Case for Diagnosis
Snow Falling Sign in a Long-Standing Tumor
Tumor de larga evolución con patrón «en copos de nieve»
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The lesion had remained stable over time.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Physical Examination</span><p id="par0010" class="elsevierStylePara elsevierViewall">The lesion was nodular, elastic, well delimited, and flesh-colored with a violaceous-bluish tone. It was not adherent to deeper planes (<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">B-mode ultrasound with a linear 22<span class="elsevierStyleHsp" style=""></span>MHz probe (MyLab<span class="elsevierStyleSup">TM</span> Gamma Esaote) revealed a well-delimited dermal-hypodermal lesion with 2 clearly differentiated areas (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The first was a superficial, spherical, hypoechoic area with mobile hyperechoic structures in the interior that ran from the superior to the inferior pole to create a “snow falling” image (<a class="elsevierStyleCrossRef" href="#sec0050">Video 1 of the Additional material</a>). The second area was deeper, solid, heterogeneously echoic, and richly vascularized in color Doppler.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Histopathology</span><p id="par0020" class="elsevierStylePara elsevierViewall">The lesion was removed. Histopathology revealed a nonencapsulated well-delimited tumor (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>) with a large cystic component covered by a flat epithelium and a solid area. The solid area comprised 2 cell populations. The first cells had eosinophilic cytoplasm with oval or vesicular nuclei and prominent nucleoli (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>C). The second cell population comprised smaller cells with clear cytoplasm and small and eccentric nuclei (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>D). Apocrine decapitation secretion was visible in some areas, as were areas of ductal and squamous differentiation (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>B) and mucinous metaplasia in keloid-like stroma.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><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">Apocrine hidradenoma.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Progress</span><p id="par0035" class="elsevierStylePara elsevierViewall">The lesion was removed completely, with no recurrence after 1 year of follow-up.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Comment</span><p id="par0040" class="elsevierStylePara elsevierViewall">Apocrine hidradenoma, which is also known as clear cell hidradenoma, solid-cystic hidradenoma, nodular hidradenoma, and eccrine acrospiroma, is an uncommon benign tumor. Clinical diagnosis is often difficult owing to its variable clinical presentation and requires a high degree of suspicion. Therefore, the lesion generally has to be removed and undergo histology analysis in order to confirm the diagnosis.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The ultrasound characteristics of apocrine hidradenoma have received little attention in the literature.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1–5</span></a> The most commonly reported characteristic is the presence of a double solid-cystic component that is richly vascularized in Doppler color mode. It is important to remember that as some forms of apocrine hidradenoma are exclusively solid, other possible ultrasound findings should also be taken into consideration.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The presence of a fluid-fluid level and the snow falling sign, which are specific to this entity, were recently described.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">In the “fluid-fluid” pattern, we can see a cystic cavity with a clear level between a superior more hypoechoic area (less dense) and an inferior hyperechoic area (more dense). This finding highlights the presence of at least 2 fluids with different echodensity. While this finding is common in various fields of ultrasound imaging (eg, complicated hydroceles with hemorrhage or ovarian teratoma),<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a> it has not been reported in other dermatological conditions.</p><p id="par0060" class="elsevierStylePara elsevierViewall">In the snow falling sign, we can see mobile echogenic structures falling from the superior to the inferior pole within the tumor. The origin of these structures is not clear. A similar movement can be seen in some cases of hydrocele where the content is heterogeneous. The content of the cystic cavity in apocrine hidradenoma has not been established, although, in order to explain this phenomenon, we can postulate that it must be heterogeneous. The various theories on the origin of this heterogeneity include bleeding within the cystic cavity, detritus from the epithelium lining the cavity, or even the apocrine secretion found in some cells of this tumor.