Case for Diagnosis
Long-standing Scaly Erythematous Tumor on the Lower Leg
Tumor eritemato-descamativo en la pierna de largo tiempo de evolución
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Abarzúa-Araya, E. Ortiz-Lazo, S. González-Bombardiere" "autores" => array:3 [ 0 => array:3 [ "nombre" => "A." "apellidos" => "Abarzúa-Araya" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:4 [ "nombre" => "E." "apellidos" => "Ortiz-Lazo" "email" => array:1 [ 0 => "eaortiz@uc.cl" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 2 => array:3 [ "nombre" => "S." "apellidos" => "González-Bombardiere" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Anatomía Patológica, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Tumor eritemato-descamativo en la pierna de largo tiempo de evolución" ] ] "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" => 727 "Ancho" => 1333 "Tamanyo" => 78116 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A, Single, dome-shaped, erythematous tumor on the anterior aspect of the left leg. B, Firm, erythematous-violaceous scaly tumor.</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 36-year-old woman with no relevant personal history attended the clinic because of an asymptomatic lesion of 8 years duration on the left leg. The lesion was growing slowly, with constant scaling. The patient could not recall any trigger associated with this lesion.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Physical Examination</span><p id="par0010" class="elsevierStylePara elsevierViewall">The physical examination demonstrated the presence of a dome-shaped, erythematous lesion of hard consistency with superficial scaling, measuring 1.5<span class="elsevierStyleHsp" style=""></span>cm, on the anterior aspect of the left leg (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>A and B).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Dermoscopy examination revealed a central whitish-yellow, scaly lesion with traces of irregularly distributed pigment, surrounded by a diffuse, vascularized erythematous area, with some polymorphous-atypical vessels (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>). There were no additional findings in the physical examination.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Histopathology</span><p id="par0020" class="elsevierStylePara elsevierViewall">The histopathology study showed an epidermis with focal ulceration, parakeratosis, and acanthosis with follicular induction. A tumor was located in the dermis, composed of spindle cells with vacuolated eosinophilic cytoplasm, arranged in a storiform pattern, embedded in a collagenous stroma with multiple foci of lamellar bone spicules but no osteoblasts or osteoclasts (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>A and B).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">What was the diagnosis?</span></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Diagnosis</span><p id="par0030" class="elsevierStylePara elsevierViewall">Dermatofibroma with metaplastic bone formation on the leg.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Course and Treatment</span><p id="par0035" class="elsevierStylePara elsevierViewall">The lesions were completely excised and, given their benign nature, the surgical margins were not extended.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Remarks</span><p id="par0040" class="elsevierStylePara elsevierViewall">Dermatofibroma is a complex entity with a wide range of clinical, dermoscopic, and histopathologic features, probably as a result of a series of as yet unknown triggers. The case presented is the second report of a dermatofibroma with metaplastic bone formation without osteoclast-type giant cells.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> Recognition in the histopathological study is very important, as identification of metaplastic bone formation in the skin opens up a wide range of differential diagnoses, from inflammatory-reactive processes to benign and malignant skin tumors.