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Seborrheic Keratosis on the Palm. Or is it Not?Liau MeiQi May,

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Seborrheic Keratosis on the Palm. Or is it Not?

Liau MeiQi May,* MD, Yang Shiyao Sam, MD, Huang Jing Xiang, MD, Aw Chen Wee Derrick, MD

Address: National University Health System, Singapore E-mail: maylmq@gmail.com

* Corresponding Author: Dr. Liau MeiQi May, National University Health System, 6 Countryside Road, 789772, Singapore

Case Report DOI: 10.6003/jtad.16104c3

Published:

J Turk Acad Dermatol 2016; 10 (4): 16104c3

This article is available from: http://www.jtad.org/2016/4/jtad16104c3.pdf Keywords: Pigmented eccrine poroma, seborrheic keratosis, histopathology

Abstract

Observation: Eccrine poroma (EP) often presents as a reddish nodule with a predilection for the distal extremities. This report describes a lesion with clinical and dermoscopic findings classical of seborrheic keratosis. However, histopathological examination revealed an alternative diagnosis of pigmented eccrine poroma on the palm, a rare variant of EP in a highly unusual location.

Introduction

Eccrine poroma (EP) is a benign neoplasm of the eccrine terminal duct, composed of epit- helial cells that show tubular differentiation.

It often presents as a reddish nodule with a predilection for the distal extremities. This re- port describes a lesion with clinical and der- moscopic findings classical of seborrheic keratosis. However, histopathological exami- nation revealed an alternative diagnosis of pigmented eccrine poroma on the palm, a rare variant of EP in a highly unusual loca- tion.

Case Report

An 84 year-old Indian lady presented with a 5-year history of an asymptomatic hyperpigmented ver- rucous nodule over her left palm. It measured 8 x 5mm in size and had a stuck-on appearance with a sessile base (Figure 1). There was no other si- milar lesion elsewhere and systemic examination was unremarkable. The initial clinical impression was that of a seborrheic keratosis on the palm, an

extremely unlikely location. A shave biopsy of the lesion was performed.

Histopathological examination revealed a verru- cous lesion with anastomosing downgrowths (Fi- gure 2A).  There are horn cysts scattered throughout the tumor and there is no sharp de- marcation between keratinocytes of the epidermis and the lesion.   Many of the cells contain brown melanin pigmentation (Figure 2B).  The cells show moderate amounts of eosinophilic cytoplasm with ovoid nuclei exhibiting minimal nuclear pleo- morphism and containing some nucleoli.   Focally, intercellular bridges may be discerned.  On closer examination, some ductal structures are seen (Fi- gure 2C), which are highlighted by immunostai- ning with polyclonal antibody against CEA (Figure 2D).

The diagnosis of the lesion was pigmented eccrine poroma (EP).

Discussion

The pigmented form of EP is very rare, and usually occurs in non-acral sites [1], unlike the other EP variants. Our case report stands

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out by its location on the palm and impor- tantly, it’s striking clinical similarity to se- borrheic keratosis.

The diagnosis of EP is essentially histopatho- logical. Pigmented EP is characterized by the presence of melanin in the tumour cells and colonization by melanocytes. The mechanism leading to melanocyte incorporation in these tumours is not well understood. Several of the hypotheses proposed include: (i) activa- tion of persistent melanocytes in the eccrine acrosyringium under the influence of tumour related growth factors (including endothelin- 1, stem cell factor, nerve growth factor) which are known to promote proliferation, survival, adhesion and migration of melanocytes [2, 3];

or (ii) migration of melanocytes from surroun- ding epidermis or nearby hair follicles [4].

Besides being clinically similar to a range of other benign and malignant tumours, EP is also considered a great dermoscopic imitator.

Cases of EP displaying arborizing telangiec- tasia and blue-grey ovoid nests, resembling pigmented BCC have been reported [5]. EP can also have dermoscopic findings of co- medo-like opening and perivascular white halos, mimicking seborrheic keratosis [6].

The standard therapy for EP is surgical exci- sion. As there have been reports of recurrence or even malignant progression into eccrine porocarcinoma, appropriate follow-up is ad- vised for all patients.

In conclusion, the similarities between pig- mented EP and other cutaneous lesions, in- cluding seborrheic keratosis, can be very striking. A definite diagnosis can only be clinched through histopathological results.

References

1. Lan CC, Yu HS, Wu CS, Chen GS. Immotile acral me- lanocytes? Br J Dermatol 2006; 155: 1300-1301.

PMID: 17107411

2. Imokawa G, Yada Y, Miyagishi M. Endothelins secre- ted from human keratinocytes are intrinsic mitogens for human melanocytes. J Biol Chem 1992; 267:

24675-24680. PMID: 1280264

3. Manaka L1, Kadono S, Kawashima M, Kobayashi T, Imokawa G. The mechanism of hyperpigmentation in seborrhoeic keratosis involves the high expression of endothelin-converting enzyme-1a and TNF-a, which stimulate secretion of endothelin 1. Br J Dermatol 2001; 145: 895-903. PMID: 11899142

4. Ohatu U, Hara H, Suzuki H. Pigmented eccrine po- roma occurring on the scalp: Derivation of melanocy- tes in the tumor. Am J Dermatopathol  2006; 28:

138-141. PMID: 16625076

5. Kuo H-W, Ohara K. Pigmented Eccrine Poroma: A Re- port of Two Cases and Study With Dermatoscopy.

Dermatog Surg 2003; 29: 1076-1079. PMID:

12974711

6. Lallas A, Chellini PR, Guimarães MG, et al. Eccrine poroma: the great dermoscopic imitator. J Eur Acad Dermatol Venereol 2015; DOI:10.1111/jdv.13302.

PMID: 26333195

J Turk Acad Dermatol 2016; 10 (4): 16104c3. http://www.jtad.org/2016/4/jtad16104c3.pdf

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(page number not for citation purposes) Figure 1. A: Hyperpigmented verrucous lesion on left

palm, B: Close up view of nodule

Figure 2. A, B and C: Photomicrographs of H&E stained section of tumour, D: Slide stained by immunohistochemistry with polyclonal CEA antibody,

highlighting ductal structures

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