A 27-year-old woman presented with a 2-year history of an asymptomatic papule located on her right cheek. The physical examination revealed a firm, well-defined with a raised annular border, skin-colored papule, 5 mm in maximum diameter

Arzberger, E

Hofmann-Wellenhof, R

Oliveira, A

Zalaudek, I

Oliveira, AndrÃ©

Arzberger, Edith

Zalaudek, Iris

Hofmann-Wellenhof, Rainer

Archivio istituzionale della ricerca - Università di Trieste

Desmoplastic trichoepithelioma and melanocytic nevus: Dermoscopic and reflectance confocal microscopy presentation of a rare collision tumor

Repositório do Centro Hospitalar de Lisboa Central, EPE

Desmoplastic trichoepithelioma and melanocyticnevus: Dermoscopic and reflectance confocalmicroscopy presentation of a rare collision tumorAndre Oliveira, MD,a Edith Arzberger, MD,b Iris Zalaudek, MD,b and Rainer Hofmann-Wellenhof, MDbLisbon, Portugal, and Graz, AustriaFromCDAPublFundConfCLINICAL PRESENTATIONA 27-year-old woman presented with a 2-year history of an asymptomatic papule located on herright cheek. The physical examination revealed a firm, well-defined with a raised annular border, skin-colored papule, 5 mm in maximum diameter.DERMOSCOPIC APPEARANCESharply focused, fine arborizing vessels, mostly at the periphery, were observed on a white-ivorybackground in the upper half of the lesion and structureless light-brown vessels were observed in thelower half. Few white clods, probably corresponding to horn cysts, were also seen (Fig 1).Fig 1. Desmoplastic trichoepithelioma and melanocytic nevus (collision tumor). Dermoscopyof the skin-colored papule on the right cheek (clinical detail) disclosed sharply focused, finearborizing vessels (arrows), mostly at the periphery on a white-ivory background (blackasterisk) in the upper half of the lesion and structureless light-brown (white asterisk) in thelower half. Few white clods (arrowheads) probably corresponding to horn cysts were alsoseen. There were no leaflike structures, ovoid nests, or shiny-white streaks.CONFOCAL MICROSCOPY APPEARANCEDark, small, round, and elongated tumor islands were seen in the superficial dermis. Within thesestructures, round, small black spaces were filled with highly refractile material (early horn cysts).Brightly refractile collagen arranged in parallel bundles was seen surrounding the tumor islands andalso some dilated vessels throughout the stroma. Compact, larger, ovoid, highly refractile structureswere seen within a few tumor islands, representing focus of tumor calcification. At the dermal-epidermal junction, a meshwork pattern with edged papillae, junctional thickenings, and nests wereobserved (Fig 2).the Department of Dermatology, Hospital de Curry Cabral eentro Hospitalar de Lisboa Central,a Lisboa, Portugal, and theepartment of Dermatology, Medical University of Graz, Graz,ustria.bication of this article was supported by 3Gen.ing sources: None.licts of interest: None declared.Reprint requests: Andre Oliveira, MD, Department of Dermatology,Hospital de Curry Cabral e Centro Hospitalar de Lisboa Central,1169-045 Lisboa, Portugal. E-mail: andre.oliveira@sapo.pt.J Am Acad Dermatol 2015;72:S13-5.0190-9622/$36.00ª 2014 by the American Academy of Dermatology, Inc.http://dx.doi.org/10.1016/j.jaad.2014.03.047S13Fig 2. Desmoplastic trichoepithelioma and melanocytic nevus (collision tumor). Reflectanceconfocal microscopy (RCM) examination (A, RCM mosaic, 3 3 3 mm; B, basic image, 0.5 30.5 mm) revealed numerous dark, round, and elongated tumor islands in the superficial dermis.Within these structures, round, small black spaces were filled with highly refractile materialcorresponding to early horn cysts (red asterisks). Brightly refractile collagen arranged inparallel bundles was seen surrounding the tumor islands (red arrows) and also dilated vessels(white arrow). Larger, ovoid, highly refractile structures were seen within a few dark tumorislands representing focus of tumor calcification ( yellow square). At the dermal-epidermaljunction, a meshwork pattern with edged papillae, junctional thickenings ( yellow arrow), andnests ( yellow asterisk) were observed.J AM ACAD DERMATOLJANUARY 2015S14 Oliveira et alHISTOLOGIC DIAGNOSISHistopathologic examination confirmed a collision tumor between a desmoplastic trichoepithe-lioma (DTE) with focus of calcification and a melanocytic nevus (Fig 3).Fig 3. Desmoplastic trichoepithelioma and melanocytic nevus (collision tumor). Histopatho-logic examination showed a collision tumor between a desmoplastic trichoepithelioma withfocus of calcification and a melanocytic nevus ( yellow asterisk). Note narrow strands of tumorcells composed of small basaloid cells without atypia or mitosis (black arrow), horn cysts( yellow arrow), and some areas of calcification (arrowhead ) in a densely collagenous stroma(black asterisks). The desmoplastic stroma correlates with the white-ivory background seen indermoscopy and with the brightly refractile parallel bundles of collagen in reflectance confocalmicroscopy (RCM). The strands of tumor cells correlate with the dark, small, round structuresobserved in RCM, while the horn cysts correlate with the white clods featured in dermoscopyand the highly refractile structures observed within the dark tumor islands in RCM. Thestructureless brown area seen in dermoscopy probably corresponds to the melanocytic nevus.(A, Hematoxylin and eosin stain; original magnification 340. B, Hematoxylin and eosin stain;original magnification 3400.)J AM ACAD DERMATOLVOLUME 72, NUMBER 1Oliveira et al S15KEY MESSAGEDTE is a benign adnexal tumor. Although rare, typical clinical, dermoscopic, and reflectanceconfocal microscopy features of DTE were seen here with an associated melanocytic nevus.1 Toour knowledge, this is the first report of dermoscopic and reflectance confocal microscopypresentation of this rare collision tumor, supporting the role of these noninvasive techniques asan aid to its histopathologic diagnosis.2RENCESREFE1. Ardigo M, Zieff J, Scope A, Gill M, Spencer P, Deng L, et al. Dermoscopic and reflectance confocal microscopy findings oftrichoepithelioma. Dermatology 2007;215:354-8.2. Moscarella E, Rabinovitz H, Oliviero MC, Brown L, Longo C, Zalaudek I, et al. The role of reflectance confocal microscopy as an aid in thediagnosis of collision tumors. Dermatology 2013;227:109-17.

Desmoplastic Trichoepithelioma and Melanocytic Nevus: Dermoscopic and Reflectance Confocal Microscopy Presentation of a Rare Collision Tumor

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Desmoplastic Trichoepithelioma and Melanocytic Nevus: Dermoscopic and Reflectance Confocal Microscopy Presentation of a Rare Collision Tumor

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