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mas aproximadamente&#160;10&#37;&#8208;20&#37; dos pacientes t&#234;m hist&#243;ria pr&#233;via de neoplasias hematol&#243;gicas&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">A NCDPB &#233; caracterizada por comportamento agressivo com r&#225;pida dissemina&#231;&#227;o&#46; Quando presentes&#44; as les&#245;es cut&#226;neas apresentam&#8208;se como placas&#44; p&#225;pulas ou n&#243;dulos&#44; &#250;nicas ou m&#250;ltiplas&#44; de consist&#234;ncia firme&#44; eritematosas e&#47;ou viol&#225;ceas&#44; pruriginosas ou n&#227;o&#46; Destaca&#8208;se que a NCDPB pode se apresentar inicialmente j&#225; com acometimento sist&#234;mico ou evoluir&#44; a partir da forma prim&#225;ria cut&#226;nea&#44; com acometimento secund&#225;rio de linfonodos e sintomas sist&#234;micos como perda ponderal&#46; A sobrevida m&#233;dia &#233; de poucos meses &#40;12&#160;a&#160;14&#160;meses&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1&#44;4</span></a> Dessa maneira&#44; por ser doen&#231;a extremamente rara e de manifesta&#231;&#245;es cl&#237;nicas variadas e ainda pouco descritas&#44; o diagn&#243;stico configura um desafio do ponto de vista cl&#237;nico e histopatol&#243;gico&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Diante do exposto&#44; o objetivo do presente artigo &#233; descrever um caso de NCDPB diagnosticado precocemente&#44; com enfoque nos achados histopatol&#243;gicos por meio da proposi&#231;&#227;o de fluxograma para diagn&#243;stico histopatol&#243;gico&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Relato do caso</span><p id="par0025" class="elsevierStylePara elsevierViewall">Paciente do sexo masculino&#44; 38&#160;anos&#44; apresentando&#44; ao exame cl&#237;nico dermatol&#243;gico&#44; placas e n&#243;dulos eritemato&#8208;viol&#225;ceos associadas a prurido e distribu&#237;das no tronco&#44; membros superiores e regi&#227;o frontal &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46; Negava perda ponderal&#44; febre ou linfonodomegalias e n&#227;o referia doen&#231;as pr&#233;vias de import&#226;ncia&#46; Foi realizada bi&#243;psia com as hip&#243;teses cl&#237;nicas de farmacodermia&#44; sarcoidose&#44; urtic&#225;ria vasculite e micose fungoide&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">O exame histopatol&#243;gico revelou um denso infiltrado d&#233;rmico superficial e profundo&#44; com acometimento difuso e perianexial&#46; O infiltrado estava caracterizado por c&#233;lulas com morfologia de blastos exibindo n&#250;cleos irregulares&#44; cromatina granulosa&#44; um ou v&#225;rios nucl&#233;olos&#44; citoplasma agranular e escasso &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>&#41;&#46; Havia mitoses frequentes &#40;mais de cinco mitoses por&#160;1&#160;mm<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a>&#41;&#44; incluindo formas at&#237;picas&#46; N&#227;o se observou necrose e angioinvas&#227;o&#46; A epiderme encontrava&#8208;se preservada e separada da neoplasia por uma zona grenz&#46; Ao estudo imuno&#8208;histoqu&#237;mico&#44; observou&#8208;se positividade para CD45&#44; CD4&#44; CD43&#44; CD56&#44; TDT&#44; CD123&#44; elevado &#237;ndice de prolifera&#231;&#227;o celular &#40;Ki&#8208;67 estimado em 50&#37;&#41; e negatividade para os demais marcadores testados &#40;CD3&#44; CD20&#44; CD30&#44; CD34&#44; CD138 e mieloperoxidase&#41; &#8211; <a class="elsevierStyleCrossRef" href="#tbl0005">tabela 1</a>&#44; <a class="elsevierStyleCrossRefs" href="#fig0015">figuras 3 e 4</a>&#46; Os exames complementares realizados &#40;tomografias de cr&#226;nio&#44; t&#243;rax e abdome&#59; coleta de l&#237;quor&#59; mielograma&#59; cari&#243;tipo de medula &#243;ssea&#59; imunofenotipagem de medula &#243;ssea e bi&#243;psia de medula &#243;ssea&#41; n&#227;o revelaram comprometimento extracut&#226;neo pela neoplasia&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">O esquema HyperCVAD &#40;ciclofosfamida hiperfracionada&#44; vincristina&#44; doxorrubicina e dexametasona alternado com altas doses de metotrexato e citarabina&#41; foi o tratamento utilizado&#44; obtendo&#8208;se bons resultados&#44; e o paciente segue em avalia&#231;&#227;o para poss&#237;vel&#160;transplante de medula &#243;ssea alog&#234;nico&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Discuss&#227;o</span><p id="par0040" class="elsevierStylePara elsevierViewall">Descrita