Case for Diagnosis
Stony-Hard Subcutaneous Mass on the Arm of a Young Woman
Masa subcutánea pétrea en el brazo de una mujer joven
E. Agut-Busquet
, M. Yébenes, J. Luelmo
Corresponding author
Servicio de Dermatología, Hospital de Sabadell, Sabadell, Barcelona, Spain
Read
5560
Timeswas read the article
1582
Total PDF
3978
Total HTML
Share statistics
array:24 [ "pii" => "S1578219016000135" "issn" => "15782190" "doi" => "10.1016/j.adengl.2016.01.011" "estado" => "S300" "fechaPublicacion" => "2016-03-01" "aid" => "1281" "copyright" => "AEDV" "copyrightAnyo" => "2015" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Actas Dermosifiliogr. 2016;107:149-50" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 1126 "formatos" => array:3 [ "EPUB" => 45 "HTML" => 940 "PDF" => 141 ] ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S0001731015004391" "issn" => "00017310" "doi" => "10.1016/j.ad.2015.04.023" "estado" => "S300" "fechaPublicacion" => "2016-03-01" "aid" => "1281" "copyright" => "AEDV" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Actas Dermosifiliogr. 2016;107:149-50" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 782 "formatos" => array:3 [ "EPUB" => 3 "HTML" => 202 "PDF" => 577 ] ] "es" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Casos para el diagnóstico</span>" "titulo" => "Masa subcutánea pétrea en el brazo de una mujer joven" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "149" "paginaFinal" => "150" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Stony-Hard Subcutaneous Mass on the Arm of a Young Woman" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figura 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 812 "Ancho" => 1083 "Tamanyo" => 234516 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Tinción para CK20 ×40.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "E. Agut-Busquet, M. Yébenes, J. Luelmo" "autores" => array:3 [ 0 => array:2 [ "nombre" => "E." "apellidos" => "Agut-Busquet" ] 1 => array:2 [ "nombre" => "M." "apellidos" => "Yébenes" ] 2 => array:2 [ "nombre" => "J." "apellidos" => "Luelmo" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S1578219016000135" "doi" => "10.1016/j.adengl.2016.01.011" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219016000135?idApp=UINPBA000044" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731015004391?idApp=UINPBA000044" "url" => "/00017310/0000010700000002/v2_201603080122/S0001731015004391/v2_201603080122/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S1578219015003510" "issn" => "15782190" "doi" => "10.1016/j.adengl.2015.12.001" "estado" => "S300" "fechaPublicacion" => "2016-03-01" "aid" => "1181" "copyright" => "AEDV" "documento" => "article" "crossmark" => 1 "subdocumento" => "sco" "cita" => "Actas Dermosifiliogr. 2016;107:151-2" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 646 "formatos" => array:3 [ "EPUB" => 38 "HTML" => 506 "PDF" => 102 ] ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Residents Forum</span>" "titulo" => "RF-Oral Nonsteroidal Anti-inflammatory Drug Use May Reduce the Risk of Cutaneous Squamous Cell Carcinoma" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "151" "paginaFinal" => "152" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "FR-El consumo oral de antiinflamatorios no esteroideos podría disminuir el riesgo de aparición de carcinoma espinocelular cutáneo" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "C. Bernárdez, E. Macías del Toro, J.L. Ramírez Bellver, F. Feltes" "autores" => array:4 [ 0 => array:2 [ "nombre" => "C." "apellidos" => "Bernárdez" ] 1 => array:2 [ "nombre" => "E." "apellidos" => "Macías del Toro" ] 2 => array:2 [ "nombre" => "J.L." "apellidos" => "Ramírez Bellver" ] 3 => array:2 [ "nombre" => "F." "apellidos" => "Feltes" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0001731015002112" "doi" => "10.1016/j.ad.2015.04.011" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731015002112?idApp=UINPBA000044" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219015003510?idApp=UINPBA000044" "url" => "/15782190/0000010700000002/v2_201703220318/S1578219015003510/v2_201703220318/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S1578219016000147" "issn" => "15782190" "doi" => "10.1016/j.adengl.2016.01.012" "estado" => "S300" "fechaPublicacion" => "2016-03-01" "aid" => "1274" "copyright" => "AEDV" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Actas Dermosifiliogr. 2016;107:e7-e11" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 779 "formatos" => array:3 [ "EPUB" => 41 "HTML" => 626 "PDF" => 112 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">e- Case Report</span>" "titulo" => "Skin Flaps for the Repair of Multiple Adjacent Tumors" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "e7" "paginaFinal" => "e11" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Colgajos cutáneos para la resolución de múltiples tumores próximos adyacentes" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 699 "Ancho" => 1950 "Tamanyo" => 295919 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A-T advancement flap designed for the excision of 3 tumors on the scalp.