Case for Diagnosis
A Nodule on the Breast after Radiation Therapy
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Pindado-Ortega, D. Ortega-Quijano, R. Carrillo-Gijón" "autores" => array:3 [ 0 => array:4 [ "nombre" => "C." "apellidos" => "Pindado-Ortega" "email" => array:1 [ 0 => "cpindadoortega@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "D." "apellidos" => "Ortega-Quijano" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "R." "apellidos" => "Carrillo-Gijón" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Departamento de Dermatología, Hospital Ramón y Cajal, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Dermopatología, Hospital Ramón y Cajal, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1610 "Ancho" => 750 "Tamanyo" => 391312 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">B) Hematoxilina-eosina, ×20. C) Hematoxilina-eosina, ×200.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Clinical findings</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 61-year-old woman was referred to our department due to a 3 mm violaceus papule located on the presternal area (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). There was neither regional lymph node enlargement nor systemic involvement. She had a history of left breast ductal carcinoma in situ in December 2014. She underwent conservative breast surgery plus ipsilateral axillary lymph node dissection. Tumor margins and lymph nodes were free of disease. She was prescribed Letrozol and a course of postoperative radiotherapy.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Histopathological findings</span><p id="par0010" class="elsevierStylePara elsevierViewall">Histological examination showed a dome-shaped, well circumscribed, nodular lesion in the upper dermis (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B). It was composed of a predominantly solid proliferation of large epithelioid cells with ample eosinophilic cytoplasm, enlarged vesicular nuclei and prominent nucleoli. Some of these cells showed intracytoplasmic vacuoles. There were numerous intralesional vascular channels containing erythrocytes and scattered inflammatory cells, predominantly neutrophils and eosinophils (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C). Mitoses were sparse, and none of them atypical. Dilated vascular spaces and mild fibrosis were evident in perilesional areas. The immunohistochemical staining was positive for CD31 in the epithelioid cells, as well as in the vascular endothelial cells, CD34 and factor VIII; they were negative for cytokeratins 8, 18,19, CD30, CD68, Melan-A, S100, D2-40, c-MYC, GATA 3 and estrogen receptor. Ki-67 status was 10%.</p><p id="par0015" class="elsevierStylePara elsevierViewall">What is your diagnosis?</p><p id="par0020" class="elsevierStylePara elsevierViewall">DIAGNOSIS</p><p id="par0025" class="elsevierStylePara elsevierViewall">Cutaneous Epithelioid Angiomatous Nodule</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">Cutaneous Epithelioid Angiomatous Nodule (CEAN) is an uncommon benign lesion with distinctive histological features. It is characterized by a well-delimited, predominantly solid vascular proliferation in the superficial dermis. Well defined vessels are frequently found permeating the lesion, which also shows a certain degree of inflammatory infiltration. It is composed by large, epithelioid, endothelial cells that contain vesicular nuclei and prominent nucleoli.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The abundant cytoplasm consistently contains intracytoplasmic vacuoles.</p><p id="par0035" class="elsevierStylePara elsevierViewall">It clinically presents as a small, fast-growing, small reddish papule or nodule, most frequently located on the head, neck, trunk or limbs of adults. Most cases are solitary, but multiple lesions have been documented.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The differential diagnosis includes several benign and malignant vascular neoplasms in which epithelioid cells can be seen.</p><p id="par0045" class="elsevierStylePara elsevierViewall">In this case, due to the patient's history of breast radiotherapy and peculiar histology of the lesion, a differential diagnosis must be made with radiation-induced angiosarcoma (RIA). RIA is an uncommon complication after radiotherapy for breast cancer with an incidence of 0.05–0.3% which usually bears very poor prognosis<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>. Histologically, it is a malignant tumor that frequently shows solid component and irregular vascular channels. Despite the more aggressive clinical behavior, the epithelioid variant of angiosarcoma (EA) shares some morphologic features with CEAN. Pleomorphism of the cells and high number of mitosis, some of them atypical, are clues for the diagnosis. Positive immunohistochemical staining for CD31, CD34 and factor VIII confirms endothelial differentiation, while c-MYC positivity and a high Ki67 index (>40%) in both the solid component and the vascular channels are consistent markers of malignancy.