pela primeira vez em&#160;1994 como linfoma de c&#233;lulas NK pela express&#227;o positiva de CD56&#44; apenas em&#160;2016 a NCDPB foi classificada como entidade pr&#243;pria pela Organiza&#231;&#227;o Mundial da Sa&#250;de&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">O progn&#243;stico ruim exige suspeita e diagn&#243;stico precoce para que o tratamento possa ser o mais eficaz poss&#237;vel&#46; Para patologistas cir&#250;rgicos&#44; a NCDPB deve ser lembrada em caso de infiltra&#231;&#227;o d&#233;rmica por neoplasia com morfologia de blastos&#46; Para o diagn&#243;stico final&#44; o estudo imuno&#8208;histoqu&#237;mico &#233; indispens&#225;vel&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Diante de um caso com infiltra&#231;&#227;o d&#233;rmica por uma neoplasia pouco diferenciada&#44; a marca&#231;&#227;o para CD45 confirma a origem hematolinfoide&#46; A negatividade para os marcadores CD3&#44; CD20&#44; CD138 e mieloperoxidase exclui diferencia&#231;&#227;o para linf&#243;cito&#160;T&#44; linf&#243;citos&#160;B&#44; plasm&#243;citos e diferencia&#231;&#227;o mieloide&#44; respectivamente&#46; A marca&#231;&#227;o para CD56 confirma o perfil citot&#243;xico&#46; Salienta&#8208;se que NCDPB tamb&#233;m apresenta express&#227;o de marcadores de c&#233;lulas&#160;T como CD4 e CD43&#44; assim como marcadores de neoplasias de c&#233;lulas imaturas como o TDT&#59; no entanto&#44; n&#227;o h&#225; express&#227;o de CD34&#44; marcador frequentemente positivo nos blastos &#40;<a class="elsevierStyleCrossRef" href="#fig0025">fig&#46; 5</a>&#41;&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Apesar da poss&#237;vel boa reposta inicial &#224; quimioterapia&#44; invariavelmente os casos apresentam recorr&#234;ncia &#8211; quadro leuc&#234;mico fulminante &#233; uma das principais causas de &#243;bito&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> Os principais diagn&#243;sticos diferenciais do ponto de vista histopatol&#243;gico s&#227;o&#58; infiltra&#231;&#227;o cut&#226;nea por neoplasias mieloproliferativas ou s&#237;ndrome mielodispl&#225;sicas&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1&#44;5</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Considerando as demais neoplasias cut&#226;neas CD56 positivas&#44; o diagn&#243;stico baseado no trip&#233; da cl&#237;nica&#44; morfologia microsc&#243;pica e resultado do estudo imuno&#8208;histoqu&#237;mico permite excluir os demais diagn&#243;sticos diferenciais&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a> Clinicamente&#44; &#233; poss&#237;vel excluir a possibilidade de papulose linfomatoide&#46; Al&#233;m disso&#44; a negatividade para CD30 auxilia na exclus&#227;o das neoplasias cut&#226;neas CD30 positivas&#46; Do ponto de vista morfol&#243;gico&#44; a aus&#234;ncia de necrose&#44; angiocentrismo e destrui&#231;&#227;o da parede vascular excluem a possibilidade de linfoma de c&#233;lulas T&#47;NK extranasal&#46; A infiltra&#231;&#227;o cut&#226;nea por leucemia mieloide aguda &#40;LMA&#41; CD56 positiva pode compartilhar marcadores imunofenot&#237;picos com a NCDPB&#59; no entanto&#44; LMA raramente ser&#225; positiva para CD123&#44; e mais comumente expressa mieloperoxidase&#44; marcador negativo na NCDPB&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Quanto &#224;s modalidades de tratamento&#44; ainda permanece discut&#237;vel o impacto da utiliza&#231;&#227;o da terapia&#8208;alvo anti&#8208;CD123 &#40;tagraxofusp&#41; para NCDPB&#46; No entanto&#44; estudos demonstram boa resposta da utiliza&#231;&#227;o desse f&#225;rmaco&#44; seja em primeira linha de tratamento ou na recorr&#234;ncia da doen&#231;a&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">H&#225; que se considerar que a baixa incid&#234;ncia da NCDPB influencia o pequeno n&#250;mero de possibilidades terap&#234;uticas dispon&#237;veis t&#227;o bem quanto dificulta o conhecimento mais profundo dessa neoplasia do ponto de vista molecular&#46; Salienta&#8208;se que&#44; de maneira contr&#225;ria &#224; falsa ideia de que doen&#231;as dermatol&#243;gicas apresentam bom progn&#243;stico&#44; a NCDPB deve ser reconhecida pelos dermatologistas e patologistas para agilizar o diagn&#243;stico e possibilitar o tratamento precoce&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Suporte financeiro</span><p id="par0075" class="elsevierStylePara elsevierViewall">Nenhum&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Contribui&#231;&#227;o