Case and Research Letters
Large, Long-standing Tumor on the Scalp and Ipsilateral Lymphadenopathy
Tumoración en cuero cabelludo de gran tamaño de larga evolución con adenopatías ipsilaterales
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A skin-colored nodule of elastic consistency, not adherent to the deeper tissues, was observed in the ipsilateral retroauricular region (<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">In both the initial biopsy and the complete excision of the lesion, specimens were obtained for hematoxylin-eosin staining. Both specimens showed a well-defined, unencapsulated cystic tumor formed by several different-sized lobules composed of an external layer of basaloid cells and several layers of eosinophilic spindle cells with abrupt keratinization (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). No atypia or mitotic figures were observed at higher magnification (<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">Fine-needle aspiration of the retroauricular nodule revealed reactive lymphadenitis without evidence of tumor cells.</p><p id="par0025" class="elsevierStylePara elsevierViewall">What Is Your Diagnosis?</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Diagnosis</span><p id="par0030" class="elsevierStylePara elsevierViewall">Proliferating trichilemmal tumor (PTT).</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical Course and Treatment</span><p id="par0035" class="elsevierStylePara elsevierViewall">The lesion was completely excised with safety margins of 1<span class="elsevierStyleHsp" style=""></span>cm and no evidence of recurrence has been observed after 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">PTT is a rare malignancy derived from the follicular outer root sheath that was first described in 1966 by Wilson-Jones.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> PTT is more common in women over 60 years of age. The lesions are located on the scalp in 90% of cases, but other sites have also been reported. PTT can appear at the site of a preexisting trichilemmal cyst or arise de novo.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Clinically, PTT presents as a slow-growing tumor of variable size—from <1<span class="elsevierStyleHsp" style=""></span>cm to 25<span class="elsevierStyleHsp" style=""></span>cm—although in some cases the lesion can be fast-growing, which can indicate malignancy. In many cases, the lesion has a lobulated appearance, gradually becomes ulcerated, and can secrete a whitish, foul-smelling material.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Histologically, PTT is a lobulated tumor consisting of a basement membrane that delimits the lesion, a layer of palisading basaloid cells, and a squamous epithelium with an area of abrupt keratinization, giving rise to cystic cavities that contain a homogeneous eosinophilic material that can show foci of calcification in 25% of cases. Dyskeratosis, mitotic figures, and cells with low-grade nuclear atypia are observed in some cases.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Although the lesions can have an aggressive histologic appearance, the behavior of PTT is benign in most cases. However, there is a malignant variant that can cause lymph node or distant metastases in 30% of cases and is associated with high mortality.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Factors associated with a risk of malignant transformation include non-scalp location, history of rapid growth, size >5<span class="elsevierStyleHsp" style=""></span>cm, infiltrative growth pattern, and the presence of marked cytologic atypia with abundant mitotic figures.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Immunohistochemistry and flow cytometry can sometimes be useful to predict the behavior of these tumors, as it has been observed that some malignant PTTs have a higher rate of cell proliferation, decreased CD34 expression, and DNA aneuploidy, although the diagnosis should be based mainly on histologic findings.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">The differential diagnosis includes epidermoid carcinomas, epidermoid cysts, sweat gland tumors, dermatofibrosarcoma protuberans, pilomatrixomas, and angiosarcomas.