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M.J. Suárez-Valladares, A. Pérez-Bustillo, B. González-Sixto, M. Otero-Rivas, M.A. Rodríguez-Prieto" "autores" => array:5 [ 0 => array:2 [ "nombre" => "M.J." "apellidos" => "Suárez-Valladares" ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Pérez-Bustillo" ] 2 => array:2 [ "nombre" => "B." "apellidos" => "González-Sixto" ] 3 => array:2 [ "nombre" => "M." "apellidos" => "Otero-Rivas" ] 4 => array:2 [ "nombre" => "M.A." "apellidos" => "Rodríguez-Prieto" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0001731015004329" "doi" => "10.1016/j.ad.2015.03.024" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731015004329?idApp=UINPBA000044" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219016000147?idApp=UINPBA000044" "url" => "/15782190/0000010700000002/v2_201703220318/S1578219016000147/v2_201703220318/en/main.assets" ] "en" => array:15 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case for Diagnosis</span>" "titulo" => "Stony-Hard Subcutaneous Mass on the Arm of a Young Woman" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "149" "paginaFinal" => "150" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "E. Agut-Busquet, M. Yébenes, J. Luelmo" "autores" => array:3 [ 0 => array:4 [ "nombre" => "E." "apellidos" => "Agut-Busquet" "email" => array:1 [ 0 => "eagutbusquet@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "M." "apellidos" => "Yébenes" ] 2 => array:2 [ "nombre" => "J." "apellidos" => "Luelmo" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Dermatología, Hospital de Sabadell, Sabadell, Barcelona, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Masa subcutánea pétrea en el brazo de una mujer joven" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 488 "Ancho" => 650 "Tamanyo" => 125945 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Staining for cytokeratin 20 ×40.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Clinical Characteristics</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 31-year-old woman, with skin phototype <span class="elsevierStyleSmallCaps">IV</span> and no relevant personal history, presented in our clinic with a painful progressively growing lesion that first appeared 1 year earlier.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Physical Examination</span><p id="par0010" class="elsevierStylePara elsevierViewall">Of note in the physical examination was the presence of a well-defined subcutaneous mass measuring 3<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>2.5<span class="elsevierStyleHsp" style=""></span>cm (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>). The lesion was of stony-hard consistency and infiltrated down to deep layers.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Histopathology</span><p id="par0015" class="elsevierStylePara elsevierViewall">Biopsy was performed and sections were obtained for hematoxylin-eosin staining and immunohistochemical (IHC) staining. Infiltration of the deep dermis and the subcutaneous cell tissue by small, uniform, cells was observed. These cells were arranged in a trabecular structure between a myxoid stroma (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>). At higher magnification, a vesicular nucleus was observed in these cells with a high mitotic index. Large areas of necrosis were observed with abundant apoptotic bodies. IHC study was positive for cytokeratin 20 (CK20) (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>), chromogranin, synaptophysin, and CD56. Focal positivity for myogenin and desmin was also observed.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Additional Tests</span><p id="par0020" class="elsevierStylePara elsevierViewall">Magnetic resonance imaging was performed and involvement of the deep layers was ruled out. An oncologic positron emission tomography-computed tomography scan did not detect any evidence of disease spread.</p><p id="par0025" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">¿What was the diagnosis?</span></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Diagnosis</span><p id="par0030" class="elsevierStylePara elsevierViewall">Merkel cell carcinoma (MCC) with rhabdomyoblastic differentiation.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Course and Treatment</span><p id="par0035" class="elsevierStylePara elsevierViewall">The lesions were completely excised with safety margins. Ipsilateral lymph node dissection was performed. Radiotherapy of the tumor bed and adjuvant chemotherapy were also administered. The patient is currently free of disease 1 year after diagnosis.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Comment</span><p id="par0040" class="elsevierStylePara elsevierViewall">MCC is an uncommon primary neuroendocrine carcinoma. It usually appears in patients with a low phototype, elderly patients, immunodepressed patients, and on sun-exposed areas, although it has also been reported at sites such as the crotch or the buttocks.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1,2</span></a> The most typical presentation is in the form of a rapidly-growing firm nodule with a red-violaceous color, but cases have also been reported with lesions in the form of panniculitis-like subcutaneous plaque.