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but a cutaneous metastasis needed to be ruled out&#46; Complete lesion excision revealed a dermal proliferation of mononucleated foamy histiocytes and Touton&#8217;s giant cells&#44; which were positive for CD68 and negative for S100 and CD1a immunohistochemical stains &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; A diagnosis of solitary adult xanthogranuloma was made&#46; After complete excision&#44; the lesion has not recurred&#46; The patient remains in complete remission of her breast carcinoma&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Adult xanthogranuloma is a subtype of non-Langerhans Cell Histiocytosis &#40;LCH&#41; belonging to the xanthogranuloma family&#44; classified into the C &#40;&#8220;Cutaneous&#8221;&#41; group of the revised classification of histiocytoses&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Adult xanthogranuloma is histologically identical to Juvenile Xanthogranuloma &#40;JXG&#41;&#44; the most common non-LCH&#46; It usually presents in males in the first two decades of life&#44; and the most common presentation is a solitary asymptomatic papule or nodule varying from 5&#8239;mm to 1&#8210;2&#8239;cm in size&#44; with a translucent&#44; smooth&#44; yellowish to brownish surface and occasional telangiectasias&#46; In adults&#44; this lesion tends to persist over time&#44; rather than involute with time as in children&#46; Adult and juvenile xanthogranulomas are usually located in the head and neck region&#44; followed by the trunk and extremities&#59; however&#44; all cutaneous locations have been described&#44; including palms and soles&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Case reports including cases of JXG on the volar surfaces &#40;palms and soles&#41; have described unusual colors appearing in this location&#44; such as dull red or flesh-colored&#44; and a well-defined hyperkeratotic peripheral rim upon dermoscopy&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Typical dermoscopic findings of adult and juvenile xanthogranuloma include a yellow&#47;orange and red&#47;pink homogeneous background&#44; often referred to as the &#8216;setting sun&#8217; pattern&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Clinical differential diagnosis includes several benign and malignant tumors&#44; such as Spitz nevus&#44; dermatofibroma&#44; adnexal neoplasms&#44; molluscum contagiosum&#44; hemangioma&#44; basal cell carcinoma&#44; amelanotic melanoma&#44; and lymphomas&#46; On volar locations&#44; the differential diagnosis must include volar neoplasms such as eccrine poroma&#44; pyogenic granuloma&#44; digital fibrokeratoma&#44; nevi&#44; viral verruca&#44; amelanotic melanoma&#44; and solitary reticulohistiocytoma&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> There are few reports describing the sonographic characteristics of xanthogranulomas&#46; These present as a well-defined hypoechoic dermal nodule&#44; with thin low-velocity arterial vascularity &#40;maximum peak systolic velocity&#44; 6&#46;5&#8239;cm&#47;s&#41; detected internally on color Doppler ultrasonography&#46; No posterior enhancement or acoustic shadowing artifact has been reported&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In this case&#44; a cutaneous metastasis had to be ruled out given the patient&#8217;s past medical history&#46; Excluding melanoma&#44; breast carcinoma is the most frequent source of cutaneous metastasis in women&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Because of its high incidence&#44; breast carcinoma cutaneous metastases are the cutaneous metastases most frequently evaluated by dermatologists&#46; The most common presentation of breast cancer cutaneous metastasis is an asymptomatic&#44; skin-colored&#44; or pink-brown nodule located on the chest wall or abdomen which might also occur on the extremities&#46; A wide spectrum of clinical presentations has been described in cutaneous breast cancer metastases&#44; which might mimic a wide variety of benign skin lesions&#44; such as acral fibrokeratoma&#44; pyogenic granuloma&#44; follicular cysts&#44; dermatofibromas or hemangioma&#44; included in the differential diagnosis of adult xanthogranuloma&#46; Ultrasound examination has proven to be a useful tool to support the diagnosis of cutaneous metastasis of melanoma&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> There is less evidence supporting the use of ultrasonography for the detection of cutaneous metastasis of solid tumors&#44; however&#44; this technique has been shown to aid in the diagnosis of malignant nodular and subcutaneous lesions in small series&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9</span></a> Sonographic characteristics suggestive of cutaneous metastases include polycyclic shape