Case for Diagnosis
Tumor-Like Lesions Grouped on a Patient's Leg
Lesiones tumorales agrupadas en la extremidad inferior
A. Mota-Burgos
, R. Castillo-Muñoz, E. Herrera-Ceballos
Corresponding author
Servicio de Dermatología, Hospital Clínico Universitario, Málaga, Spain
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"apellidos" => "Herrera-Ceballos" ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "Servicio de Dermatología, Hospital Clínico Universitario, Málaga, Spain" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Lesiones tumorales agrupadas en la extremidad inferior" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 667 "Ancho" => 890 "Tamanyo" => 160295 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin-eosin, original magnification<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>400.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Medical History</span><p id="par0005" class="elsevierStylePara elsevierViewall">An 83-year-old man with no relevant past history visited our emergency service for evaluation of asymptomatic nodular lesions on the right leg. The patient reported that the lesions had appeared 5 months earlier and had grown gradually, but that multiple similar lesions had suddenly started to appear close to the original lesions approximately 4 weeks earlier. The patient did not present constitutional symptoms or any other systemic symptoms.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Physical Examination</span><p id="par0010" class="elsevierStylePara elsevierViewall">The patient presented skin lesions in the form of nodules and indurated plaques grouped on the posterior aspect of the right leg; the lesions measured between 8 and 13<span class="elsevierStyleHsp" style=""></span>mm in diameter, were reddish-pink and infiltrated on palpation (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). An enlarged lymph node could be felt in the right groin on palpation; the node was hard and attached to the deeper layers.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Histopathology</span><p id="par0015" class="elsevierStylePara elsevierViewall">The histopathology study revealed an infiltrate composed of atypical small blue cells in the dermis and subcutaneous cellular tissue. These cells presented a round vesicular nucleus with fine chromatin granules, multiple nucleoli, and abundant mitotic figures (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The epidermis was not involved. Immunohistochemistry was positive for neuron specific enolase (NSE) and cytokeratin (CK) 20 (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). Staining with protein S-100, leukocyte common antigen, and CK7 was negative.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Additional Tests</span><p id="par0020" class="elsevierStylePara elsevierViewall">A full workup with tumor makers was normal, except for elevated levels of β2-microglobulin. A computed tomography scan of the chest, abdomen, and pelvis showed an enlarged lymph node in the right groin; the node measured 3.5 x 2<span class="elsevierStyleHsp" style=""></span>cm and displayed tumorous characteristics.</p><p id="par0025" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">What Is Your Diagnosis?</span></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Diagnosis</span><p id="par0030" class="elsevierStylePara elsevierViewall">Metastatic Merkel cell carcinoma.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Clinical Course and Treatment</span><p id="par0035" class="elsevierStylePara elsevierViewall">Fine-needle aspiration biopsy of the lymph node was compatible with metastasis of neuroendocrine carcinoma. After studying the case in the skin cancer committee, it was decided to perform palliative treatment with radiation therapy.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Comment</span><p id="par0040" class="elsevierStylePara elsevierViewall">Merkel cell carcinoma is a rare but highly aggressive malignant skin cancer that originates in the Merkel cells located in the basal layer of the dermis.</p><p id="par0045" class="elsevierStylePara elsevierViewall">It is more frequent in patients aged<span class="elsevierStyleHsp" style=""></span>65 years or older and most commonly appears on exposed areas of the head and neck.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> However, pathogenesis of this tumor has recently been linked to the polyomavirus (approximately 80% of Merkel cell carcinoma tissue samples present the polyomavirus genome compared to between 8% and 16% of control tissue samples).