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1,2</span></a> Aberrant differentiation of MCC is uncommon. The documented subtypes are eccrine, squamous, rhabdomyoblastic, sarcomatous, and leiomyosarcomatous.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In the pathology study, MCC with rhabdomyoblastic differentiation presents as a small cell tumor that infiltrates down to the subcutaneous tissue. IHC study of the tumor shows results characteristic of neuroendocrine tumors consistent with MCC (QAE 1/2, CK20, chromogranin, synaptophysin, and CD56 positivity), but focal positivity for myogenin and desmin is also present, thus showing the presence of rhabdomyoblastic differentiation.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> The immunophenotype enables differential diagnosis to be established with other types of tumor such as primary cutaneous Ewing sarcoma (negative for CK20, chromogranin, and synaptophysin stains). Although the sarcoma always shows positivity for CD99, it should be remembered that up to 30% of MCC are also positive. Alveolar rhabdomyosarcoma (negative for CK, synaptophysin, and chromogranin), metastasis of small cell lung cancer (negative for CK20 and positive for TFF-1), and malignant amelanotic melanoma with rhabdomyoblastic differentiation (positive for stains characteristic of melanoma) should also be included in the differential diagnosis.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">4,5</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Currently, there is discussion about the association between MCC and Merkel cell polyomavirus (MCP). In 2008, Feng et al. isolated MCP in 8 of 10 samples from patients with typical MCC. However, in 2013, Martin et al.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a> presented a series of 12 patients with MCC with divergent differentiation in which MCP was not isolated in any samples, bringing into question the association, at least in MCC with divergent differentiation. In our case, the determination for MCP was also negative.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Treatment consists of excision with safety margins, lymph node dissection, and radiotherapy and chemotherapy. The general prognosis for MCC is poor, with 70% survival at 5 years. This survival rate is lower still for aberrant types.</p><p id="par0060" class="elsevierStylePara elsevierViewall">In conclusion, we present the first case in an immunocompetent patient, with no evidence of actinic damage, who developed MCC with rhabdomyoblastic differentiation and who was negative for MCP.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of Interest</span><p id="par0065" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Clinical Characteristics" ] 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" => "Course and Treatment" ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Comment" ] 7 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflicts of Interest" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Agut-Busquet E, Yébenes M, Luelmo J. Masa subcutánea pétrea en el brazo de una mujer joven. Actas Dermosifiliogr. 2016;107:149–150.</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" => 488 "Ancho" => 650 "Tamanyo" => 58813 ] ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 650 "Ancho" => 488 "Tamanyo" => 122350 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin-eosin ×10.</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" => 488 "Ancho" => 650 "Tamanyo" => 125945 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Staining for cytokeratin 20 ×40.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Primary Merkel cell carcinoma clinically presenting as deep oedematous mass of the groin" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "T. Gambichler" 1 => "S. Kobus" 2 => "A. Kreuter" 3 => "U. Wieland" 4 => "M. Stücker" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Eur J Med Res" "fecha" => "2010" "volumen" => "15" "paginaInicial" => "274" "paginaFinal" => "276" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20696637" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0040" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Giant Merkel cell carcinoma masquerading as a benign cyst on the buttock of an African American man" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M.J. Perman" 1 => "J.M. King" 2 => "L.L. Leithauser" 3 => "H.M. Gloster" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1155/2011/849767" "Revista" => array:5 [ "tituloSerie" => "Case Rep Oncol Med." "fecha" => "2011" "volumen" => "2011" "paginaInicial" => "849767" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22606448" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0045" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Merkel cell carcinoma with sarcomatous differentiation: Is it a poor prognostic factor?