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soft nodular lesion&#44; measuring 1 to 10&#160;cm in diameter&#44; on the scalp of elderly women&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3</span></a> and may be associated with an area of alopecia&#46; More rarely&#44; it can affect other topographies such as the neck&#44; trunk&#44; groin&#44; mons pubis&#44; vulva&#44; gluteal region&#44; and skull base&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">This report describes the case of a 52-year-old male patient&#44; with no comorbidities&#44; who sought medical care complaining of a lesion on the scalp&#44; with discomfort on palpation&#44; that had been growing for about a year&#46; He had a personal history of scalp cyst removal years before&#46; On clinical examination&#44; a tumor-like&#44; erythematous lesion with a pedunculated structure in the center&#44; measuring approximately 3&#160;cm in its largest diameter&#44; was observed in the parieto-occipital region &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The main hypothesis was trichilemmal cyst with atypical clinical presentation and&#44; for this reason&#44; an incisional spindle biopsy was performed&#44; measuring about 2&#160;cm in its largest diameter for anatomopathological analysis&#46; Histopathology showed a dermal tumor&#44; with no connection with the epidermis&#44; consisting of an expansive lobular proliferation of squamous cells with ample eosinophilic cytoplasm and abrupt keratinization&#44; without the formation of a granular layer - trichilemmal-type keratinization &#8210; in the central portion of the lobes &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Some of these cells had atypical nuclei&#44; but no mitosis &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#44; findings consistent with a proliferating trichilemmal tumor&#46; The patient was referred for complete excision of the lesion and showed good evolution&#44; with no signs of recurrence to date&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The anatomopathological analysis is crucial for the diagnosis of PTT&#44; because clinically&#44; as in the case reported herein&#44; it can be mistaken for a trichilemmal cyst&#44; or other adnexal tumors&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> What histopathologically characterizes this tumor is the proliferation of squamous cells with trichilemmal keratinization &#40;defined by the abrupt transition from nucleated to anucleated epithelial cells&#44; with the absence of a granular layer&#41; and varying degrees of atypia&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a> The presence of poorly-defined borders&#44; high-grade atypia&#44; aneuploidy&#44; necrosis&#44; cellular pleomorphism and atypical mitoses are related to malignancy &#40;malignant proliferating trichilemmal tumor&#41; and&#44; in this case&#44; distant metastases may rarely appear&#44; even years after the excision of the primary tumor&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3&#44;5</span></a> Immunohistochemistry can be used to help in the detection of malignancy&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Treatment consists of surgical excision&#44; with margins ranging from 1&#160;cm to large resections&#44; depending on the histopathology of the tumor&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3</span></a> Radiotherapy and chemotherapy have been described as alternative or adjuvant treatments&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3</span></a> To reduce the risk of recurrence&#44; the evaluation of the margins with Mohs micrographic surgery is the procedure of choice&#44;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3&#44;4</span></a> as well as the close follow-up of these patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0025" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors&#39; contributions</span><p id="par0030" class="elsevierStylePara elsevierViewall">Andrea Ab&#234; Pereira&#58; Critical review of the literature&#59; drafting and editing of the manuscript&#59; approval of the final version of the manuscript&#59; design and planning of the study&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">J&#233;ssica L&#252;ders Bueno&#58; Critical review of the literature&#59; approval of the final version of the manuscript&#59; design and planning of the study&#59; drafting and editing of the manuscript&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Ana Let&#237;cia Boff&#58; Drafting and editing of the manuscript&#59; collection&#44; analysis and interpretation of data&#59; critical review of the manuscript&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Paulo Ricardo Martins Souza&#58; Approval of the final version of the manuscript&#59; design and planning of the study&#59; drafting and editing of the manuscript&#59; collection&#44; analysis and interpretation of data&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the 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="par0050" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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Letter - Clinical
Proliferating trichilemmal tumor
Andrea Abê Pereiraa,b,
Autor para correspondência
andrea.abetm@gmail.com

Corresponding author.
