=10.1136/bmj.d8009 | pmc=3251328 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22217630  }}</ref><ref name="pmid22405464">{{cite journal| author=Li J, Fadare O, Xiang L, Kong B, Zheng W| title=Ovarian serous carcinoma: recent concepts on its origin and carcinogenesis. | journal=J Hematol Oncol | year= 2012 | volume= 5 | issue=  | pages= 8 | pmid=22405464 | doi=10.1186/1756-8722-5-8 | pmc=3328281 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22405464  }}</ref>'''
 | style="background: #F5F5F5; padding: 5px;" |
 * [[Asymptomatic]] at first