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "E. Gómez-Moyano" 1 => "A. Vera-Casaño" 2 => "A. Sanz-Trelles" 3 => "L. Martínez" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1365-4632.2012.05675.x" "Revista" => array:6 [ "tituloSerie" => "Int J Dermatol" "fecha" => "2013" "volumen" => "52" "paginaInicial" => "93" "paginaFinal" => "95" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23278615" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0050" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Merkel cell carcinoma with heterologous rhabdomyoblastic differentiation: The role of immunohistochemistry for Merkel cell polyomavrius large T-antigen in confirmation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "L.A. Adhikari" 1 => "T.H. McCalmont" 2 => "A.L. Folpe" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1600-0560.2011.01794.x" "Revista" => array:6 [ "tituloSerie" => "J Cutan Pathol" "fecha" => "2012" "volumen" => "39" "paginaInicial" => "47" "paginaFinal" => "51" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22032237" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0055" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Primary cutaneous small cell carcinoma; a case report with differential diagnosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "T. Terrada" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Int J Clin Exp Pathol" "fecha" => "2013" "volumen" => "6" "paginaInicial" => "1164" "paginaFinal" => "1168" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23696937" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0060" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Merkel cell carcinoma with divergent differentiation: Histopathological and immunohistochemical study of 15 cases with PCR analysis for Merkel cell polyomavirus" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "B. Martin" 1 => "E. Poblet" 2 => "J.J. Ríos" 3 => "D. Kazakov" 4 => "H. Kutzner" 5 => "T. Brenn" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/his.12091" "Revista" => array:6 [ "tituloSerie" => "Histopathology" "fecha" => "2013" "volumen" => "62" "paginaInicial" => "711" "paginaFinal" => "77220" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23530585" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/15782190/0000010700000002/v2_201703220318/S1578219016000135/v2_201703220318/en/main.assets" "Apartado" => array:4 [ "identificador" => "6154" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case for Diagnosis" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15782190/0000010700000002/v2_201703220318/S1578219016000135/v2_201703220318/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219016000135?idApp=UINPBA000044" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 3 | 0 | 3 |
| 2024 October | 96 | 44 | 140 |
| 2024 September | 127 | 26 | 153 |
| 2024 August | 134 | 53 | 187 |
| 2024 July | 110 | 43 | 153 |
| 2024 June | 85 | 31 | 116 |
| 2024 May | 80 | 32 | 112 |
| 2024 April | 80 | 18 | 98 |
| 2024 March | 92 | 35 | 127 |
| 2024 February | 73 | 35 | 108 |
| 2024 January | 50 | 30 | 80 |
| 2023 December | 63 | 17 | 80 |
| 2023 November | 73 | 25 | 98 |
| 2023 October | 77 | 24 | 101 |
| 2023 September | 87 | 28 | 115 |
| 2023 August | 55 | 19 | 74 |
| 2023 July | 66 | 34 | 100 |
| 2023 June | 61 | 19 | 80 |
| 2023 May | 59 | 20 | 79 |
| 2023 April | 64 | 20 | 84 |
| 2023 March | 65 | 21 | 86 |
| 2023 February | 64 | 15 | 79 |
| 2023 January | 44 | 26 | 70 |
| 2022 December | 63 | 31 | 94 |
| 2022 November | 28 | 20 | 48 |
| 2022 October | 34 | 17 | 51 |
| 2022 September | 37 | 40 | 77 |
| 2022 August | 27 | 35 | 62 |
| 2022 July | 25 | 34 | 59 |
| 2022 June | 21 | 13 | 34 |
| 2022 May | 36 | 29 | 65 |
| 2022 April | 44 | 26 | 70 |
| 2022 March | 42 | 41 | 83 |
| 2022 February | 27 | 24 | 51 |
| 2022 January | 56 | 34 | 90 |
| 2021 December | 27 | 26 | 53 |
| 2021 November | 44 | 29 | 73 |
| 2021 October | 57 | 50 | 107 |
| 2021 September | 48 | 42 | 90 |
| 2021 August | 31 | 23 | 54 |
| 2021 July | 29 | 21 | 50 |
| 2021 June | 44 | 25 | 69 |
| 2021 May | 30 | 28 | 58 |
| 2021 April | 42 | 31 | 73 |
| 2021 March | 71 | 16 | 87 |
| 2021 February | 54 | 23 | 77 |
| 2021 January | 32 | 14 | 46 |
| 2020 December | 35 | 13 | 48 |
| 2020 November | 31 | 14 | 45 |
| 2020 October | 38 | 13 | 51 |
| 2020 September | 34 | 8 | 42 |
| 2020 August | 26 | 15 | 41 |
| 2020 July | 33 | 10 | 43 |
| 2020 June | 50 | 21 | 71 |
| 2020 May | 39 | 24 | 63 |
| 2020 April | 51 | 19 | 70 |
| 2020 March | 37 | 17 | 54 |
| 2020 February | 8 | 0 | 8 |
| 2020 January | 4 | 0 | 4 |
| 2019 December | 8 | 0 | 8 |
| 2019 November | 4 | 0 | 4 |
| 2019 September | 9 | 0 | 9 |
| 2019 August | 4 | 0 | 4 |
| 2019 July | 2 | 0 | 2 |
| 2019 June | 6 | 0 | 6 |
| 2019 May | 3 | 1 | 4 |
| 2019 April | 0 | 3 | 3 |
| 2019 March | 2 | 4 | 6 |
| 2019 February | 2 | 0 | 2 |
| 2019 January | 2 | 0 | 2 |
| 2018 November | 2 | 0 | 2 |
| 2018 October | 6 | 0 | 6 |
| 2018 September | 4 | 0 | 4 |
| 2018 March | 3 | 1 | 4 |
| 2018 February | 83 | 7 | 90 |
| 2018 January | 84 | 7 | 91 |
| 2017 December | 77 | 7 | 84 |
| 2017 November | 56 | 8 | 64 |
| 2017 October | 43 | 8 | 51 |
| 2017 September | 41 | 4 | 45 |
| 2017 August | 36 | 11 | 47 |
| 2017 July | 36 | 3 | 39 |
| 2017 June | 56 | 9 | 65 |
| 2017 May | 76 | 5 | 81 |
| 2017 April | 49 | 5 | 54 |
| 2017 March | 30 | 10 | 40 |
| 2017 February | 38 | 6 | 44 |
| 2017 January | 26 | 4 | 30 |
| 2016 December | 50 | 8 | 58 |
| 2016 November | 56 | 15 | 71 |
| 2016 October | 41 | 13 | 54 |
| 2016 May | 0 | 2 | 2 |
Show all