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Usually, dermatofibromas present as a solid papule or nodule of red or coffee color with a smooth or keratotic surface. The dimple sign can be observed with lateral compression, but this is not exclusive to dermatofibroma and may not be very evident. In the dermoscopy examination, the most frequent pattern is a central white scar-like patch, with a fine peripheral pigment network.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1–3</span></a> This pigmented network is not often distributed irregularly throughout the lesion (2.7%).<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a> The presence of vascular structures has been reported in 50% of cases.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">2,3</span></a> Several dermoscopic findings and atypical patterns have been described. These are uncommon and simulate other tumors. Findings include homogenous or irregular pigmentation, multiple whitish patches, whitish network, coffee spots, crusty scabs, ulcers, fissures, irregular linear and polymorphic vessels, and globular structures.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a> Differential diagnosis is therefore usually broad and the lesions are sometimes difficult to distinguish from melanoma, basal cell carcinoma and spindle cell carcinoma, dermatofibrosarcoma protuberans, Kaposi sarcoma, morphea, neurofibroma, or adnexal tumor.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a> In these cases, surgical excision is necessary for pathology study to clarify diagnosis.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The key pathological findings are presence of a spindle-cell dermal tumor with fibrohistiocytic differentiation, without atypia, with trapped hyalinized collagen bundles in the periphery, variable hemorrhage and hemosiderin deposition, and epidermal changes (acanthosis and follicular induction). There are several histopathological variants according to the predominant microscopic component, with fibrocollagenous, histiocytic, sclerotic, cellular, hemosiderotic, and cobblestone subtypes, among others.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a> The presence of metaplastic bone formation in dermatofibroma is rare, with few cases reported and no dermoscopic description of the lesion.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">4–6</span></a> In general, osteoclast-like giant cells are present.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The presence of bone tissue in the skin is uncommon, and can be explained by a metaplastic process in response to trauma or local inflammatory processes. The most common cutaneous tumors with metaplastic bone formation are melanocytic nevi, basal cell carcinomas, and pilomatrixomas.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> The presence of metaplastic bone tissue in the dermis and hypodermis may be a distraction during pathology study and mask the main lesion, particularly when present in substantial amounts, as in the case presented. Metaplastic bone formation may correspond to the main component in certain tumors or be a process secondary to the main lesion. Reactive processes with metaplastic bone tissue include scarring and panniculitis ossificans. It is the main component of osteomas, osteosarcomas, ossifying fibromyxoid tumor, and osteogenic melanoma, or may be a secondary process in pilomatrixoma, melanocytic nevi, trichilemmal or pilar cysts, and hemangiomas, among others.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">5–7</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conflicts of Interest</span><p id="par0060" 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" => "Clinical Characteristics" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Physical Examination" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Histopathology" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Diagnosis" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Course and Treatment" ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "Remarks" ] 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: Abarzúa-Araya A, Ortiz-Lazo E, González-Bombardiere S. Tumor eritemato-descamativo en la pierna de largo tiempo de evolución. Actas Dermosifiliogr. 