CASE FOR DIAGNOSIS
Hyperkeratotic Subungual Tumor
Lesión tumoral hiperqueratósica subungueal
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Ayala, V. Puglia, E. Jordá" "autores" => array:3 [ 0 => array:4 [ "nombre" => "D." "apellidos" => "Ayala" "email" => array:1 [ 0 => "dayalca83@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "V." "apellidos" => "Puglia" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "E." "apellidos" => "Jordá" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Clínico Universitario de Valencia, Valencia, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Anatomía Patológica, Hospital Clínico Universitario de Valencia, Valencia, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Lesión tumoral hiperqueratósica subungueal" ] ] "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" => 502 "Ancho" => 1000 "Tamanyo" => 122923 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A, Hematoxylin-eosin, original magnification ×<span class="elsevierStyleHsp" style=""></span>4. B, Hematoxylin-eosin, original magnification<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>40.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Medical History</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 40-year-old man with no relevant past history came to our clinic for assessment of a subungual tumor affecting the fifth toe of the right foot that had first appeared approximately 2 years earlier. The lesion had initially grown rapidly and subsequently stabilized. The patient reported discomfort caused by friction against his footwear. There had been no episodes of bleeding or ulceration.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Physical Examination</span><p id="par0010" class="elsevierStylePara elsevierViewall">Physical examination revealed a well-defined 1<span class="elsevierStyleHsp" style=""></span>cm nodular subungueal lesion with a rough, hyperkeratotic surface that was causing the detachment of the nail (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Additional Tests</span><p id="par0015" class="elsevierStylePara elsevierViewall">Complete excision of the lesion was performed. Histopathologic examination revealed a diffuse unencapsulated dermal lesion that extended to the deep margin of the resection specimen (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A). The tumor contained a prominent myxoid stroma with low cellularity consisting of spindle-shaped cells, without atypia or mitotic figures. A vascular network of numerous elongated capillaries with narrow lumens was present. No inflammatory infiltrate was observed (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>B).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Immunohistochemistry was positive for CD34 only in the vascular component of the tumor and was negative for S-100 protein, epithelial membrane antigen, and MUC4 in the vascular component and the fibroblastic component.</p><p id="par0025" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">What Is Your Diagnosis</span>?</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Diagnosis</span><p id="par0030" class="elsevierStylePara elsevierViewall">Subungual superficial angiomyxoma.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Clinical Course and Treatment</span><p id="par0035" class="elsevierStylePara elsevierViewall">After excision of the subungueal tumor we performed a direct suture closure. Because the deep margin of the resected specimen was affected, we initially considered extending the surgical margins. However, the patient refused additional surgery and no evidence of tumor recurrence has been found during 12 months of follow-up.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Comment</span><p id="par0040" class="elsevierStylePara elsevierViewall">Superficial angiomyxoma is a rare mesenchymal tumor classified as a benign cutaneous myxoma. It was first described by Carney et al.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> as being associated with Carney complex. It is mainly necessary to rule out Carney syndrome in patients with superficial angiomyxomas on the outer ear and patients with multiple lesions.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> We determined that our patient did not have Carney syndrome because the subungueal tumor was not accompanied by extracutaneous myxomas, skin pigmentation, or endocrine alterations.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Superficial angiomyxoma is more common in men, usually between 20 and 50 years of age. It normally appears as a single lesion<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> and has a very heterogeneous clinical presentation. The lesion presents as a skin-colored papule, nodule, or polypoid lesion ranging from 1 to 5<span class="elsevierStyleHsp" style=""></span>cm in size.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The most common site in the reported series is the trunk, followed by the lower limbs and head or neck.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a> It is very rare to find this lesion in a subungueal site, as in our patient. Only 3 cases of subungueal superficial angiomyxoma have been reported.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Histologically, superficial angiomyxoma is a dermal tumor that extends into the subcutaneous tissue. The lesion usually presents a multi-lobed growth pattern with nodules of low cellularity immersed in a myxoid stroma.