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Treatment consists of surgical excision with safety margins of 1<span class="elsevierStyleHsp" style=""></span>cm (deep to the galea aponeurotica) or Mohs surgery because PTT is a tumor with a high rate of recurrence, despite its benign behavior.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">2,6</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">We have reported this case because PTT is a rare tumor that can have a very alarming clinical appearance, although histologic examination and clinical follow-up show it to be benign.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of Interest</span><p id="par0085" 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: Hermosa-Gelbard A, Moreno García del Real C, Vañó-Galván S. Tumoración en cuero cabelludo de gran tamaño de larga evolución con adenopatías ipsilaterales. Actas Dermosifiliogr. 2018;109:63–64.</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" => 1401 "Ancho" => 1067 "Tamanyo" => 481248 ] ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 875 "Ancho" => 1167 "Tamanyo" => 345862 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin-eosin, original magnification ×2.</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" => 875 "Ancho" => 1167 "Tamanyo" => 308144 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin-eosin, original magnification ×10.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Proliferating epidermoid cysts" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "E. 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Sangueza" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1524-4725.2007.33225.x" "Revista" => array:6 [ "tituloSerie" => "Dermatol Surg" "fecha" => "2007" "volumen" => "33" "paginaInicial" => "1102" "paginaFinal" => "1108" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17760602" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0045" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Proliferating trichilemmal tumors: Clinicopathologic evaluation is a guide to biologic behavior" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "A.L. Folpe" 1 => "A.K. Reisenauer" 2 => "T. Mentzel" 3 => "A. Rütten" 4 => "A.R. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 10 | 7 | 17 |
| 2024 Octubre | 67 | 29 | 96 |
| 2024 Septiembre | 58 | 14 | 72 |
| 2024 Agosto | 113 | 58 | 171 |
| 2024 Julio | 84 | 24 | 108 |
| 2024 Junio | 77 | 27 | 104 |
| 2024 Mayo | 76 | 29 | 105 |
| 2024 Abril | 73 | 17 | 90 |
| 2024 Marzo | 71 | 29 | 100 |
| 2024 Febrero | 80 | 39 | 119 |
| 2024 Enero | 51 | 27 | 78 |
| 2023 Diciembre | 128 | 13 | 141 |
| 2023 Noviembre | 169 | 21 | 190 |
| 2023 Octubre | 147 | 24 | 171 |
| 2023 Septiembre | 121 | 32 | 153 |
| 2023 Agosto | 79 | 16 | 95 |
| 2023 Julio | 102 | 30 | 132 |
| 2023 Junio | 56 | 20 | 76 |
| 2023 Mayo | 104 | 26 | 130 |
| 2023 Abril | 93 | 19 | 112 |
| 2023 Marzo | 74 | 25 | 99 |
| 2023 Febrero | 92 | 28 | 120 |
| 2023 Enero | 57 | 33 | 90 |
| 2022 Diciembre | 67 | 36 | 103 |
| 2022 Noviembre | 40 | 26 | 66 |
| 2022 Octubre | 40 | 19 | 59 |
| 2022 Septiembre | 27 | 29 | 56 |
| 2022 Agosto | 41 | 26 | 67 |
| 2022 Julio | 29 | 34 | 63 |
| 2022 Junio | 25 | 21 | 46 |
| 2022 Mayo | 43 | 44 | 87 |
| 2022 Abril | 56 | 49 | 105 |
| 2022 Marzo | 45 | 56 | 101 |
| 2022 Febrero | 23 | 33 | 56 |
| 2022 Enero | 53 | 41 | 94 |
| 2021 Diciembre | 40 | 49 | 89 |
| 2021 Noviembre | 40 | 53 | 93 |
| 2021 Octubre | 39 | 55 | 94 |
| 2021 Septiembre | 28 | 50 | 78 |
| 2021 Agosto | 32 | 50 | 82 |
| 2021 Julio | 23 | 35 | 58 |
| 2021 Junio | 20 | 47 | 67 |
| 2021 Mayo | 33 | 47 | 80 |
| 2021 Abril | 68 | 83 | 151 |
| 2021 Marzo | 60 | 54 | 114 |
| 2021 Febrero | 61 | 44 | 105 |
| 2021 Enero | 32 | 38 | 70 |
| 2020 Diciembre | 54 | 35 | 89 |
| 2020 Noviembre | 28 | 46 | 74 |
| 2020 Octubre | 18 | 24 | 42 |
| 2020 Septiembre | 30 | 22 | 52 |
| 2020 Agosto | 24 | 26 | 50 |
| 2020 Julio | 24 | 26 | 50 |
| 2020 Junio | 41 | 34 | 75 |
| 2020 Mayo | 25 | 18 | 43 |
| 2020 Abril | 24 | 13 | 37 |
| 2020 Marzo | 27 | 20 | 47 |
| 2020 Febrero | 5 | 0 | 5 |
| 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 | 4 | 1 | 5 |
| 2019 Abril | 2 | 0 | 2 |
| 2019 Marzo | 2 | 0 | 2 |
| 2018 Diciembre | 4 | 0 | 4 |
| 2018 Octubre | 1 | 0 | 1 |
| 2018 Septiembre | 5 | 0 | 5 |
| 2018 Febrero | 70 | 23 | 93 |
| 2018 Enero | 68 | 33 | 101 |
| 2017 Diciembre | 12 | 16 | 28 |
| 2017 Noviembre | 1 | 1 | 2 |
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