Case for Diagnosis
A Nodule on the Breast after Radiation Therapy
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Pindado-Ortega, D. Ortega-Quijano, R. Carrillo-Gijón" "autores" => array:3 [ 0 => array:4 [ "nombre" => "C." "apellidos" => "Pindado-Ortega" "email" => array:1 [ 0 => "cpindadoortega@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "D." "apellidos" => "Ortega-Quijano" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "R." "apellidos" => "Carrillo-Gijón" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Departamento de Dermatología, Hospital Ramón y Cajal, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Dermopatología, Hospital Ramón y Cajal, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1610 "Ancho" => 750 "Tamanyo" => 391312 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">B) Hematoxilina-eosina, ×20. C) Hematoxilina-eosina, ×200.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Clinical findings</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 61-year-old woman was referred to our department due to a 3 mm violaceus papule located on the presternal area (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). There was neither regional lymph node enlargement nor systemic involvement. She had a history of left breast ductal carcinoma in situ in December 2014. She underwent conservative breast surgery plus ipsilateral axillary lymph node dissection. Tumor margins and lymph nodes were free of disease. She was prescribed Letrozol and a course of postoperative radiotherapy.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Histopathological findings</span><p id="par0010" class="elsevierStylePara elsevierViewall">Histological examination showed a dome-shaped, well circumscribed, nodular lesion in the upper dermis (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B). It was composed of a predominantly solid proliferation of large epithelioid cells with ample eosinophilic cytoplasm, enlarged vesicular nuclei and prominent nucleoli. Some of these cells showed intracytoplasmic vacuoles. There were numerous intralesional vascular channels containing erythrocytes and scattered inflammatory cells, predominantly neutrophils and eosinophils (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C). Mitoses were sparse, and none of them atypical. Dilated vascular spaces and mild fibrosis were evident in perilesional areas. The immunohistochemical staining was positive for CD31 in the epithelioid cells, as well as in the vascular endothelial cells, CD34 and factor VIII; they were negative for cytokeratins 8, 18,19, CD30, CD68, Melan-A, S100, D2-40, c-MYC, GATA 3 and estrogen receptor. Ki-67 status was 10%.</p><p id="par0015" class="elsevierStylePara elsevierViewall">What is your diagnosis?</p><p id="par0020" class="elsevierStylePara elsevierViewall">DIAGNOSIS</p><p id="par0025" class="elsevierStylePara elsevierViewall">Cutaneous Epithelioid Angiomatous Nodule</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">Cutaneous Epithelioid Angiomatous Nodule (CEAN) is an uncommon benign lesion with distinctive histological features. It is characterized by a well-delimited, predominantly solid vascular proliferation in the superficial dermis. Well defined vessels are frequently found permeating the lesion, which also shows a certain degree of inflammatory infiltration. It is composed by large, epithelioid, endothelial cells that contain vesicular nuclei and prominent nucleoli.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The abundant cytoplasm consistently contains intracytoplasmic vacuoles.</p><p id="par0035" class="elsevierStylePara elsevierViewall">It clinically presents as a small, fast-growing, small reddish papule or nodule, most frequently located on the head, neck, trunk or limbs of adults. Most cases are solitary, but multiple lesions have been documented.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The differential diagnosis includes several benign and malignant vascular neoplasms in which epithelioid cells can be seen.</p><p id="par0045" class="elsevierStylePara elsevierViewall">In this case, due to the patient's history of breast radiotherapy and peculiar histology of the lesion, a differential diagnosis must be made with radiation-induced angiosarcoma (RIA). RIA is an uncommon complication after radiotherapy for breast cancer with an incidence of 0.05–0.3% which usually bears very poor prognosis<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>. Histologically, it is a malignant tumor that frequently shows solid component and irregular vascular channels. Despite the more aggressive clinical behavior, the epithelioid variant of angiosarcoma (EA) shares some morphologic features with CEAN. Pleomorphism of the cells and high number of mitosis, some of them atypical, are clues for the diagnosis. Positive immunohistochemical staining for CD31, CD34 and factor VIII confirms endothelial differentiation, while c-MYC positivity and a high Ki67 index (>40%) in both the solid component and the vascular channels are consistent markers of malignancy.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Epithelioid hemangioendotelioma (EHE) is an intermediate malignant potential tumor, composed of nests of epithelioid endothelial cells. EHE may show significant histologic overlap with CEAN. However, EHE typically occurs as a nonvasoformative nodule composed of cords and strands of epithelioid cells embedded in a fibromyxoid stroma. The cells usually show various degrees of pleomorphism, and mitotic figures are conspicuous, including the presence of atypical ones.