</p><p id="par0065" class="elsevierStylePara elsevierViewall">We report a new case of apocrine hidradenoma with ultrasound findings. We need studies that shed light on the composition of the cystic component of these tumors, as well as a description of the ultrasound findings in other variants of the condition.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of Interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Clinical History" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Physical Examination" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Additional Tests" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Histopathology" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Diagnosis" ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "Progress" ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Comment" ] 7 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflicts of Interest" ] 8 => array:2 [ "identificador" => "xack435375" "titulo" => "Acknowledgments" ] 9 => 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: Toro EMd, González YCP, Cembranos MDM. Tumor de larga evolución con patrón «en copos de nieve»Eczema y urticaria en Portugal. 2019;110:765–766.</p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0085" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0050" ] ] ] ] "multimedia" => array:4 [ 0 => array:6 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 500 "Ancho" => 500 "Tamanyo" => 41499 ] ] ] 1 => array:6 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 514 "Ancho" => 700 "Tamanyo" => 33799 ] ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 526 "Ancho" => 700 "Tamanyo" => 140510 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin-eosin: a) ×1; b) ×10; c) ×40; d) ×20.</p>" ] ] 3 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc1.mp4" "ficheroTamanyo" => 560100 "Video" => array:2 [ "flv" => array:5 [ "fichero" => "mmc1.flv" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "mp4" => array:5 [ "fichero" => "mmc1.m4v" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] ] ] "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" => "Eccrine acrospiroma of breast: Mammographic and ultrasound findings" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "S. 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José Luis Díaz Recuero and Alejandra Pérez Plaza for their help in the preparation of the article and to Dr. Luis Requena Caballero for his willingness and interest in teaching.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/15782190/0000011000000009/v2_201911260739/S1578219019302665/v2_201911260739/en/main.assets" "Apartado" => array:4 [ "identificador" => "6154" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case for Diagnosis" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15782190/0000011000000009/v2_201911260739/S1578219019302665/v2_201911260739/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219019302665?idApp=UINPBA000044" ]
| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 5 | 11 | 16 |
| 2024 Octubre | 80 | 80 | 160 |
| 2024 Septiembre | 73 | 67 | 140 |
| 2024 Agosto | 102 | 112 | 214 |
| 2024 Julio | 132 | 63 | 195 |
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| 2024 Enero | 65 | 33 | 98 |
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| 2023 Noviembre | 87 | 35 | 122 |
| 2023 Octubre | 58 | 27 | 85 |
| 2023 Septiembre | 57 | 32 | 89 |
| 2023 Agosto | 43 | 22 | 65 |
| 2023 Julio | 61 | 34 | 95 |
| 2023 Junio | 48 | 24 | 72 |
| 2023 Mayo | 50 | 29 | 79 |
| 2023 Abril | 41 | 24 | 65 |
| 2023 Marzo | 67 | 32 | 99 |
| 2023 Febrero | 45 | 27 | 72 |
| 2023 Enero | 47 | 41 | 88 |
| 2022 Diciembre | 56 | 47 | 103 |
| 2022 Noviembre | 66 | 30 | 96 |
| 2022 Octubre | 59 | 32 | 91 |
| 2022 Septiembre | 54 | 48 | 102 |
| 2022 Agosto | 65 | 40 | 105 |
| 2022 Julio | 57 | 46 | 103 |
| 2022 Junio | 43 | 38 | 81 |
| 2022 Mayo | 45 | 53 | 98 |
| 2022 Abril | 39 | 24 | 63 |
| 2022 Marzo | 58 | 58 | 116 |
| 2022 Febrero | 32 | 20 | 52 |
| 2022 Enero | 68 | 30 | 98 |
| 2021 Diciembre | 36 | 50 | 86 |
| 2021 Noviembre | 43 | 42 | 85 |
| 2021 Octubre | 55 | 47 | 102 |
| 2021 Septiembre | 33 | 35 | 68 |
| 2021 Agosto | 31 | 29 | 60 |
| 2021 Julio | 22 | 25 | 47 |
| 2021 Junio | 21 | 30 | 51 |
| 2021 Mayo | 38 | 35 | 73 |
| 2021 Abril | 57 | 91 | 148 |
| 2021 Marzo | 61 | 24 | 85 |
| 2021 Febrero | 52 | 22 | 74 |
| 2021 Enero | 29 | 10 | 39 |
| 2020 Diciembre | 30 | 15 | 45 |
| 2020 Noviembre | 17 | 16 | 33 |
| 2020 Octubre | 36 | 14 | 50 |
| 2020 Septiembre | 29 | 11 | 40 |
| 2020 Agosto | 21 | 14 | 35 |
| 2020 Julio | 9 | 13 | 22 |
| 2020 Junio | 15 | 23 | 38 |
| 2020 Mayo | 14 | 12 | 26 |
| 2020 Abril | 8 | 9 | 17 |
| 2020 Marzo | 10 | 5 | 15 |
| 2020 Febrero | 4 | 2 | 6 |
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