and hypervascularity with multiple peripheral poles and internal vessels&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Cutaneous metastases herald a poor prognosis&#44; hence the importance of dermatology in determining an early diagnosis&#46;</p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Financial support</span><p id="par0020" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Authors&#8217; contributions</span><p id="par0025" class="elsevierStylePara elsevierViewall">Laura Serra-Garc&#237;a&#58; Effective participation in critical review of the literature&#44; drafting and editing of the manuscript and approval of the final version of the manuscript&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Cristina Carrera&#58; Intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#59; critical review of the manuscript&#59; approval of the final version of the manuscript&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Priscila Giavedoni&#58; Intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#59; critical review of the manuscript&#59; approval of the final version of the manuscript&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Constanza Riquelme-Mc Loughlin&#58; Effective participation in research orientation&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#59; critical review of the manuscript&#59; approval of the final version of the manuscript&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conflicts of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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Letter - Clinical
Solitary palmar adult xanthogranuloma
Laura Serra-García, Cristina Carrera, Priscila Giavedoni, Constanza Riquelme-Mc Loughlin
Autor para correspondência
mcriquelme@clinic.cat

Corresponding author.
Department of Dermatology, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, Spain
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    "titulo" => "Solitary palmar adult xanthogranuloma"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Histological characteristics of volar adult xanthogranuloma&#46; &#40;A and B&#41; Dermal proliferation of mononucleated foamy histiocytes and Touton&#8217;s giant cells &#40;Hematoxylin &#38; eosin&#44; &#215;40 and &#215;400&#44; respectively&#41;&#46; &#40;C and D&#41; Immunohistochemical stains revealing CD68 positive and CD1a negative foamy histiocytes&#44; respectively &#40;magnification &#215;200&#41;&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 45-year-old woman with a history of breast cancer two years earlier&#44; consulted for an enlarging asymptomatic lesion on the right palm which had appeared 4 months prior to consultation&#46; During physical examination&#44; she presented a 5&#8239;mm dome-shaped yellowish papule with a desquamative peripheral rim &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;&#46; Dermoscopy revealed homogeneous symmetric yellow structure-less areas with a central crust and pink surrounding rim &#40;&#8216;setting sun&#8217; pattern&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41;&#46; Skin ultrasound revealed a round hypoechoic lesion occupying dermis and hypodermis&#44; with multiple peripheral small vessels &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; A benign adnexal tumor was suspected&#44; but a cutaneous metastasis needed to be ruled out&#46; Complete lesion excision revealed a dermal proliferation of mononucleated foamy histiocytes and Touton&#8217;s giant cells&#44; which were positive for CD68 and negative for S100 and CD1a immunohistochemical stains &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; A diagnosis of solitary adult xanthogranuloma was made&#46; After complete excision&#44; the lesion has not recurred&#46; The patient remains in complete remission of her breast carcinoma&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Adult xanthogranuloma is a subtype of non-Langerhans Cell Histiocytosis &#40;LCH&#41; belonging to the xanthogranuloma family&#44; classified into the C &#40;&#8220;Cutaneous&#8221;&#41; group of the revised classification of histiocytoses&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Adult xanthogranuloma is histologically identical to Juvenile Xanthogranuloma &#40;JXG&#41;&#44; the most common non-LCH&#46; It usually presents in males in the first two decades of life&#44; and the most common presentation is a solitary asymptomatic papule or nodule varying from 5&#8239;mm to 1&#8210;2&#8239;cm in size&#44; with a translucent&#44; smooth&#44; yellowish to brownish surface and occasional telangiectasias&#46; In adults&#44; this lesion tends to persist over time&#44; rather than involute with time as in children&#46; Adult and juvenile xanthogranulomas are usually located in the head and neck region&#44; followed by the trunk and