Case and Research Letters
Unusual Ultrasound Appearance of Subungual Keratoacanthoma With Clinical and Histological Correlation
Presentación ecográfica no habitual de queratoacantoma subungueal con correlación clínica e histológica
a Departamento de Dermatología, Centro de Referencia de Salud Peñalolén Cordillera Oriente, Peñalolén, Santiago, Chile
b Escuela de Medicina, Universidad de los Andes, Santiago, Chile
c Departamento de Medicina, Facultad de Medicina, Universidad de los Andes, Santiago, Chile
d Departamento de Patología, Citolab, Santiago, Chile
e Departamento de Radiología y Departamento de Dermatología, Instituto de Investigación y Diagnóstico por Imágenes en Piel y Tejidos Blandos, Clínica Servet, Facultad de Medicina, Universidad de Chile, Santiago, Chile
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A. Zoom ×<span class="elsevierStyleHsp" style=""></span>2. Neoplasia pavimentosa crateriforme, bien diferenciada, en la cual destacan numerosas células disqueratósicas dispersas, que son una clave diagnóstica. B. Zoom ×<span class="elsevierStyleHsp" style=""></span>10. Brotes tumorales con leves atipias nucleares, células disqueratósicas dispersas, microabscesos intratumorales e inflamación periférica.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M. Le-Bert, D. Soto, V. Vial, R. Bentjerodt, X. Wortsman" "autores" => array:5 [ 0 => array:2 [ "nombre" => "M." "apellidos" => "Le-Bert" ] 1 => array:2 [ "nombre" => "D." "apellidos" => "Soto" ] 2 => array:2 [ "nombre" => "V." "apellidos" => "Vial" ] 3 => array:2 [ "nombre" => "R." "apellidos" => "Bentjerodt" ] 4 => array:2 [ "nombre" => "X." 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Aportación de un caso y revisión de la literatura" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 755 "Ancho" => 3000 "Tamanyo" => 371718 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A, Symmetrical telangiectatic plaques on the lateral aspect of the forearms. B, Telangiectasias on the thighs. C, Telangiectasias on the lower legs.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "I. Castiñeiras-Mato, R. Rodríguez-Lojo, M.L. Fernández-Díaz, F. Bal-Nieves" "autores" => array:4 [ 0 => array:2 [ "nombre" => "I." "apellidos" => "Castiñeiras-Mato" ] 1 => array:2 [ "nombre" => "R." 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Homogeneous globular network with asymmetric globules peripherally (red arrow). Milia-like cysts and comedo-like openings (in square). B, Confocal microscopy image of 5.5<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>mm. The yellow square outlines the area with the bright annular structures and the hyperreflective round structures with a smooth outline (green arrow); on the right, at higher power, the ring pattern is visible at the dermoepidermal junction, with an area of crest fusion (arrow). C, The histologic image shows the presence in the same area of a compound melanocytic nevus and a seborrheic keratosis.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "L. Ascanio Armada, R. Gamo Villegas, A. Pampin Franco, F. Pinedo Moraleda" "autores" => array:4 [ 0 => array:2 [ "nombre" => "L." "apellidos" => "Ascanio Armada" ] 1 => array:2 [ "nombre" => "R." 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Le-Bert, D. Soto, V. Vial, R. Bentjerodt, X. Wortsman" "autores" => array:5 [ 0 => array:3 [ "nombre" => "M." "apellidos" => "Le-Bert" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "D." "apellidos" => "Soto" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "V." "apellidos" => "Vial" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "R." "apellidos" => "Bentjerodt" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] 4 => array:4 [ "nombre" => "X." "apellidos" => "Wortsman" "email" => array:1 [ 0 => "xworts@yahoo.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "aff0025" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:5 [ 0 => array:3 [ "entidad" => "Departamento de Dermatología, Centro de Referencia de Salud Peñalolén Cordillera Oriente, Peñalolén, Santiago, Chile" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Escuela de Medicina, Universidad de los Andes, Santiago, Chile" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Departamento de Medicina, Facultad de Medicina, Universidad de los Andes, Santiago, Chile" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Departamento de Patología, Citolab, Santiago, Chile" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Departamento de Radiología y Departamento de Dermatología, Instituto de Investigación y Diagnóstico por Imágenes en Piel y Tejidos Blandos, Clínica Servet, Facultad de Medicina, Universidad de Chile, Santiago, Chile" "etiqueta" => "e" "identificador" => "aff0025" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Presentación ecográfica no habitual de queratoacantoma subungueal con correlación clínica e histológica" ] ] "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" => 870 "Ancho" => 2835 "Tamanyo" => 228390 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Nail ultrasound in keratoacanthoma. A, Gray scale (longitudinal axis, right thumb, ulnar border) shows a hypoechoic tumor (asterisk, between<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>signs) with lower echogenicity centrally (o). Observe remodeling of the underlying bone surface (arrow). B, Color Doppler of the nail (longitudinal axis, right thumb, ulnar border) showing hypervascularity (in color) at the periphery of the tumor (asterisk).