Case and Research Letters
Nodule on the External Ear
Nódulo en el pabellón auricular
S. Heras-González
, L. Aspe-Unanue, R. González-Pérez
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Servicio de Dermatología, Hospital Universitario Araba, Vitoria-Gasteiz, Spain
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Heras-González, L. Aspe-Unanue, R. González-Pérez" "autores" => array:3 [ 0 => array:4 [ "nombre" => "S." "apellidos" => "Heras-González" "email" => array:1 [ 0 => "soniaherasgonzalez@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "L." "apellidos" => "Aspe-Unanue" ] 2 => array:2 [ "nombre" => "R." "apellidos" => "González-Pérez" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Dermatología, Hospital Universitario Araba, Vitoria-Gasteiz, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Nódulo en el pabellón auricular" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:6 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 746 "Ancho" => 995 "Tamanyo" => 253446 ] ] ] ] "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 30-year-old man with no relevant past medical history presented with a lesion on the lower helix of the right ear that had first appeared several months earlier. The lesion was asymptomatic and its growth had remained stable since it first appeared. The patient reported no history of trauma at the site and had no similar lesions at other sites.</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 soft, raised, well-defined, erythematous-violaceous tumor approximately 1<span class="elsevierStyleHsp" style=""></span>cm in diameter that had a smooth surface and was not painful to the touch (<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">Histopathology</span><p id="par0015" class="elsevierStylePara elsevierViewall">Hematoxylin-eosin staining (<a class="elsevierStyleCrossRef" href="#fig0010">Figs. 2A and B</a>) revealed a dermal lymphoid infiltrate composed of small to medium-sized lymphocytes with little atypia, no mitotic figures, and no phenomena of avascular necrosis or epidermotropism. In addition, a grenz zone separating the lesion from the dermis—which was completely spared—was also observed. Immunohistochemical staining was clearly positive for the CD3 and CD8 markers, partially positive for CD4, and negative for CD20 and CD30 (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Additional Tests</span><p id="par0020" class="elsevierStylePara elsevierViewall">A blood workup revealed no alterations and a computed tomography study of the abdominal and pelvic region was entirely normal.</p><p id="par0025" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">What Is Your Diagnosis?</span></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Diagnosis</span><p id="par0030" class="elsevierStylePara elsevierViewall">Indolent CD8+ lymphoid proliferation of the ear.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical Course and Treatment</span><p id="par0035" class="elsevierStylePara elsevierViewall">Complete excision of the lesion was performed, followed by closure by plasty. No recurrence was detected during 2 years of follow-up.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Comment</span><p id="par0040" class="elsevierStylePara elsevierViewall">Indolent CD8+ lymphoid proliferation of the ear, first described by Petrella et al. in 2007, is a rare lymphoproliferative process that is not considered to be a cutaneous T-cell lymphoma according to the 2005 classification of the World Health Organization–European Organization for Research and Treatment of Cancer. Although it presents immunophenotypic characteristics also seen in aggressive CD8+ T-cell lymphomas, this new indolent lymphoproliferative process is probably a phenotypic variant of primary cutaneous CD4+ small-medium pleomorphic T-cell lymphoma, as first suggested by Beltraminelli et al. in 2009.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1,2</span></a> Clinically, the entity is characterized by slow-growing lesions confined to a single cutaneous site, usually the ears or acral sites. In the cases reported to date, the entity has exhibited indolent clinical behavior and shown no signs of systemic involvement.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1–3</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Cutaneous CD8+ T-cell lymphomas were initially considered to be aggressive lymphomas with frequent extracutaneous involvement and poor prognosis. Subsequently, CD8+ lymphomas with a favorable prognosis—which did not match the original descriptions—were reported. In 2007, Petrella et al.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> reported for the first time 4 cases of a nonaggressive, nonepidermotropic, monoclonal, CD8+ lymphoid proliferation on the ear that did not appear to belong to any of the recognized types of cutaneous T-cell lymphoma. Other cases with the same clinical, histologic, and immunophenotypic characteristics were subsequently reported, prompting various authors to suggest that this new entity might be a new phenotypic variant of primary cutaneous CD4+ small-medium pleomorphic T-cell lymphoma.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1,2,4–6</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Physical examination of these indolent cases usually reveals an asymptomatic, slow-growing, erythematous nodule on the helix of the ear measuring approximately 1<span class="elsevierStyleHsp" style=""></span>cm in diameter.