dos autores</span><p id="par0080" class="elsevierStylePara elsevierViewall">Gabriel Taylor Castolde&#58; Revis&#227;o bibliogr&#225;fica e reda&#231;&#227;o do artigo&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Alexandre Lizardo Louren&#231;o Pontes&#58; Dermatologista respons&#225;vel pelo atendimento do paciente&#59; realiza&#231;&#227;o da bi&#243;psia e revis&#227;o cr&#237;tica do manuscrito final&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Gabriel Macedo Cortopassi&#58; Hematologista respons&#225;vel pelo tratamento&#44; aux&#237;lio na reda&#231;&#227;o do artigo e revis&#227;o cr&#237;tica do manuscrito final&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Jos&#233; C&#226;ndido Caldeira Xavier&#8208;J&#250;nior&#58; Concep&#231;&#227;o do artigo e do fluxograma&#59; reda&#231;&#227;o do artigo&#59; supervis&#227;o do trabalho e revis&#227;o da vers&#227;o final&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflito de interesses</span><p id="par0100" class="elsevierStylePara elsevierViewall">Nenhum&#46;</p></span></span>"
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                  \t\t\t\t">L26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Negativo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CD30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ber&#8208;H2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Negativo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CD34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">QBEnd 10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Negativo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CD43&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">DF&#8208;T1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Positivo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CD45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2B11<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>PD7&#47;26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Positivo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CD56&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">123C3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Positivo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CD68&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">PG&#8208;M1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Positivo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CD123&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6H6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Positivo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CD138&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">MI15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Negativo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">TDT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">EP266&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Positivo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mieloperoxidase&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Policlonal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Negativo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ki&#8208;67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">MIB&#8208;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Positivo &#40;alto &#237;ndice&#58; estimado em&#160;50&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                0 => array:2 [
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                        0 => array:2 [
                          "etal" => false
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                            2 => "S&#46;M&#46; El Jamal"
                            3 => "A&#46;A&#46; Lane"
                            4 => "J&#46; Mascarenhas"
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                    0 => array:2 [
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                      "doi" => "10.3324/haematol.2012.072645"
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Cartas ‐ Dermatopatologia
Neoplasia de células dendríticas plasmocitoides blásticas: dificuldade diagnóstica e proposta de fluxograma para diagnóstico histopatológico
Gabriel Taylor Castoldea, Alexandre Lizardo Lourenço Pontesb, Gabriel Macedo Cortopassib, José Cândido Caldeira Xavier‐Júniora,c,d,
Corresponding author
josecandidojr@yahoo.com.br

Autor para correspondência.