, Jéssica Lüders Buenoa,b, Ana Letícia Boffa,b, Paulo Ricardo Martins Souzaa,b
a Department of Dermatology, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brazil
b Department of Dermatology, Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, RS, Brazil
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Proliferating trichilemmal tumor &#40;PTT&#41; is a rare adnexal neoplasm<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> derived from the outer sheath of the hair follicle and may originate from a pre-existing pilar&#47;trichilemmal cyst as a result of trauma and&#47;or inflammation in the latter&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3</span></a> It was first reported in 1966 by Wilson Jones<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;4&#44;5</span></a> and it is benign in most cases<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a> but eventually it can be malignant&#44; recur locally&#44; invade adjacent tissues and cause distant metastases&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3&#8211;5</span></a> It often presents as a solitary&#44; soft nodular lesion&#44; measuring 1 to 10&#160;cm in diameter&#44; on the scalp of elderly women&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3</span></a> and may be associated with an area of alopecia&#46; More rarely&#44; it can affect other topographies such as the neck&#44; trunk&#44; groin&#44; mons pubis&#44; vulva&#44; gluteal region&#44; and skull base&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">This report describes the case of a 52-year-old male patient&#44; with no comorbidities&#44; who sought medical care complaining of a lesion on the scalp&#44; with discomfort on palpation&#44; that had been growing for about a year&#46; He had a personal history of scalp cyst removal years before&#46; On clinical examination&#44; a tumor-like&#44; erythematous lesion with a pedunculated structure in the center&#44; measuring approximately 3&#160;cm in its largest diameter&#44; was observed in the parieto-occipital region &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The main hypothesis was trichilemmal cyst with atypical clinical presentation and&#44; for this reason&#44; an incisional spindle biopsy was performed&#44; measuring about 2&#160;cm in its largest diameter for anatomopathological analysis&#46; Histopathology showed a dermal tumor&#44; with no connection with the epidermis&#44; consisting of an expansive lobular proliferation of squamous cells with ample eosinophilic cytoplasm and abrupt keratinization&#44; without the formation of a granular layer - trichilemmal-type keratinization &#8210; in the central portion of the lobes &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Some of these cells had atypical nuclei&#44; but no mitosis &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#44; findings consistent with a proliferating trichilemmal tumor&#46; The patient was referred for complete excision of the lesion and showed good evolution&#44; with no signs of recurrence to date&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The anatomopathological analysis is crucial for the diagnosis of PTT&#44; because clinically&#44; as in the case reported herein&#44; it can be mistaken for a trichilemmal cyst&#44; or other adnexal tumors&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> What histopathologically characterizes this tumor is the proliferation of squamous cells with trichilemmal keratinization &#40;defined by the abrupt transition from nucleated to anucleated epithelial cells&#44; with the absence of a granular layer&#41; and varying degrees of atypia&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a> The presence of poorly-defined borders&#44; high-grade atypia&#44; aneuploidy&#44; necrosis&#44; cellular pleomorphism and atypical mitoses are related to malignancy &#40;malignant proliferating trichilemmal tumor&#41; and&#44; in this case&#44; distant metastases may rarely appear&#44; even years after the excision of the primary tumor&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3&#44;5</span></a> Immunohistochemistry can be used to help in the detection of malignancy&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Treatment consists of surgical excision&#44; with margins ranging from 1&#160;cm to large resections&#44; depending on the histopathology of the tumor&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3</span></a> Radiotherapy and chemotherapy have been described as alternative or adjuvant treatments&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3</span></a> To reduce the risk of recurrence&#44; the evaluation of the margins with Mohs micrographic surgery is the procedure of choice&#44;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3&#44;4</span></a> as well as the close follow-up of these patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0025" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors&#39; contributions</span><p id="par0030" class="elsevierStylePara elsevierViewall">Andrea Ab&#234; Pereira&#58; Critical review of the literature&#59; drafting and editing of the manuscript&#59; approval of the final version of the manuscript&#59; design and planning of the study&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">J&#233;ssica L&#252;ders Bueno&#58; Critical review of the literature&#59; approval of the final version of the manuscript&#59; design and planning of the study&#59; drafting and editing of the manuscript&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Ana Let&#237;cia Boff&#58; Drafting and editing of the manuscript&#59; collection&#44; analysis and interpretation of data&#59; critical review of the manuscript&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Paulo Ricardo Martins Souza&#58; Approval of the final version of the manuscript&#59; design and planning of the study&#59; drafting and editing of the manuscript&#59; collection&#44; analysis and interpretation of data&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the 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="par0050" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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