extremities&#59; however&#44; all cutaneous locations have been described&#44; including palms and soles&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Case reports including cases of JXG on the volar surfaces &#40;palms and soles&#41; have described unusual colors appearing in this location&#44; such as dull red or flesh-colored&#44; and a well-defined hyperkeratotic peripheral rim upon dermoscopy&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Typical dermoscopic findings of adult and juvenile xanthogranuloma include a yellow&#47;orange and red&#47;pink homogeneous background&#44; often referred to as the &#8216;setting sun&#8217; pattern&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Clinical differential diagnosis includes several benign and malignant tumors&#44; such as Spitz nevus&#44; dermatofibroma&#44; adnexal neoplasms&#44; molluscum contagiosum&#44; hemangioma&#44; basal cell carcinoma&#44; amelanotic melanoma&#44; and lymphomas&#46; On volar locations&#44; the differential diagnosis must include volar neoplasms such as eccrine poroma&#44; pyogenic granuloma&#44; digital fibrokeratoma&#44; nevi&#44; viral verruca&#44; amelanotic melanoma&#44; and solitary reticulohistiocytoma&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> There are few reports describing the sonographic characteristics of xanthogranulomas&#46; These present as a well-defined hypoechoic dermal nodule&#44; with thin low-velocity arterial vascularity &#40;maximum peak systolic velocity&#44; 6&#46;5&#8239;cm&#47;s&#41; detected internally on color Doppler ultrasonography&#46; No posterior enhancement or acoustic shadowing artifact has been reported&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In this case&#44; a cutaneous metastasis had to be ruled out given the patient&#8217;s past medical history&#46; Excluding melanoma&#44; breast carcinoma is the most frequent source of cutaneous metastasis in women&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Because of its high incidence&#44; breast carcinoma cutaneous metastases are the cutaneous metastases most frequently evaluated by dermatologists&#46; The most common presentation of breast cancer cutaneous metastasis is an asymptomatic&#44; skin-colored&#44; or pink-brown nodule located on the chest wall or abdomen which might also occur on the extremities&#46; A wide spectrum of clinical presentations has been described in cutaneous breast cancer metastases&#44; which might mimic a wide variety of benign skin lesions&#44; such as acral fibrokeratoma&#44; pyogenic granuloma&#44; follicular cysts&#44; dermatofibromas or hemangioma&#44; included in the differential diagnosis of adult xanthogranuloma&#46; Ultrasound examination has proven to be a useful tool to support the diagnosis of cutaneous metastasis of melanoma&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> There is less evidence supporting the use of ultrasonography for the detection of cutaneous metastasis of solid tumors&#44; however&#44; this technique has been shown to aid in the diagnosis of malignant nodular and subcutaneous lesions in small series&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9</span></a> Sonographic characteristics suggestive of cutaneous metastases include polycyclic shape and hypervascularity with multiple peripheral poles and internal vessels&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Cutaneous metastases herald a poor prognosis&#44; hence the importance of dermatology in determining an early diagnosis&#46;</p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Financial support</span><p id="par0020" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Authors&#8217; contributions</span><p id="par0025" class="elsevierStylePara elsevierViewall">Laura Serra-Garc&#237;a&#58; Effective participation in critical review of the literature&#44; drafting and editing of the manuscript and approval of the final version of the manuscript&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Cristina Carrera&#58; Intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#59; critical review of the manuscript&#59; approval of the final version of the manuscript&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Priscila Giavedoni&#58; Intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#59; critical review of the manuscript&#59; approval of the final version of the manuscript&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Constanza Riquelme-Mc Loughlin&#58; Effective participation in research orientation&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#59; critical review of the manuscript&#59; approval of the final version of the manuscript&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conflicts of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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