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Keratoacanthomas (KA) form a group of tumors of epidermal origin but whose nature remains controversial. They are thought to be low-grade squamous cell carcinomas (SCC) that may become more aggressive in immunocompromised individuals. KAs are characterized by a rapid, exophytic growth, usually followed by spontaneous regression, and they typically occur in sun-exposed areas in elderly patients.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The subungual or periungual variant of KA is rare; it is usually locally destructive and is less likely to undergo spontaneous involution. This variant is more common in white male patients and in the fifth decade of life. The cause is still unknown, but associations have been reported with trauma, carcinogen exposure, eczema, psoriasis, atopic dermatitis, xeroderma pigmentosum, and incontinentia pigmenti.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case Description</span><p id="par0015" class="elsevierStylePara elsevierViewall">We present the case of a 45-year-old woman with a history of incontinentia pigmenti. She consulted for a 1-month history of a painful, rapidly growing swelling in the periungual region of the right thumb.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Physical examination revealed a skin-colored nodular lesion that occupied the ulnar and proximal borders of the nail of the first digit of the right hand (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Color Doppler ultrasound was requested. The report described a solid, hypoechoic tumor with a center of lower echogenicity and of solid appearance, located at the ulnar border of the periungual region and extending into the nail bed on the same side; the ultrasound appearance was not suggestive of malignancy. The lesion measured 11<span class="elsevierStyleHsp" style=""></span>mm (transverse)<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10.7<span class="elsevierStyleHsp" style=""></span>mm (longitudinal)<span class="elsevierStyleHsp" style=""></span>x<span class="elsevierStyleHsp" style=""></span>8.3<span class="elsevierStyleHsp" style=""></span>mm (depth). Vascularization was predominantly peripheral, in the form of narrow vessels with low-velocity arterial flow, and there was remodeling of the surface of the underlying distal phalanx. In addition, signs of inflammatory (hypervascularity) were observed in the nail bed, and the nail plate showed changes probably of secondary dystrophic origin (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">The lesion was excised and histology revealed a well-differentiated, cobblestoned crateriform tumor with numerous scattered dyskeratotic cells, intralesional microabscesses, and mixed peripheral inflammation, compatible with periungual KA (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">The histology report was drafted in accordance with the medical principles of the Declaration of Helsinki, and the patient gave her consent for publication.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Discussion</span><p id="par0040" class="elsevierStylePara elsevierViewall">This case demonstrates the usefulness of ultrasound in the diagnosis of ungual pathology, and also draws attention to the clinical signs that can lead us to suspect the presence of a tumor in the region of the nail.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Color Doppler ultrasound typically reveals a lesion with a heterogeneous ultrasound structure, with a hypoechoic border of solid appearance and an anechoic center of fluid appearance. Remodeling of the surface of the underlying bone is common.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">3–5</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Our case presented an unusual ultrasound appearance, as the lesion was hypoechoic and had a central area of lower echogenicity, but not the anechoic fluid component typically reported.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The central region of the tumor corresponds to the keratin-filled central crater<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">2–4</span></a>; in our case, the ultrasound finding would appear to be due to a more compact central keratin mass. Ultrasound also enabled us to confirm the neoplastic nature of the lesion and to establish the differential diagnosis with other types of tumors of the nail region that present distinct ultrasound patterns, such as glomus tumor and onychomatrixoma.