<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Clinically, it develops rapidly, in weeks or months, as an asymptomatic, indurated, erythematous-violaceous nodule with a smooth, shiny surface.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> As well as these common hemispherical or nodular forms, the tumor may manifest as an indurated plaque, although this form of presentation is less common.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Ulceration is rare and usually appears in advanced tumors.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Nevertheless, satellite metastases, as occurred in our patient, are not uncommon.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The disease predominantly affects the head and neck (><span class="elsevierStyleHsp" style=""></span>50% of cases); the limbs are involved in 40% of cases and the torso in less than 10% of cases.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Because of the nonspecific nature of the clinical characteristics, diagnosis is determined by means of histopathology in most cases.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,4</span></a> Histopathology shows a dermal tumor that often extends to the subcutaneous cellular tissue. The papillary dermis, the epidermis, and the adnexa are usually not involved. The study shows a dense infiltrate of small basaloid monomorphous cells with a hyperchromatic nucleus and scant cytoplasm.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>Because of its cytologic characteristics, the tumor should be differentiated from metastases of visceral neuroendocrine carcinomas (particularly small cell lung cancer) and from some types of lymphoma and melanoma.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Immunohistochemistry makes is possible to distinguish Merkel cell carcinoma from these tumors. Merkel cell carcinoma expresses neuroendocrine markers (NSE, chromogranin, synaptophysin) and cytokeratin markers with a low molecular weight (CK20, CAM 5.2, CK AE1), and is negative for protein S-100 and leukocyte common antigen.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,4,5</span></a> Furthermore, thyroid transcription factor-1, which is positive in small cell lung cancer, is negative in Merkel cell carcinoma.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4–6</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Prognosis is poor owing to the high rate of recurrence (12%-50%), regional lymph node metastasis (17%-76%), and distant metastasis (12%-50%).<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,5</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">The most important prognostic factor for survival and development of systemic disease is lymph node involvement.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Traditional surgery with margins of between 2 and 3<span class="elsevierStyleHsp" style=""></span>cm is the treatment of choice for patients with no metastatic disease.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,4–6</span></a> Lymph node metastasis should be treated with radical lymph node resection. Postoperative radiation therapy of the tumor and lymph node region is recommended in these cases.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Radiation therapy is used in patients with systemic disease and may be accompanied by surgery and/or chemotherapy.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,4,5</span></a></p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:8 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Medical History" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Physical Examination" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Histopathology" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Additional Tests" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Diagnosis" ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "Clinical Course and Treatment" ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Comment" ] 7 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Mota-Burgos A, et al. Lesiones tumorales agrupadas en la extremidad inferior. Actas Dermosifi-liogr. 2013; 104:159-60.</p>" ] ] "multimedia" => array:3 [ 0 => array:6 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 665 "Ancho" => 883 "Tamanyo" => 43943 ] ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 667 "Ancho" => 890 "Tamanyo" => 160295 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin-eosin, original magnification<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>400.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 665 "Ancho" => 890 "Tamanyo" => 146381 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Immune staining for cytokeratin 20.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Merkel cell carcinoma: critical review with guidelines for multidisciplinary management" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "C.K. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 14 | 10 | 24 |