a Faculdade de Medicina, Centro Universitário Católico Unisalesiano Auxilium, Araçatuba, SP, Brasil
b Clínica Privada, Araçatuba, SP, Brasil
c Faculdade de Medicina, Universidade do Estado de São Paulo, Botucatu, SP, Brasil
d Instituto de Patologia de Araçatuba, Araçatuba, SP, Brasil
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mas aproximadamente&#160;10&#37;&#8208;20&#37; dos pacientes t&#234;m hist&#243;ria pr&#233;via de neoplasias hematol&#243;gicas&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">A NCDPB &#233; caracterizada por comportamento agressivo com r&#225;pida dissemina&#231;&#227;o&#46; Quando presentes&#44; as les&#245;es cut&#226;neas apresentam&#8208;se como placas&#44; p&#225;pulas ou n&#243;dulos&#44; &#250;nicas ou m&#250;ltiplas&#44; de consist&#234;ncia firme&#44; eritematosas e&#47;ou viol&#225;ceas&#44; pruriginosas ou n&#227;o&#46; Destaca&#8208;se que a NCDPB pode se apresentar inicialmente j&#225; com acometimento sist&#234;mico ou evoluir&#44; a partir da forma prim&#225;ria cut&#226;nea&#44; com acometimento secund&#225;rio de linfonodos e sintomas sist&#234;micos como perda ponderal&#46; A sobrevida m&#233;dia &#233; de poucos meses &#40;12&#160;a&#160;14&#160;meses&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1&#44;4</span></a> Dessa maneira&#44; por ser doen&#231;a extremamente rara e de manifesta&#231;&#245;es cl&#237;nicas variadas e ainda pouco descritas&#44; o diagn&#243;stico configura um desafio do ponto de vista cl&#237;nico e histopatol&#243;gico&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Diante do exposto&#44; o objetivo do presente artigo &#233; descrever um caso de NCDPB diagnosticado precocemente&#44; com enfoque nos achados histopatol&#243;gicos por meio da proposi&#231;&#227;o de fluxograma para diagn&#243;stico histopatol&#243;gico&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Relato do caso</span><p id="par0025" class="elsevierStylePara elsevierViewall">Paciente do sexo masculino&#44; 38&#160;anos&#44; apresentando&#44; ao exame cl&#237;nico dermatol&#243;gico&#44; placas e n&#243;dulos eritemato&#8208;viol&#225;ceos associadas a prurido e distribu&#237;das no tronco&#44; membros superiores e regi&#227;o frontal &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46; Negava perda ponderal&#44; febre ou linfonodomegalias e n&#227;o referia doen&#231;as pr&#233;vias de import&#226;ncia&#46; Foi realizada bi&#243;psia com as hip&#243;teses cl&#237;nicas de farmacodermia&#44; sarcoidose&#44; urtic&#225;ria vasculite e micose fungoide&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">O exame histopatol&#243;gico revelou um denso infiltrado d&#233;rmico superficial e profundo&#44; com acometimento difuso e perianexial&#46; O infiltrado estava caracterizado por c&#233;lulas com morfologia de blastos exibindo n&#250;cleos irregulares&#44; cromatina granulosa&#44; um ou v&#225;rios nucl&#233;olos&#44; citoplasma agranular e escasso &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>&#41;&#46; Havia mitoses frequentes &#40;mais de cinco mitoses por&#160;1&#160;mm<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a>&#41;&#44; incluindo formas at&#237;picas&#46; N&#227;o se observou necrose e angioinvas&#227;o&#46; A epiderme encontrava&#8208;se preservada e separada da neoplasia por uma zona grenz&#46; Ao estudo imuno&#8208;histoqu&#237;mico&#44; observou&#8208;se positividade para CD45&#44; CD4&#44; CD43&#44; CD56&#44; TDT&#44; CD123&#44; elevado &#237;ndice de prolifera&#231;&#227;o celular &#40;Ki&#8208;67 estimado em 50&#37;&#41; e negatividade para os demais marcadores testados &#40;CD3&#44; CD20&#44; CD30&#44; CD34&#44; CD138 e mieloperoxidase&#41; &#8211; <a class="elsevierStyleCrossRef" href="#tbl0005">tabela 1</a>&#44; <a class="elsevierStyleCrossRefs" href="#fig0015">figuras 3 e 4</a>&#46; Os exames complementares realizados &#40;tomografias de cr&#226;nio&#44; t&#243;rax e abdome&#59; coleta de l&#237;quor&#59; mielograma&#59; cari&#243;tipo de medula &#243;ssea&#59; imunofenotipagem de medula &#243;ssea e bi&#243;psia de medula &#243;ssea&#41; n&#227;o revelaram comprometimento extracut&#226;neo pela neoplasia&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">O esquema HyperCVAD &#40;ciclofosfamida hiperfracionada&#44; vincristina&#44; doxorrubicina e dexametasona alternado com altas doses de metotrexato e citarabina&#41; foi o tratamento utilizado&#44; obtendo&#8208;se bons