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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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 12 | 9 | 21 |
| 2024 Octubre | 62 | 40 | 102 |
| 2024 Septiembre | 72 | 29 | 101 |
| 2024 Agosto | 90 | 46 | 136 |
| 2024 Julio | 94 | 30 | 124 |
| 2024 Junio | 74 | 20 | 94 |
| 2024 Mayo | 54 | 39 | 93 |
| 2024 Abril | 73 | 28 | 101 |
| 2024 Marzo | 84 | 27 | 111 |
| 2024 Febrero | 61 | 34 | 95 |
| 2024 Enero | 49 | 31 | 80 |
| 2023 Diciembre | 46 | 12 | 58 |
| 2023 Noviembre | 57 | 27 | 84 |
| 2023 Octubre | 50 | 14 | 64 |
| 2023 Septiembre | 47 | 33 | 80 |
| 2023 Agosto | 32 | 20 | 52 |
| 2023 Julio | 61 | 36 | 97 |
| 2023 Junio | 50 | 22 | 72 |
| 2023 Mayo | 61 | 24 | 85 |
| 2023 Abril | 60 | 23 | 83 |
| 2023 Marzo | 64 | 20 | 84 |
| 2023 Febrero | 50 | 14 | 64 |
| 2023 Enero | 51 | 27 | 78 |
| 2022 Diciembre | 62 | 36 | 98 |
| 2022 Noviembre | 33 | 20 | 53 |
| 2022 Octubre | 29 | 15 | 44 |
| 2022 Septiembre | 29 | 36 | 65 |
| 2022 Agosto | 23 | 27 | 50 |
| 2022 Julio | 29 | 36 | 65 |
| 2022 Junio | 21 | 16 | 37 |
| 2022 Mayo | 42 | 39 | 81 |
| 2022 Abril | 58 | 37 | 95 |
| 2022 Marzo | 50 | 51 | 101 |
| 2022 Febrero | 31 | 22 | 53 |
| 2022 Enero | 67 | 39 | 106 |
| 2021 Diciembre | 56 | 50 | 106 |
| 2021 Noviembre | 72 | 35 | 107 |
| 2021 Octubre | 62 | 50 | 112 |
| 2021 Septiembre | 37 | 43 | 80 |
| 2021 Agosto | 24 | 23 | 47 |
| 2021 Julio | 25 | 17 | 42 |
| 2021 Junio | 23 | 31 | 54 |
| 2021 Mayo | 27 | 48 | 75 |
| 2021 Abril | 68 | 52 | 120 |
| 2021 Marzo | 53 | 23 | 76 |
| 2021 Febrero | 48 | 31 | 79 |
| 2021 Enero | 19 | 7 | 26 |
| 2020 Diciembre | 22 | 14 | 36 |
| 2020 Noviembre | 24 | 16 | 40 |
| 2020 Octubre | 25 | 23 | 48 |
| 2020 Septiembre | 37 | 15 | 52 |
| 2020 Agosto | 23 | 13 | 36 |
| 2020 Julio | 11 | 17 | 28 |
| 2020 Junio | 32 | 28 | 60 |
| 2020 Mayo | 15 | 5 | 20 |
| 2020 Abril | 15 | 22 | 37 |
| 2020 Marzo | 22 | 13 | 35 |
| 2020 Febrero | 3 | 0 | 3 |
| 2019 Septiembre | 3 | 0 | 3 |
| 2019 Mayo | 0 | 2 | 2 |
| 2019 Abril | 0 | 1 | 1 |
| 2019 Febrero | 2 | 0 | 2 |
| 2019 Enero | 2 | 0 | 2 |
| 2018 Diciembre | 2 | 0 | 2 |
| 2018 Noviembre | 2 | 0 | 2 |
| 2018 Octubre | 1 | 0 | 1 |
| 2018 Septiembre | 3 | 0 | 3 |
| 2018 Febrero | 18 | 2 | 20 |
| 2018 Enero | 47 | 2 | 49 |
| 2017 Diciembre | 47 | 9 | 56 |
| 2017 Noviembre | 23 | 8 | 31 |
| 2017 Octubre | 30 | 7 | 37 |
| 2017 Septiembre | 23 | 5 | 28 |
| 2017 Agosto | 35 | 6 | 41 |
| 2017 Julio | 18 | 5 | 23 |
| 2017 Junio | 37 | 8 | 45 |
| 2017 Mayo | 67 | 30 | 97 |
| 2017 Abril | 16 | 12 | 28 |
| 2017 Marzo | 2 | 5 | 7 |
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