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The SCC was excised and the wound was closed with a graft&#46; The patient evolved well in the immediate and late postoperative period&#46; The anatomopathological examination showed tumor-free margins&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">NL is a chronic degenerative disease of the dermal connective tissue characterized clinically by yellowish plaques with a narrow granulomatous border&#44; central atrophy&#44; and a tendency to ulceration&#44; most commonly affecting the pre-tibial region of the lower limbs&#46; It is more frequently observed in diabetic patients and&#44; unlike in the reported&#44; most patients also present microvascular complications related to DM&#44; such as nephropathy and retinopathy&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The etiology and pathogenesis of NL are uncertain&#59; it is believed that external trauma&#44; primary vascular disorders&#44; and microangiopathy can contribute to its development&#44; regardless of the presence of DM&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The onset of SCC in areas of ulceration and scarring is well documented in a variety of skin diseases&#46; Ulceration is the main complication of NL&#44; observed in a quarter of patients with this disease&#46; However&#44; despite presenting a chronic course and a tendency to ulceration&#44; the onset of SCC in NL lesions has been seldom reported&#46; It is not clear whether the transformation to SCC is the result of chronic ulceration or of long-standing changes in NL&#46; Risk factors that may be involved in malignant transformation include loss of melanin&#44; which facilitates the lesion&#44; chronic inflammation&#44; and hypoxia&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> In the present patient&#44; the neoplasm presented as a new ulceration ten years after the diagnosis of the disease&#44; a long period &#8211; similarly to other cases described in the literature&#46; However&#44; unlike others&#44; the present case of SCC on an NL lesion did not have a history of recurrent or intractable ulcers&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Metastases have been described in the literature&#44; and may be related to delayed diagnosis &#40;ulcerations are common in NL&#44; delaying the diagnosis of SCC&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In the case reported&#44; diagnosis and treatment were performed early&#59; the patient is currently being followed-up and is without lymph node metastases or the appearance of new lesions&#46; To the best of the authors&#8217; knowledge&#44; this is the 17<span class="elsevierStyleSup">th</span> case reported in the international literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;5</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The onset of SCC on a NL lesion is very rare&#46; This possibility should be considered in patients with NL with chronic ulcers&#44; as well as in new lesions in patients with NL&#46; Early detection and treatment of SCC associated with NL is of fundamental importance to allow conservative surgical treatment and the best possible clinical outcome&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0040" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors&#8217; contributions</span><p id="par0045" class="elsevierStylePara elsevierViewall">Maria Em&#237;lia Vieira de Souza&#58; Approval of the final version of the manuscript&#59; conception and planning of the study&#59; elaboration and writing of the manuscript&#59; critical review of the literature&#59; critical review of the manuscript&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Julia Kanaan Recuero&#58; 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intellectual participation in propaedeutic and&#47;or therapeutic conduct of studied cases&#59; critical review of the literature&#59; critical review of the manuscript&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0065" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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Case Letter
Squamous cell carcinoma superimposed on necrobiosis lipoidica: a rare complication
Maria Emilia Vieira de Souzaa,b,
Autor para correspondência
maria.vsouza@hotmail.com

Corresponding author.
