J Cutan Pathol 2015: 42: 657–659 doi: 10.1111/cup.12496 John Wiley & Sons. Printed in Singapore

© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Journal of Cutaneous Pathology

Letter to the Editor

True cutaneous chondroma: a case report Keywords: cutaneous neoplasm, dermatology, dermatopathology, histopathology, soft tissue tumors To the Editor , A chondroma is a benign cartilaginous tumor with a slow growth rate. The spectrum includes enchondroma, periosteal chondroma, soft tissue chondroma or chondroma cutis, depending on location in the medullary cavity of a bone, the periosteal region, the soft tissue or the dermis, respectively.1 A 33-year-old man presented with a 5-year history of an asymptomatic lesion on his left hand. With the presumptive diagnosis of verruca vulgaris, the patient had been initially treated with cryotherapy, with rapid recurrence after that. He denied having had previous trauma at this site. On physical examination, a firm, skin-colored, 8 mm nodule was observed on the left palm (Fig. 1). Radiographic examination did not reveal alterations in the underlying bone or a bony connection. The lesion was removed with a suspected diagnosis of a fibrous tumor. Pathologic examination revealed a well-demarcated lobulated dermal tumor surrounded by compressed fibrous connective tissue, composed of single and grouped chondrocytes embedded within a hyaline cartilaginous matrix. Atypical mitotic figures were not evident. Effacement of the overlying epidermis was also observed (Figs. 2 and 3). A diagnosis of true cutaneous chondroma was made. Chondroma cutis or true cutaneous chondroma is extremely rare. Some authors consider true cutaneous chondromas and soft tissue chondromas to represent the same entity, being grouped under the term of extraskeletal chondromas. In the literature, there is frequently an overlap concerning the characteristics of both tumors. These features will be dealt with in this report. For these reasons we prefer and we will

Fig. 1. There was a firm and fleshy nodule on the left palm.

use the term ‘extraskeletal chondroma’ throughout this manuscript. The pathogenesis of these entities remains unknown. Due to the proximity of soft-tissue chondromas with fibrous tissues (such as tendons, tendon sheath or the joint capsule) or with synovium, a synovial origin has been proposed. On the other hand, chondroma cutis has been related to sebaceous hyperplasia or angiofibromas, and although these lesions can appear as primary, they can also be formed via cartilaginous metaplasia.2,3 In addition, several authors have found chromosomal anomalies in a few cases of chondroma cutis.1 A familial case of multiple facial chondroma cutis has also been reported, suggesting a dominant mode of inheritance.3 Extraskeletal chondromas characteristically present as insidious growing masses that may occasionally be painful. They are more commonly located on hands (principally on fingers

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Letter to the Editor

Fig. 2. Lobules of chondrocytes are surrounded by a thin fibrous pseudocapsule and embedded within mature hyaline cartilage, with effacement of the overlying epidermis (hematoxylin and eosin staining).

Fig. 3. At higher magnification, mature chondrocytes without significant atypia are apparent within hyaline cartilaginous matrix (hematoxylin and eosin staining).

or on the palmar side) and feet. There is no gender predilection, but they usually occur between the third and sixth decades of life.4 Extraskeletal chondromas may be intradermal or subcutaneous. In previous reports, chondroma cutis has been considered when the lesion was exclusively within the dermis, while the term soft tissue chondroma has been preferred if the tumor also affected the subcutis. There is, characteristically, no connection with the underlying bone or the periostium. Extraskeletal chondromas show lobulated areas of cartilage of hyaline type, and are usually surrounded by a thin fibrous pseudocapsule.2 Occasionally, focal areas of variable atypia of chondrocytes such as pleomorphic nuclei, multinucleation, macronucleoli or scattered mitosis, may result in a mistaken diagnosis of chondrosarcoma.1 These features are more typically described in cases

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of soft-tissue chondroma than in cases of chondroma cutis.3 Extraskeletal chondromas may also show chondroblastic and epitheloid cells, calcification, ossification, haemorrhagic areas, myxoid degeneration or granulomatous changes. They commonly show positive immunostaining for S-100 protein, vimentin, chondroitin-4 or 6-sulfate proteoglycans while lacking expression of epithelial and myoepithelial markers.2 The differential diagnosis of extraskeletal chondroma mainly includes cartilaginous hamartomas, such as a Meckel cartilaginous remnant, accessory tragus, or bronchogenic or dermoid cysts. Cartilaginous hamartomas are the most common cartilaginous lesions. They are usually congenital and located in the head and neck area. Microscopically, these hamartomas are composed of cartilage and vellus hair follicles. In the differential diagnosis, it may also be necessary to consider juvenile aponeurotic fibroma, skeletal tumors with cartilaginous differentiation such as osteochondroma, subungual exostosis and synovial chondromatosis, chondroid syringomas and cutaneous metastases of chondrosarcoma or chondroblastic osteosarcoma.5 Quite often, the distinction between benign and low-grade malignant cartilaginous tumors can be difficult to attain. Currently, cytogenetic or molecular genetic data could be useful for the differential diagnosis.1 Extraskeletal chondromas show characteristic radiographic features, as they have been observed as a curvilinear, round or irregularly calcified shadow without invasion of the underlying bone.4 Nevertheless, although extraskeletal chondromas are located outside the periostium, compression deformity and destruction can occur.5 Although malignant transformation has not been reported, total excision is the treatment of choice. Complete tumor removal prevents local persistence, which has been reported in 15% of cases, usually due to previous inadequate resection.4 In conclusion, we have reported a new case of extraskeletal chondroma exclusively confined to the dermis, namely chrondroma cutis or true cutaneous chondroma. Acknowledgements We are indebted to Dr. Luis Requena for reviewing this case.

Ana Batalla, MD1 Hae Jin Suh-Oh, MD1 Rosa Pardavila, MD2

Letter to the Editor Carlos de la Torre, MD, PhD1 Department of Dermatology Complejo Hospitalario de Pontevedra, Xestióln Integrada Pontevedra-Salnés Pontevedra, Spain 1

2

Department of Pathology Complejo Hospitalario de Pontevedra, Xestióln Integrada Pontevedra-Salnés Pontevedra, Spain e-mail: [email protected]

References 1. Buddingh EP, Naumann S, Nelson M, Neffa JR, Birch N, Bridge JA. Cytogenetic findings in benign cartilaginous neoplasms. Cancer Genet Cytogenet 2003; 141: 164. 2. Shinojima Y, Hara H, Shimojima H, Terui T. Cutaneous chondroma with overlying

pigmentation clinically mimicking dermatofibroma. Br J Dermatol 2006; 154: 178. 3. Humphreys TR, Herzberg AJ, Elenitsas R, Johnson BL, Goldstein J. Familial occurrence of multiple cutaneous chondromas. Am J Dermatopathol 1994; 16: 56.

4. Vaseenon T, Cheewawattanachai C, Pattamapaspong N, Settakorn J, Leerapun T. Extraskeletal chondroma on the sole of the foot. Foot Ankle Spec 2014; 7: 232. 5. Hsueh S, Santa Cruz DJ. Cartilaginous lesions of the skin and superficial soft tissue. J Cutan Pathol 1982; 9: 405.

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True cutaneous chondroma: a case report.

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