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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Clinical image of the lesion&#46; A&#41; Nodule located on the right upper lip&#44; with preservation of the follicles in that area&#46; B&#41; Detail of the lesion&#46;</p>"
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    "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 61-year-old woman without any relevant past medical or surgical history presented with a several-year history of a tumor nodule located on her right upper lip&#46; She was asymptomatic but the tumor exhibited progressive growth&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Physical examination</span><p id="par0010" class="elsevierStylePara elsevierViewall">On examination&#44; an erythematous macule with fine telangiectasias and preserved follicular openings was observed&#44; within which a 20<span class="elsevierStyleHsp" style=""></span>mm subcutaneous nodule was palpable&#44; along with an erythematous hue on the surface&#44; fine telangiectasias&#44; and preserved follicular openings &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The nodule was hard&#44; with an irregular surface&#44; slightly mobile&#44; and adhered to deep planes&#46; The lesion was confined to the skin and spared the oral mucosa&#46; Dermoscopy of the lesion showed the presence of fine sharply focused arborizing vessels on a pink background without any other relevant structures&#46;</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 of the lesion showed an epidermis of regular thickness with a preserved maturation gradient&#44; beneath which a nodular tumor proliferation was observed in the deep dermis &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#44; with mixed cellularity&#44; consisting of areas of epithelial cells forming ducts lined by a single layer of cuboidal epithelium &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3A</a>&#41;&#46; Cells were positive for cytokeratins &#40;CKAE1-3&#43;&#41; and broad areas of myxoid stroma with chondroid areas were observed &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3B</a>&#41;&#46; The histopathological study revealed few mitoses and no nuclear pleomorphism&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">What is your diagnosis&#63;</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Diagnosis</span><p id="par0020" class="elsevierStylePara elsevierViewall">Cutaneous mixed tumor &#40;chondroid syringoma&#41;&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Comment</span><p id="par0025" class="elsevierStylePara elsevierViewall">After diagnosing the lesion&#8212;despite its benign nature&#8212;complete excision of the lesion was decided due to its size and the functional discomfort reported by the patient&#46; The study of the complete specimen confirmed the findings made on the skin biopsy&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The cutaneous mixed tumor&#44; or chondroid syringoma&#44; is a benign adnexal tumor with follicular and apocrine differentiation&#44; consisting of both an epithelial and a mesenchymal component&#44; hence its name&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1&#44;2</span></a> Some authors believe it should be considered a hamartoma rather than an adnexal tumor&#44; same as it happens with other neoplasms derived from adnexal structures&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">It is a rare entity and typically presents as a papule or nodule&#44; depending on its size&#44; on the face or neck&#44; although it can grow anywhere&#44; even in the genital region&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">2&#44;3</span></a> Clinically&#44; it can be confused with any other benign adnexal tumor&#44; primarily cystic&#44; infundibular&#44; or trichilemmal&#44; or malignant&#44; such as basal cell carcinoma or sebaceous carcinoma&#44; or even vascular proliferations when they acquire a bluish coloration&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Histologically&#44; its dual origin &#40;epithelial and mesenchymal&#41; translates into the existence of 2 intermingled cellular populations in a nodular&#44; usually dermal&#44; well-circumscribed lesion&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">2&#44;3</span></a> The epithelial component predominantly shows tubular&#44; branched&#44; and interconnected structures covered by 2 cell layers&#58; the luminal one&#8212;made of cylindrical cells with decapitation secretion&#8212;and the outer one&#8212;which is in contact with the stroma&#8212;made of cuboidal cells&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> This pattern is known as a mixed tumor with apocrine differentiation&#44; while when made of small&#44; rounded ducts distributed across the stroma&#44; it shows a pattern with eccrine differentiation&#46; Regardless of the differentiation&#44; it is surrounded by a predominant collagen component&#44; which may be accompanied&#44; to varying degrees&#44; by myxoid zones and&#47;or adipocytes&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> Despite the term &#8220;chondroid&#44;&#8221; the appearance of cartilaginous tissue as part of the stroma is rare&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">2&#44;3</span></a> Given the broad differentiation potential of both components&#44; this lesion may raise diagnostic suspicion with other entities&#44; such as fibromyxoid and ossifying soft tissue tumors&#44; chondrosarcoma myxoid &#40;both lacking ductal&#47;tubular components&#41;&#44; and paracordoma &#40;which would be negative for epithelial markers&#44; unlike the cutaneous mixed tumor&#41;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">It is a benign tumor&#44; and due to symptoms or the patient&#39;s wishes&#44; surgical treatment is ideal&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">3&#44;4</span></a> Given its low recurrence rate&#44; complete excision is recommended&#44; but without the need for safety margins&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Its indolent behavior is impaired by the existence of malignant forms&#44; usually based on undifferentiated adnexal tumors&#44; which can be associated with local recurrences and even distant metastases&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">4-6</span></a> These are histopathologically characterized by cellular atypia&#44; a high mitotic index&#44; local invasion&#44; and poorly defined lesion borders&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Additionally&#44; similarities have been established with the mixed tumor of the salivary gland&#8212;also known as pleomorphic adenoma&#46; However&#44; this tumor is associated with a higher risk of malignancy and&#47;or local recurrence when excision is incomplete&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> This spectrum of mixed tumors has led to the existence of reports in the literature of &#8220;cutaneous&#8221; pleomorphic adenoma &#40;true cutaneous mixed tumors and non-cutaneous forms of pleomorphic adenomas of salivary origin&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">5&#44;6</span></a> which underscores the need for analyzing both entities understanding them as 2 separate neoplasms&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conflicts of interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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Cases for diagnosis
Long-Standing Skin Cancer: Malignant or Benign?