, Julia Kanaan Recuerob, Manoella Freitas Santosa,b, Renan Rangel Bonamigoa,b
a Department of Dermatology, Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, RS, Brazil
b Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Necrobiosis lipoidica &#40;NL&#41; is a chronic idiopathic disease&#44; of a granulomatous nature&#44; which affects the dermis&#46; The lesions are characterized by brownish-yellow plaques&#44; and the most common location is the pre-tibial region&#46; It more often affects females &#40;3&#58;1&#41; and appears&#44; in general&#44; from the third decade of life onwards&#46; There is an association with diabetes mellitus &#40;DM&#41;&#44; and microangiopathy is considered an etiopathogenic factor for the condition&#46; Ulceration is a common complication&#44; while reports of the onset of squamous cell carcinoma &#40;SCC&#41; in NL lesions are rare&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> After reviewing the literature&#44; 16 cases of SCC in NL lesions were retrieved&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">A 62-year-old female patient presented an ulcerated&#44; hyperkeratotic lesion in the NL area&#44; on the right leg&#44; about three months prior&#44; with no history of local trauma&#46; She had been diagnosed with NL in the pre-tibial region of both legs ten years before&#44; with no history of recurrent ulceration&#46; The patient had controlled systemic arterial hypertension and type 2 DM&#46; She used oral hypoglycemic agents&#44; with good control in the last years&#44; and did not present retinopathy or diabetic nephropathy&#46; At the physical examination&#44; the patient presented atrophic bilateral plaques on the pre-tibial region and&#44; on her right leg&#44; a small hyperkeratotic ulcerated plaque over a NL lesion &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The anatomopathological examination showed a moderately differentiated SCC with invasion of the reticular dermis in an NL lesion &#40;<a class="elsevierStyleCrossRefs" href="#fig0010">Figs&#46; 2 and 3</a>&#41;&#46; No palpable lymphadenomegalies were observed&#46; The SCC was excised and the wound was closed with a graft&#46; The patient evolved well in the immediate and late postoperative period&#46; The anatomopathological examination showed tumor-free margins&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">NL is a chronic degenerative disease of the dermal connective tissue characterized clinically by yellowish plaques with a narrow granulomatous border&#44; central atrophy&#44; and a tendency to ulceration&#44; most commonly affecting the pre-tibial region of the lower limbs&#46; It is more frequently observed in diabetic patients and&#44; unlike in the reported&#44; most patients also present microvascular complications related to DM&#44; such as nephropathy and retinopathy&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The etiology and pathogenesis of NL are uncertain&#59; it is believed that external trauma&#44; primary vascular disorders&#44; and microangiopathy can contribute to its development&#44; regardless of the presence of DM&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The onset of SCC in areas of ulceration and scarring is well documented in a variety of skin diseases&#46; Ulceration is the main complication of NL&#44; observed in a quarter of patients with this disease&#46; However&#44; despite presenting a chronic course and a tendency to ulceration&#44; the onset of SCC in NL lesions has been seldom reported&#46; It is not clear whether the transformation to SCC is the result of chronic ulceration or of long-standing changes in NL&#46; Risk factors that may be involved in malignant transformation include loss of melanin&#44; which facilitates the lesion&#44; chronic inflammation&#44; and hypoxia&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> In the present patient&#44; the neoplasm presented as a new ulceration ten years after the diagnosis of the disease&#44; a long period &#8211; similarly to other cases described in the literature&#46; However&#44; unlike others&#44; the present case of SCC on an NL lesion did not have a history of recurrent or intractable ulcers&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Metastases have been described in the literature&#44; and may be related to delayed diagnosis &#40;ulcerations are common in NL&#44; delaying the diagnosis of SCC&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In the case reported&#44; diagnosis and treatment were performed early&#59; the patient is currently being followed-up and is without lymph node metastases or the appearance of new lesions&#46; To the best of the authors&#8217; knowledge&#44; this is the 17<span class="elsevierStyleSup">th</span> case reported in the international literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;5</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The onset of SCC on a NL lesion is very rare&#46; This possibility should be considered in patients with NL with chronic ulcers&#44; as well as in new lesions in patients with NL&#46; Early detection and treatment of SCC associated with NL is of fundamental importance to allow conservative surgical treatment and the best possible clinical outcome&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0040" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors&#8217; contributions</span><p id="par0045" class="elsevierStylePara elsevierViewall">Maria Em&#237;lia Vieira de Souza&#58; Approval of the final version of the manuscript&#59; conception and planning of the study&#59; elaboration and writing of the manuscript&#59; critical review of the literature&#59; critical review of the manuscript&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Julia Kanaan Recuero&#58; Approval of the final version of the manuscript&#59; conception and planning of the study&#59; elaboration and writing of the manuscript&#59; obtaining&#44; analyzing&#44; and interpreting the data&#59; intellectual participation in propaedeutic and&#47;or therapeutic conduct of studied cases&#59; critical review of the literature&#59; critical review of the manuscript&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Manoella Freitas Santos&#58; Approval of the final version of the manuscript&#59; conception and planning of the study&#59; elaboration and writing of the manuscript&#59; critical review of the literature&#59; critical review of the manuscript&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Renan Rangel Bonamigo&#58; Approval of the final version of the manuscript&#44; conception and planning of the study&#44; elaboration and writing of the manuscript&#59; obtaining&#44; analyzing&#44; and interpreting the data&#59; effective participation in research orientation&#59; intellectual participation in propaedeutic and&#47;or therapeutic conduct of studied cases&#59; critical review of the literature&#59; critical review of the manuscript&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0065" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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