| 2024 October | 101 | 31 | 132 |
| 2024 September | 111 | 28 | 139 |
| 2024 August | 118 | 60 | 178 |
| 2024 July | 88 | 24 | 112 |
| 2024 June | 77 | 27 | 104 |
| 2024 May | 58 | 31 | 89 |
| 2024 April | 85 | 22 | 107 |
| 2024 March | 60 | 23 | 83 |
| 2024 February | 60 | 28 | 88 |
| 2024 January | 48 | 33 | 81 |
| 2023 December | 45 | 12 | 57 |
| 2023 November | 71 | 27 | 98 |
| 2023 October | 65 | 26 | 91 |
| 2023 September | 63 | 28 | 91 |
| 2023 August | 41 | 16 | 57 |
| 2023 July | 57 | 28 | 85 |
| 2023 June | 62 | 17 | 79 |
| 2023 May | 49 | 26 | 75 |
| 2023 April | 50 | 22 | 72 |
| 2023 March | 43 | 18 | 61 |
| 2023 February | 34 | 16 | 50 |
| 2023 January | 49 | 27 | 76 |
| 2022 December | 48 | 35 | 83 |
| 2022 November | 29 | 23 | 52 |
| 2022 October | 27 | 21 | 48 |
| 2022 September | 16 | 38 | 54 |
| 2022 August | 21 | 29 | 50 |
| 2022 July | 25 | 34 | 59 |
| 2022 June | 20 | 33 | 53 |
| 2022 May | 39 | 32 | 71 |
| 2022 April | 41 | 36 | 77 |
| 2022 March | 55 | 46 | 101 |
| 2022 February | 40 | 27 | 67 |
| 2022 January | 52 | 30 | 82 |
| 2021 December | 26 | 42 | 68 |
| 2021 November | 41 | 34 | 75 |
| 2021 October | 58 | 50 | 108 |
| 2021 September | 47 | 31 | 78 |
| 2021 August | 38 | 35 | 73 |
| 2021 July | 31 | 31 | 62 |
| 2021 June | 35 | 20 | 55 |
| 2021 May | 26 | 37 | 63 |
| 2021 April | 53 | 65 | 118 |
| 2021 March | 90 | 19 | 109 |
| 2021 February | 65 | 23 | 88 |
| 2021 January | 41 | 16 | 57 |
| 2020 December | 37 | 21 | 58 |
| 2020 November | 18 | 18 | 36 |
| 2020 October | 20 | 11 | 31 |
| 2020 September | 50 | 6 | 56 |
| 2020 August | 27 | 16 | 43 |
| 2020 July | 20 | 5 | 25 |
| 2020 June | 48 | 16 | 64 |
| 2020 May | 27 | 20 | 47 |
| 2020 April | 26 | 16 | 42 |
| 2020 March | 37 | 12 | 49 |
| 2020 February | 6 | 1 | 7 |
| 2020 January | 4 | 1 | 5 |
| 2019 December | 8 | 3 | 11 |
| 2019 November | 4 | 1 | 5 |
| 2019 September | 10 | 1 | 11 |
| 2019 August | 4 | 0 | 4 |
| 2019 July | 2 | 1 | 3 |
| 2019 June | 4 | 21 | 25 |
| 2019 May | 3 | 28 | 31 |
| 2019 April | 2 | 4 | 6 |
| 2019 March | 0 | 7 | 7 |
| 2019 February | 2 | 2 | 4 |
| 2018 December | 0 | 2 | 2 |
| 2018 November | 3 | 0 | 3 |
| 2018 October | 2 | 2 | 4 |
| 2018 September | 2 | 0 | 2 |
| 2018 March | 2 | 1 | 3 |
| 2018 February | 39 | 5 | 44 |
| 2018 January | 56 | 4 | 60 |
| 2017 December | 61 | 6 | 67 |
| 2017 November | 45 | 2 | 47 |
| 2017 October | 38 | 2 | 40 |
| 2017 September | 36 | 4 | 40 |
| 2017 August | 52 | 11 | 63 |
| 2017 July | 52 | 7 | 59 |
| 2017 June | 44 | 10 | 54 |
| 2017 May | 46 | 5 | 51 |
| 2017 April | 47 | 11 | 58 |
| 2017 March | 34 | 9 | 43 |
| 2017 February | 96 | 4 | 100 |
| 2017 January | 25 | 3 | 28 |
| 2016 December | 55 | 13 | 68 |
| 2016 November | 58 | 6 | 64 |
| 2016 October | 90 | 9 | 99 |
| 2016 September | 187 | 23 | 210 |
| 2016 August | 90 | 6 | 96 |
| 2016 July | 37 | 7 | 44 |
| 2016 June | 9 | 0 | 9 |
| 2016 May | 5 | 2 | 7 |
| 2016 April | 10 | 0 | 10 |
| 2016 March | 4 | 0 | 4 |
| 2016 February | 8 | 2 | 10 |
| 2016 January | 9 | 1 | 10 |
| 2015 December | 7 | 0 | 7 |
| 2015 November | 18 | 2 | 20 |
| 2015 October | 12 | 2 | 14 |
| 2015 September | 5 | 4 | 9 |
| 2015 August | 10 | 1 | 11 |
| 2015 July | 136 | 9 | 145 |
| 2015 June | 77 | 5 | 82 |
| 2015 May | 100 | 15 | 115 |
| 2015 April | 65 | 8 | 73 |
| 2015 March | 54 | 9 | 63 |
| 2015 February | 33 | 4 | 37 |
| 2015 January | 26 | 1 | 27 |
| 2014 December | 28 | 6 | 34 |
| 2014 November | 22 | 3 | 25 |
| 2014 October | 38 | 2 | 40 |
| 2014 September | 17 | 2 | 19 |
| 2014 August | 30 | 4 | 34 |
| 2014 July | 32 | 4 | 36 |
| 2014 June | 42 | 6 | 48 |
| 2014 May | 45 | 5 | 50 |
| 2014 April | 32 | 1 | 33 |
| 2014 March | 32 | 7 | 39 |
| 2014 February | 27 | 2 | 29 |
| 2014 January | 26 | 3 | 29 |
| 2013 December | 31 | 4 | 35 |
| 2013 November | 11 | 1 | 12 |
| 2013 October | 7 | 2 | 9 |
| 2013 September | 10 | 1 | 11 |
| 2013 August | 3 | 6 | 9 |
| 2013 July | 3 | 6 | 9 |
| 2013 June | 3 | 6 | 9 |
| 2013 May | 6 | 2 | 8 |
| 2013 April | 9 | 11 | 20 |
| 2013 March | 10 | 5 | 15 |
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