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">For some authors CEAN can be classified inside the spectrum of angiolymphoid hyperplasia with eosinophilia (ALHE), also known as epithelioid hemangioma. They appear as loosely lobed proliferations of capillary-sized vessels coated with large endothelium that shows identical characteristics of the endothelium of CEAN. An inflammatory infiltrate composed mainly of lymphocytes and eosinophils is quite characteristic, and more prominent in ALHE than in CEAN.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Other differential diagnosis include amelanotic melanoma, ductal breast carcinoma, Langerhans cell histiocytosis and CD-30 positive proliferations.</p><p id="par0065" class="elsevierStylePara elsevierViewall">To conclude, CAEN is a benign, uncommon vascular tumor with no recurrence or metastasis reported to date. Physicians should bear it in mind within the differential diagnosis of vascular tumors in the skin.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Funding sources</span><p id="par0105" class="elsevierStylePara elsevierViewall">None.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Clinical findings" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Histopathological findings" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 3 => array:2 [ "identificador" => "sec0040" "titulo" => "Funding sources" ] 4 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-01-31" "fechaAceptado" => "2018-05-28" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Pindado-Ortega C, Ortega-Quijano D, Carrillo-Gijón R. Nódulo en mama tras radioterapia. Actas Dermo-Sifiliográficas. 2019;110:859–860.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1610 "Ancho" => 750 "Tamanyo" => 391312 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">B) Hematoxilina-eosina, ×20. C) Hematoxilina-eosina, ×200.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "[1]" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cutaneous epithelioid angiomatous nodule: a case series and proposed classification" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "O.P. Sangüeza" 1 => "S.N. Walsh" 2 => "D.J. Sheehan" 3 => "A.F. Orland" 4 => "B. Llombart" 5 => "L. 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Shin" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.humpath.2013.11.002" "Revista" => array:7 [ "tituloSerie" => "Hum Pathol" "fecha" => "2014" "volumen" => "45" "numero" => "April (4)" "paginaInicial" => "709" "paginaFinal" => "716" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24457083" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "[4]" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Epithelioid hemangioendothelioma of skin and soft tissues: clinicopathologic and immunohistochemical study of 30 cases" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "T. Mentzel" 1 => "A. Beham" 2 => "E. Calonje" 3 => "D. Katenkamp" 4 => "C.D. 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"fecha" => "2015" "volumen" => "139" "numero" => "April (5)" "paginaInicial" => "683" "paginaFinal" => "686" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25927152" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/15782190/0000011000000010/v1_201912080808/S157821901930294X/v1_201912080808/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/15782190/0000011000000010/v1_201912080808/S157821901930294X/v1_201912080808/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S157821901930294X?idApp=UINPBA000044" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 18 | 12 | 30 |
| 2024 October | 134 | 58 | 192 |
| 2024 September | 149 | 34 | 183 |
| 2024 August | 161 | 66 | 227 |
| 2024 July | 168 | 42 | 210 |
| 2024 June | 138 | 61 | 199 |
| 2024 May | 160 | 55 | 215 |
| 2024 April | 143 | 33 | 176 |
| 2024 March | 110 | 35 | 145 |
| 2024 February | 131 | 34 | 165 |
| 2024 January | 137 | 33 | 170 |
| 2023 December | 98 | 21 | 119 |
| 2023 November | 135 | 33 | 168 |
| 2023 October | 107 | 34 | 141 |
| 2023 September | 67 | 21 | 88 |
| 2023 August | 55 | 18 | 73 |
| 2023 July | 100 | 33 | 133 |
| 2023 June | 68 | 26 | 94 |
| 2023 May | 73 | 22 | 95 |
| 2023 April | 46 | 26 | 72 |
| 2023 March | 52 | 27 | 79 |
| 2023 February | 73 | 24 | 97 |
| 2023 January | 24 | 30 | 54 |
| 2022 December | 51 | 39 | 90 |
| 2022 November | 40 | 32 | 72 |
| 2022 October | 34 | 25 | 59 |
| 2022 September | 27 | 35 | 62 |
| 2022 August | 33 | 36 | 69 |
| 2022 July | 26 | 53 | 79 |
| 2022 June | 17 | 37 | 54 |
| 2022 May | 54 | 50 | 104 |
| 2022 April | 74 | 33 | 107 |
| 2022 March | 64 | 62 | 126 |
| 2022 February | 51 | 30 | 81 |
| 2022 January | 40 | 40 | 80 |
| 2021 December | 35 | 38 | 73 |
| 2021 November | 56 | 50 | 106 |
| 2021 October | 62 | 49 | 111 |
| 2021 September | 36 | 29 | 65 |
| 2021 August | 36 | 20 | 56 |
| 2021 July | 25 | 17 | 42 |
| 2021 June | 23 | 20 | 43 |
| 2021 May | 27 | 38 | 65 |
| 2021 April | 62 | 112 | 174 |
| 2021 March | 37 | 33 | 70 |
| 2021 February | 35 | 19 | 54 |
| 2021 January | 26 | 16 | 42 |
| 2020 December | 20 | 11 | 31 |
| 2020 November | 22 | 14 | 36 |
| 2020 October | 23 | 11 | 34 |
| 2020 September | 15 | 11 | 26 |
| 2020 August | 19 | 17 | 36 |
| 2020 July | 17 | 10 | 27 |
| 2020 June | 11 | 17 | 28 |
| 2020 May | 21 | 13 | 34 |
| 2020 April | 15 | 15 | 30 |
| 2020 March | 39 | 17 | 56 |
| 2020 February | 7 | 4 | 11 |
| 2020 January | 1 | 2 | 3 |
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