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,4,5</span></a> It contains cells of fibroblast morphology with fusiform, elongated, or stellate shapes that do not usually present atypia or mitotic figures. The presence of abundant vessels with narrow lumens is characteristic, and a perivascular neutrophilic and lymphocytic inflammatory infiltrate is seen in a third of cases. Immunohistochemical features of the lesions are fibroblast cells that are negative for CD34, smooth muscle actin, S-100 protein, epithelial membrane antigen, and desmin; however, myofibroblast differentiation may be present in some cases.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">For subungueal lesions,<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a> the main differential diagnosis is superficial acral fibromyxoma, a slow-growing benign tumor usually found on the toes and fingers.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Histologically, this lesion presents as a well-defined dermal tumor that, in contrast to superficial angiomyxoma, has a less abundant myxoid stroma, higher cell density, increased microvascularization, and less prominent capillaries. Immunohistochemically, the lesion is characterized by CD34 expression in fibroblasts.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> In our patient, immunohistochemistry was negative for CD34 in the spindle-shaped fibroblastic component.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Superficial angiomyxoma is treated by surgery and local recurrences occur in 30% to 40% of cases.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3,5</span></a> The lesion is considered to be a benign myxoid tumor. No metastatic cases have been reported to date.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">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:8 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Medical History" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Physical Examination" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Additional Tests" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Diagnosis" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Clinical Course and Treatment" ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "Comment" ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflicts of Interest" ] 7 => 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: Ayala D, Puglia V, Jordá E. Lesión tumoral hiperqueratósica subungueal. Actas Dermosifiliogr. 2017;108:361–362.</p>" ] ] "multimedia" => array:2 [ 0 => array:6 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 378 "Ancho" => 1000 "Tamanyo" => 60933 ] ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 502 "Ancho" => 1000 "Tamanyo" => 122923 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A, Hematoxylin-eosin, original magnification ×<span class="elsevierStyleHsp" style=""></span>4. B, Hematoxylin-eosin, original magnification<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>40.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cutaneous myxomas: A major component of myxomas, spotty pigmentation, and endocrine overactivity" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J.A. Carney" 1 => "J.T. Headington" 2 => "W.P.D. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 11 | 7 | 18 |
| 2024 October | 62 | 40 | 102 |
| 2024 September | 72 | 29 | 101 |
| 2024 August | 90 | 46 | 136 |
| 2024 July | 94 | 30 | 124 |
| 2024 June | 74 | 20 | 94 |
| 2024 May | 54 | 39 | 93 |
| 2024 April | 73 | 28 | 101 |
| 2024 March | 84 | 27 | 111 |
| 2024 February | 61 | 34 | 95 |
| 2024 January | 49 | 31 | 80 |
| 2023 December | 46 | 12 | 58 |
| 2023 November | 57 | 27 | 84 |
| 2023 October | 50 | 14 | 64 |
| 2023 September | 47 | 33 | 80 |
| 2023 August | 32 | 20 | 52 |
| 2023 July | 61 | 36 | 97 |
| 2023 June | 50 | 22 | 72 |
| 2023 May | 61 | 24 | 85 |
| 2023 April | 60 | 23 | 83 |
| 2023 March | 64 | 20 | 84 |
| 2023 February | 50 | 14 | 64 |
| 2023 January | 51 | 27 | 78 |
| 2022 December | 62 | 36 | 98 |
| 2022 November | 33 | 20 | 53 |
| 2022 October | 29 | 15 | 44 |
| 2022 September | 29 | 36 | 65 |
| 2022 August | 23 | 27 | 50 |
| 2022 July | 29 | 36 | 65 |
| 2022 June | 21 | 16 | 37 |
| 2022 May | 42 | 39 | 81 |
| 2022 April | 58 | 37 | 95 |
| 2022 March | 50 | 51 | 101 |
| 2022 February | 31 | 22 | 53 |
| 2022 January | 67 | 39 | 106 |
| 2021 December | 56 | 50 | 106 |
| 2021 November | 72 | 35 | 107 |
| 2021 October | 62 | 50 | 112 |
| 2021 September | 37 | 43 | 80 |
| 2021 August | 24 | 23 | 47 |
| 2021 July | 25 | 17 | 42 |
| 2021 June | 23 | 31 | 54 |
| 2021 May | 27 | 48 | 75 |
| 2021 April | 68 | 52 | 120 |
| 2021 March | 53 | 23 | 76 |
| 2021 February | 48 | 31 | 79 |
| 2021 January | 19 | 7 | 26 |
| 2020 December | 22 | 14 | 36 |
| 2020 November | 24 | 16 | 40 |
| 2020 October | 25 | 23 | 48 |
| 2020 September | 37 | 15 | 52 |
| 2020 August | 23 | 13 | 36 |
| 2020 July | 11 | 17 | 28 |
| 2020 June | 32 | 28 | 60 |
| 2020 May | 15 | 5 | 20 |
| 2020 April | 15 | 22 | 37 |
| 2020 March | 22 | 13 | 35 |
| 2020 February | 3 | 0 | 3 |
| 2019 September | 3 | 0 | 3 |
| 2019 May | 0 | 2 | 2 |
| 2019 April | 0 | 1 | 1 |
| 2019 February | 2 | 0 | 2 |
| 2019 January | 2 | 0 | 2 |
| 2018 December | 2 | 0 | 2 |
| 2018 November | 2 | 0 | 2 |
| 2018 October | 1 | 0 | 1 |
| 2018 September | 3 | 0 | 3 |
| 2018 February | 18 | 2 | 20 |
| 2018 January | 47 | 2 | 49 |
| 2017 December | 47 | 9 | 56 |
| 2017 November | 23 | 8 | 31 |
| 2017 October | 30 | 7 | 37 |
| 2017 September | 23 | 5 | 28 |
| 2017 August | 35 | 6 | 41 |
| 2017 July | 18 | 5 | 23 |
| 2017 June | 37 | 8 | 45 |
| 2017 May | 67 | 30 | 97 |
| 2017 April | 16 | 12 | 28 |
| 2017 March | 2 | 5 | 7 |
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