Tumor cutáneo de larga evolución: ¿maligno o no?
L.M. Nieto-Benito
Autor para correspondencia
lula.m.nieto@gmail.com

Corresponding author.
, M. Córdoba-García-Rayo, M. Rogel-Vence
Servicio de Dermatología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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    "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 61-year-old woman without any relevant past medical or surgical history presented with a several-year history of a tumor nodule located on her right upper lip&#46; She was asymptomatic but the tumor exhibited progressive growth&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Physical examination</span><p id="par0010" class="elsevierStylePara elsevierViewall">On examination&#44; an erythematous macule with fine telangiectasias and preserved follicular openings was observed&#44; within which a 20<span class="elsevierStyleHsp" style=""></span>mm subcutaneous nodule was palpable&#44; along with an erythematous hue on the surface&#44; fine telangiectasias&#44; and preserved follicular openings &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The nodule was hard&#44; with an irregular surface&#44; slightly mobile&#44; and adhered to deep planes&#46; The lesion was confined to the skin and spared the oral mucosa&#46; Dermoscopy of the lesion showed the presence of fine sharply focused arborizing vessels on a pink background without any other relevant structures&#46;</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 of the lesion showed an epidermis of regular thickness with a preserved maturation gradient&#44; beneath which a nodular tumor proliferation was observed in the deep dermis &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#44; with mixed cellularity&#44; consisting of areas of epithelial cells forming ducts lined by a single layer of cuboidal epithelium &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3A</a>&#41;&#46; Cells were positive for cytokeratins &#40;CKAE1-3&#43;&#41; and broad areas of myxoid stroma with chondroid areas were observed &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3B</a>&#41;&#46; The histopathological study revealed few mitoses and no nuclear pleomorphism&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">What is your diagnosis&#63;</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Diagnosis</span><p id="par0020" class="elsevierStylePara elsevierViewall">Cutaneous mixed tumor &#40;chondroid syringoma&#41;&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Comment</span><p id="par0025" class="elsevierStylePara elsevierViewall">After diagnosing the lesion&#8212;despite its benign nature&#8212;complete excision of the lesion was decided due to its size and the functional discomfort reported by the patient&#46; The study of the complete specimen confirmed the findings made on the skin biopsy&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The cutaneous mixed tumor&#44; or chondroid syringoma&#44; is a benign adnexal tumor with follicular and apocrine differentiation&#44; consisting of both an epithelial and a mesenchymal component&#44; hence its name&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1&#44;2</span></a> Some authors believe it should be considered a hamartoma rather than an adnexal tumor&#44; same as it happens with other neoplasms derived from adnexal structures&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">It is a rare entity and typically presents as a papule or nodule&#44; depending on its size&#44; on the face or neck&#44; although it can grow anywhere&#44; even in the genital region&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">2&#44;3</span></a> Clinically&#44; it can be confused with any other benign adnexal tumor&#44; primarily cystic&#44; infundibular&#44; or trichilemmal&#44; or malignant&#44; such as basal cell carcinoma or sebaceous carcinoma&#44; or even vascular proliferations when they acquire a bluish coloration&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Histologically&#44; its dual origin &#40;epithelial and mesenchymal&#41; translates into the existence of 2 intermingled cellular populations in a nodular&#44; usually dermal&#44; well-circumscribed lesion&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">2&#44;3</span></a> The epithelial component predominantly shows tubular&#44; branched&#44; and interconnected structures covered by 2 cell layers&#58; the luminal one&#8212;made of cylindrical cells with decapitation secretion&#8212;and the outer one&#8212;which is in contact with the stroma&#8212;made of cuboidal cells&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> This pattern is known as a mixed tumor with apocrine differentiation&#44; while when made of small&#44; rounded ducts distributed across the stroma&#44; it shows a pattern with eccrine differentiation&#46; Regardless of the differentiation&#44; it is surrounded by a predominant collagen component&#44; which may be accompanied&#44; to varying degrees&#44; by myxoid zones and&#47;or adipocytes&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> Despite the term &#8220;chondroid&#44;&#8221; the appearance of cartilaginous tissue as part of the stroma is rare&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">2&#44;3</span></a> Given the broad differentiation potential of both components&#44; this lesion may raise diagnostic suspicion with other entities&#44; such as fibromyxoid and ossifying soft tissue tumors&#44; chondrosarcoma myxoid &#40;both lacking ductal&#47;tubular components&#41;&#44; and paracordoma &#40;which would be negative for epithelial markers&#44; unlike the cutaneous mixed tumor&#41;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">It is a benign tumor&#44; and due to symptoms or the patient&#39;s wishes&#44; surgical treatment is ideal&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">3&#44;4</span></a> Given its low recurrence rate&#44; complete excision is recommended&#44; but without the need for safety margins&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Its indolent behavior is impaired by the existence of malignant forms&#44; usually based on undifferentiated adnexal tumors&#44; which can be associated with local recurrences and even distant metastases&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">4-6</span></a> These are histopathologically characterized by cellular atypia&#44; a high mitotic index&#44; local invasion&#44; and poorly defined lesion borders&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Additionally&#44; similarities have been established with the mixed tumor of the salivary gland&#8212;also known as pleomorphic adenoma&#46; However&#44; this tumor is associated with a higher risk of malignancy and&#47;or local recurrence when excision is incomplete&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> This spectrum of mixed tumors has led to the existence of reports in the literature of &#8220;cutaneous&#8221; pleomorphic adenoma &#40;true cutaneous mixed tumors and non-cutaneous forms of pleomorphic adenomas of salivary origin&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">5&#44;6</span></a> which underscores the need for analyzing both entities understanding them as 2 separate neoplasms&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conflicts of interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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