resultados&#44; e o paciente segue em avalia&#231;&#227;o para poss&#237;vel&#160;transplante de medula &#243;ssea alog&#234;nico&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Discuss&#227;o</span><p id="par0040" class="elsevierStylePara elsevierViewall">Descrita pela primeira vez em&#160;1994 como linfoma de c&#233;lulas NK pela express&#227;o positiva de CD56&#44; apenas em&#160;2016 a NCDPB foi classificada como entidade pr&#243;pria pela Organiza&#231;&#227;o Mundial da Sa&#250;de&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">O progn&#243;stico ruim exige suspeita e diagn&#243;stico precoce para que o tratamento possa ser o mais eficaz poss&#237;vel&#46; Para patologistas cir&#250;rgicos&#44; a NCDPB deve ser lembrada em caso de infiltra&#231;&#227;o d&#233;rmica por neoplasia com morfologia de blastos&#46; Para o diagn&#243;stico final&#44; o estudo imuno&#8208;histoqu&#237;mico &#233; indispens&#225;vel&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Diante de um caso com infiltra&#231;&#227;o d&#233;rmica por uma neoplasia pouco diferenciada&#44; a marca&#231;&#227;o para CD45 confirma a origem hematolinfoide&#46; A negatividade para os marcadores CD3&#44; CD20&#44; CD138 e mieloperoxidase exclui diferencia&#231;&#227;o para linf&#243;cito&#160;T&#44; linf&#243;citos&#160;B&#44; plasm&#243;citos e diferencia&#231;&#227;o mieloide&#44; respectivamente&#46; A marca&#231;&#227;o para CD56 confirma o perfil citot&#243;xico&#46; Salienta&#8208;se que NCDPB tamb&#233;m apresenta express&#227;o de marcadores de c&#233;lulas&#160;T como CD4 e CD43&#44; assim como marcadores de neoplasias de c&#233;lulas imaturas como o TDT&#59; no entanto&#44; n&#227;o h&#225; express&#227;o de CD34&#44; marcador frequentemente positivo nos blastos &#40;<a class="elsevierStyleCrossRef" href="#fig0025">fig&#46; 5</a>&#41;&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Apesar da poss&#237;vel boa reposta inicial &#224; quimioterapia&#44; invariavelmente os casos apresentam recorr&#234;ncia &#8211; quadro leuc&#234;mico fulminante &#233; uma das principais causas de &#243;bito&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> Os principais diagn&#243;sticos diferenciais do ponto de vista histopatol&#243;gico s&#227;o&#58; infiltra&#231;&#227;o cut&#226;nea por neoplasias mieloproliferativas ou s&#237;ndrome mielodispl&#225;sicas&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1&#44;5</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Considerando as demais neoplasias cut&#226;neas CD56 positivas&#44; o diagn&#243;stico baseado no trip&#233; da cl&#237;nica&#44; morfologia microsc&#243;pica e resultado do estudo imuno&#8208;histoqu&#237;mico permite excluir os demais diagn&#243;sticos diferenciais&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a> Clinicamente&#44; &#233; poss&#237;vel excluir a possibilidade de papulose linfomatoide&#46; Al&#233;m disso&#44; a negatividade para CD30 auxilia na exclus&#227;o das neoplasias cut&#226;neas CD30 positivas&#46; Do ponto de vista morfol&#243;gico&#44; a aus&#234;ncia de necrose&#44; angiocentrismo e destrui&#231;&#227;o da parede vascular excluem a possibilidade de linfoma de c&#233;lulas T&#47;NK extranasal&#46; A infiltra&#231;&#227;o cut&#226;nea por leucemia mieloide aguda &#40;LMA&#41; CD56 positiva pode compartilhar marcadores imunofenot&#237;picos com a NCDPB&#59; no entanto&#44; LMA raramente ser&#225; positiva para CD123&#44; e mais comumente expressa mieloperoxidase&#44; marcador negativo na NCDPB&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Quanto &#224;s modalidades de tratamento&#44; ainda permanece discut&#237;vel o impacto da utiliza&#231;&#227;o da terapia&#8208;alvo anti&#8208;CD123 &#40;tagraxofusp&#41; para NCDPB&#46; No entanto&#44; estudos demonstram boa resposta da utiliza&#231;&#227;o desse f&#225;rmaco&#44; seja em primeira linha de tratamento ou na recorr&#234;ncia da doen&#231;a&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">H&#225; que se considerar que a baixa incid&#234;ncia da NCDPB influencia o pequeno n&#250;mero de possibilidades terap&#234;uticas dispon&#237;veis t&#227;o bem quanto dificulta o conhecimento mais profundo dessa neoplasia do ponto de vista molecular&#46; Salienta&#8208;se que&#44; de maneira contr&#225;ria &#224; falsa ideia de que doen&#231;as dermatol&#243;gicas apresentam bom progn&#243;stico&#44; a NCDPB deve ser reconhecida pelos dermatologistas e