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Epithelioid hemangioendotelioma (EHE) is an intermediate malignant potential tumor, composed of nests of epithelioid endothelial cells. EHE may show significant histologic overlap with CEAN. However, EHE typically occurs as a nonvasoformative nodule composed of cords and strands of epithelioid cells embedded in a fibromyxoid stroma. The cells usually show various degrees of pleomorphism, and mitotic figures are conspicuous, including the presence of atypical ones.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">For some authors CEAN can be classified inside the spectrum of angiolymphoid hyperplasia with eosinophilia (ALHE), also known as epithelioid hemangioma. They appear as loosely lobed proliferations of capillary-sized vessels coated with large endothelium that shows identical characteristics of the endothelium of CEAN. An inflammatory infiltrate composed mainly of lymphocytes and eosinophils is quite characteristic, and more prominent in ALHE than in CEAN.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Other differential diagnosis include amelanotic melanoma, ductal breast carcinoma, Langerhans cell histiocytosis and CD-30 positive proliferations.</p><p id="par0065" class="elsevierStylePara elsevierViewall">To conclude, CAEN is a benign, uncommon vascular tumor with no recurrence or metastasis reported to date. Physicians should bear it in mind within the differential diagnosis of vascular tumors in the skin.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Funding sources</span><p id="par0105" class="elsevierStylePara elsevierViewall">None.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Clinical findings" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Histopathological findings" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 3 => array:2 [ "identificador" => "sec0040" "titulo" => "Funding sources" ] 4 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-01-31" "fechaAceptado" => "2018-05-28" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Pindado-Ortega C, Ortega-Quijano D, Carrillo-Gijón R. Nódulo en mama tras radioterapia. Actas Dermo-Sifiliográficas. 2019;110:859–860.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1610 "Ancho" => 750 "Tamanyo" => 391312 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">B) Hematoxilina-eosina, ×20. C) Hematoxilina-eosina, ×200.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "[1]" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cutaneous epithelioid angiomatous nodule: a case series and proposed classification" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "O.P. Sangüeza" 1 => "S.N. Walsh" 2 => "D.J. Sheehan" 3 => "A.F. Orland" 4 => "B. Llombart" 5 => "L. 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"fecha" => "2015" "volumen" => "139" "numero" => "April (5)" "paginaInicial" => "683" "paginaFinal" => "686" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25927152" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/15782190/0000011000000010/v1_201912080808/S157821901930294X/v1_201912080808/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/15782190/0000011000000010/v1_201912080808/S157821901930294X/v1_201912080808/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S157821901930294X?idApp=UINPBA000044" ]
| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 17 | 12 | 29 |
| 2024 Octubre | 134 | 58 | 192 |
| 2024 Septiembre | 149 | 34 | 183 |
| 2024 Agosto | 161 | 66 | 227 |
| 2024 Julio | 168 | 42 | 210 |
| 2024 Junio | 138 | 61 | 199 |
| 2024 Mayo | 160 | 55 | 215 |
| 2024 Abril | 143 | 33 | 176 |
| 2024 Marzo | 110 | 35 | 145 |
| 2024 Febrero | 131 | 34 | 165 |
| 2024 Enero | 137 | 33 | 170 |
| 2023 Diciembre | 98 | 21 | 119 |
| 2023 Noviembre | 135 | 33 | 168 |
| 2023 Octubre | 107 | 34 | 141 |
| 2023 Septiembre | 67 | 21 | 88 |
| 2023 Agosto | 55 | 18 | 73 |
| 2023 Julio | 100 | 33 | 133 |
| 2023 Junio | 68 | 26 | 94 |
| 2023 Mayo | 73 | 22 | 95 |
| 2023 Abril | 46 | 26 | 72 |
| 2023 Marzo | 52 | 27 | 79 |
| 2023 Febrero | 73 | 24 | 97 |
| 2023 Enero | 24 | 30 | 54 |
| 2022 Diciembre | 51 | 39 | 90 |
| 2022 Noviembre | 40 | 32 | 72 |
| 2022 Octubre | 34 | 25 | 59 |
| 2022 Septiembre | 27 | 35 | 62 |
| 2022 Agosto | 33 | 36 | 69 |
| 2022 Julio | 26 | 53 | 79 |
| 2022 Junio | 17 | 37 | 54 |
| 2022 Mayo | 54 | 50 | 104 |
| 2022 Abril | 74 | 33 | 107 |
| 2022 Marzo | 64 | 62 | 126 |
| 2022 Febrero | 51 | 30 | 81 |
| 2022 Enero | 40 | 40 | 80 |
| 2021 Diciembre | 35 | 38 | 73 |
| 2021 Noviembre | 56 | 50 | 106 |
| 2021 Octubre | 62 | 49 | 111 |
| 2021 Septiembre | 36 | 29 | 65 |
| 2021 Agosto | 36 | 20 | 56 |
| 2021 Julio | 25 | 17 | 42 |
| 2021 Junio | 23 | 20 | 43 |
| 2021 Mayo | 27 | 38 | 65 |
| 2021 Abril | 62 | 112 | 174 |
| 2021 Marzo | 37 | 33 | 70 |
| 2021 Febrero | 35 | 19 | 54 |
| 2021 Enero | 26 | 16 | 42 |
| 2020 Diciembre | 20 | 11 | 31 |
| 2020 Noviembre | 22 | 14 | 36 |
| 2020 Octubre | 23 | 11 | 34 |
| 2020 Septiembre | 15 | 11 | 26 |
| 2020 Agosto | 19 | 17 | 36 |
| 2020 Julio | 17 | 10 | 27 |
| 2020 Junio | 11 | 17 | 28 |
| 2020 Mayo | 21 | 13 | 34 |
| 2020 Abril | 15 | 15 | 30 |
| 2020 Marzo | 39 | 17 | 56 |
| 2020 Febrero | 7 | 4 | 11 |
| 2020 Enero | 1 | 2 | 3 |
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