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1,2</span></a> Clinical differential diagnosis of this entity includes conditions such as cutaneous pseudolymphoma (benign lymphocytoma cutis) caused by <span class="elsevierStyleItalic">Borrelia burgdorferi</span> infection or by ear piercing. Histopathologic differential diagnosis includes benign lymphocytoma cutis, reactions to insect bites, discoid lupus erythematosus, panniculitis-like subcutaneous lymphoma, polymorphous light eruption, and angiolymphoid hyperplasia with eosinophilia, and less frequently primary cutaneous B-cell lymphoma. The CD8+/CD4- immunophenotype can be seen in CD8+ mycosis fungoides, pagetoid reticulosis, aggressive CD8+ primary lymphoma, prolymphocytic variants of leukemia, CD8+ lymphomatoid papulosis, and other conditions.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Histologically, the entity is characterized by a dense dermal infiltrate of CD8+ T cells with a lymphoblast-like appearance, T-cell clonality, and no epidermotropism. The lymphoid infiltrate is composed of medium-sized pleomorphic cells with irregular nuclei and scant cytoplasm. There is no evidence of necrosis, mitosis, ulceration, or angiodestruction.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a> Immunohistochemical staining is consistently positive for the CD3 and CD8 markers, while there is little expression of CD20, CD4, CD30, and CD56.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">4–6</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Although in some cases the histopathologic appearance suggests a high-grade lymphoma, the clinical behavior of the entity is benign and therefore it is essential to differentiate it from other cutaneous CD8+ lymphomas that are associated with a poorer prognosis in order to avoid aggressive and unnecessary treatments.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">2,3</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">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:9 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Medical History" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Physical Examination" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Histopathology" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Additional Tests" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Diagnosis" ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "Clinical Course and Treatment" ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Comment" ] 7 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflicts of Interest" ] 8 => 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: Heras-González S, Aspe-Unanue L, González-Pérez R. Nódulo en el pabellón auricular. Actas Dermosifiliogr. 2017;108:581–582.</p>" ] ] "multimedia" => array:3 [ 0 => array:6 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 833 "Ancho" => 533 "Tamanyo" => 90703 ] ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 468 "Ancho" => 995 "Tamanyo" => 227626 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A, Hematoxylin-eosin, original magnification ×<span class="elsevierStyleHsp" style=""></span>40. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 14 | 15 | 29 |
| 2024 Octubre | 128 | 49 | 177 |
| 2024 Septiembre | 126 | 31 | 157 |
| 2024 Agosto | 140 | 65 | 205 |
| 2024 Julio | 122 | 51 | 173 |
| 2024 Junio | 115 | 44 | 159 |
| 2024 Mayo | 105 | 31 | 136 |
| 2024 Abril | 107 | 27 | 134 |
| 2024 Marzo | 112 | 34 | 146 |
| 2024 Febrero | 103 | 33 | 136 |
| 2024 Enero | 98 | 40 | 138 |
| 2023 Diciembre | 81 | 19 | 100 |
| 2023 Noviembre | 109 | 28 | 137 |
| 2023 Octubre | 106 | 35 | 141 |
| 2023 Septiembre | 92 | 36 | 128 |
| 2023 Agosto | 54 | 17 | 71 |
| 2023 Julio | 84 | 35 | 119 |
| 2023 Junio | 81 | 25 | 106 |
| 2023 Mayo | 110 | 23 | 133 |
| 2023 Abril | 118 | 18 | 136 |
| 2023 Marzo | 90 | 27 | 117 |
| 2023 Febrero | 98 | 30 | 128 |
| 2023 Enero | 81 | 37 | 118 |
| 2022 Diciembre | 78 | 43 | 121 |
| 2022 Noviembre | 33 | 26 | 59 |
| 2022 Octubre | 49 | 19 | 68 |
| 2022 Septiembre | 26 | 36 | 62 |
| 2022 Agosto | 32 | 29 | 61 |
| 2022 Julio | 27 | 43 | 70 |
| 2022 Junio | 33 | 38 | 71 |
| 2022 Mayo | 53 | 36 | 89 |
| 2022 Abril | 93 | 44 | 137 |
| 2022 Marzo | 67 | 55 | 122 |
| 2022 Febrero | 72 | 32 | 104 |
| 2022 Enero | 85 | 36 | 121 |
| 2021 Diciembre | 67 | 46 | 113 |
| 2021 Noviembre | 85 | 55 | 140 |
| 2021 Octubre | 76 | 65 | 141 |
| 2021 Septiembre | 64 | 39 | 103 |
| 2021 Agosto | 72 | 42 | 114 |
| 2021 Julio | 55 | 37 | 92 |
| 2021 Junio | 61 | 34 | 95 |
| 2021 Mayo | 83 | 77 | 160 |
| 2021 Abril | 120 | 93 | 213 |
| 2021 Marzo | 100 | 41 | 141 |
| 2021 Febrero | 84 | 46 | 130 |
| 2021 Enero | 61 | 46 | 107 |
| 2020 Diciembre | 50 | 43 | 93 |
| 2020 Noviembre | 51 | 30 | 81 |
| 2020 Octubre | 28 | 23 | 51 |
| 2020 Septiembre | 66 | 20 | 86 |
| 2020 Agosto | 42 | 24 | 66 |
| 2020 Julio | 35 | 21 | 56 |
| 2020 Junio | 41 | 25 | 66 |
| 2020 Mayo | 19 | 10 | 29 |
| 2020 Abril | 22 | 15 | 37 |
| 2020 Marzo | 26 | 9 | 35 |
| 2020 Febrero | 1 | 0 | 1 |
| 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 | 5 | 0 | 5 |
| 2019 Abril | 2 | 0 | 2 |
| 2019 Febrero | 2 | 0 | 2 |
| 2018 Diciembre | 4 | 0 | 4 |
| 2018 Noviembre | 9 | 0 | 9 |
| 2018 Octubre | 6 | 0 | 6 |
| 2018 Septiembre | 5 | 0 | 5 |
| 2018 Febrero | 24 | 2 | 26 |
| 2018 Enero | 40 | 4 | 44 |
| 2017 Diciembre | 45 | 10 | 55 |
| 2017 Noviembre | 40 | 6 | 46 |
| 2017 Octubre | 27 | 13 | 40 |
| 2017 Septiembre | 30 | 10 | 40 |
| 2017 Agosto | 34 | 20 | 54 |
| 2017 Julio | 51 | 31 | 82 |
| 2017 Junio | 16 | 20 | 36 |
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