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">6,7</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Glomus tumor usually presents as a solid, moderately well-defined, hypoechoic nodular lesion that provokes remodeling of the surface of the distal phalanx. The majority of glomus tumors have internal vascularization and are situated in the proximal nail bed.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">5,6</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Onychomatrixoma has a hypoechoic appearance with hyperechoic lines or foci that affect the nail matrix and extend into the interplate space. These tumors usually have a reduced vascularity and do not tend to produce erosion or remodeling of the underlying bone surface.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">5–7</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">On ultrasound, SCC is less well defined and, rather than an anechoic or hypoechoic center, it has a heterogeneous, hypoechoic echostructure, with erosion of the nail plate and a variable degree of vascularity.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a> In contrast to SCC, plain x-rays of a bone defect caused by a KA typically show well-defined borders, as KAs do not show intensely invasive behavior.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Other imaging studies to evaluate bone involvement, apart from ultrasound, include computed tomography and magnetic resonance imaging. However, color Doppler ultrasound has been described as the method of choice as it provides the most sensitive images for the diagnosis of ungual and periungual tumors. Computed tomography and magnetic resonance imaging usually present false negatives in tumors measuring less than 3<span class="elsevierStyleHsp" style=""></span>mm and poor definition of the ungual and periungual planes.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">In conclusion, when an ungual tumor is suspected, the clinical findings should be correlated with the ultrasound findings, and this should be completed by adequate histological analysis. Although the ultrasound findings were unusual in our case, color Doppler ultrasound enabled the diagnosis of a periungual tumor to be confirmed. This can favor early diagnosis and aid surgical planning.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of Interest</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Case Description" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Discussion" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflicts of Interest" ] 3 => 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: Le-Bert M, Soto D, Vial V, Bentjerodt R, Wortsman X. Presentación ecográfica no habitual de queratoacantoma subungueal con correlación clínica e histológica. Actas Dermosifiliogr. 2016;107:442–444.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 764 "Ancho" => 900 "Tamanyo" => 89053 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Clinical photograph of the keratoacanthoma. The nodular, skin-colored lesion affected the proximal and ulnar borders of the nail and periungual region of the right thumb.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 870 "Ancho" => 2835 "Tamanyo" => 228390 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Nail ultrasound in keratoacanthoma. A, Gray scale (longitudinal axis, right thumb, ulnar border) shows a hypoechoic tumor (asterisk, between<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>signs) with lower echogenicity centrally (o). Observe remodeling of the underlying bone surface (arrow). B, Color Doppler of the nail (longitudinal axis, right thumb, ulnar border) showing hypervascularity (in color) at the periphery of the tumor (asterisk).</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" => 691 "Ancho" => 1704 "Tamanyo" => 394389 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Histology of keratoacanthoma. A, Well-differentiated, cobblestoned crateriform neoplasm. The numerous and clearly visible scattered dyskeratotic cells are a key to diagnosis. Hematoxylin-eosin (H&E), original magnification ×<span class="elsevierStyleHsp" style=""></span>2. B, Tumor foci with mild nuclear atypia, scattered dyskeratotic cells, intratumoral microabscesses, and peripheral inflammation. H&E, original magnification ×<span class="elsevierStyleHsp" style=""></span>10.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0040" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Natural course of keratoacanthoma and related lesions after partial biopsy: Clinical analysis of 66 lesions" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "T. Takai" 1 => "N. Misago" 2 => "Y. 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