patologistas para agilizar o diagn&#243;stico e possibilitar o tratamento precoce&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Suporte financeiro</span><p id="par0075" class="elsevierStylePara elsevierViewall">Nenhum&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Contribui&#231;&#227;o dos autores</span><p id="par0080" class="elsevierStylePara elsevierViewall">Gabriel Taylor Castolde&#58; Revis&#227;o bibliogr&#225;fica e reda&#231;&#227;o do artigo&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Alexandre Lizardo Louren&#231;o Pontes&#58; Dermatologista respons&#225;vel pelo atendimento do paciente&#59; realiza&#231;&#227;o da bi&#243;psia e revis&#227;o cr&#237;tica do manuscrito final&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Gabriel Macedo Cortopassi&#58; Hematologista respons&#225;vel pelo tratamento&#44; aux&#237;lio na reda&#231;&#227;o do artigo e revis&#227;o cr&#237;tica do manuscrito final&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Jos&#233; C&#226;ndido Caldeira Xavier&#8208;J&#250;nior&#58; Concep&#231;&#227;o do artigo e do fluxograma&#59; reda&#231;&#227;o do artigo&#59; supervis&#227;o do trabalho e revis&#227;o da vers&#227;o final&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflito de interesses</span><p id="par0100" class="elsevierStylePara elsevierViewall">Nenhum&#46;</p></span></span>"
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                  \t\t\t\t">L26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Negativo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CD30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ber&#8208;H2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Negativo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CD34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">QBEnd 10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Negativo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CD43&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">DF&#8208;T1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Positivo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CD45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2B11<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>PD7&#47;26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Positivo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CD56&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">123C3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Positivo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CD68&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">PG&#8208;M1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Positivo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CD123&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6H6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Positivo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CD138&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">MI15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Negativo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">TDT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">EP266&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Positivo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mieloperoxidase&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Policlonal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Negativo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ki&#8208;67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">MIB&#8208;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Positivo &#40;alto &#237;ndice&#58; estimado em&#160;50&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "pt" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Resultado de painel imuno&#8208;histoqu&#237;mico aplicado no presente caso</p>"
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                        0 => array:2 [
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                            0 => "S&#46; Venugopal"
                            1 => "S&#46; Zhou"
                            2 => "S&#46;M&#46; El Jamal"
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                      "doi" => "10.1016/j.clml.2019.06.002"
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ISSN: 26662752
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Idiomas
Anais Brasileiros de Dermatologia
en pt
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