2017;108:153–154.</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" => 727 "Ancho" => 1333 "Tamanyo" => 78116 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A, Single, dome-shaped, erythematous tumor on the anterior aspect of the left leg. B, Firm, erythematous-violaceous scaly tumor.</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" => 723 "Ancho" => 858 "Tamanyo" => 105608 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Dermoscopic lesion with a whitish central scaly plaque of scarred appearance surrounded by a vascularized erythematous area.</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" => 606 "Ancho" => 1650 "Tamanyo" => 436716 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A, Low-magnification view showing epidermal follicular induction and a dermal spindle-cell tumor with metastatic bone formation. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 11 | 15 | 26 |
| 2024 Octubre | 82 | 39 | 121 |
| 2024 Septiembre | 83 | 38 | 121 |
| 2024 Agosto | 102 | 81 | 183 |
| 2024 Julio | 67 | 32 | 99 |
| 2024 Junio | 85 | 38 | 123 |
| 2024 Mayo | 66 | 33 | 99 |
| 2024 Abril | 66 | 28 | 94 |
| 2024 Marzo | 73 | 33 | 106 |
| 2024 Febrero | 62 | 26 | 88 |
| 2024 Enero | 49 | 37 | 86 |
| 2023 Diciembre | 56 | 17 | 73 |
| 2023 Noviembre | 80 | 27 | 107 |
| 2023 Octubre | 95 | 21 | 116 |
| 2023 Septiembre | 86 | 30 | 116 |
| 2023 Agosto | 59 | 15 | 74 |
| 2023 Julio | 85 | 28 | 113 |
| 2023 Junio | 51 | 24 | 75 |
| 2023 Mayo | 72 | 20 | 92 |
| 2023 Abril | 73 | 21 | 94 |
| 2023 Marzo | 91 | 26 | 117 |
| 2023 Febrero | 68 | 27 | 95 |
| 2023 Enero | 65 | 46 | 111 |
| 2022 Diciembre | 78 | 40 | 118 |
| 2022 Noviembre | 39 | 31 | 70 |
| 2022 Octubre | 45 | 36 | 81 |
| 2022 Septiembre | 54 | 34 | 88 |
| 2022 Agosto | 88 | 43 | 131 |
| 2022 Julio | 82 | 42 | 124 |
| 2022 Junio | 36 | 75 | 111 |
| 2022 Mayo | 42 | 46 | 88 |
| 2022 Abril | 53 | 29 | 82 |
| 2022 Marzo | 56 | 44 | 100 |
| 2022 Febrero | 47 | 32 | 79 |
| 2022 Enero | 73 | 38 | 111 |
| 2021 Diciembre | 55 | 43 | 98 |
| 2021 Noviembre | 59 | 51 | 110 |
| 2021 Octubre | 60 | 49 | 109 |
| 2021 Septiembre | 45 | 44 | 89 |
| 2021 Agosto | 63 | 38 | 101 |
| 2021 Julio | 44 | 28 | 72 |
| 2021 Junio | 25 | 30 | 55 |
| 2021 Mayo | 41 | 64 | 105 |
| 2021 Abril | 110 | 64 | 174 |
| 2021 Marzo | 53 | 38 | 91 |
| 2021 Febrero | 68 | 35 | 103 |
| 2021 Enero | 44 | 28 | 72 |
| 2020 Diciembre | 38 | 24 | 62 |
| 2020 Noviembre | 27 | 19 | 46 |
| 2020 Octubre | 36 | 15 | 51 |
| 2020 Septiembre | 41 | 25 | 66 |
| 2020 Agosto | 31 | 26 | 57 |
| 2020 Julio | 23 | 23 | 46 |
| 2020 Junio | 31 | 37 | 68 |
| 2020 Mayo | 19 | 13 | 32 |
| 2020 Abril | 18 | 13 | 31 |
| 2020 Marzo | 18 | 9 | 27 |
| 2020 Febrero | 7 | 0 | 7 |
| 2020 Enero | 4 | 0 | 4 |
| 2019 Diciembre | 4 | 0 | 4 |
| 2019 Noviembre | 4 | 0 | 4 |
| 2019 Septiembre | 4 | 0 | 4 |
| 2019 Agosto | 4 | 0 | 4 |
| 2019 Julio | 4 | 0 | 4 |
| 2019 Junio | 4 | 0 | 4 |
| 2019 Mayo | 7 | 1 | 8 |
| 2019 Abril | 2 | 3 | 5 |
| 2019 Febrero | 4 | 0 | 4 |
| 2018 Diciembre | 4 | 0 | 4 |
| 2018 Noviembre | 1 | 0 | 1 |
| 2018 Octubre | 1 | 0 | 1 |
| 2018 Septiembre | 2 | 0 | 2 |
| 2018 Febrero | 32 | 4 | 36 |
| 2018 Enero | 44 | 4 | 48 |
| 2017 Diciembre | 47 | 6 | 53 |
| 2017 Noviembre | 37 | 4 | 41 |
| 2017 Octubre | 32 | 4 | 36 |
| 2017 Septiembre | 27 | 4 | 31 |
| 2017 Agosto | 34 | 6 | 40 |
| 2017 Julio | 23 | 4 | 27 |
| 2017 Junio | 39 | 7 | 46 |
| 2017 Mayo | 37 | 14 | 51 |
| 2017 Abril | 37 | 22 | 59 |
| 2017 Marzo | 74 | 33 | 107 |
| 2017 Febrero | 25 | 17 | 42 |
| 2017 Enero | 3 | 8 | 11 |
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